Session Plan

Outline of Discussion

What is the site of depression on the map of MD?

{Classification of Mental Disorders}ICD-10-PHC & DSM-4

Why Depression?

Size of the problem

(Morbidity &Burden of Illness…)

When do you consider (suspect) depression?

How do you diagnose a depression?

Clinical presentation and D.D

Tips and Pitfalls in diagnosis of depression?

Management Plan

Risk assessment

Preventive issues related to Mental Disorders.

A 34-years-old lady presented to your office, she told you that she has been ‘way down’ for the past 4 months and has not felt much like doing anything.

She had a previous “nervous breakdown” when she was 22 years old. She was working as business executive until 4 months ago but has found it impossible not only to work but also to do anything else.

She had worked at her present position for approximately 18 months but was finding work an increasing stress.

She was working approximately 75 hours/week and having to deal with daily difficulties and conflicts. She is currently on long term sick leave.

Patient problem

She expresses her current situation best by saying, “I have no joy left in life”. I do not enjoy doing anything, I have not any interest in any of my previous activities.

Her other symptoms include sleep approximately 14 hours/day, almost continual feelings of guilt and hopeless, a state of having almost no energy “ all of the time” decreased concentrating ability, no appetite and loss of weight + 12 Kg, and being unable to “ move around “ or get anything done.

Her marriage is described as “excellent” her husband is very supportive. She does admit, however, to a significant decrease in sexual interest and activity. Her family history is significant for alcoholism in her father. She is on no drug and has no allergies.

Her physical examination is completely normal in all systems.

1.What is the most likely diagnosis in this patient? Select the best answer to the following questions A) Adjustment disorder secondary to work stress B) Generalized anxiety disorder C) Major depressive disorder D) Organic affective disorder E) Dysthymia

2.Which of the following types of psychotherapy are most commonly used in the illness above?

1. Psychoanalytic psychotherapy2. Behavioral Psychotherapy3. Cognitive psychotherapy4. Supportive psychotherapy5. All of above

3. The aims or goals of the psychotherapy for this condition include which of the following?

A. Providing a therapeutic rationale or

explanation for the patient's symptomsB. Providing ongoing education regarding the

illness, prognosis and treatmentC. Guiding the patient with respect to

interpersonal relationships, work, and major life adjustments

D. Helping to bolster the patient’s moraleE. All of the above.

4.What is the pharmacologic agent of choice in the disorder described?

A) a selective serotonin reuptake inhibitor (SSRI) B) a tricyclic antidepressant C) a non selective MOA inhibitor D) a selective MAO inhibitor E) Lithium carbonate

A 41-years old male presents with 3-year history of a “depressed mood”. He states that he feels “depressed most of the time”, although there are periods when he feels better than others.

He feels chronically tired, has some difficulty concentrating at work, and has found it difficult to remain productive and efficient as representative of a major company. He has had no other symptoms. His health is otherwise good. He is on no medications.

Patient problem

1) What is the most likely diagnosis? Adjustment disorder Dysthymic disorder Major depressive disorder Organic affective disorder None of the above

2) What is the treatment of choice for this patient?A tricyclic antidepressantSerotinin reuptake inhibitorSupportive and/or cognitive psychotherapyA and CB and C

Answer of the second problem

1.C2.E3.E4.A

Answer of the second problem

1.B2.E

WHEN DO YOU CONSIDER DEPRESSION ?

How ?Screening Tool

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Outline of Discussion

What is the site of depression on the map of MD?

{Classification of Mental Disorders}ICD-10-PHC & DSM-4

Why Depression?

Size of the problem

(Morbidity &Burden of Illness…)

When do you consider (suspect) depression?

How do you diagnose a depression?

Clinical presentation and D.D

Tips and Pitfalls in diagnosis of depression?

Management Plan

Risk assessment

Preventive issues related to Mental Disorders.

