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This document provides an outline for a presentation on depressive disorders. It begins with approaching patients with depressive symptoms and differentiating between types of depression according to the DSM. The most common types are described along with their prevalence, management, and treatment options. Guidelines are provided for when to refer patients to psychiatry. A clinical case example is presented and the most likely diagnosis is discussed. The document also covers interviewing psychiatric patients in primary health care and includes sections on goal of assessment, components of history and mental status examination.

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Depressive Disorders Saleh Al-Khalid R2 Supervised By Dr. Nashwa Banani Special thanks to Dr. Ahmad Al-Saleh
Outline  Approach to Patient with Depressive Symptoms  Differentiate between types of depression according to the DSM ◦ Major depression ◦ Dysthymia ◦ Bipolar ◦ Cyclothymia ◦ Adjustment ◦ Grief ◦ Acute stress disorder ◦ Post traumatic stress disorder  Each disease: Prevalence in PHC, Management  Lest Treatment Option  When to Refer to psychiatry
Clinical case problem:  A 28 year old man comes to the office with his wife because he has been "feeling tired” during the past 4 months. He says he always feels “run down” but also notes that he does not sleep well. He says he is able to fall asleep when he goes to bed at 10 PM ,but he wakes up at 3 AM and is unable to get back to sleep, he notes that he often has trouble with focus and concentration  he lacks the energy to finish his tasks at home. His appetite has decreased and you note a 10 pound weight loss since his last visit 6 months ago he denies fever, nausea, vomiting, or night sweat. He has no other medical problems and any other medication, his physical examination is normal
What is most likely diagnosis ? A. adjustment disorder with depressed mood B.GAD C.MDD D. mood disorder caused by a general medical condition. E. dysthymic disorder
Interviewing Psychiatric Patients in PHC
Goal of Psychiatric Assessment  To make a diagnosis  To describe patient’s condition  To identify psychiatric emergencies  To find out the predisposing and primary cause of behavior  To plan an interventions
Components of Psychiatric Assessment  Psychiatric History  Mental Status Examination  Physical Examination  Investigations
Psychiatric History  Source & Reliability of Information  Identification Data  Chief Complaints  History of Present Illness  Past Psychiatric History  Past Medical History  Medications & Allergy  Family Psychiatric History  Personal & Social History
Identification Data  Name  Age  Sex  Marital Status  Children  Living Arrangement  Work
Chief Complaint
History of Present Illness  Onset / Duration  Depressive symptoms ◦ 5/9 symptoms (M or I is required) for two weeks  M mood (depressed)  S sleep disturbance  I interest (loss)  G guilt  E energy (decreased)  C concentration difficulties  A appetite/weight changes  P psychomotor abnormalities  S suicidal ideation
History of Present Illness  Suicide assessment  Bipolar symptoms  Psychotic symptoms  Anxiety symptoms  Recent stressors
Past Psychiatric History  Previous Visits to Mental Health Professionals  Previous Diagnoses  Psychiatric Hospitalizations  Suicide in the past
Past Medical History  Medical Diseases ◦ Epilepsy ◦ Head injury ◦ Hypothyroidism ◦ Anemia  Surgeries
Medications & Allergy  Psychiatric Medications  Other Medications  Over the counter medications  Herbal Remedies  Allergy
Family Psychiatric History  Psychiatric Illnesses in the Family  Substances in the Family  Suicide in the Family
Personal & Social History  Perinatal history  Place of birth  Place of upbringing  Childhood  Parents (age, job, personality, relationship)  Siblings (numbers, brothers & sisters, rank, relationship)
Personal & Social History  Abuse (emotional, physical, and sexual)  Educational history  Occupational history (current and past jobs)  Sexual & Marital history ◦ Spouse (age, personality, relationship) ◦ Serious relationships
Personal & Social History  Caffeine consumption  Cigarettes  Alcohol and street drugs use  Criminal history  Interpersonal relationship  Activity level
Mental Status Examination Components  Appearance  Behaviors  Attitude  Speech  Mood  Affect  Thought Process (Thought Form)  Thought Content  Perceptual Disturbance  Cognition & Sensorium  Insight and Judgment
Appearance  Actual & Apparent Age  Hygiene & Grooming  Body Habitus  Physical Abnormalities  Jewelry & Cosmetic Use  Tattoo and Piercing
Behaviors  Patient’s motor behavior ◦ Restlessness ◦ Fidgety movements ◦ Psychomotor Agitation ◦ Psychomotor Retardation ◦ Compulsions, tics
Attitude  Toward the examiner ◦ Cooperative ◦ Seductive ◦ Guarded ◦ Childish  Eye contact ◦ Good eye contact (Appropriate) ◦ Limited eye contact ◦ Poor eye contact
Speech  Fluent  Stuttering  Tone  Rate ◦ Pressured speech ◦ Slow speech  Speech latency
Mood  Mood: Subjective emotional state ◦ “Depressed”/”down” ◦ “Happy” ◦ “Angry” ◦ “Anxious”
Affect  Affect: Objective Emotional State ◦ Adequate ◦ Constricted ◦ Dramatic ◦ Blunted ◦ Flat
Thought Process  Organized, goal-directed  Disorganized ◦ Circumstantiality (wander, but go back to the point) ◦ Tangentiality (wander, but doesn’t go back) ◦ Flight of Ideas (fast, connection between ideas) ◦ Loose Association (no connection between ideas) ◦ Thought Blocking (sudden stopping in speech) ◦ “Word Salad” (random intact words) ◦ Incoherent (words meaningless)
Thought Content  Obsessions  Overvalued Ideas  Delusions ◦ Paranoid/Persecutory ◦ Grandiose ◦ Religious ◦ Somatic  Suicidal/Homicidal Thoughts
Perceptual Disturbances  Illusion: Misperception of an existing stimulus  Hallucination: Perception without real stimulus ◦ Auditory ◦ Visual ◦ Tactile ◦ Olfactory ◦ Gustatory
Sensorium & Cognition  Alertness / Level of Consciousness: ◦ (e.g. alert/awake, clouding of consciousness)  Orientation (Time, Place, and Person)  Concentration and Attention ◦ (Serial 7’s, Spell “WORLD” backwards)  Memory (Immediate, recent, remote)
Insight and Judgment  Insight: ◦ Awareness of one’s illness ◦ Awareness of one’s illness impact on self and others ◦ Acknowledgment of the need of treatment  Full Insight  Partial Insight  Impaired/No Insight
Insight and Judgment  Judgment: ◦ Ability to understand and communicate ideas ◦ Intact cognitive abilities ◦ Control over impulses  Intact Judgment  Limited Judgment  Impaired Judgment
What is Mental Illness?  Definition of Mental Disorder (DSM-V): ◦ A health condition characterized by significant dysfunction in an individual’s cognitions, emotions, or behaviors that reflects a disturbance in the psychological, biological, or developmental processes underlying mental functioning  Include various affective, cognitive, behavioral and perceptual abnormalities
Myths about Mental Illness  Mental illness only affect few people ◦ Fact: Mental illness is very common  The mentally ill are violent and dangerous ◦ Fact: Most are victims of violence, and they are more likely to harm themselves than they are to hurt other people  People with mental illness should be kept in hospital ◦ Fact: With appropriate treatment and support, they can live successfully in the community
Stigmatization  Only about 35% of people with diagnosable disorders seek treatment  The single most common barrier to seeking treatment is Shame  Why does stigma surround mental illness?  Stigma leads to: ◦ Discrimination ◦ Fears, mistrust, and isolation ◦ Not seeking help
Classification of Mental Disorders  Mental Disorders are diagnosed based on criteria listed in Diagnostic Manuals  1. Diagnostic and Statistical Manual of Mental Disorders (DSM) ◦ Developed by the American Psychiatric Association (APA) ◦ Used in North America  2. International Classification of Diseases (ICD) ◦ Developed by the World Health Organization (WHO) ◦ Used in Europe and many parts of the world
Classification of Mental Illness  Schizophrenia Spectrum & other Psychotic Disorders  Depressive Disorders  Bipolar & Related Disorders  Anxiety Disorders  Obsessive-Compulsive & Related Disorders  Trauma & Stressor Related Disorders  Dissociative Disorders  Somatic Symptom & Related Disorders  Feeding & Eating Disorders  Elimination Disorders
