Transcript Management of depression in primary health care

Management of
depression in primary
health care
Dr. Tarik S. Khammas
Consultant Psychiatrist
New Psychiatry Hospital
Abu Dhabi
INTRODUCTION
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It is estimated that depressive disorders will affect
one of five patients in general practice.
These patients may be unaware of their mental
state & its influence, seeking treatment for a
somatic disorder.
In depressed patients, the associated somatic
complaints may be also be gender related.
Information regarding these symptoms may be
difficult to obtain, often only becoming apparent
with gentle questioning. If further information is
needed, relative & a friend are often a valuable
source.
Affective Disorders
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The word ‘affect’ is a synonym for mood.
Affective disorders are so named because their main
feature is an abnormality of mood, namely depression
or elation.
ICD-10 classification (Manic episode, Depressive
episode- mild, moderate & severe, Bipolar affective
disorder, Persistent mood states- cyclothymic &
dysthymia ).
DSM-IV classification ( Manic episode, Major
depressive episode, Bipolar disorders, Cyclothymia &
dysthymia ).
Both depression & elation can be secondary to other
psychiatric syndromes & also accompany physical
illness.
Depressive disorder
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The central features of depression are low mood,
pessimistic thinking, lack of enjoyment, reduced
energy, slowness, poor concentration & low self-esteem.
Depressive disorder is frequent in general & hospital
practice but is often undetected, especially when there
are physical symptoms.
Unrecognized depressive disorder is a common cause of
distress & slow recovery from physical illness.
All doctors should be able to recognize the condition,
treat the less severe cases, identify those requiring
specialist care.
They are classified as single or recurrent episodes &
less severe form (dysthymia).
General clinical features
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Sadness is a normal emotion commonly experienced by
healthy people in response to misfortunes, especially
losses(grief). It is often accompanied by anxiety, lack of
energy & poor sleep.
More severe unhappiness associated with low mood,
depressive thinking & biological symptoms.
Depressive symptoms also occur in many other
psychiatric disorders such as schizophrenia & dementia.
Many anxiety depression seen in primary health care are
due to depressive disorder.
Sometimes the symptoms of depressive disorders is
denied & patient smiles a condition described as masked
depression.
Mild depressive disorder
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Complains of low mood, lack of energy &
enjoyment and poor sleep.
Other symptoms include anxiety, phobia &
obsessional symptoms.
Sleep disturbance is often difficult to fall asleep,
restless with period of waking during the night
followed sound sleep before waking.
Mood may vary during the day; worse in the
evening than in the morning in contrast to more
severe cases.
Biological features are uncommon.
Moderately severe depressive
disorder
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Appearance-sad appearance & psychomotor retardation
Low mood-misery, worse in the morning & irritability and
agitation.
Lack of interest & enjoyment-reduced energy, poor
concentration & memory.
Depressive thinking-pessimistic & guilty thoughts, selfblame, suicidal ideas & hypochondriacal ideas.
Biological symptoms-early wakening, weight loss reduced
appetite& reduced sexual drive.
Other symptoms-obsessional symptoms, depersonalization
etc.
Severe depressive disorder
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All the features described under moderate depressive
disorder occur with greater intensity.
There may be additional symptoms; namely delusions &
hallucinations
( psychotic depression ).
Delusion namely; worthlessness, guilt, ill-health,
poverty,hypochodriacal delusions, delusion of
impoverishment, nihilistic delusions & delusion of
persecution.
Perceptual disturbances; fall short of hallucinations but few
experience true hallucinations usually auditory.
Suicidal ideas & rarely homicidal ideas; particularly
important when related to young children.
Variants of depression
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Agitated depression: is applied to depressive disorders in
which agitation is severe, common in middle-aged &
elderly.
Retarded depression: is applied to depressive disorders in
which psychomotor retardation is prominent, may lead to
depressive stupor.
Depressive stupor: is a rare variant of severe depression,
the patient is motionless, mute& refusing tp eat & drink.
Atypical depression: a minority of patients have severe
anxiety, severe fatigue, increased sleep & increased
appetite.
Seasonal affective disorder (SAD): some people develop
depression at the same time of the year.
Who develops depression?
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Certain events in life are known to precipitate depression;
reaction to loss of a parent in early childhood, a limb or
another part of the body ( mastectomy), miscarriage,or loss
of self-esteem, divorce or separation.
Women more prone to depression premenstrually, after
childbirth & at menopause.
A prepubertal child may develop depression as a reaction
to organic or environmental ( familial or scholastic )
conditions.
The confusing social, emotional & physical changes
experienced in adolescence may cause depression.
Depression is common in the elderly especially when there
is loneliness, isolation or bereavement.
What somatic symptoms are
suggestive of depression ?
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The more insightful & articulate patient may help in the
diagnosis of depression.
In depressed patient many physical discomforts are often of a
psychosomatic in nature.
Complaints of gastrointestinal disturbance, headache,
muscular pains, backache, menstrual disturbances, thoracic
pain, etc. are common.
Physical examination & laboratory procedures need to be
conducted to exclude possible organic causes. These may
include anaemia, hypothyroidism, neoplasm, chronic fatigue
syndrome, cardiac diseases, peptic ulcer, bowel disease as
well as other somatic diseases.
Management
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A full psychiatric & physical examination
should be completed & any underlying organic
cause identified & treated.
If no organic cause exists, the best approach to
treatment will often be individualized & global
in nature integrating pharmacotherapy,
psychotherapy & prophylactic measures.
Medication may be particularly necessary
when the depression is associated with genuine
somatic condition
Psychopharmacology
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Anxiolytics such as benzodiazepines are effective in
treating anxiety.
Antidepressants of choice would be an agent which has
been demonstrated to be safe & effective without sedation
& other adverse effects including anticholinergic,
potentiation with alcohol, drug interaction & toxicity in
case of suicide attempt.
In general practice, tricyclic antidepressants are widely
prescribed ( Imipramine & amitryptyline).
New agents have been developed which act more rapidly,
are less toxic & nonsedating (Prozac,seroxat, zoloft,
faverin, effexsor & cipram ).