depressive illness dr. sarma r v s n consultant physician visit : drsarma
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Depressive Illness Dr. Sarma R V S N Consultant Physician visit : www.drsarma.in. With thanks for the resource material from. http://www.hcc.bcu.ac.uk/craig_jackson/ psychopharmacology%20and%20serotonin.ppt. Neurotics build castles in the air Psychotics live in them and enjoy - PowerPoint PPT PresentationTRANSCRIPT
Depressive IllnessDepressive Illness
Dr. Sarma R V S NConsultant Physician
visit: www.drsarma.in
http://www.hcc.bcu.ac.uk/craig_jackson/psychopharmacology%20and%20serotonin.ppt
With thanks for the resource material from
Neurotics build castles in the air
Psychotics live in them and enjoy
Psychiatrists collect rent for those castles
PathogenPathogen DiseaseDisease (pathology)(pathology)
ModifiersModifiersLifestyleLifestyleIndividual susceptibilityIndividual susceptibility
Traditional model of Disease DevelopmentTraditional model of Disease Development
Dominance of the biopsychosocial modelDominance of the biopsychosocial model
Mainstream in last 15 yearsMainstream in last 15 years
Hazard Hazard
Psychosocial FactorsPsychosocial FactorsAttitudesAttitudesBehaviourBehaviourQuality of LifeQuality of Life
Illness Illness (well-being)(well-being)
Rise of the person as a Rise of the person as a “psychological entity”“psychological entity”
MDD and Anxiety Disorders
AnxietyDisorders
59%59%MajorDepression
MajorDepression
Association of Psychiatric Disorders
MDD: Indian Facts and FiguresMDD: Indian Facts and Figures
The World Health Report 2001 accessed from http://www.who.int/whr2001/2001/main/en/contents.htm. last accessed on 30.12.02WHR 2001: Box 3.8 Two national approaches to suicide prevention
Total populationapprox.103 crores (2001 census)
Total populationapprox.103 crores (2001 census)
Total no of depressed patients approx. 9 croresTotal no of depressed patients approx. 9 crores
Depressed patients per psychiatrist approx. 25,714 Depressed patients per psychiatrist approx. 25,714
Common disorderCommon disorder
Bangalore: 9.1% (WHR 2001)Bangalore: 9.1% (WHR 2001)
Spectrum of mood disturbanceSpectrum of mood disturbance
Mild Mild thru to thru to SevereSevere
Transience Transience thru to thru to Persistence Persistence
Continuous distribution in populationContinuous distribution in population
Clinically significant when:Clinically significant when:(1) interferes with normal activities(1) interferes with normal activities(2) persists for min. 2 weeks(2) persists for min. 2 weeks
Diagnosis of depression / depressive disorderDiagnosis of depression / depressive disorder““Persistent & pervasive low mood”Persistent & pervasive low mood”““Loss of interest or pleasure in activities”Loss of interest or pleasure in activities”
Depressive IllnessDepressive Illness
Usually treatableUsually treatable
CommonCommon
Marked disabilityMarked disability
Reduced survivalReduced survival
Increased costsIncreased costs
Depression may beDepression may be
Coincidental associationCoincidental association
Complication of physical illness Complication of physical illness
Cause of / Exacerbation of somatic symptomsCause of / Exacerbation of somatic symptoms
Depressive IllnessDepressive Illness
2% of population suffer from2% of population suffer from pure depressionpure depression(evenly distributed between mild, moderate,(evenly distributed between mild, moderate, and severe)and severe)
Further 8% suffer from a mixture of anxietyFurther 8% suffer from a mixture of anxiety and depressionand depression
Patients with symptoms not severe enoughPatients with symptoms not severe enough to qualify for diagnosis of either to qualify for diagnosis of either anxiety or depression..... ???anxiety or depression..... ???
Impaired working and social lives and many unexplainedImpaired working and social lives and many unexplained physical symptomsphysical symptoms
Greater use of medical servicesGreater use of medical services
EpidemiologyEpidemiology
2nd biggest cause of disability 2nd biggest cause of disability
worldwide by 2020 (WHO) worldwide by 2020 (WHO)
(IHD still the biggest)(IHD still the biggest)
Associated with increasedAssociated with increasedphysical illnessphysical illness
• 5% during lifetime have MDD5% during lifetime have MDD• 1 in 20 consultations1 in 20 consultations• MDD & Dysthymia > in femalesMDD & Dysthymia > in females• 20% develop chronic depression20% develop chronic depression• 30% of in-patients have depressive symptoms30% of in-patients have depressive symptoms
MDD and PhysiciansMDD and Physicians
Training physicians and general health care staff in
the detection and treatment of common mental and
behavioral disorders is an important public health
measure. This can be facilitated by liaison with
local community-based mental health staff.