World Health Organization's classification of mental disorders in primary healthcare

================================================================================================

Organic D Mood, stress related, and anxiety D physiological D

FOO Dementia F32 Depression F50 Eating disorders

F05 Delirium F40 Phobic disorder F51 Sleep D

F41.0 Panic disorder F52 Sexual D

Psychoactive substance use F41.1 Generalized anxiety

F41.2 Mixed anxiety and depression

FI Alcohol use disorder F43 Adjustment disorde

F11 Drug use disorder F44 Dissociative disorder

F17.1 Tobacco use F45 Unexplained somatic complaints

F48 Neurasthenia

==============================================================================================

Psychotic disorders Development disorders

F20 Chronic psychotic disorder F 70 Mental retardation

F23 Acute psychotic disorder

F31 Bipolar disorder,

Disorders of childhood

F90 Hyperkinetic disorder

F91 Conduct disorder

F98 Enuresis

================================================================================================

In multi-center worldwide study conducted in

15 countries in general health care screened +

26422 persons using 12-item GHQ, About 25%

had well defined mental disorders, further 9%

had subthreshold conditions (WHO,1993).

The most common disorders were depression

(10%), general anxiety disorder (8%), and

harmful use of alcohol (3%)(WHO,1993).

SIZE OF THE PROBLEM

WHY DEPRESSION

Lifetime prevalence of major depression

(7-12%) among men in epidemiological

studies.

Lifetime prevalence of major depression

(20-25%) among women in epidemiological

studies.

The prevalence of major depression in PHC

settings (5-10% )

SIZE OF THE PROBLEM

WHY DEPRESSION

SIZE OF THE PROBLEM

WHY DEPRESSION

Studies demonstrate that one out of seven adult persons in the USA have a mood disorder during a single year, 7% in Brazil, almost 10% in Germany and 4.2% in Turkey.

In the USA, 5% of children aged 9-17 were found to have depression, a disorder thought to spare youth and adolescents. Ignoring this reality can result in suicide.

Prevalence rate of the psychiatric disorders among patients

attending primary health care (Ismailia Governorate) using GHQ

was 33.5% (Awad, 1985). [The commonest mental disorder was

depression (61.5%)].

Prevalence of psychiatric disorders in rural Egypt was found to

be as high as 42.4% in leading community study (El- Akabawy et

al.1982).

The prevalence rate of the psychiatric disorders among general

population in rural Menia using GHQ was 31.7% (Soliman et al.

1997).[Prevalence rate of depression was 22.8 %& anxiety was

18.6 %& somatization was 18.5%].

WHY DEPRESSION

SIZE OF THHE PROBLEM IN EGYPT

WHY DEPRESSION

SIZE OF THHE PROBLEM IN EGYPT

Eastern Mediterranean Health Journal, Vol. 15, No. 1, 2009 65National Survey of Prevalence of Mental Disorders in Egypt:preliminary surveyM. Ghanem,1 M. Gadallah,2 F.A. Meky,2 S. Mourad3 and G. El-Kholy1

This study was conducted in 2003 as an initial step for the

National Survey of Prevalence of Mental Disorders in Egypt.

We conducted a door-to-door household survey of 14 640

adults aged 18–64 years in 5 regions in Egypt including

Ismailia.

Overall prevalence was estimated at 16.93% of the studied

adult population.

The main problems were mood disorders, 6.43%, anxiety

disorders, 4.75%, and multiple disorders, 4.72%.

WHY DEPRESSION

SIZE OF THHE PROBLEM IN EGYPT

The 1993 world development report of the World Bank estimated that mental health problems represent 8% of the global burden of disease. Its toll is greater than that of TB, cancer or heart disease (World Bank Report, 1993).

It is also responsible for the greatest proportion of burden attributable to non fatal health outcomes, accounting for almost 12% of total years lived with disability

BURDEN OF ILLNESSCONSEQUENCES OF DEPRESSION

WHY DEPRESSION

The total annual cost estimate (both direct and indirect costs) is $43.7 billion in the United States

Stigma and QOL

Mortality rate

BURDEN OF ILLNESSCONSEQUENCES OF DEPRESSION

WHY DEPRESSION

WHEN DO YOU CONSIDER DEPRESSIONFactors which render a person more vulnerable to get

depression… examples are:

Positive family historyLoss of mother before the age of 11YCancer in the familyWomen with 3 or more children under 14 years of age and living alone, with no close relationship Post- natal period.Bereavement, especially widows with no familyPoor dietSocial isolation.

Significant life eventsDeath of a loved one- child, spouse (husband or wife) or a relative.Divorce or separationLoss of a job.Breakdown of a relationship.Moving house.Adverse financial conditions.