Classification of Mental Illness  Sleep-Wake Disorders  Sexual Dysfunctions  Disruptive, Impulse-Control & Conduct Disorders  Substance-Related and Addictive Disorders  Personality Disorders  Neurocognitive Disorders  Neurodevelopmental Disorders  Paraphilic Disorders
Depressive Disorders  Major Depressive Disorder ◦ One or more Major Depressive Episode  Dysthymic Disorder (Persistent Depressive Disorder)  Premenstrual Dysphoric Disorder
Bipolar Disorders  Bipolar I Disorder ◦ ≥ Manic Episode  Bipolar II Disorder ◦ ≥ Hypomanic Episode + ≥ MDE  Cyclothymic Disorder
Anxiety Disorders  Separation Anxiety Disorder  Specific Phobia (Simple Phobia)  Social Anxiety Disorder (Social Phobia)  Generalized Anxiety Disorder  Panic Disorder  Agoraphobia
Schizophrenia Spectrum & Other Psychotic Disorders  Brief Psychotic Disorder: ◦ Positive psychotic symptoms last from one day to one month with full return to premorbid level of functioning  Schizophreniform Disorder: ◦ Psychotic symptoms last from one month to 6 moths with full return to premorbid level of functioning  Schizophrenia: ◦ Psychotic symptoms last more than 6 months, chronic illness
Schizophrenia Spectrum & Other Psychotic Disorders  Schizoaffective Disorder: ◦ Manic Episode or Major Depressive Episode together with psychotic symptoms  Delusional Disorder: ◦ One or more delusions, no prominent hallucinations, symptoms are encapsulated, no significant impairment in function, behavior is not obviously bizarre or odd
Personality Disorders  Cluster A: ◦ Paranoid, Schizoid, Schizotypal  Cluster B: ◦ Antisocial, Borderline, Histrionic, Narcissistic  Cluster C: ◦ Avoidant, Dependent, Obsessive-Compulsive
Violence and Mental Health  People and Media always link mental illness to violence and criminality  100 times more likely to kill themselves than another person  Predictors of violence with mental illness: ◦ Previous violence ◦ Substance abuse ◦ Personality disorders (Antisocial and Borderline PD) ◦ Paranoid Psychosis
Victimization  People with major mental illness are more likely to become victims of emotional and physical abuse,  WHY?  Kelly & McKenna (1997) surveyed one hundred people with mental health problems: ◦ 15 had stones thrown at windows ◦ 14 were verbally abused ◦ 5 had offensive graffiti ◦ 12 harassed outside home
Suicide
Definitions  Suicide: the act of intentionally ending one's own life  Suicide Ideation: thoughts of engaging in behavior intended to end one's life  Suicide Plan: the formulation of a specific method through which one intends to die  Suicide Attempt: engagement in potentially self- injurious behavior in which there is at least some intent to die  Non-suicidal Self-injury: self-injury in which a person has no intent to die
Some Facts About Suicide  8th leading cause of death in USA  3rd leading cause of death in young people (15-24 years old) in USA  Takes the lives of nearly 30,000 Americans every year  Highest rate in white men over 65  50-75% seek help before suicide
Global Suicide Rates (2008)
Suicide Risk Factors  Psychiatric Illness ◦ 90% of suicide had psychiatric illness ◦ 15% of those who are clinically depressed eventually die by suicide ◦ Mood disorders, schizophrenia, and substance abuse ◦ Alcoholism associated with up to half of all suicides ◦ 15% of alcohol dependent patients commit suicide  Age ◦ 15-24, > 45  Sex ◦ 4 male completed suicides for every female completed suicide
Suicide Risk Factors  Marital Status ◦ Socially isolated (Divorced, widowed, unmarried)  Employment ◦ Unemployed  Religion ◦ Atheist have a higher risk  Physical Health ◦ Patients with chronic pain, burns, HIV, cancers  Skills and Personality Character ◦ Impulsivity, poor problem solving, and poor coping with stress
SAD PERSON Scale  S Sex (Male)  A Age (<20 or >44)  D Depression  P Previous Attempts  E ETOH abuse  R Rational thinking loss  S Suicide in the family / Social support lacking  O Organized plan  N No spouse, no significant other  S Sickness (Chronic, Debilitating, and Severe)
Suicide Prevention  Education and public awareness  Decrease social isolation  Identify mental illness, substance abuse, victimization, and rejection  Treatment of mental illness  Secure or remove firearms  Decrease barriers around help seeking  Mental health crisis line  Psychiatric Hospitalization
Causes of Mental Illness  Biological factors  Psychological factors  Environmental/Social factors  Interaction between other factors
Biological Factors  Biochemistry  Genetics  Brain defect or injury  Infections  Perinatal injury  Substance abuse  Poor nutrition / Toxins
Psychological Factors  Traumatic experience  Important early loss  Learned behaviors  Attachment styles  Parenting styles  Poor coping skills  Personality traits
Environmental/Social Factors  Death or divorce  Dysfunctional family life  Social isolation  Social or cultural expectations
Depressive Disorders
Depression  It is NOT something to be ashamed of  It is NOT a sign of weakness  No one with depression can just “Snap Out of It”  Depression is an illness that involves thoughts, mood, and the body  It impacts the way a person functions socially, academically, and at work
Major Depressive Disorder (MDD)  Unipolar Depression  Single or Recurrent  Symptoms cause marked distress or impairment in social, occupational, or other important areas of functioning.  Symptoms are not due to a substance or a general medical condition  NO Hx. of mania, or hypomania
5/9 symptoms (M or I is required) for two weeks  M mood (depressed)  S sleep disturbance  I interest (loss)  G guilt  E energy (decreased)  C concentration difficulties  A appetite/weight changes  P psychomotor abnormalities  S suicidal ideation
Persistent Depressive Disorder (Dysthymia)  For at least 2 years, presence of Depressed mood +  2/6 for most of the day, more days than not ◦ A Appetite change (Increased or decreased) ◦ C Concentration difficulties ◦ H Hopelessness ◦ E Energy (low) ◦ S Sleep disturbance (Insomnia or Hypersomnia) ◦ S Self esteem (low)  No more than 2 months w/o symptoms
Premenstrual Dysphoric Disorder (PMDD)  5 symptoms present in the final week before the onset of menses, and improve after the onset of menses in the majority of menstrual cycles  ≥ 1 of 4: ◦ Marked affective liability ◦ Marked irritability ◦ Marked depressed mood, or feeling hopelessness ◦ Marked anxiety  Plus
Premenstrual Dysphoric Disorder  ≥ 1 of 7: ◦ Interest (decreased) ◦ Concentration difficulties ◦ Energy (Marked decreased) ◦ Appetite change (Marked increased or decreased) ◦ Sleep disturbance (Insomnia or Hypersomnia) ◦ Sense of being overwhelmed or out of control ◦ Physical sx. (breast tenderness, joint or muscle pain, bloating)  Symptoms cause significant distress or interference with work, school, social activities , or relationship with others  Symptoms are not due to a substance or a general medical  condition
Medical Disorders Associated With Depression  Hypothyroidism  Cushing’s Disease  Diabetes  Myocardial Infarction  Cerebrovascular Accident  Parkinson’s Disease, Huntington's disease, Multiple Sclerosis, Epilepsy  Cancers  Autoimmune Disorders  Nutritional Deficiencies  HIV  Chronic Pain
Substances Associated with Depression  Alcohol  CNS Depressants (e.g. Benzodiazepines)  Cocaine, Opiates, Cannabis  Anabolic Steroids (e.g. Testosterone)  Interferon  Steroids and Hormones  Cardiovascular and Antihypertensive medications  Antimicrobials and Antimalarial drugs  Phenytoin  Cimetidine
Depression Subtypes  With Anxious Distress  With Mixed Features  With Atypical Features  With Psychotic Features  With Peripartum Onset  With Seasonal Pattern
Etiology  Neurotransmitter Model  Genetic Transmission Model  Stress - Diathesis Model  Sleep Disturbance Model  Psychological Models
Epidemiology  Affects over 350 millions people worldwide (WHO)  Affects all genders, ages, and backgrounds  Prevalence  Males: 5-12%  Females: 10-25%  First degree relatives have 2 to 3 times the risk of developing depression  More prevalent in: ◦ Females (2:1) ◦ Pregnant/Postpartum women ◦ Divorced/Widowed individuals/Low income
Prevalence in KSA  KSA study (Al- Faris) 2012: ◦ Mental disorders in patients attending PHC = 30 – 46%. ◦ Men: 5 – 12% ◦ Women: 10 – 25% ( Cause ? ) ◦ The highest incidence = 25 – 34 years.
