Transcript PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax: 4970847

Module 5
Depression in primary
care
INTRODUCTION TO PRIMARY CARE:
A C O U R S E O F T H E C E N T E R O F P O S T G R A D U AT E S T U D I E S I N F M
DR WEDAD BARDISI
PO Box 27121 – Riyadh 11417
Tel: 4912326 – Fax: 4970847
Objectives
 Know thhe prevalence of depression in KSA
 know the size of the problem in primary health care.
 Encourage trainee to use DSM IV diagnostic criteria.
 Encourage recognition of depression and determine its
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cause & classification.
know proper history taking and physical examination.
know evidence based management options.
Know methods of screening for depression in family
practice.
know how to do proper follow up.
know when to refer.
Size Of The Problem
 The World Health Organization ranks major depression
among the most burdensome diseases in the world
 Approximately 5 to 10 percent of primary care patients
meet DSM-IV criteria for major depression, 3 to 5 percent
for dysthymia, and 10 percent for minor depression.
 About 70%-80% of all psychiatric patients had been firstly
visit their Family physician or primary care doctors before
seen by psychiatrist.
 Depression often Goes Undetected
Prevalence
 Depression symptoms are very common. 13 to 20% of the
population being affected at any one time.
 In KSA the prevalence is similar to that of world wide i.e
20%.
 The prevalence of major depression is estimated at 10 to 20
percent in patients with medical illnesses such as diabetes
and heart disease.
 Women are affected more than men.
Major Depressive Disorder(MDD)
 Major depression is a relapsing, remitting illness in
most patients.
 Recurrence rate is 40% following the first episode
over two years.
 After two episodes, the risk of recurrence within five
years is approximately 75 percent.
 10 to 30 % of patients treated for a major depressive
episode will have an incomplete recovery, with
persistent symptoms or dysthymia
 Depression if untreated or inadequately treated , is a disease associated
with high mortality, morbidity and economic costs, and danger serious
disorder 15% of the patient commit suicide.
 Many patients find a diagnosis of depression difficult to accept
Suicide rate by age and gender. 2004 data compiled from CDC. The
mean suicide rate for the entire population was 12.8/100,000/year.
Classification
according to DSM IV
1.
Major depressive disorder ( Unipolar).
2.
Dysthymic disorder (mild sepression)- At least 2 years of lowerlevel depressive symptoms
3.
Bipolar depression - A major depressive episode arises in a
patient with a history of hypomanic, manic, or mixed episodes
4.
Adjustment disorder - Emotional or behavioral symptoms that
arise in response to an identifiable stressor and that cease once
the stressor has terminated
Predisposing Factors
 (1) Genetic & familial factors.
 (2) Impaired social supports
 (3) Loneliness.
 (4) Bereavement.
 (5) Negative life events.
 (6) Childhood abuse and neglect.
 (7) postpartum.
 As well as cumulative load of stressors like:
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- Unhappy marriage.
- Problems at work.
- Unsatisfactory housing.
- Lack of employment.
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- Lack of confiding relationship.
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OTHER ILLNESSES CAN CAUSE DEPRESSIVE SYMPTOMS
• DM, hypothyroidism, hyperthyroidism, rheumatoid arthritis
Chronic
diseases
• Chronic infections: infectious mononucleosis, hepatitis, herpes
zoster, tuberculosis.
• Cancer of lung, brain, or head of pancreas
Neurologic •Parkinsonism, Cerebrovascular accident, multiple sclerosis,
Alzheimer's disease
Pharmacolo
gic
• Steroids, beta blockers, reserpine, , antibiotics, barbiturates,
alphamethydopa.
• Alcoholism &Drug addiction
Clinical Picture
MOOD
SYMPTOMS
PSYCOLOGICAL
SYMPTOMS
•Sad
•Depressed
• anhedonia
•Greif
•Suicidal Ideas.
•Guilt Feeling
• Low Self Esteem
•Lack Of
Concentration
SOMATIC
SYMPTOMS
•Disturbed sleep
pattern.
•Appetite change.
•Weight change.
•Decreased sexual
drive.
•Loss of energy,
fatigue.
CATEGORIES OF
DEPRESSIVE
SYMPTOMPS
BEHAVIOURAL
SYMOPTOMS
•Retardation
•Agitation.
•Negligence Of Work
•Negligence Of Social
Activity
MOST COMMON PRESENTING SYPMTOMS
 Sleep disturbance.
 Fatigue
 Pain.
