DEPRESSIONDEPRESSION

Terminologi Mood ??? Afek

Jenis depresi Bipolar Unipolar

3

Projected Global Burden of Disease(DALYs, 2020)

1. Ischemic heart disease2. Unipolar major depression3. Road traffic accidents4. CVA5. COPD6. Lower respiratory infection7. TB8. War

(WHO, 2000)

Female > male (20%:12%) The rate of depression in medical illness

varies from 10-40% Comorbidity of depression and medical illness

will worsen the prognostic Depression in medical illness can be treated

*Goodnick, PJ, Treatment of deression in medical illness, Ashley Publication, 2000

Depression in Primary Care 74 % of patients in US go to GP

rather than to a psychiatrist for depressive symptoms1

20 to 30 % of primary care patients present with depressive symptoms2

The severity of medical conditions in correlation with clinical depression1

1 Montano B, J Clin Psychiatry, 1994;55(12):18-332 Zung, WK et al, J Fam Practice, 1993;37;337-344

Current Treatment Patterns:Depression is still…

UnderdiagnosedLess than ½ of patients with major

depression are explicitly recognized as being depressed

Inadequately Only about ½ of all depressed

patients receive some form of therapy for their illness

Only about ¼ of depressed patients receive an adequate dose and duration of antidepressant treatment

Katon W, et el, Med Care, 1992; 39 (1);67-76

Why…

The physician: poor recognition of depressive illness, misdiagnosis of physical complaints (symptom overlap : fatigue and insomnia can be symptoms of medical illness i.e.cardiac illness, cancer), depressive symptoms perceived as ‘understandable’ reactions to circumstances, inadequate time to counsel and treat psychiatric illness

8

DepressionPast Understanding

Depression is a “character defect “ or ”weakness”

Patients could handle depression by themselves

Treatments are not effective

9

DepressionCurrent Understanding

Depression = a medical illness (not a “character defect “ or

”weakness”) Recovery is the rule, not the

exception Treatments are effective Doctors should be alert to early

signs & symptoms

10

The need to treat Depression

15% patients with depression will die from suicide(Guze & Robins, 1970; Henriksson, Aro, Marttunen, 1993)

Depression is present in >50% completed suicide(Asgard, 1990)

Diminished immune response caused by depression(Schliefe, Keller. Camerino, Thornton, Steik 1983)

Major depression morbidity is higher than: HT, CRF & DM causes loss of US$ 50 billion/year in USA(Greenberg, Stiglin, Finkelstein & Berndt, 1993)

11

What should be treated?

Disability Social functioning impaired Significant suffering Seek for care Seek for help Occupational impairment

Hergueta & Lecrubier, 2000

12

Depressive Disorders: Aims of Treatment

Treatment

Reduce/removesigns, symptoms

Restorerole

function

Minimizerelapse/recurrence

risk

ETIOLOGY Unknown multiple factor Factor :

Genetic Non Genetic: biogenic amin disregulation,

neuroendocrin disregulation, neurofisiology changes, psycho dinamic, psychosocial factor (loss of object)

HPA (hypothalamic pituitary adrenal) axis hypersensitivity??

Neurotransmitter that involve: Serotonin Norepinephrin Dopamin GABA Glutamat

14

“Bio-Psycho-Social” modelBiological

Psycho-cognitive Socio-environmental

MODEL

Hergueta & Lecrubier, 2000

15

Duration of treatmentPast Understanding

Depression treatment :2 weeks, 3 weeks, 4 weeks ???