Why do we Treat Depression  WHO ranked depression as 4th disabling illness , 2nd by 2020  Depression increases risk for:  Heart attack  Stroke  Worsen diabetes  Chronic disease  Increases utilization of medical services (e.g., emergency room visits, hospitalization)  Increase risk of suicide (40-60% of completed suicide involve patients with depression)
The Global Burden of Disease  1990  Lower Respiratory  Infections  Diarrheal Diseases  Perinatal conditions  Depression  Heart Diseases  Cerebrovascular D/O  2020  Heart Diseases  Depression  Traffic accidents  Cerebrovascular D/O  COPD  Lower Respiratory  Infections
Course and Prognosis  Major cause of morbidity and disability  Risk of having another episode: ◦ ≥ 60% if one previous episode ◦ ≥ 70% if two previous episodes ◦ ≥ 90% if three previous episodes ◦ 5%-10% will go on to develop Bipolar Disorder ◦ Up to 15% of patients with severe MDD will kill themselves
History  Review Depressive symptoms  Assess suicidality  Review other psychiatric disorders (Bipolar, Psychosis)  Stressors  Past psych Hx including prior treatments and response  Medical Hx  Medications  Family Psych Hx  Social & Personal Hx  Don’t forget to ask about ETOH & drugs abuse  Current support system
Workup  CBC  Electrolytes & Renal Function  Liver Function Test  Thyroid Function Test  B12, Folate
Therapeutic Approaches Biopsychosocial  Always assess for SUICIDE  Education and support  Psychotherapies  Cognitive  Group  Grief Work  Family involvement  Medications (SSRIs, SNRIs, TCAs..)  Brain Stimulation (ECT, TMS)
Treatment Goals Treatment Reduce/Remove Signs, Symptoms Restore Role/ Function Minimize Relapse/ Recurrence Risk
Treatment  Medications: ◦ Selective serotonin reuptake inhibitors (SSRIs) ◦ Tricyclic antidepressants (TCAs) ◦ Monoamine oxidase inhibitors (MAOIs) ◦ Others: Venlafaxine, Mirtazapine, Bupropion  Psychotherapy: ◦ Cognitive Behavioral Therapy (CBT) ◦ Interpersonal Therapy (IPT)  Others: ◦ Electroconvulsive Therapy (ECT) ◦ Transcranial Magnetic Stimulation (TMS) ◦ Light Therapy – for Seasonal depression
Choice of Antidepressant?  Cost  Patient’s preference  Previous response/Family history of response  Depression Subtype  Side effects  Comorbidity (Medical/Psychiatric)  Potential for drug-drug interactions
Tricyclic antidepressants  E.g.: Amitriptyline, imipramine, amoxapine.  MOA: inhibit the re-uptake of monoamine neurotransmitter (serotonin and NE) into the presynaptic neuron  Side effects: ◦ anticholinergic (antimuscarinic ) effects  Dry mouth, blurred vision, constipation, urinary retention. ◦ Sedation as a result of histamine blockade ◦ Orthostatic hypotension due to peripheral alpha 1 blockade  Elderly ◦ Lower seizure threshold seizures can be provoked ◦ Cardiac toxicity in overdose (arrhythmias, AV block) ◦ Weight gain. Appetite stimulant due to the weight gain.
Heterocyclic Antidepressants
Tricyclic Antidepressant  All TCA are equally effective.  Two groups: sedative , less sedative.  All require 2-4 weeks for clinical improvement.
Tricyclic Antidepressant  Sedative TCA : Amitriptaline, Doxepin, Trazodone.  Less sedative TCA : Imipramine, Nortriptyline. Usual Daily Doses:  Amitriptaline ( Elavil ) 75 – 300 mg  Doxepin ( Sinequan ) 75 – 300 mg  Imipramine ( Tofranil ) 75 – 300 mg  Nortriptyline ( Pamelor ) 50 -150 mg
Selective Serotonin Reuptake Inhibitors (SSRIs)  e.g. Citalopram, Fluoxetine, Paroxetine, Sertraline  MOA: reduce serotonin reuptake ( increase synaptic serotonin concentration) with less or no effect in NE reuptake.  They have a more favorable profile of unwanted effects than TCAs because of low affinity for muscarinic, histamine and alpha 1 receptor  Pharmacokinetics ◦ Citalopram, fluoxetine, sertraline have very long half-life (range 24-80 hr)  Norfluxetine (active metabolite of fluxetin) half-life = 6 days
Selective Serotonin Reuptake Inhibitors (SSRIs)
Selective Serotonin Reuptake Inhibitors (SSRIs)  Advantage : safer in overdose, little or no anticholinergic effects, little or cardiovascular effects ◦ Less sedation ◦ Less weight gain  Side effects ◦ Decrease appetite (5HT) ◦ Nausea /vomiting ◦ Insomnia ◦ Anxiety, agitation ◦ Dry mouth and constipation with paroxetine ◦ Hyponatremia ◦ Sexual dysfunction  Drug-Drug interaction ◦ The most serious is with MAOIs ◦ Fluoxetine, fluvoxamine and paroxetine inhibit CYP450 and it can increase the plasma level of drugs metabolized by this enzyme.
Serotonin Reuptake Inhibitor (SSRI)  Usual daily doses ◦ Fluoxetine (Prozac cap) 20 -60 mg daily. ◦ Paroxetine (Seroxat tab) 20 -50 mg daily. ◦ Fluvoxamine (Faverine tab) 100- 300 mg daily. ◦ Sertraline (Lustral tab) 50 – 200 mg
Dual Serotonin and Norepinephrine Reuptake Inhibitor (SNRI)  E.g. duloxetine, venlafaxine  MOA : inhibit reuptake of serotonin and NE. At a low dose they inhibit serotonin reuptake.  Low affinity to muscarinic and histamine receptors, and alpha 1 adrenoceptor.  Weak inhibitors to CYP450 enzymes  Side effects ◦ Nausea, vomiting, constipation. ◦ Insomnia, drowsiness, dizziness, confusion. ◦ Sexual dysfunction ◦ QT segment prolongation which can predispose ventricular arrhythmias.  Venlafaxine should be avoided in people at high risk of arrhythmias.
Monoamine oxidase inhibitors (MAOI)  Rarely used for depression.  Choice after no response to other antidepressant.  Have serious side effects.  Should be reserved for use by experts.
Classic (non-selective) MAO  E.g. phenelzine  MAO: nonselective blockade  Side effects: ◦ Dose-related orthostatic hypotension ◦ CNS stimulation : irritability, insomnia (give AM) ◦ Hypertensive crisis – with tyramine containing food, pressors  Headache, stiff neck, increase BP, palpitation, sweating  Effects of drug last 14 days with irreversible agents  Interactions ◦ Sympathomimetic agents ◦ SSRIs – 5HT syndrome  Shivering, sweating, ataxia, hyperactivity, fever, high BP, disorentation ◦ Diet – avoid tyramine contacting food
Monoamine oxidase inhibitors  Two types ◦ Classic (non-selective) MAO  E.g. phenelzine ◦ Reversible inhibitors of MAO A  E.g. Moclobemide
Essential Information for Patient  Medication is NOT addictive.  Medication must be taken everyday.  Improvement will build up over 2-3 weeks after starting medication.  Mild S/E may occur but usually fade in 7-10 days.
Essential Information for Patient  Medication should NOT be discontinued without physician knowledge.  Continue full dose for at least 4-6 months after the condition improves to prevent relapse.  Withdraw gradually, preferably over 4 weeks in weekly decrements.
Treatment  Response: 50% reduction of Depressive symptoms Remission: 2/12 completely free of symptoms  Goal of Treatment: to achieve Remission  Untreated residual Symptoms:  Increase risk of relapse  More severe and chronic course of illness
Follow up Visit  Monitor with frequent contacts during initial period of acute phase therapy. First contact within 2 weeks.  Reassess at 4 – 6 weeks to include compliance with medications.  If partial response – continue treatment with frequent contacts with a goal of having 3 visits during first 12 weeks of acute phase therapy.  Continue Antidepressant therapy for 4 – 9 months.
Follow up Visit  If no response after 6 weeks or partial response after12 weeks change dose, medication, use adjunctive therapy counseling, psychotherapy, support groups.  Long term maintenance therapy for several months required in patients suffer from relapse, sever symptoms return within 6 month following remission, or pt . With H/O 3 or more episodes.
Referral:  Unconfirmed diagnosis.  Psychotic major depression.  Failure or partial response to treatment.  Substance abuse.  High suicidal risk.  Refuse medication or treatment.
