Depession; clinical approch Dr. Mohammad Hussein April 2019

1. Depress
ion;
A clinical
Approach

2. Depre
ssion

3. Depre
ssion
Lifetime
rates
10-20%

4. Depre
ssion
Lifetime
rates
10-20%
2 and 9 %
attempt
suicide

5. Depre
ssion
4th cause of disability
worldwide
Depression is
treatable

6. Descriptive
Epidemiolog
y

7. Descrip
tive
Epidemi
ology
10-20%
Lifetime rates
1:2
Male: female
ratio
24-44
Age of onset
No
difference
Socioeconomic
Difference

8. Diagnosis
of
Depressio
n

9. Core
symptoms

10. Why?
3 Core
symptoms

11. Why?
3 Core
symptoms
persis
tent
sadnes
s
or low
loss
of
intere
sts
or
fatigu
e or
low
energy
most of the
time,
most days,
for at least 2
weeks

12. Why?
3 Core symptoms
persistent
sadness
or low mood
loss of
interests
or pleasure
fatigue or
low energy

13. Why?
3 Core symptoms
persistent
sadness
or low mood
loss of
interests
or pleasure
fatigue or
low energy
Associated
symptoms
disturbed
sleep
guilt or self-
blame
poor
concentration
disturbed
appetite
low self-
confidence
agitation or
slowing of
movements
suicidal thoughts or acts

14. Sever
ity
of
Depre
ssion
No Depression
Less than 4
symptoms
Mild
Depression
4 symptoms
Moderate
Depression
5-6 symptoms
Severe
Depression
More than 6
symptoms

15. Clinical
Picture

16. Clini
cal
Pictu
re
Mood
symptoms
Cognitive
symptoms
Behavioral
symptoms
Vegetative

17. Clini
cal
Pictu
re
 Low mood
 loss of interest or pleasure
(anhedonia)
 Hopelessness
 Guilt
 Moodiness
 Angry outbursts
 Loss of interest in friends,
family and favorite
activities,
 Patients may describe a
depressed mood in a number of
ways, such as feeling sad,
dejected, despondent,

18. Clini
cal
Pictu
re
 Reduced
concentration
 Impaired memory
 Poor self-esteem
 Guilt
 Hopelessness
 Death wishes
 Suicide or self-
harm

19. Clini
cal
Pictu
re
 Psychomotor
retardation or
agitation
Withdrawing from
people
 Substance abuse
 Missing work, school
or other commitments
 Attempts to harm
self

20. Clini
cal
Pictu
re
 Biological (somatic)
symptoms
 Disturbed sleep ( ↓↑ )
 Early morning wakening
 Disturbed appetite ( ↓↑ )
 weight loss
 Depression worse in the
morning
 Decreased sexual desire
 Psychomotor retardation or
agitation
easy fatigability
 pain

21. Clini
cal
Pictu
re
Mood
symptoms
Cognitive
symptoms
Behavioral
symptoms
Vegetative

22. Clini
cal
Pictu
re
Mood
symptoms
Cognitive
symptoms
Behavioral
symptoms
Vegetative

23. Faces Of
Depression

24. Face
s of
Depre
ssion

25. Face
s of
Depre
ssion

26. Face
s of
Depre
ssion

27. Face
s of
Depre
ssion

28. Face
s of
Depre
ssion

29. Face
s of
Depre
ssion

30. Managem
ent

31. Managem
ent
‫ميته‬ ‫من‬ ‫احنا‬
‫بنعالج؟‬
.!!
..
‫بنشخص‬ ‫احنا‬
‫ميته‬ ‫من‬ ‫احنا‬
‫بنعالج؟‬
...!!
‫بنشخص‬ ‫احنا‬
‫بس‬

32. Depressio
n
Is

33. Managem
ent
nt

34. Managem
ent
Where?
Inpatient
outpatient
When?
Short term
therapy
Long term
therapy
What?
Pharmacothe
rapy
Psychothera
Who?
Psychiatris
t
Psychologis

35. Managem
ent
tricyclic
antidepre
ssants
TCAs
selectiv
e
serotoni
n
reuptake
inhibito
rs
SSRIs
serotoni
n
norepine
phrine
reuptake
inhibito
rs
SNRIs
dopamine
norepine
phrine
reuptake
inhibito
rs
DNRIs
Others
Mono
Amine
Oxidase
Inhibito
rs
MOIs