Be biased toward diagnosis of depression

WHEN DO YOU CONSIDER DEPRESSION

Difficult consultations

Frequent attendantsPatients with chronic painful physical illness- cancer, diabetes.Patients with unexplained physical symptomsPatients with decreased libido

Factors that predispose to a new episode of depression or the past history of:

A long history of depressionManic depressive illnessSever attack of depressionMore than one episode that lasted for more than 2 weeks.

Be biased toward diagnosis of depression

How DO YOU Screen for Depression

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DIAGNOSTIC CRITERIA OF DEPRESSIONDSM4Criteria

A- Five symptoms from the mentioned list, but depressed mood or anhedonia are required. The symptoms must have been present all of the day, nearly every day for 2 weeks.

1.Depressed mood (sadness)2.Anhedonia (lack of interest or pleasure in almost all activities)

3.loss of energy (fatigue)4. Reduced self esteem or guilt5.Reduced concentration or trouble making decisions6. Recurrent thoughts of death or suicidal ideas7. Psychomotor retardation or agitation (observed by others)

8. Sleep disorder (insomnia or hypersomnia)9. Appetite loss, weight loss & appetite gain, weight gain

DIAGNOSTIC CRITERIA OF DEPRESSION

Criteria

B- The symptoms cause clinically significant distress or impairment in functioning (social, occupational or other areas)

C- The symptoms are not due to Physical or organic factors or illness

D-The symptoms are not better explained by bereavement (although this can be complicated by depression).

DIAGNOSTIC CRITERIA OF DEPRESSION

A mnemonic for major depressive disorder is as follow:==================================== SIG: EMCAPS

1) S = Sleep (hypersomnia)

2) I = Interest (lack of interest in life in general)3) G = Guilt or hopelessness4) E = Energy or fatigue5) M =Mood (depressed, sad)6) C =Concentration (lack of)7) A =Appetite (increased or decreased, weight loss or

gain)

8) P =Psychomotor (retardation or agitation)9) S =Suicidal ideation

====================================Major depressive disorder can be diagnosed based on presence of 5 out of 9 including no. (2 or 5).

SEVERITY OF DEPRESSION

Each depressive episode could be graded according to the severity into mild, moderate or severe :====================================

Mild to Moderate Depression

Threshold number (5) of symptoms with minimal

functional impairment.

Marked symptoms and impairment of function.

Severe depression

All or nearly all symptoms and marked functional

impairment in all areas of life====================================

CLASSIFICATION OF DEPRESSION

Primary DepressionUnipolar Major depressive disorder (single episode) Recurrent depressive disorder (recurrent episodes) Dysthyma

Bipolar Bipolar affective disorder Cyclothyma

Others Seasonal affective disorder Mixed anxiety and depressive disorder

Secondary Depression

DIAFFERENTIAL D. OF DEPRESSION

1-Medical Mimics of Depression-Masquerades-2ry Endocrine Disorders

Hypo/hyperthyroidism Cushing's syndrome

Collagen V D (SLE/RA..) Hematological D (Anemia) Infectious D (Hepatitis;Influenza;HIV) Neurological D

Dementia Parkinsonism CVS

Neoplastic D Nutritional/Metabolic D

Hypokalemia/ hyponatremia Uremia Malnutrition particularly in elderly

2- Drug Induced Depression

3- Other Mental D

DIAFFERENTIAL D. OF DEPRESSION2-Drug induced Depression

Cardiovascular agents Beta B; CCB,Aldomet; Reserpine; Clonidine;

Digitalis;Dyslipedemic D (Pravcastatin) Respiratory Agents

Corticosteroids; Antituberculous D (INH) GIT Agents

H2 antagonist Neurological Agents

Carbamezapine Phenytoin PhenobarbitalParkinsonism

Gynecological Preparation Contraceptives

Cancer Treatment Psychotropic Agents

Benzodiazepines Antipsychotic Barbiturates

DIAFFERENTIAL D. OF DEPRESSION

3-Drug induced Depression

Acute Psychotic Disorders

Consider acute psychotic disorders if hallucinations

(hearing voices, seeing visions) or delusions (strange or

unusual beliefs) are present.

Bipolar Disorder

Consider bipolar disorder if history of manic episode

(excitement, elevated mood, and rapid speech) is

present.