Risk Factors for Treatment Failure  Inaccurate Diagnosis  Inadequate Medication Dose or Inadequate Treatment Duration  Poor Treatment Compliance  Comorbid Substance abuse  Comorbid Psychiatric conditions  Comorbid Medical conditions
SSRIs Discontinuation Syndrome  Flu-like symptoms: dizziness, vertigo, and nausea  Jolt-like bursts several times throughout the day  Occur within 1-3 days after abrupt DC of the SSRI  Most prominent with Paroxetine  Treatment: ◦ Taper the SSRI slowly or start another SSRI
Serotonin Syndrome  Caused by excessive enhancement of serotonin neurotransmission when 2 or more different serotonergic agents are combined  Triad of: ◦ Autonomic instability: fever, diaphoresis, BP instability ◦ Mental status changes: hallucinations, confusion, delirium ◦ Physical findings: tremors, myoclonus, hypertonicity, hyperreflexia
 Onset range from hours to days  Serious complications: seizures, hyperthermia, respiratory failure and death  Treatment: ◦ DC Serotonergic Agents ◦ Antipyretics ◦ Muscle relaxants ◦ Serotonin antagonist: Cyproheptadine
Electroconvulsive therapy (ECT)  Up to 80% - 90 % remission rate with 8-12 treatments; less in Tx-resistant depression  Up to 50%-80% relapse within 6 months  Side effects: transient cognitive problems, headaches, fatigue  May be first line for certain populations (e.g., medically ill, intensely suicidal, catatonic)
Bipolar Disorders
Bipolar Disorders  Bipolar I Disorder  Bipolar II Disorder  Cyclothymic Disorder  Substance/Medication – Induced Bipolar & Related Disorder  Bipolar & Related Disorder due to Medical Condition
Bipolar I Disorder  Manic Episode + Depressive Episode
Manic Episode (ME)  Mood disturbance = Abnormally and persistently elevated, expansive, or irritable mood ≥ 1 week (or less if treated)  Euphoria + ≥ 3 symptoms or irritable + ≥ 4 symptoms: ◦ § Grandiosity or inflated self-esteem ◦ § Increased Goal Directed Activity ◦ § Decreased Judgment (Impulsivity) ◦ § Distractibility ◦ § Irritability ◦ § Need for sleep decreased ◦ § Euphoria ◦ § Speedy Thoughts ◦ § Speedy Talk  Marked social/occupational impairment or require hospitalization or presence of psychotic symptoms  Not due to drugs or medical conditions
Bipolar II Disorder  Hypomania + Major Depressive Episode
Hypomanic Episode (HE)  Mood disturbance = Abnormally and persistently elevated, expansive, or irritable mood for ≥ 4 days (or less if treated)  Symptoms similar to ME, but: ◦ For 4 days ◦ No Psychosis ◦ No severe impairment ◦ No Hospitalization  Not due to drugs or medical conditions
Major Depressive Episode  5/9 symptoms (M or I is required) for two weeks ◦ M mood (depressed) ◦ S sleep disturbance ◦ I interest (loss) ◦ G guilt ◦ E energy (decreased) ◦ C concentration difficulties ◦ A appetite/weight changes ◦ P psychomotor abnormalities ◦ S suicidal ideation  Symptoms cause marked distress or impairment in social, occupational, or other important areas of functioning  Symptoms are not due to a substance or a general medical condition
Bipolar & Related Disorders  Bipolar I Disorder ◦ ≥ Manic Episode  Bipolar II Disorder ◦ ≥ Hypomanic Episode + ≥ MDE ◦ Never been a ME  Cyclothymic Disorder
Cyclothymic Disorder (Cyclothymia)  Milder form of bipolar  More chronic form
Cyclothymic Disorder (Cyclothymia):  For at least 2 years:  Numerous periods with Hypomanic sx (Not meeting HE)  Numerous periods with Depressive sx (Not meeting MDE)  Periods persisted for at least half the time and No more than 2 months w/o symptoms  No history of MDE, ME, or HE  Symptoms are not due to a substance or a general medical condition  Symptoms cause distress or impairment in social, occupational, or other important areas of functioning
Bipolar Subtypes  With Anxious Distress  With Mixed Features  With Rapid Cycling  With Atypical Features  With Psychotic Features  With Peripartum Onset  With Seasonal Pattern
Bipolar with Rapid Cycling  Rapid Cycling ◦ > 4 mood episodes/year
Bipolar Episodes
Medical Disorders Associated With Bipolar  Hyperthyroidism  Cushing’s Disease  CVA ◦ Right side lesion can cause mania ◦ Left side can cause depression  Multiple Sclerosis  CNS tumors  CNS infections (Meningitis, Neurosyphilis)  SLE  HIV
Substances Associated with Bipolar  Alcohol  Cocaine, hallucinogens  Methylphenidate ◦ ADHD  Interferon ◦ Hip. C  Ionizide ◦ TB  Digoxin ◦ HF  Glucocorticoids  Disulfiram ◦ Anti abuse
 Genetic factors  37% MDD (Sullivan et al., 2000)  93% Bipolar Disorder (Kieseppa et al., 2004)
Epidemiology  Bipolar I disorder ◦ Prevalence:1% of general population ◦ M=F  Bipolar II disorder: ◦ Prevalence: 0.3 – 2% of general population ◦ F>M (3:1)  Average age of onset in 20s
Negative Prognostic Factors  Rapid cycling pattern  Increasing frequency of bipolar episodes  Psychotic symptoms during ME  Severe index episodes  Active substance abuse  Male gender  Onset at young age
Treatment  § Consider hospitalization esp. if the patient is  experiencing manic episode  § Mood Stabilizers: ◦ § Lithium ◦ § Valproic acid (Depakene) ◦ § Carbamazapine (Tegretol) ◦ § Lamotrigine (Lamictal) for Bipolar depression ◦ § Gabapentin (Neurontin) ◦ § Topiramate (Topamax)
Treatment  Antipsychotic: ◦ Quetiapine (Seroquel) ◦ Olanzapine (Zyprexa ) ◦ Risperidone (Risperdal) ◦ Aripiprazole (Abilify) ◦ Clozapine (Clozaril)  Antidepressants: ◦ Used with mood stabilizers for Bipolar Depression  Benzodiazepines: ◦ Used during acute mania
Treatment  Electroconvulsive Therapy: ◦ Effective and rapid response ◦ Effective in both depressive and manic phases
Lithium  Effective in: ◦ Manic episode ◦ Depressive episode ◦ Maintenance  Side effects profile affects compliance to Li  Li lowers the elevated glutamate neurotransmitter  Slow effect in treating manic episode (14 days)
Lithium Side Effects  Hematological: leukocytosis, leukopenia, anemia  GI: nausea, vomiting, diarrhea, metallic taste  Endocrine: Hypothyroidism (34%), diffuse non toxic Goiter, Hyperparathyoidism  Renal: Polyuria, Polydipsia, Nephrogenic DI, Interstitial fibrosis, tubular atrophy, Glomerular sclerosis  Cardiac: bradycardia, benign T-wave changes (flattening or inversion) and QRS widening  CNS: sedation, lethargy, cognitive dullness
Lithium Toxicity  Early signs: nausea, vomiting, diarrhea, fine hand tremors  Late signs: lethargy, nystagmus, blurred vision, coarse hand tremors, increased tendon reflexes, ataxia, altered mental status, and confusion  Cardiac arrhythmia, seizures, and coma can follow  Death in 10-15% of significant toxicity  Survivors may have permanent neurological / renal damage
Treatment of Li Toxicity  DC Lithium  May require ICU admission  Cardiac monitoring  Gastric lavage/aspiration  Maintenance of hydration  Treatment of arrhythmia  Treatment of electrolyte imbalance  Hemodialysis
VERY IMPORTANT High Recurrence
. Adjustment D/O • Develops in response to a stressor (w/in 3mos) • Terminates w/in 6mos of the end of the original precipitating stressor • Clinically significant b/c: •There is marked distress out of proportion to the severity of the stressor •Or there is significant impairment
Summery
Quiz:  You have diagnosed a 30-year-old woman with depression. She is concerned that medical treatment may cause sexual dysfunction. In order to avoid sexual side-effects, which antidepressant would be the best choice?  Amitriptyline  Paroxetine  Citalopram  Sertraline  Bupropion
Quiz :  Which of the following factors associated with dysthmic disorder ? A. Substance abuse. B. Sleep disturbance. C. Mania. D. Myasthenia gravis E. Flight of idea.
Quiz:  “ atypical “ depression includes all of the following features except: A. Paralysis B. Panic attack C. Long standing pattern on interpersonal rejection D. Hypersomnia E. Anorexia
Quiz :  Which of the following statement is true regarding the diagnosis of major depressive disorder?  There is virtually always a clear precipitating factor.  Symptoms must present for 2 weeks, with a clear change baseline status.  Both a depressed mood and diminished interest in pleasurable activities are required  The individual is more likely to evidence psychomotor agitation than psychomotor retardation.  Difficulty getting to sleep is a common complaint
References  DSM-V  ICD-10  BMJ  DynaMed Plus  AAFP  American Psychiatric Association  Pocket handbook of clinical psychiatry -kaplan.  Primary care Medicine – Goroll.  Text book of Family practice – Rackel.  www.who.org  www.smj.org.sa  www.aafp.org  www.ncbi.nlm.nih.gov/PubMed  www.psych.org
 Thank you for listening  Hope you learned something or new thing

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Depressive Disorders.pdf

  • 1.
    Depressive Disorders Saleh Al-KhalidR2 Supervised By Dr. Nashwa Banani Special thanks to Dr. Ahmad Al-Saleh
  • 2.
    Outline  Approach toPatient with Depressive Symptoms  Differentiate between types of depression according to the DSM ◦ Major depression ◦ Dysthymia ◦ Bipolar ◦ Cyclothymia ◦ Adjustment ◦ Grief ◦ Acute stress disorder ◦ Post traumatic stress disorder  Each disease: Prevalence in PHC, Management  Lest Treatment Option  When to Refer to psychiatry
  • 3.