36. tricyclic
antidepressants
TCAs

37. tricycli
c
antidepr
essants
TCAs
 well-established
efficacy
 possibly more effective
in severe depression;
 Low cost.
Advantages
 toxicity in overdose;
 may be less well
tolerated than SSRIs;
 all TCAs may slow
cardiac conduction and
lower seizure threshold
Disadvanta
ges
 acute MI,
 heart block,
 arrhythmias,
 severe liver disease
 pregnancy and lactation
Contraindi
cations

38. tricycli
c
antidepr
essants
TCAs
 (Anafranil) (Anafronil)
 starting dose :
75mg/day(divided or just
at night)
• Max daily dose : 250mg
Clomipramine
 (Prothiaden)
 starting dose : 75–
150mg/day
 Max daily dose : 225mg
Dosulepin
 (Tofranil) (Imipramine)
 starting dose : 25mg up
to tds
Imipramine

39. selective serotonin
reuptake inhibitors
SSRIs

40. selectiv
e
serotoni
n
reuptake
inhibito
rs
 ease of dosing;
 better tolerated than
TCAs
 Less cardiotoxic
 fewer anticholinergic
side-effects;
 low toxicity in
overdose.
Advantages
 commonly cause nausea
and GI upset headache
 restlessness, and
insomnia
 may be less effective
for severe depressive
Episodes
 problems on
discontinuation.
Disadvanta
ges
 manic episode
 concomitant use of
MAOIs.
Contraindi
cations

41. selectiv
e
serotoni
n
reuptake
inhibito
rs
 (Prozac) (Alzac) (Flutin)
(Octozac)
 starting dose : 20mg od
 Max daily dose : 60mg
 Most alerting, May cause
weight loss
Fluoxetine
 (Seroxate) (Paroxidur)
(paxitin) (Paroxtin)
 starting dose : 20mg od
 Max daily dose : 50mg
 Most anticholinergic.
 Withdrawal syndrome
 may be more frequent.
 May be sedating
Paroxetine

42. selectiv
e
serotoni
n
reuptake
inhibito
rs
 (Lustral) (Moodapex)
(Serpass) (Sesrine)
 starting dose : 50
 Max daily dose : 200mg
 Moderately alerting.
 Fewer drug interactions,
Sertraline
 (Faverin) (Statomin)
 starting dose : 50–100mg
od
 Max daily dose : 300mg
 Moderately sedating
Fluvoxamine

43. selectiv
e
serotoni
n
reuptake
inhibito
rs
 (Cipram) (Depram)
(Ramdeep) (Citalo)
 starting dose : 20mg od
 Max daily dose : 60mg
 Least likely to interact
with other drugs.
Citalopram
 (Cipralex) (Cipra-pro)
(Escita) (Estikan) ……..
 starting dose : 10mg od
 Max daily dose : 20mg
 Moderately sedating
Escitalopram

44. serotonin
norepinephrine reuptake
inhibitors
SNRIs

45. serotoni
n
norepine
phrine
reuptake
inhibito
rs
 well-established
efficacy
 possibly more effective
in severe depression;
 more rapid onset of
action
Advantages
 need to monitor blood
pressure
 discontinuation effects
common
Disadvanta
ges
 manic episode
Contraindi
cations

46. serotoni
n
norepine
phrine
reuptake
inhibito
rs
 (Efexor) (Efegad)
(Venllamsh)
 starting dose : 75mg
 Max daily dose :
375mg/day
 Most alerting,
Venlafaxine
 (Cymbalta) (Karblata)
(Depretreve)
 starting dose : 60mg od
 Max daily dose : 120mg/day
 May have utility in
treating chronic pain and
urinary incontinence.
Duloxetine
 (Pristiq) (prismven)
(bedremine)
 starting dose : 50 mg od
 Max daily dose : 400
mg/day
 discontinuations were more
common at higher doses
Desvenlafaxin
e

47. Cognitive
Behaviour
al

48. Cognit
ive
Behavi
oural
Therap
1.Increase level of
pleasurable activities.
2.Decrease time spent
alone.
3.Increase reciprocal
behaviour in
interpersonal activities.
4.Increase ability to
complete effortful or
challenging tasks (e.g.,
problem solving at work
and in more demanding
activities of daily
Behavio
ral
Activat
ion

49. ECT
Admission

50. ‫يحبذ‬ ‫حسين‬

51. ‫يحبذ‬ ‫حسين‬

52. t

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