Alcohol Use Disorders

Consider alcohol use disorders if there is a history of

alcohol use.

Dementia particularly among elderly

Interview and history taking

Physical Examination

Mental state Examination

If we go through this process, it will

lead to early and definite diagnosis of

depression

HOW DO YOU DIAGNOSE DEPRESSION ?

The patient may be presented initially with one or

more physical symptoms (fatigue, pain).

Further inquiry will reveal depression or loss of

interest.

Sometimes the depression presents as irritability.

CLINICAL PRESENTATION OF DEPRESSION

WHO-ICD-10

Presenting Complaints

Low OR sad mood Loss of interest OR pleasure Associated symptoms are frequently present:

Disturbed sleep Guilt or low self-worth Fatigue or loss of energy Poor concentration Disturbed appetite Suicidal thoughts or acts

Movements and speech may be slowed, but may also appear agitated.

Symptoms of anxiety or nervousness are frequently also present.

CLINICAL PRESENTATION OF DEPRESSIONWHO-ICD-10

Diagnostic Features

Non pharmacological Therapy

Pharmacological (Biological) therapy Others,(ECT)

MANAGEMENT OF PATIENT WITH DEPRESSION

Tell the patient that he/she has

Depression

Do not tell the patient that he/she has Depression

Presenting the diagnosis

How??

Exercise

Presenting the diagnosis

A 45- year old- single woman came to see her family physician complaining of abdominal pain and nervous exhaustion. In the interview her physician noted that her affect was flat and that she spoke with long latencies. She was having trouble sleeping, frequent awaking after 4 hours, sleep with perspiration, heart palpitations, and obsessive worries about her job.

She had assumed a new job 4 months earlier as manager of a hospital clinic that was converting to a new data

management system. After the physician ascertained that the patient was not suicidal, She summarized the patient

concerns and presented her diagnosis in the following dialogue:

Presenting the diagnosis

Doctor: It is obvious that last few weeks have been like torture for you.It sounds like you carry a lot of responsibilities (including the working in the clinic that is depending on you). Let’s talk about what I think is going on and then I, d like to get your ideas about that.

You have said that you are finding less energy during the day and that you awaken frequently at night, sometimes

only getting a few hours, sleep. You tend to judge your self harshly, and lately you feel guilty that you are not

accomplishing more. You have lost interest in things you used to enjoy, and lately all you can think about is your job. You are finding it harder to concentrate, and making simple

decisions. Did I leave out anything?

Presenting the diagnosis

Doctor: All these symptoms indicate to me that you are suffering from depression. This is an illness that affects our

nervous system in way that robs us of our usual ability to enjoy the pleasure of life and to have confidence in our

abilities. Your depressed mood is leading you to view yourself through a distorted lens that filters out all

recognition of your competencies and abilities.

[Pause to check patient’s response. After head nod from the patient, The doctor proceeds as follow]

Any person is prone to that, fortunately, depression is very treatable illness and there are some very effective strategies you and I can work on together. This may be hard for you to believe right now, because of hopeless feeling that accompanies depression, but I’m quite confident that within a few weeks you will be feeling much better about yourself and about life.

Presenting the diagnosis

Summarize the symptoms

May you add a couple of additional symptoms not mentioned

by the patient to check their presence or absence.

Express the common existing of such illness to relieve the

associated stigma.

May you use some diagrams to explain the illness

Emphasize on that depression is curable illness.

Discuss the available resources that may help in overcoming

the stresses that precipitated the occurrence of depression.

Important Tips

1) Depression is common and effective treatments are available.

2) Depression is not weakness or laziness; patients are trying their hardest to cope.

MANAGEMENT OF PATIENT WITH DEPRESSION

A) Essential Information for Patient and Family

B) Specific Counseling to Patient and Family

(1)Ask about risk of suicide. Has the patient thought of death or dying? Does the patient have a specific suicide plan? Can the patient be sure not to act on suicidal ideas? Close supervision by family or friends may be needed.

How ?