    Clinical case problem: A 28 year old man comes to the office with his wife because he has been "feeling tired” during the past 4 months. He says he always feels “run down” but also notes that he does not sleep well. He says he is able to fall asleep when he goes to bed at 10 PM ,but he wakes up at 3 AM and is unable to get back to sleep, he notes that he often has trouble with focus and concentration  he lacks the energy to finish his tasks at home. His appetite has decreased and you note a 10 pound weight loss since his last visit 6 months ago he denies fever, nausea, vomiting, or night sweat. He has no other medical problems and any other medication, his physical examination is normal
  • 4.
    What is mostlikely diagnosis ? A. adjustment disorder with depressed mood B.GAD C.MDD D. mood disorder caused by a general medical condition. E. dysthymic disorder
  • 5.
  • 6.
    Goal of PsychiatricAssessment  To make a diagnosis  To describe patient’s condition  To identify psychiatric emergencies  To find out the predisposing and primary cause of behavior  To plan an interventions
  • 7.
    Components of PsychiatricAssessment  Psychiatric History  Mental Status Examination  Physical Examination  Investigations
  • 8.
    Psychiatric History  Source& Reliability of Information  Identification Data  Chief Complaints  History of Present Illness  Past Psychiatric History  Past Medical History  Medications & Allergy  Family Psychiatric History  Personal & Social History
  • 9.
    Identification Data  Name Age  Sex  Marital Status  Children  Living Arrangement  Work
  • 10.
  • 11.
    History of PresentIllness  Onset / Duration  Depressive symptoms ◦ 5/9 symptoms (M or I is required) for two weeks  M mood (depressed)  S sleep disturbance  I interest (loss)  G guilt  E energy (decreased)  C concentration difficulties  A appetite/weight changes  P psychomotor abnormalities  S suicidal ideation
  • 12.
    History of PresentIllness  Suicide assessment  Bipolar symptoms  Psychotic symptoms  Anxiety symptoms  Recent stressors
  • 13.
    Past Psychiatric History Previous Visits to Mental Health Professionals  Previous Diagnoses  Psychiatric Hospitalizations  Suicide in the past
  • 14.
    Past Medical History Medical Diseases ◦ Epilepsy ◦ Head injury ◦ Hypothyroidism ◦ Anemia  Surgeries
  • 15.
    Medications & Allergy Psychiatric Medications  Other Medications  Over the counter medications  Herbal Remedies  Allergy
  • 16.
    Family Psychiatric History Psychiatric Illnesses in the Family  Substances in the Family  Suicide in the Family
  • 17.
    Personal & SocialHistory  Perinatal history  Place of birth  Place of upbringing  Childhood  Parents (age, job, personality, relationship)  Siblings (numbers, brothers & sisters, rank, relationship)
  • 18.
    Personal & SocialHistory  Abuse (emotional, physical, and sexual)  Educational history  Occupational history (current and past jobs)  Sexual & Marital history ◦ Spouse (age, personality, relationship) ◦ Serious relationships
  • 19.
    Personal & SocialHistory  Caffeine consumption  Cigarettes  Alcohol and street drugs use  Criminal history  Interpersonal relationship  Activity level
  • 20.
    Mental Status ExaminationComponents  Appearance  Behaviors  Attitude  Speech  Mood  Affect  Thought Process (Thought Form)  Thought Content  Perceptual Disturbance  Cognition & Sensorium  Insight and Judgment
  • 21.
    Appearance  Actual &Apparent Age  Hygiene & Grooming  Body Habitus  Physical Abnormalities  Jewelry & Cosmetic Use  Tattoo and Piercing
  • 22.
    Behaviors  Patient’s motorbehavior ◦ Restlessness ◦ Fidgety movements ◦ Psychomotor Agitation ◦ Psychomotor Retardation ◦ Compulsions, tics
  • 23.
    Attitude  Toward theexaminer ◦ Cooperative ◦ Seductive ◦ Guarded ◦ Childish  Eye contact ◦ Good eye contact (Appropriate) ◦ Limited eye contact ◦ Poor eye contact
  • 24.
    Speech  Fluent  Stuttering Tone  Rate ◦ Pressured speech ◦ Slow speech  Speech latency
  • 25.
    Mood  Mood: Subjectiveemotional state ◦ “Depressed”/”down” ◦ “Happy” ◦ “Angry” ◦ “Anxious”
  • 26.
    Affect  Affect: ObjectiveEmotional State ◦ Adequate ◦ Constricted ◦ Dramatic ◦ Blunted ◦ Flat
  • 27.
    Thought Process  Organized,goal-directed  Disorganized ◦ Circumstantiality (wander, but go back to the point) ◦ Tangentiality (wander, but doesn’t go back) ◦ Flight of Ideas (fast, connection between ideas) ◦ Loose Association (no connection between ideas) ◦ Thought Blocking (sudden stopping in speech) ◦ “Word Salad” (random intact words) ◦ Incoherent (words meaningless)
  • 28.
    Thought Content  Obsessions Overvalued Ideas  Delusions ◦ Paranoid/Persecutory ◦ Grandiose ◦ Religious ◦ Somatic  Suicidal/Homicidal Thoughts
  • 29.
    Perceptual Disturbances  Illusion:Misperception of an existing stimulus  Hallucination: Perception without real stimulus ◦ Auditory ◦ Visual ◦ Tactile ◦ Olfactory ◦ Gustatory
  • 30.
    Sensorium & Cognition Alertness / Level of Consciousness: ◦ (e.g. alert/awake, clouding of consciousness)  Orientation (Time, Place, and Person)  Concentration and Attention ◦ (Serial 7’s, Spell “WORLD” backwards)  Memory (Immediate, recent, remote)
  • 31.
    Insight and Judgment Insight: ◦ Awareness of one’s illness ◦ Awareness of one’s illness impact on self and others ◦ Acknowledgment of the need of treatment  Full Insight  Partial Insight  Impaired/No Insight
  • 32.
    Insight and Judgment Judgment: ◦ Ability to understand and communicate ideas ◦ Intact cognitive abilities ◦ Control over impulses  Intact Judgment  Limited Judgment  Impaired Judgment
  • 33.
    What is MentalIllness?  Definition of Mental Disorder (DSM-V): ◦ A health condition characterized by significant dysfunction in an individual’s cognitions, emotions, or behaviors that reflects a disturbance in the psychological, biological, or developmental processes underlying mental functioning  Include various affective, cognitive, behavioral and perceptual abnormalities
  • 34.
    Myths about MentalIllness  Mental illness only affect few people ◦ Fact: Mental illness is very common  The mentally ill are violent and dangerous ◦ Fact: Most are victims of violence, and they are more likely to harm themselves than they are to hurt other people  People with mental illness should be kept in hospital ◦ Fact: With appropriate treatment and support, they can live successfully in the community
  • 35.
    Stigmatization  Only about35% of people with diagnosable disorders seek treatment  The single most common barrier to seeking treatment is Shame  Why does stigma surround mental illness?  Stigma leads to: ◦ Discrimination ◦ Fears, mistrust, and isolation ◦ Not seeking help
  • 36.
    Classification of MentalDisorders  Mental Disorders are diagnosed based on criteria listed in Diagnostic Manuals  1. Diagnostic and Statistical Manual of Mental Disorders (DSM) ◦ Developed by the American Psychiatric Association (APA) ◦ Used in North America  2. International Classification of Diseases (ICD) ◦ Developed by the World Health Organization (WHO) ◦ Used in Europe and many parts of the world
  • 37.
    Classification of MentalIllness  Schizophrenia Spectrum & other Psychotic Disorders  Depressive Disorders  Bipolar & Related Disorders  Anxiety Disorders  Obsessive-Compulsive & Related Disorders  Trauma & Stressor Related Disorders  Dissociative Disorders  Somatic Symptom & Related Disorders  Feeding & Eating Disorders  Elimination Disorders
  • 38.
    Classification of MentalIllness  Sleep-Wake Disorders  Sexual Dysfunctions  Disruptive, Impulse-Control & Conduct Disorders  Substance-Related and Addictive Disorders  Personality Disorders  Neurocognitive Disorders  Neurodevelopmental Disorders  Paraphilic Disorders
  • 39.
    Depressive Disorders  MajorDepressive Disorder ◦ One or more Major Depressive Episode  Dysthymic Disorder (Persistent Depressive Disorder)  Premenstrual Dysphoric Disorder
  • 40.
    Bipolar Disorders  BipolarI Disorder ◦ ≥ Manic Episode  Bipolar II Disorder ◦ ≥ Hypomanic Episode + ≥ MDE  Cyclothymic Disorder
  • 41.
    Anxiety Disorders  SeparationAnxiety Disorder  Specific Phobia (Simple Phobia)  Social Anxiety Disorder (Social Phobia)  Generalized Anxiety Disorder  Panic Disorder  Agoraphobia
  • 42.
    Schizophrenia Spectrum &Other Psychotic Disorders  Brief Psychotic Disorder: ◦ Positive psychotic symptoms last from one day to one month with full return to premorbid level of functioning  Schizophreniform Disorder: ◦ Psychotic symptoms last from one month to 6 moths with full return to premorbid level of functioning  Schizophrenia: ◦ Psychotic symptoms last more than 6 months, chronic illness
  • 43.
