Depression Dr. Mohammad Hussein October 2017

1. ‫د‬
.
‫حسين‬ ‫محمد‬
#
‫هاحكي‬
_
‫عن‬
_
‫اإلكتئاب‬
Mohammed
Hussein
consultant
psychiatrist

2. ‫أجندة‬
importance
‫؟‬
What is
depression?
Their words
Clinical
pictures
Etiology
Differential
diagnosis
Management
Epidemiology

3. Importance‫؟‬

4. Importance
Lifetime
rates
10-20%
Depression is among the
most treatable of
psychiatric illnesses.
2 and 9 %
attempt
suicide
They rank fourth as
causes of disability
worldwide
Depression is a serious condition. It’s also, unfortunately, a common one

5. from their words ‫أقوالهم‬‫من‬

6. 
‫بالخنقة‬ ‫شديد‬ ‫إحساس‬ ‫عندي‬

‫هدومي‬ ‫أغير‬ ‫عايز‬ ‫مش‬

‫جدا‬ ‫شديد‬ ‫نفس‬ ‫لوم‬ ‫عندي‬

‫عبادة‬ ‫ضيعت‬ ‫إني‬ ‫حاسس‬
10
‫سنين‬

‫قرار‬ ‫أي‬ ‫آخد‬ ‫بطلت‬

‫بنام‬ ‫مش‬
...
‫نايم‬ ‫مش‬ ‫كأني‬ ‫نمت‬ ‫ولو‬

‫باكل‬ ‫مش‬ ‫تقريبا‬

‫جنبها‬ ‫مجتش‬ ‫سنة‬ ‫بقالي‬ ‫زوجتي‬

‫الشغل‬ ‫في‬ ‫منتظمة‬ ‫مش‬

‫خالص‬ ‫نوم‬ ‫مفيش‬

‫وال‬ ‫بيه‬ ‫حاسس‬ ‫ومحدش‬ ‫ضدي‬ ‫أسرتي‬
‫بيلوموني‬ ‫بل‬ ‫بيساعدني‬

‫األصدقاء‬ ‫مع‬ ‫دلوقتي‬ ‫تواصل‬ ‫مفيش‬

‫بايظة‬ ‫الشخصية‬ ‫حياتي‬

‫متفائل‬ ‫البلد‬ ‫في‬ ‫محدش‬

‫جديد‬ ‫ال‬
...
‫جدي‬ ‫فيه‬ ‫هيكون‬ ‫مش‬ ‫إن‬ ‫عارفة‬ ‫أنا‬
‫د‬

‫مفيدة‬ ‫مش‬ ‫إني‬ ‫حاسة‬

‫خالص‬ ‫الموت‬ ‫إن‬ ‫حاسة‬

‫دلوقتي‬ ‫وبفكر‬ ‫كده‬ ‫قبل‬ ‫أنتحر‬ ‫حاولت‬

‫الدنيا‬ ‫في‬ ‫الزمة‬ ‫ماليش‬

‫بيكلمني‬ ‫ودني‬ ‫في‬ ‫صوت‬ ‫فيه‬

‫كتير‬ ‫نوم‬

‫جامد‬ ‫كسل‬

‫علطول‬ ‫خنقة‬

‫نفسي‬ ‫في‬ ‫خالص‬ ‫ثقة‬ ‫مفيش‬

7. What is depression?

8. What is depression?
at least one of these,
 most days,
 most of the time
 for at least 2 weeks
 persistent sadness or low
mood;and/or
 loss of interests or pleasure
 fatigue or low energy
associated symptoms:
disturbed sleep
poor concentration or
indecisiveness
low self-confidence
poor or increased appetite
suicidal thoughts or acts
agitation or slowing of
movements
guilt or self-blame
No
Depression
Less than
4 symptoms
Mild
Depression
4 symptoms
moderate
Depression
5-6
symptoms
Severe
Depression
5-6
symptoms
3 Core symptoms

9. What is depression?

10. What is depression?
Major depression

11. What is depression?
Dysthymia.

12. What is depression?
Double depression

13. What is depression?
Major depression

14. What is depression?
Bipolar II

15. Epidemiology

16. Epidemiology
Descriptive epidemiology
 Lifetime rates: 10-20%
 Sex ratio male : female = 1:2.
 Age of onset : 24-44
 No sex difference
 No socioeconomic difference (urban
vs rural - rich vs poor differences)
Analytical epidemiology

17. Epidemiology
Analytical epidemiology
 Genetic :
heritability estimates 17 to 75% (mean 37%)
 Childhood experiences:
loss of a parent, lack of parental care, parental
alcoholism/antisocial traits, childhood sexual abuse.
 Social circumstances:
• Marital status : low rates associated with
marriage,
high rates with separation or divorce
• Adverse life events—particularly ‘loss’ events
(increased risk 2–3mths after event) in vulnerable
individuals.
 Personality traits:
anxiety, impulsivity, obsessionality
 Physical illness:
 chronic, severe, or painful.
 Neurological disorders (e.g. Parkinson’s
disease, MS, stroke, epilepsy) have
higher risk.
 Higher rates also noted in post-MI,
diabetic,
 cancer patients,
“Risk Factors”

