Depression, depressive Disorder, psychiatry assessment

1. Depressive Disorders
Saleh Al-Khalid R2
Supervised By Dr. Nashwa Banani
Special thanks to Dr. Ahmad Al-Saleh

2. 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

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 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

5. Interviewing Psychiatric Patients
in PHC

6. 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

7. Components of Psychiatric Assessment
 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. Chief Complaint

11. 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

12. History of Present Illness
 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 & Social History
 Perinatal history
 Place of birth
 Place of upbringing
 Childhood
 Parents (age, job, personality, relationship)
 Siblings (numbers, brothers & sisters, rank,
relationship)

18. 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

19. Personal & Social History
 Caffeine consumption
 Cigarettes
 Alcohol and street drugs use
 Criminal history
 Interpersonal relationship
 Activity level

20. Mental Status Examination Components
 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 motor behavior
◦ Restlessness
◦ Fidgety movements
◦ Psychomotor Agitation
◦ Psychomotor Retardation
◦ Compulsions, tics

23. Attitude
 Toward the examiner
◦ 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: Subjective emotional state
◦ “Depressed”/”down”
◦ “Happy”
◦ “Angry”
◦ “Anxious”

26. Affect
 Affect: Objective Emotional 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 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. Depressive Disorders
 Major Depressive Disorder
◦ One or more Major Depressive Episode
 Dysthymic Disorder (Persistent Depressive
Disorder)
 Premenstrual Dysphoric Disorder

40. Bipolar Disorders
 Bipolar I Disorder
◦ ≥ Manic Episode
 Bipolar II Disorder
◦ ≥ Hypomanic Episode + ≥ MDE
 Cyclothymic Disorder

41. Anxiety Disorders
 Separation Anxiety 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
 Cluster A:
◦ Paranoid, Schizoid, Schizotypal
 Cluster B:
◦ Antisocial, Borderline, Histrionic, Narcissistic
 Cluster C:
◦ Avoidant, Dependent, Obsessive-Compulsive

45. 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

46. 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

47. Suicide

48. 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

49. 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

50. Global Suicide Rates (2008)

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
 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

55. Causes of Mental Illness
 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
 Traumatic experience
 Important early loss
 Learned behaviors
 Attachment styles
 Parenting styles
 Poor coping skills
 Personality traits

58. Environmental/Social Factors
 Death or divorce
 Dysfunctional family life
 Social isolation
 Social or cultural expectations

59. Depressive Disorders

60. 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

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 (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

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
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

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
 With Anxious 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 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

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 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)

73. 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

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 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

76. Workup
 CBC
 Electrolytes & Renal Function
 Liver Function Test
 Thyroid Function Test
 B12, Folate

77. 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)

78. Treatment Goals
Treatment
Reduce/Remove
Signs, Symptoms
Restore Role/
Function
Minimize
Relapse/
Recurrence Risk

79. 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

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. Heterocyclic Antidepressants

83. Tricyclic Antidepressant
 All TCA are equally effective.
 Two groups: sedative , less sedative.
 All require 2-4 weeks for clinical improvement.

84. 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

85. 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

86. Selective Serotonin Reuptake Inhibitors
(SSRIs)

87. 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.

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 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.

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 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.

94. 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.

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 for Treatment
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
 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

102.  Onset range from 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. Bipolar Disorders

105. Bipolar Disorders
 Bipolar I 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 & Related Disorders
 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
 With Anxious Distress
 With Mixed Features
 With Rapid Cycling
 With Atypical Features
 With Psychotic Features
 With Peripartum Onset
 With Seasonal Pattern

115. Bipolar with Rapid Cycling
 Rapid Cycling
◦ > 4 mood episodes/year

116. Bipolar Episodes

119. 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

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 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

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
 § 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)

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
 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

130. 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

131. VERY IMPORTANT
High Recurrence

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. Summery

134. 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

135. 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.

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 :
 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

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 you for listening
 Hope you learned something or new thing