    Schizophrenia Spectrum &Other Psychotic Disorders  Schizoaffective Disorder: ◦ Manic Episode or Major Depressive Episode together with psychotic symptoms  Delusional Disorder: ◦ One or more delusions, no prominent hallucinations, symptoms are encapsulated, no significant impairment in function, behavior is not obviously bizarre or odd
  • 44.
    Personality Disorders  ClusterA: ◦ Paranoid, Schizoid, Schizotypal  Cluster B: ◦ Antisocial, Borderline, Histrionic, Narcissistic  Cluster C: ◦ Avoidant, Dependent, Obsessive-Compulsive
  • 45.
    Violence and MentalHealth  People and Media always link mental illness to violence and criminality  100 times more likely to kill themselves than another person  Predictors of violence with mental illness: ◦ Previous violence ◦ Substance abuse ◦ Personality disorders (Antisocial and Borderline PD) ◦ Paranoid Psychosis
  • 46.
    Victimization  People withmajor mental illness are more likely to become victims of emotional and physical abuse,  WHY?  Kelly & McKenna (1997) surveyed one hundred people with mental health problems: ◦ 15 had stones thrown at windows ◦ 14 were verbally abused ◦ 5 had offensive graffiti ◦ 12 harassed outside home
  • 47.
  • 48.
    Definitions  Suicide: theact of intentionally ending one's own life  Suicide Ideation: thoughts of engaging in behavior intended to end one's life  Suicide Plan: the formulation of a specific method through which one intends to die  Suicide Attempt: engagement in potentially self- injurious behavior in which there is at least some intent to die  Non-suicidal Self-injury: self-injury in which a person has no intent to die
  • 49.
    Some Facts AboutSuicide  8th leading cause of death in USA  3rd leading cause of death in young people (15-24 years old) in USA  Takes the lives of nearly 30,000 Americans every year  Highest rate in white men over 65  50-75% seek help before suicide
  • 50.
  • 51.
    Suicide Risk Factors Psychiatric Illness ◦ 90% of suicide had psychiatric illness ◦ 15% of those who are clinically depressed eventually die by suicide ◦ Mood disorders, schizophrenia, and substance abuse ◦ Alcoholism associated with up to half of all suicides ◦ 15% of alcohol dependent patients commit suicide  Age ◦ 15-24, > 45  Sex ◦ 4 male completed suicides for every female completed suicide
  • 52.
    Suicide Risk Factors Marital Status ◦ Socially isolated (Divorced, widowed, unmarried)  Employment ◦ Unemployed  Religion ◦ Atheist have a higher risk  Physical Health ◦ Patients with chronic pain, burns, HIV, cancers  Skills and Personality Character ◦ Impulsivity, poor problem solving, and poor coping with stress
  • 53.
    SAD PERSON Scale S Sex (Male)  A Age (<20 or >44)  D Depression  P Previous Attempts  E ETOH abuse  R Rational thinking loss  S Suicide in the family / Social support lacking  O Organized plan  N No spouse, no significant other  S Sickness (Chronic, Debilitating, and Severe)
  • 54.
    Suicide Prevention  Educationand public awareness  Decrease social isolation  Identify mental illness, substance abuse, victimization, and rejection  Treatment of mental illness  Secure or remove firearms  Decrease barriers around help seeking  Mental health crisis line  Psychiatric Hospitalization
  • 55.
    Causes of MentalIllness  Biological factors  Psychological factors  Environmental/Social factors  Interaction between other factors
  • 56.
    Biological Factors  Biochemistry Genetics  Brain defect or injury  Infections  Perinatal injury  Substance abuse  Poor nutrition / Toxins
  • 57.
    Psychological Factors  Traumaticexperience  Important early loss  Learned behaviors  Attachment styles  Parenting styles  Poor coping skills  Personality traits
  • 58.
    Environmental/Social Factors  Deathor divorce  Dysfunctional family life  Social isolation  Social or cultural expectations
  • 59.
  • 60.
    Depression  It isNOT something to be ashamed of  It is NOT a sign of weakness  No one with depression can just “Snap Out of It”  Depression is an illness that involves thoughts, mood, and the body  It impacts the way a person functions socially, academically, and at work
  • 61.
    Major Depressive Disorder(MDD)  Unipolar Depression  Single or Recurrent  Symptoms cause marked distress or impairment in social, occupational, or other important areas of functioning.  Symptoms are not due to a substance or a general medical condition  NO Hx. of mania, or hypomania
  • 62.
    5/9 symptoms (Mor I is required) for two weeks  M mood (depressed)  S sleep disturbance  I interest (loss)  G guilt  E energy (decreased)  C concentration difficulties  A appetite/weight changes  P psychomotor abnormalities  S suicidal ideation
  • 63.
    Persistent Depressive Disorder (Dysthymia) For at least 2 years, presence of Depressed mood +  2/6 for most of the day, more days than not ◦ A Appetite change (Increased or decreased) ◦ C Concentration difficulties ◦ H Hopelessness ◦ E Energy (low) ◦ S Sleep disturbance (Insomnia or Hypersomnia) ◦ S Self esteem (low)  No more than 2 months w/o symptoms
  • 64.
    Premenstrual Dysphoric Disorder(PMDD)  5 symptoms present in the final week before the onset of menses, and improve after the onset of menses in the majority of menstrual cycles  ≥ 1 of 4: ◦ Marked affective liability ◦ Marked irritability ◦ Marked depressed mood, or feeling hopelessness ◦ Marked anxiety  Plus
  • 65.
    Premenstrual Dysphoric Disorder ≥ 1 of 7: ◦ Interest (decreased) ◦ Concentration difficulties ◦ Energy (Marked decreased) ◦ Appetite change (Marked increased or decreased) ◦ Sleep disturbance (Insomnia or Hypersomnia) ◦ Sense of being overwhelmed or out of control ◦ Physical sx. (breast tenderness, joint or muscle pain, bloating)  Symptoms cause significant distress or interference with work, school, social activities , or relationship with others  Symptoms are not due to a substance or a general medical  condition
  • 66.
    Medical Disorders Associated WithDepression  Hypothyroidism  Cushing’s Disease  Diabetes  Myocardial Infarction  Cerebrovascular Accident  Parkinson’s Disease, Huntington's disease, Multiple Sclerosis, Epilepsy  Cancers  Autoimmune Disorders  Nutritional Deficiencies  HIV  Chronic Pain
  • 67.
    Substances Associated with Depression Alcohol  CNS Depressants (e.g. Benzodiazepines)  Cocaine, Opiates, Cannabis  Anabolic Steroids (e.g. Testosterone)  Interferon  Steroids and Hormones  Cardiovascular and Antihypertensive medications  Antimicrobials and Antimalarial drugs  Phenytoin  Cimetidine
  • 68.
    Depression Subtypes  WithAnxious Distress  With Mixed Features  With Atypical Features  With Psychotic Features  With Peripartum Onset  With Seasonal Pattern
  • 69.
    Etiology  Neurotransmitter Model Genetic Transmission Model  Stress - Diathesis Model  Sleep Disturbance Model  Psychological Models
  • 70.
    Epidemiology  Affects over350 millions people worldwide (WHO)  Affects all genders, ages, and backgrounds  Prevalence  Males: 5-12%  Females: 10-25%  First degree relatives have 2 to 3 times the risk of developing depression  More prevalent in: ◦ Females (2:1) ◦ Pregnant/Postpartum women ◦ Divorced/Widowed individuals/Low income
  • 71.
    Prevalence in KSA KSA study (Al- Faris) 2012: ◦ Mental disorders in patients attending PHC = 30 – 46%. ◦ Men: 5 – 12% ◦ Women: 10 – 25% ( Cause ? ) ◦ The highest incidence = 25 – 34 years.
  • 72.
    Why do weTreat Depression  WHO ranked depression as 4th disabling illness , 2nd by 2020  Depression increases risk for:  Heart attack  Stroke  Worsen diabetes  Chronic disease  Increases utilization of medical services (e.g., emergency room visits, hospitalization)  Increase risk of suicide (40-60% of completed suicide involve patients with depression)
  • 73.
    The Global Burdenof Disease  1990  Lower Respiratory  Infections  Diarrheal Diseases  Perinatal conditions  Depression  Heart Diseases  Cerebrovascular D/O  2020  Heart Diseases  Depression  Traffic accidents  Cerebrovascular D/O  COPD  Lower Respiratory  Infections
  • 74.
    Course and Prognosis Major cause of morbidity and disability  Risk of having another episode: ◦ ≥ 60% if one previous episode ◦ ≥ 70% if two previous episodes ◦ ≥ 90% if three previous episodes ◦ 5%-10% will go on to develop Bipolar Disorder ◦ Up to 15% of patients with severe MDD will kill themselves
  • 75.