(World Health Report 2001)
Training physicians and general health care staff in
the detection and treatment of common mental and
behavioral disorders is an important public health
measure. This can be facilitated by liaison with
local community-based mental health staff.
(World Health Report 2001)
The World Health Report 2001 accessed from http://www.who.int/whr2001/2001/main/en/contents.htm. last accessed on 30.12.02
PRIME MD TODAYTMPRIME MD TODAYTM
A Screening and
Diagnostic
Instrument
for Major Depressive
Disorder (MDD)
A Screening and
Diagnostic
Instrument
for Major Depressive
Disorder (MDD)
Primary Care Evaluation of Mental Disorders
Kaplan & Sadock’s Synopsis of Psychiatry, 8th ed., p 941 Harrison’s Principles of Internal Medicine, 15th ed., p 2543
SuicideSuicide
SuicideSuicide
Final clinical pathwayFinal clinical pathway
1 million deaths per year, 10-12 million attempts1 million deaths per year, 10-12 million attempts
Males – most common in olderMales – most common in older
Female – most common in middle ageFemale – most common in middle age
15 per 15 per 100,000 deaths males100,000 deaths males
6 per 6 per 100,000 deaths females100,000 deaths females
Almost 50% fail on first attemptAlmost 50% fail on first attempt
Previous attempters 23 times more likely to dies from suicide than those Previous attempters 23 times more likely to dies from suicide than those without previous attemptswithout previous attempts
Internal stressInternal stress
Pre-existing psychiatric morbidityPre-existing psychiatric morbidity
DemographicsDemographics
OpportunitiesOpportunities
Behavioural IndicatorsBehavioural Indicators
- recent bereavement or other life-altering loss - recent bereavement or other life-altering loss
-- recent break-up of a close relationship recent break-up of a close relationship
-- major disappointment (failed exams or missed job promotion) major disappointment (failed exams or missed job promotion) - change in circumstances (retire, redundant or children leaving home) - change in circumstances (retire, redundant or children leaving home) - physical illness- physical illness- mental illness - mental illness - substance misuse / addiction- substance misuse / addiction- deliberate self-harm, (particularly in women)- deliberate self-harm, (particularly in women)- previous suicide attempts - previous suicide attempts - loss of close friend / relative by suicidal means- loss of close friend / relative by suicidal means- loss of status- loss of status- feelings of hopelessness, powerlessness and worthlessness- feelings of hopelessness, powerlessness and worthlessness- declining performance in work / activities (sometimes this can be reversed)- declining performance in work / activities (sometimes this can be reversed)- declining interest in friends, sex, or previous activities- declining interest in friends, sex, or previous activities- neglect of personal welfare and hygiene- neglect of personal welfare and hygiene- alterations in sleeping habits (either direction) or eating habits- alterations in sleeping habits (either direction) or eating habits
EpidemiologyEpidemiology
Depression more common in those with:Depression more common in those with:
• Life threatened / limited / chronic physical illnessLife threatened / limited / chronic physical illness
• Unpleasant / demanding treatmentUnpleasant / demanding treatment
• Low social supportLow social support
• Adverse social circumstancesAdverse social circumstances
• Personal / family history of depression / psychological vulnerabilityPersonal / family history of depression / psychological vulnerability
• Substance misuseSubstance misuse
• Anti-hypertensive / Corticosteroid / Chemotherapy useAnti-hypertensive / Corticosteroid / Chemotherapy use
Q o LQ o L
Different Reasons
Most depressions have triggering life events - Reactive depression
Especially in a first episode
Many patients present with physical symptoms - Somatisation syndrome
Some may show multiple symptoms of depression in the apparent absence
of low mood - Masked Depression
Complication of physical illness - Secondary depression
Some depression has no triggering cause - Endogenous Depression
More persistent and resistant to treatment
Clinical FeaturesClinical Features
• Adjustment DisordersAdjustment Disorders mildmild short-livedshort-lived reactive episodesreactive episodes
• Major Depressive Disorder (MDD)Major Depressive Disorder (MDD) 5 symptoms displayed in 14 days5 symptoms displayed in 14 days
• DysthymiaDysthymia depressed mood for 2+ yearsdepressed mood for 2+ years not severenot severe chronic depressionchronic depression unhealthy lifestyle associationsunhealthy lifestyle associations
• Bipolar Disorder / manic depressionBipolar Disorder / manic depression major depression & maniamajor depression & mania
Major depression (DSM IV-TR)Major depression (DSM IV-TR)
5 or more…..5 or more…..