SUICIDE RISK ASSESSMENT

(SAD PERSONS INDEX)==========================================

Score > 7 means high suicide risk==========================================

1. Male2. <20 >45 years3. Major Depression4. Previous attempts5. Substance abuser6. Psychotic, s depression7. Loss of spouse8. Determined suicide plan9. No back up ; isolated10. Chronic illness

1. Sex2. Age3. Depression4. Psychiatric history5. Excessive drug use6. Rationality loss7. Separated8. Organized plan9. No support10. Sickness

1121121211

MANAGEMENT OF PATIENT WITH DEPRESSION

B) Specific Counseling to Patient and Family

(2) plan short-term activities, which give enjoyment or build

confidence

(3) Resist pessimism and self-criticism.

Do not act on pessimistic ideas (e.g. ending marriage, leaving job).

Do not concentrate on negative or guilty thoughts.

(4)Identify current life problems or social stresses. Focus on small, specific steps that patient might take

towards reducing or better managing these problem.

Avoid major decisions or life change.

How do you Help your Pt ?

MANAGEMENT OF PATIENT WITH DEPRESSION

SPEAK Approach to help Pt to overcome Depression

Schedule

Pleasurable Activities

Exercise

Assertiveness (sharing other feeling)

Kind thoughts about your self (replace

negative ones with positive)

MANAGEMENT OF PATIENT WITH DEPRESSION

B) Specific Counseling to Patient and Family

(5)If physical symptoms are present, discuss link

between physical symptoms and mood

(6) After improvement, discuss signs of relapse,

plan with patient action to be taken if signs of

relapse occur.

MANAGEMENT OF PATIENT WITH DEPRESSION

C) Pharmacological treatment

(1)Consider antidepressant drugs if sad mood or loss of interest is prominent for at least 2 weeks and 4 or more of associated symptoms are present:

In severe cases consider medication at the first visit. If good response to one drug in the past uses that again.If older or medically ill, use newer medication with fewer side effects.If anxious or unable to sleep, use more sedating drug.

MANAGEMENT OF PATIENT WITH DEPRESSION

C) Pharmacological treatment

(2)Build up to effective dose (e.g. imipramine starting at 25 to 50 mg each night and Increasing to 100- 150 mg by I0 days) - lower doses if older or medically ill.

(3) Explain how medications should be used: Medication must be taken every day, Improvement will build over 2-3 weeks. Mild side effects may occur and usually fade in 7-10

days. Check with the doctor before stopping medication.

(4) Continue antidepressant at least 3 months after symptoms Improve.

MANAGEMENT OF PATIENT WITH DEPRESSION

C) Pharmacological treatment

Antidepressant Agents

Table 1. A guide to the selection of commonly used antidepressants tableGeneric Name Brand Name Common Dosage Range Common Adverse Effects

Tricyclic antidepressants

Imipramine Tofranil 50‑300 ing daily Sedation, dry mouth, orthostatic hypotension, prolonged QT interval

Desipramine Norpramin 50‑300 ing daily Similar to but less thanirmpramine; commonly used in the elderly

Nortriptyline Pamelor, Aventyl 50‑150 mg daily Fewer adverse effects compared with imipramine, commonly used in elderly

Selective serotonin reuptake inhibitors

Fluxetine Prozac 20‑40 mg daily Tremulousness, gastrointestinal upset,difficulty sleeping, sexual Dysfunction

Paraxetine Paxil 2‑50 ing daily Same as fluoxetine, usually more sedating

Citaloprain Celexa 20‑60 ing daily Less sexual dysfunction; loose stools are common

Serotonin‑norepinephrine reuptake inhibitors

Nefazodone Serzone 150‑300 ing twice daily None consistently (no effect on sexual dysfunction)

Ventafaxine Effexor, Effexor XR 75‑225 ing daily (SR) or in divided doses

Sedation, hypertension

Other

Trazodone Desyrel 50‑500 ing daily or in divided doses Sedation (useful at low doses for sleep), orthostatic Hypotension

Bupropion Welibutrin, Wellbutrin

SR

300‑450 ing divided three times daily or twice daily (SR form)

Agitation, lowered seizure Threshold

WHEN DO YOU REFER ??

Uncertainty about diagnosis

Inpatient care obviously necessary

Severe depression

Inability to cope at home

Psychotically depressed( with delusion or hallucinations)

Substantial suicide risk

Failure of response to routine antidepressant therapy

Associated physical and psychiatric disorders

Children with apparent major depression

Difficult problem in elderly where diagnosis

including dementia is doubtful.

Is it possible to prevent depression in your practice population?

Task

Screening for Depression