Antidepressants are addictive: the longer treatment you give, the more addictive patients will be

16

Duration of treatmentCurrent Understanding

Depression need a long term treatment

No antidepressants have been proven to create addiction

Relapse and recurrence are high. Risk of recurrence :

50% after one episode70% after two episodes90% after three episodes

Gejala umum depresi

1. Di bidang mood, motivasi, psikologik>murung terus menerus>kehilangan minat/gairah>putus asa>tak berdaya>merasa diri tak berharga

>rasa bersalah/sikap negatif terhadap diri

sendiri>konsentrasi/memori terganggu>pikiran tentang kematian/bunuh diri>mudah menangis

2. Gejala fisik>motorik lamban atau agitasi>cepat lelah/kurang tenaga>gangguan tidur>gangguan nafsu makan (berat badan

berkurang atau bertambah)

KRITERIA DIAGNOSTIK(PPDGJ III)

Episode depresi ringan Tanpa gejala somatik Dengan gejala somatik

Episode depresi sedang Tanpa gejala somatik Dengan gejala somatik

Episode depresi berat Tanpa gejala psikotik Dengan gejala psikotik

Penatalaksanaan

Farmakoterapi ECT Psikoterapi :

- Individual- CBT (Cognitive Behavioural

Therapy)- Stress Management Training

FARMAKOTERAPI Pemberian farmakoterapi

disesuaikan dengan manifestasi gejala

Dasar pemilihan antidepresan sbb :

>efektifitas setara dengan antidepresi

terdahulu (TCA)>efek samping minimal>interaksi dengan obat lain

minimal>dapat ditoleransi dengan

baik

Farmakoterapi

Antidepresan Waktu 3-4 mgg efek terapi

signifikan Terapi diteruskan min 6 bln sejak

perbaikan Jenis SSRI (fluoxetin, paroxetin, sertralin) Trisiklik (amitriptilin), tetrasiklik

(maproptilin) Jenis lain: bupropion, venlavaxin,

nefazodon, mirtazapin (remeron) Efek samping: mual, muntah, gelisah, Gol benzodiazepin bila perlu

Psikoterapi

CBT (Cognitive Behavioral Therapy) - Membuat pasien menyadari pandangannya terhadap situasi stress, bahwa pandangan tersebut akan mempengaruhi timbulnya emosi dan respons perilaku negatif,

- Mengajari pasien untuk mengubah pola pandangnya.

Electro Convulsive Therapi

Tidak berespon dengan farmakoterapi adekuat

Tidak dapat mentoleransi farmakoterapi

Tentamen suicide Tampilan klinis yang sangat berat

Latihan manajemen stress, yang terdiri dari

- self-observation- cognitive restructuring- relaxation training- time management- problem solving

Prognosis

Cenderung kronik dan kambuh-kambuhan

Kekambuhan 50 % dalam 1 tahun pada episode pertama depresi berat

Jumlah relap perburuk prognosis Perlu terapi profilaksis pada pasien

yg alami > 2x episode Prognosis baik: gejala psikotik (-),

rawat inap singkat, faktor psikososial baik, komorbiditas ggn psikiatri lain (-)

Alternatif pertanyaan yang dapat diajukan untuk mengungkap depresi

1. Apakah anda merasa sedih atau murung ?

2. Apakah anda kehilangan minat atau rasa senang terhadap hal-hal yang dulunya anda minati ?

3. Apakah anda merasa tenaga anda menurun dan/atau lelah sepanjang waktu?

4. Apakah anda mengalami masalah masuk tidur atau bangun jauh lebih awal dari sebelumnya ?

5. Apakah anda kehilangan nafsu makan atau makan lebih dari biasanya ?

6. Apakah anda sulit konsentrasi ?7. Apakah anda menjadi lebih

lambat dalam berpikir atau waktu bergerak ?

8. Apakah minat seksual anda kurang ?

9. Apakah anda menilai negatif terhadap diri sendiri ?

10. Apakah anda berpikir tentang kematian ?

11. Apakah anda sering merasa bersalah ?

Pertanyaan selanjutnya adalah tentang aktivitas sehari-hari (khususnya yang berhubungan dengan fungsi sosial dan pekerjaan) seperti, hubungan dengan keluarga, pasangan, anak, kerabat, aktivitas sosial, pergaulan, produktivitas dan mutu kerja, serta absensi

Thank you