    History  Review Depressivesymptoms  Assess suicidality  Review other psychiatric disorders (Bipolar, Psychosis)  Stressors  Past psych Hx including prior treatments and response  Medical Hx  Medications  Family Psych Hx  Social & Personal Hx  Don’t forget to ask about ETOH & drugs abuse  Current support system
  • 76.
    Workup  CBC  Electrolytes& Renal Function  Liver Function Test  Thyroid Function Test  B12, Folate
  • 77.
    Therapeutic Approaches Biopsychosocial  Alwaysassess for SUICIDE  Education and support  Psychotherapies  Cognitive  Group  Grief Work  Family involvement  Medications (SSRIs, SNRIs, TCAs..)  Brain Stimulation (ECT, TMS)
  • 78.
    Treatment Goals Treatment Reduce/Remove Signs, Symptoms RestoreRole/ Function Minimize Relapse/ Recurrence Risk
  • 79.
    Treatment  Medications: ◦ Selectiveserotonin reuptake inhibitors (SSRIs) ◦ Tricyclic antidepressants (TCAs) ◦ Monoamine oxidase inhibitors (MAOIs) ◦ Others: Venlafaxine, Mirtazapine, Bupropion  Psychotherapy: ◦ Cognitive Behavioral Therapy (CBT) ◦ Interpersonal Therapy (IPT)  Others: ◦ Electroconvulsive Therapy (ECT) ◦ Transcranial Magnetic Stimulation (TMS) ◦ Light Therapy – for Seasonal depression
  • 80.
    Choice of Antidepressant? Cost  Patient’s preference  Previous response/Family history of response  Depression Subtype  Side effects  Comorbidity (Medical/Psychiatric)  Potential for drug-drug interactions
  • 81.
    Tricyclic antidepressants  E.g.:Amitriptyline, imipramine, amoxapine.  MOA: inhibit the re-uptake of monoamine neurotransmitter (serotonin and NE) into the presynaptic neuron  Side effects: ◦ anticholinergic (antimuscarinic ) effects  Dry mouth, blurred vision, constipation, urinary retention. ◦ Sedation as a result of histamine blockade ◦ Orthostatic hypotension due to peripheral alpha 1 blockade  Elderly ◦ Lower seizure threshold seizures can be provoked ◦ Cardiac toxicity in overdose (arrhythmias, AV block) ◦ Weight gain. Appetite stimulant due to the weight gain.
  • 82.
  • 83.
    Tricyclic Antidepressant  AllTCA are equally effective.  Two groups: sedative , less sedative.  All require 2-4 weeks for clinical improvement.
  • 84.
    Tricyclic Antidepressant  SedativeTCA : Amitriptaline, Doxepin, Trazodone.  Less sedative TCA : Imipramine, Nortriptyline. Usual Daily Doses:  Amitriptaline ( Elavil ) 75 – 300 mg  Doxepin ( Sinequan ) 75 – 300 mg  Imipramine ( Tofranil ) 75 – 300 mg  Nortriptyline ( Pamelor ) 50 -150 mg
  • 85.
    Selective Serotonin ReuptakeInhibitors (SSRIs)  e.g. Citalopram, Fluoxetine, Paroxetine, Sertraline  MOA: reduce serotonin reuptake ( increase synaptic serotonin concentration) with less or no effect in NE reuptake.  They have a more favorable profile of unwanted effects than TCAs because of low affinity for muscarinic, histamine and alpha 1 receptor  Pharmacokinetics ◦ Citalopram, fluoxetine, sertraline have very long half-life (range 24-80 hr)  Norfluxetine (active metabolite of fluxetin) half-life = 6 days
  • 86.
    Selective Serotonin ReuptakeInhibitors (SSRIs)
  • 87.
    Selective Serotonin ReuptakeInhibitors (SSRIs)  Advantage : safer in overdose, little or no anticholinergic effects, little or cardiovascular effects ◦ Less sedation ◦ Less weight gain  Side effects ◦ Decrease appetite (5HT) ◦ Nausea /vomiting ◦ Insomnia ◦ Anxiety, agitation ◦ Dry mouth and constipation with paroxetine ◦ Hyponatremia ◦ Sexual dysfunction  Drug-Drug interaction ◦ The most serious is with MAOIs ◦ Fluoxetine, fluvoxamine and paroxetine inhibit CYP450 and it can increase the plasma level of drugs metabolized by this enzyme.
  • 88.
    Serotonin Reuptake Inhibitor(SSRI)  Usual daily doses ◦ Fluoxetine (Prozac cap) 20 -60 mg daily. ◦ Paroxetine (Seroxat tab) 20 -50 mg daily. ◦ Fluvoxamine (Faverine tab) 100- 300 mg daily. ◦ Sertraline (Lustral tab) 50 – 200 mg
  • 89.
    Dual Serotonin andNorepinephrine Reuptake Inhibitor (SNRI)  E.g. duloxetine, venlafaxine  MOA : inhibit reuptake of serotonin and NE. At a low dose they inhibit serotonin reuptake.  Low affinity to muscarinic and histamine receptors, and alpha 1 adrenoceptor.  Weak inhibitors to CYP450 enzymes  Side effects ◦ Nausea, vomiting, constipation. ◦ Insomnia, drowsiness, dizziness, confusion. ◦ Sexual dysfunction ◦ QT segment prolongation which can predispose ventricular arrhythmias.  Venlafaxine should be avoided in people at high risk of arrhythmias.
  • 90.
    Monoamine oxidase inhibitors (MAOI) Rarely used for depression.  Choice after no response to other antidepressant.  Have serious side effects.  Should be reserved for use by experts.
  • 91.
    Classic (non-selective) MAO E.g. phenelzine  MAO: nonselective blockade  Side effects: ◦ Dose-related orthostatic hypotension ◦ CNS stimulation : irritability, insomnia (give AM) ◦ Hypertensive crisis – with tyramine containing food, pressors  Headache, stiff neck, increase BP, palpitation, sweating  Effects of drug last 14 days with irreversible agents  Interactions ◦ Sympathomimetic agents ◦ SSRIs – 5HT syndrome  Shivering, sweating, ataxia, hyperactivity, fever, high BP, disorentation ◦ Diet – avoid tyramine contacting food
  • 92.
    Monoamine oxidase inhibitors Two types ◦ Classic (non-selective) MAO  E.g. phenelzine ◦ Reversible inhibitors of MAO A  E.g. Moclobemide
  • 93.
    Essential Information forPatient  Medication is NOT addictive.  Medication must be taken everyday.  Improvement will build up over 2-3 weeks after starting medication.  Mild S/E may occur but usually fade in 7-10 days.
  • 94.
    Essential Information forPatient  Medication should NOT be discontinued without physician knowledge.  Continue full dose for at least 4-6 months after the condition improves to prevent relapse.  Withdraw gradually, preferably over 4 weeks in weekly decrements.
  • 95.
    Treatment  Response: 50%reduction of Depressive symptoms Remission: 2/12 completely free of symptoms  Goal of Treatment: to achieve Remission  Untreated residual Symptoms:  Increase risk of relapse  More severe and chronic course of illness
  • 96.
    Follow up Visit Monitor with frequent contacts during initial period of acute phase therapy. First contact within 2 weeks.  Reassess at 4 – 6 weeks to include compliance with medications.  If partial response – continue treatment with frequent contacts with a goal of having 3 visits during first 12 weeks of acute phase therapy.  Continue Antidepressant therapy for 4 – 9 months.
  • 97.
    Follow up Visit If no response after 6 weeks or partial response after12 weeks change dose, medication, use adjunctive therapy counseling, psychotherapy, support groups.  Long term maintenance therapy for several months required in patients suffer from relapse, sever symptoms return within 6 month following remission, or pt . With H/O 3 or more episodes.
  • 98.
    Referral:  Unconfirmed diagnosis. Psychotic major depression.  Failure or partial response to treatment.  Substance abuse.  High suicidal risk.  Refuse medication or treatment.
  • 99.
    Risk Factors forTreatment Failure  Inaccurate Diagnosis  Inadequate Medication Dose or Inadequate Treatment Duration  Poor Treatment Compliance  Comorbid Substance abuse  Comorbid Psychiatric conditions  Comorbid Medical conditions
  • 100.
    SSRIs Discontinuation Syndrome Flu-like symptoms: dizziness, vertigo, and nausea  Jolt-like bursts several times throughout the day  Occur within 1-3 days after abrupt DC of the SSRI  Most prominent with Paroxetine  Treatment: ◦ Taper the SSRI slowly or start another SSRI
  • 101.
    Serotonin Syndrome  Causedby excessive enhancement of serotonin neurotransmission when 2 or more different serotonergic agents are combined  Triad of: ◦ Autonomic instability: fever, diaphoresis, BP instability ◦ Mental status changes: hallucinations, confusion, delirium ◦ Physical findings: tremors, myoclonus, hypertonicity, hyperreflexia
  • 102.