18. Clinical pictures

19. Clinical pictures
MOOD SYMPTOMS COGNTIVE SYMPTOMS
BEHAVIORAL SYMPTOMS VEGITATIVE SYMPTOMS

20. MOOD SYMPTOMS
.
COGNTIVE SYMPTOMS
 Low mood
 loss of interest or pleasure (anhedonia)
 Hopelessness
 Guilt
 Moodiness
 Angry outbursts
 Loss of interest in friends, family and favorite
activities,
 Patients may describe a depressed mood in a
number of ways, such as feeling sad, dejected,
despondent,
 miserable, ‘low in spirits’ or ‘heavy-hearted’.
 out of this mood and its severity is often out of
proportion to the stressors in their surrounding
social environment.
 Reduced concentration
 Impaired memory
 Poor self-esteem
 Guilt
 Hopelessness
 Death wishes
 Suicide or self-harm

21. .
VEGITATIVE SYMPTOMS
 Psychomotor retardation or agitation
Withdrawing from people
 Substance abuse
 Missing work, school or other commitments
 Attempts to harm yourself
 Biological (somatic) symptoms
 Disturbed sleep ( ↓↑ )
 Early morning wakening
 Disturbed appetite ( ↓↑ )
 weight loss
 Depression worse in the morning
 Decreased sexual desire
 Psychomotor retardation or agitation
easy fatigability
 pain
BEHAVIORAL SYMPTOMS
Psychotic symptoms

22. Etiology of Depression

23. Etiology of Depression
The biopsychosocial
model
of depression

24. Etiology of Depression
Biological causes “Monoamine Theory”

25. Etiology of Depression
Biological causes

26. Etiology of Depression
Cognitive theory
Beck's cognitive
model of
depression

27. Etiology of Depression
Cognitive theory Cognitive Distortions

‫التهويل‬

‫التهوين‬

‫التعميم‬

‫ال‬ ‫أو‬ ‫الكل‬
‫شي‬

‫عن‬ ‫األشياء‬ ‫عزل‬
‫سياقه‬

‫إلى‬ ‫القفز‬
‫االستنتاجات‬

‫لألمو‬ ‫الشخصي‬ ‫التأويل‬
‫ر‬
 Polarized Thinking (or “Black and White” Thinking)
 Overgeneralization
 Jumping to Conclusions
 Catastrophizing
 Personalization

28. Differential diagnosis of depression

29. • Other psychiatric disorders:
– dysthymia, stress-related disorders
– (adjustment disorders/bereavement, PTSD),
bipolar disorder,
– anxiety disorders (OCD, panic disorder, phobias),
eating disorders,
– schizoaffective disorders, schizophrenia (negative
symptoms),
– personality disorders (esp. borderline personality disorder
[BPD]).
• • Neurological disorders:
– dementia, Parkinson’s disease, Huntington’s
– disease, MS, stroke, epilepsy, tumours, head injury.
• • Endocrine disorders:
– Addison’s disease, Cushing’s disease,
– hyper/hypothyroidism,
– perimenstrual syndromes, menopausal symptoms,
– prolactinoma, hyperparathyroidism, hypopituitarism.
• • Metabolic disorders:
– hypoglycaemia, hypercalcaemia, porphyria.
Differential diagnosis of depression
• Haematological disorders: anaemia.
• Infl ammatory conditions: SLE.
• Infections: syphilis, Lyme disease, and HIV encephalopathy.
• Sleep disorders: esp. sleep apnoea.
• Medication-related:
– antihypertensives (beta-blockers, reserpine,methyldopa,
and calcium channel blockers);
– steroids;
– H2 blockers(e.g., ranitidine, cimetidine);
– sedatives;
– muscle relaxants;
– chemotherapy agents (e.g. vincristine, procarbazine, L-
asparaginase,
– interferon,amphotericin B, vinblastine);
– medications that affect sex hormones (oestrogen, progesterone,
testosterone, gonadotrophin-releasing hormone [GnRH]
antagonists); cholesterol-lowering agents;
– psychiatric medication (esp. antipsychotics)
• Substance misuse: alcohol, BDZs, opiates, marijuana, cocaine,
• amfetamines, and derivatives.