• decreased interest / pleasure * decreased interest / pleasure * • depressed mood *depressed mood *• reduced energyreduced energy• weight gain / lossweight gain / loss• insomnia / hypersomniainsomnia / hypersomnia• feeling worthlessfeeling worthless• guiltguilt• recurrent morbid thoughtrecurrent morbid thought• psychomotor changespsychomotor changes• fatiguefatigue• poor concentrationpoor concentration• pessimism / bleak viewspessimism / bleak views• self harm ideas / actionsself harm ideas / actions• suicide ideationsuicide ideation
Classification of Depression (ICD-10)Classification of Depression (ICD-10)
PrimaryPrimaryUnipolarUnipolar
Mixed anxiety and depressive disorder (prominent anxiety) Mixed anxiety and depressive disorder (prominent anxiety) Depressive episode (single episode) Depressive episode (single episode) Recurrent depressive disorder (recurrent episodes) Recurrent depressive disorder (recurrent episodes) Dysthymia - Persistent and mild ("depressive personality") Dysthymia - Persistent and mild ("depressive personality")
BipolarBipolar Bipolar affective disorder - manic episodes ("manic depression") Bipolar affective disorder - manic episodes ("manic depression") Cyclothymia - Persistent instability of mood Cyclothymia - Persistent instability of mood
Other primaryOther primary Seasonal affective disorder Seasonal affective disorder Brief recurrent depression Brief recurrent depression
Depressive episode may beDepressive episode may beModerate or severe Moderate or severe With/Without somatic syndrome With/Without somatic syndrome With/Without psychotic symptomsWith/Without psychotic symptoms
Somatization Syndrome (DSM IV)Somatization Syndrome (DSM IV)
4 or more…..4 or more…..
Anhedonia (inability experience pleasure)Anhedonia (inability experience pleasure)
Loss of emotional reactivity Loss of emotional reactivity
Early waking (>2 hours early) Early waking (>2 hours early)
Psychomotor retardation or agitation Psychomotor retardation or agitation
Marked loss of appetite Marked loss of appetite
Weight loss >5% of body mass in one month Weight loss >5% of body mass in one month
Loss of libido (important and often ignored)Loss of libido (important and often ignored)
Classification
• Many patients do not fit neatly into categories of either anxiety or depression
• Mixed anxiety and depression is now recognised
• Presence of physical symptoms indicates a somatic syndrome
• Value of somatic features in predicting response to treatment is not clear
• Presence of psychotic features has major implications for treatment
• Brief episodes of more severe depression - brief recurrent depression
• More prolonged recurrence is now termed recurrent depressive disorder
Risk FactorsRisk Factors
Anxiety + Sadness + Somatic discomfortAnxiety + Sadness + Somatic discomfort
Normal psychological response to life stressNormal psychological response to life stress
Clinical depression is a “final common pathway”
Resulting from interaction of Resulting from interaction of biologicalbiological, , psychologicalpsychological, and , and social factorssocial factors
Likelihood of this outcome depends on many factors:Likelihood of this outcome depends on many factors:• geneticgenetic and family predispositionand family predisposition• clinical course of concurrentclinical course of concurrent medical illnessmedical illness• nature of any treatmentnature of any treatment• functional disabilityfunctional disability• individual coping styleindividual coping style• social and other supportsocial and other support
Recognition & Diagnosis
Depressive illness is often under-diagnosed and under-treated
Especially if it coexists with physical illness
This often causes great distress for patients: mistakenly assumedthat symptoms (weakness or fatigue) are due to an underlying medicalcondition.
Practitioners must be able to diagnose and manage depressive illness • Alertness to clues in interviews; Patients' manner
Use of screening questions detect up to 95% of pts with MDD.
Screening QuestionnairesScreening Questionnaires
“How have you been feeling recently?” “Have you been low in spirits?” “Have you been able to enjoy the things you usually enjoy?” “Have you had your usual level of energy, or have you been feeling tired?”“How has your sleep been?”“Have you been able to concentrate on your favourite tv shows?”