     Onset rangefrom hours to days  Serious complications: seizures, hyperthermia, respiratory failure and death  Treatment: ◦ DC Serotonergic Agents ◦ Antipyretics ◦ Muscle relaxants ◦ Serotonin antagonist: Cyproheptadine
  • 103.
    Electroconvulsive therapy (ECT) Up to 80% - 90 % remission rate with 8-12 treatments; less in Tx-resistant depression  Up to 50%-80% relapse within 6 months  Side effects: transient cognitive problems, headaches, fatigue  May be first line for certain populations (e.g., medically ill, intensely suicidal, catatonic)
  • 104.
  • 105.
    Bipolar Disorders  BipolarI Disorder  Bipolar II Disorder  Cyclothymic Disorder  Substance/Medication – Induced Bipolar & Related Disorder  Bipolar & Related Disorder due to Medical Condition
  • 106.
    Bipolar I Disorder Manic Episode + Depressive Episode
  • 107.
    Manic Episode (ME) Mood disturbance = Abnormally and persistently elevated, expansive, or irritable mood ≥ 1 week (or less if treated)  Euphoria + ≥ 3 symptoms or irritable + ≥ 4 symptoms: ◦ § Grandiosity or inflated self-esteem ◦ § Increased Goal Directed Activity ◦ § Decreased Judgment (Impulsivity) ◦ § Distractibility ◦ § Irritability ◦ § Need for sleep decreased ◦ § Euphoria ◦ § Speedy Thoughts ◦ § Speedy Talk  Marked social/occupational impairment or require hospitalization or presence of psychotic symptoms  Not due to drugs or medical conditions
  • 108.
    Bipolar II Disorder Hypomania + Major Depressive Episode
  • 109.
    Hypomanic Episode (HE) Mood disturbance = Abnormally and persistently elevated, expansive, or irritable mood for ≥ 4 days (or less if treated)  Symptoms similar to ME, but: ◦ For 4 days ◦ No Psychosis ◦ No severe impairment ◦ No Hospitalization  Not due to drugs or medical conditions
  • 110.
    Major Depressive Episode 5/9 symptoms (M or I is required) for two weeks ◦ M mood (depressed) ◦ S sleep disturbance ◦ I interest (loss) ◦ G guilt ◦ E energy (decreased) ◦ C concentration difficulties ◦ A appetite/weight changes ◦ P psychomotor abnormalities ◦ S suicidal ideation  Symptoms cause marked distress or impairment in social, occupational, or other important areas of functioning  Symptoms are not due to a substance or a general medical condition
  • 111.
    Bipolar & RelatedDisorders  Bipolar I Disorder ◦ ≥ Manic Episode  Bipolar II Disorder ◦ ≥ Hypomanic Episode + ≥ MDE ◦ Never been a ME  Cyclothymic Disorder
  • 112.
    Cyclothymic Disorder (Cyclothymia) Milder form of bipolar  More chronic form
  • 113.
    Cyclothymic Disorder (Cyclothymia): For at least 2 years:  Numerous periods with Hypomanic sx (Not meeting HE)  Numerous periods with Depressive sx (Not meeting MDE)  Periods persisted for at least half the time and No more than 2 months w/o symptoms  No history of MDE, ME, or HE  Symptoms are not due to a substance or a general medical condition  Symptoms cause distress or impairment in social, occupational, or other important areas of functioning
  • 114.
    Bipolar Subtypes  WithAnxious Distress  With Mixed Features  With Rapid Cycling  With Atypical Features  With Psychotic Features  With Peripartum Onset  With Seasonal Pattern
  • 115.
    Bipolar with RapidCycling  Rapid Cycling ◦ > 4 mood episodes/year
  • 116.
  • 119.
    Medical Disorders Associated WithBipolar  Hyperthyroidism  Cushing’s Disease  CVA ◦ Right side lesion can cause mania ◦ Left side can cause depression  Multiple Sclerosis  CNS tumors  CNS infections (Meningitis, Neurosyphilis)  SLE  HIV
  • 120.
    Substances Associated with Bipolar Alcohol  Cocaine, hallucinogens  Methylphenidate ◦ ADHD  Interferon ◦ Hip. C  Ionizide ◦ TB  Digoxin ◦ HF  Glucocorticoids  Disulfiram ◦ Anti abuse
  • 121.
     Genetic factors 37% MDD (Sullivan et al., 2000)  93% Bipolar Disorder (Kieseppa et al., 2004)
  • 122.
    Epidemiology  Bipolar Idisorder ◦ Prevalence:1% of general population ◦ M=F  Bipolar II disorder: ◦ Prevalence: 0.3 – 2% of general population ◦ F>M (3:1)  Average age of onset in 20s
  • 123.
    Negative Prognostic Factors Rapid cycling pattern  Increasing frequency of bipolar episodes  Psychotic symptoms during ME  Severe index episodes  Active substance abuse  Male gender  Onset at young age
  • 124.
    Treatment  § Considerhospitalization esp. if the patient is  experiencing manic episode  § Mood Stabilizers: ◦ § Lithium ◦ § Valproic acid (Depakene) ◦ § Carbamazapine (Tegretol) ◦ § Lamotrigine (Lamictal) for Bipolar depression ◦ § Gabapentin (Neurontin) ◦ § Topiramate (Topamax)
  • 125.
    Treatment  Antipsychotic: ◦ Quetiapine(Seroquel) ◦ Olanzapine (Zyprexa ) ◦ Risperidone (Risperdal) ◦ Aripiprazole (Abilify) ◦ Clozapine (Clozaril)  Antidepressants: ◦ Used with mood stabilizers for Bipolar Depression  Benzodiazepines: ◦ Used during acute mania
  • 126.
    Treatment  Electroconvulsive Therapy: ◦Effective and rapid response ◦ Effective in both depressive and manic phases
  • 127.
    Lithium  Effective in: ◦Manic episode ◦ Depressive episode ◦ Maintenance  Side effects profile affects compliance to Li  Li lowers the elevated glutamate neurotransmitter  Slow effect in treating manic episode (14 days)
  • 128.
    Lithium Side Effects Hematological: leukocytosis, leukopenia, anemia  GI: nausea, vomiting, diarrhea, metallic taste  Endocrine: Hypothyroidism (34%), diffuse non toxic Goiter, Hyperparathyoidism  Renal: Polyuria, Polydipsia, Nephrogenic DI, Interstitial fibrosis, tubular atrophy, Glomerular sclerosis  Cardiac: bradycardia, benign T-wave changes (flattening or inversion) and QRS widening  CNS: sedation, lethargy, cognitive dullness
  • 129.
    Lithium Toxicity  Earlysigns: nausea, vomiting, diarrhea, fine hand tremors  Late signs: lethargy, nystagmus, blurred vision, coarse hand tremors, increased tendon reflexes, ataxia, altered mental status, and confusion  Cardiac arrhythmia, seizures, and coma can follow  Death in 10-15% of significant toxicity  Survivors may have permanent neurological / renal damage
  • 130.
    Treatment of LiToxicity  DC Lithium  May require ICU admission  Cardiac monitoring  Gastric lavage/aspiration  Maintenance of hydration  Treatment of arrhythmia  Treatment of electrolyte imbalance  Hemodialysis
  • 131.
  • 132.
    . Adjustment D/O •Develops in response to a stressor (w/in 3mos) • Terminates w/in 6mos of the end of the original precipitating stressor • Clinically significant b/c: •There is marked distress out of proportion to the severity of the stressor •Or there is significant impairment
  • 133.
  • 134.
    Quiz:  You havediagnosed a 30-year-old woman with depression. She is concerned that medical treatment may cause sexual dysfunction. In order to avoid sexual side-effects, which antidepressant would be the best choice?  Amitriptyline  Paroxetine  Citalopram  Sertraline  Bupropion
  • 135.
    Quiz :  Whichof the following factors associated with dysthmic disorder ? A. Substance abuse. B. Sleep disturbance. C. Mania. D. Myasthenia gravis E. Flight of idea.
  • 136.
    Quiz:  “ atypical“ depression includes all of the following features except: A. Paralysis B. Panic attack C. Long standing pattern on interpersonal rejection D. Hypersomnia E. Anorexia
  • 137.
    Quiz :  Whichof the following statement is true regarding the diagnosis of major depressive disorder?  There is virtually always a clear precipitating factor.  Symptoms must present for 2 weeks, with a clear change baseline status.  Both a depressed mood and diminished interest in pleasurable activities are required  The individual is more likely to evidence psychomotor agitation than psychomotor retardation.  Difficulty getting to sleep is a common complaint
  • 138.
    References  DSM-V  ICD-10 BMJ  DynaMed Plus  AAFP  American Psychiatric Association  Pocket handbook of clinical psychiatry -kaplan.  Primary care Medicine – Goroll.  Text book of Family practice – Rackel.  www.who.org  www.smj.org.sa  www.aafp.org  www.ncbi.nlm.nih.gov/PubMed  www.psych.org
  • 139.
     Thank youfor listening  Hope you learned something or new thing