30. Suicide Assessment

31. Suicide Assessment
Suicide
ideation
plan
plan can
be
achieved
Previous
attempts
Family
history

33. Management of Depression
When? Where? Who? What?

34. When?
 Short term therapy
 Long term therapy
Where?
 Inpatient
 outpatient
Who?
 Psychiatrist
 Psychologist
 Social worker
What?
 Pharmacotherapy
 Psychotherapy
 ECT
Management of Depression

35. Psychotherapy

36. Cognitive
behavioral
therapy (CBT)
How to deal with stress?
Management of Depression
Psychotherapy
Self assertiveness
Interpersonal relationship
Relaxation techniques
pleasure activity
Daily activity
Self
esteem

37. Pharmacotherapy

38. Management of Depression
Pharmacotherapy “antidepressants”
tricyclic
antidepres
sants
TCAs
selective
serotonin
reuptake
inhibitors
SSRIs
serotonin
norepinep
hrine
reuptake
inhibitors
SNRIs
dopamine
norepinep
hrine
reuptake
inhibitors
DNRIs
Others
Mono
Amine
Oxidase
Inhibitors
MOIs

39. Management of Depression
Pharmacotherapy “antidepressants”
tricyclic
antidepres
sants
TCAs
 well-established efficacy
 possibly more effective in severe depression;
 Low cost.
Advantages
 toxicity in overdose;
 may be less well tolerated than SSRIs;
 all TCAs may slow cardiac conduction and
lower seizure threshold
Disadvantages
 acute MI,
 heart block,
 arrhythmias,
 severe liver disease
 pregnancy and lactation
Contraindications

40. Management of Depression
Pharmacotherapy “antidepressants”
tricyclic
antidepres
sants
TCAs
 (Anafranil) (Anafronil)
 starting dose : 75mg/day(divided or just at night)
• Max daily dose : 250mg
Clomipramine
 (Prothiaden)
 starting dose : 75–150mg/day
 Max daily dose : 225mg
Dosulepin
 (Tofranil) (Imipramine)
 starting dose : 25mg up to tds
 Max daily dose : 200mg
Imipramine

41. Management of Depression
Pharmacotherapy “antidepressants”
 ease of dosing;
 better tolerated than TCAs
 Less cardiotoxic
 fewer anticholinergic side-effects;
 low toxicity in overdose.
Advantages
 commonly cause nausea and GI upset
headache
 restlessness, and insomnia
 may be less effective for severe depressive
Episodes
 problems on discontinuation.
Disadvantages
 manic episode
 concomitant use of MAOIs.
Contraindications
selective
serotonin
reuptake
inhibitors
SSRIs

42. Management of Depression
Pharmacotherapy “antidepressants”
 (Prozac) (Alzac) (Flutin) (Octozac)
 starting dose : 20mg od
 Max daily dose : 60mg
 Most alerting, May cause weight loss
Fluoxetine
 (Seroxate) (Paroxidur) (paxitin) (Paroxtin)
 starting dose : 20mg od
 Max daily dose : 50mg
 Most anticholinergic.
 Withdrawal syndrome
 may be more frequent.
 May be sedating
Paroxetine
selective
serotonin
reuptake
inhibitors
SSRIs

43. Management of Depression
Pharmacotherapy “antidepressants”
 (Lustral) (Moodapex) (Serpass) (Sesrine)
 starting dose : 50
 Max daily dose : 200mg
 Moderately alerting.
 Fewer drug interactions,
Sertraline
 (Faverin) (Statomin)
 starting dose : 50–100mg od
 Max daily dose : 300mg
 Moderately sedating
Fluvoxamine
selective
serotonin
reuptake
inhibitors
SSRIs

44. Management of Depression
Pharmacotherapy “antidepressants”
 (Cipram) (Depram) (Ramdeep) (Citalo)
 starting dose : 20mg od
 Max daily dose : 60mg
 Least likely to interact with other drugs.
Citalopram
 (Cipralex) (Cipra-pro) (Escita) (Estikan) ……..
 starting dose : 10mg od
 Max daily dose : 20mg
 Moderately sedating
Escitalopram
selective
serotonin
reuptake
inhibitors
SSRIs

45. Management of Depression
Pharmacotherapy “antidepressants”
 well-established efficacy
 possibly more effective in severe depression;
 more rapid onset of action
Advantages
 need to monitor blood pressure
 discontinuation effects common
Disadvantages
 manic episode
Contraindications
serotonin
norepinep
hrine
reuptake
inhibitors
SNRIs

46. Management of Depression
Pharmacotherapy “antidepressants”
serotonin
norepinep
hrine
reuptake
inhibitors
SNRIs
 (Efexor) (Efegad) (Venllamsh)
 starting dose : 75mg
 Max daily dose : 375mg/day
 Most alerting,
Venlafaxine
 (Cymbalta) (Karblata) (Depretreve)
 starting dose : 60mg od
 Max daily dose : 120mg/day
 May have utility in treating chronic pain and urinary
incontinence.
Duloxetine
 (Pristiq) (prismven) (bedremine)
 starting dose : 50 mg od
 Max daily dose : 400 mg/day
 discontinuations were more common at higher doses
Desvenlafaxine

47. Thank
you