Self-report screening instrumentsSelf-report screening instrumentsBeck Depression Inventory (BDI) General Health Questionnaire (GHQ)
Hospital Anxiety Depression Scale (HAD)
Can’t replace systematic clinical assessment – Can’t replace systematic clinical assessment – LISTENINGLISTENING
Persistent low mood and lack of interest and pleasure in life cannot be accounted for by severe physical illness alone
Simplified Algorithm
Drug Treatment
Tricyclic Antidepressants (TCAs)since the 1950s effective and cheap
limit compliance variable degrees of sedation
fatal in overdose (except Lofepramine)
dose-related anticholinergic side effects, postural hypotension
Monoamine Oxidise Inhibitors (MAOI’s)
rare fatalities tyramine-free diet
Selective Serotonin Re-uptake Inhibitors (SSRI’s)fluoxetine lack sedation - no anticholinergic effects
improved compliance less immediate benefit for disturbed sleep
safe in overdose single or narrow range of doses works
Drug Treatment
Selective Serotonin Re-uptake Inhibitors (SSRI’s) - NewerSertraline lack sedation - no anticholinergic effects
improved compliance favourable on glucose metabolism
Platelet SSRI Decreased and favourable of CHD patients
Remission Prolonged remission with Sertraline
safe in overdose single or narrow range of doses works
Dual Norepinephrine and Serotonin Re-uptake Inhibitors (SSRI’s) – Newer
Similar in action and benefits as SSRIs but also inhibit the noradrenaline pathways
Problem in hypertensive patients
Cognitive Behavioural Therapy - CBT
Electroconvulsive Threrapy - ECT
Comparative Tolerability
Treatment
Much depressive illness of all types is successfully treated in primary care
Four main reasons for referral to specialist psychiatric services:
1) Condition is severe
2) Failing to respond to treatment (e.g. Psychomotor retardation)
3) Complicated by other factors (e.g. Personality disorder)
4) Presents particular risks (e.g. Agitation and psychotic behaviour)
• Principal decision is whether to treat with drugs or a talking therapy• Most patients in primary care settings would prefer a talking therapy• Effectiveness is limited to particular forms of psychotherapy• Mild-Mod. Depression: CBT and antidepressants are equally effective• Severe Depression: antidepressant drugs are more effective
Management
The main aims of treatment:The main aims of treatment:• improve mood and quality of lifeimprove mood and quality of life• reduce the risk of medical complicationsreduce the risk of medical complications• improve complianceimprove compliance with and outcome of physical treatmentwith and outcome of physical treatment• facilitate the "appropriate"facilitate the "appropriate" use of healthcare resourcesuse of healthcare resources
PrimaryPrimary care staff should be familiar with properties and use of:care staff should be familiar with properties and use of:1) common antidepressant drugs & brief psychological treatments1) common antidepressant drugs & brief psychological treatments
2) assessment of suicidal thinking and risk2) assessment of suicidal thinking and risk
Patients with more enduring or severe symptoms will usually require specific Patients with more enduring or severe symptoms will usually require specific treatment - usually drug therapytreatment - usually drug therapy
ForFor patients with suicidal ideation / whose depression haspatients with suicidal ideation / whose depression has not responded to initial not responded to initial management, specialist referral is themanagement, specialist referral is the next stepnext step
Keys Steps in Rx of Depression
• High level of clinical suspicion• Early Diagnosis• Effective treatment of acute attack• Achieving remission• Remission maintenance with continued Rx• Prevent relapse• Follow up of recurrence
SummarySummary
• Detection can be hard – symptom overlap and patient unawareDetection can be hard – symptom overlap and patient unaware
• Depression a natural occurrence in populationDepression a natural occurrence in population
• Whole range of depressive conditions with varying severityWhole range of depressive conditions with varying severity
• Depression can be present in acute or chronic statesDepression can be present in acute or chronic states
• Depression can have physiological, biological or social causesDepression can have physiological, biological or social causes
• Depression may have a mixture of causesDepression may have a mixture of causes
• Depression co-exists with many other symptomsDepression co-exists with many other symptoms
• Depression is a natural reaction to disease diagnosis and presenceDepression is a natural reaction to disease diagnosis and presence
• Depression and symptomotology are highly relatedDepression and symptomotology are highly related
““The good physician The good physician treats the disease, treats the disease, but the great physician but the great physician treats the person.”treats the person.”
William Osler William Osler
Thank YouThank You