 Anxiety.
 Irritability
 Gastrointestinal disorders.
Unexplained Somatic symptoms:
C.V.S
 Palpitation
 Pseudoanginal pain.
Respiratory :
 Dyspnea
 Hyperventilation .
Gastrointestinal
 Vomiting
 Bowel disturbance
 Colics
Musculosklettal
 Low backache
Genitourinary
 Frequency micurition
 Impotence Vs premature
ejaculation
 Dysparonia
 frigidity
Diagnostic criteria for major depressive episode (adapted
from DSM-IV-TR 17 )
 At least 5 of the following symptoms have been present during the same
2-week period and represent a change from previous functioning. At
least 1 of the symptoms is either #1 or #2.
1.
Depressed mood most of the day, nearly every day
2.
Markedly diminished interest or pleasure in all, or almost all,
activities most of the day ( TWO SCREENING QUESTIONS)
3.
Significant weight loss when not dieting, or weight gain, or
decrease or increase in appetite
4.
Insomnia or hypersomnia
5.
Psychomotor agitation or retardation
6.
Fatigue or loss of energy
7.
Feelings of worthlessness or excessive or inappropriate guilt
8.
Diminished ability to think or concentrate, or indecisiveness
9.
Recurrent thoughts of death, recurrent suicidal ideation without a
specific plan, or a suicide attempt or a specific plan for committing
suicide
Screening of depression in primary care
 Key symptoms:
 • persistent sadness or low mood; and/or
 • loss of interests or pleasure
 • fatigue or low energy.
 At least one of these, most days, most of the time for
at least 2 weeks.
NICE Guideline – depression (amended April 2007) 
61
 If any of above present, ask about 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
 Then ask about past, family history, associated disability
and availability of social support
1. Factors that favour general advice and watchful waiting:
• four or fewer of the above symptoms
• no past or family history
• social support available
• symptoms intermittent, or less than 2 weeks duration
• not actively suicidal
• little associated disability.
 2-Factors that favour more active treatment
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in primary care:
• five or more symptoms
• past history or family history of depression
• low social support
• suicidal thoughts
• associated social disability.
 3. Factors that favour referral to mental
health professionals:
 • poor or incomplete response to two interventions
 • recurrent episode within 1 year of last one
 • patient or relatives request referral
 • self-neglect.
 4-Factors that favour urgent referral to a
psychiatrist:
 • actively suicidal ideas or plans
 • psychotic symptoms
 • severe agitation accompanying severe (more than
10) symptoms
 • severe self-neglect.
ICD-10 definitions
 Mild depression: four symptoms
 Moderate depression: five or six symptoms
 Severe depression: seven or more symptoms, with or
without psychotic features
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NICE Guideline – depression (amended April 2007)
Physical Examination
 The physical examination of a patient with depression may
reveal evidence of malnutrition or poor self-care.
 The mental status examination is central to the diagnosis
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of depression, and includes the following components:
Appearance and behavior.
Mood and affect.
Thought processes and speech.
Thought content
Cognition.
Dysthymia (mild depression)
Dysthymia: is a chronic mood disorder with a duration of at least
2 years (1 year in adolescents and children).
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It is manifested as depressed mood accompanied by at
least 2 of the following symptoms:
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Poor appetite or overeating
Insomnia or hypersomnia
Low energy or fatigue
Low self-esteem
Poor concentration
Difficulty making decisions
Feelings of hopelessness
Bipolar affective disorder
DSM IV
Manic episodes are characterized by the following
symptoms:
At least 1 week of profound mood disturbance is present,
characterized by elation, irritability, or expansiveness
OR Hypomanic episodes are characterized by the
following:
An elevated, expansive, or irritable mood of at least 4 days' duration
Alternating with major depressive episodes.
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Adjustment disorder
DSM IV
 A "maladaptive reaction to an identifiable
psychosocial stressor, or stressors, that occurs within
3 months after onset of that stressor..
The condition is:
 Acute: If the disturbance lasts less than 6 months.
 Chronic: If the disturbance lasts 6 months or longer.
A typical presentation
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In the primary care setting, the presenting complaints often
can be somatic, such as fatigue, headache, abdominal distress,
or change in weight.
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Patients may complain more of irritability than of sadness or
low mood.
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Elderly persons may present with confusion or a general
decline in functioning.
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Children with major depressive disorder may also present with
irritability, decline in school performance, or social withdrawal
Assessment of suicidal ideation
 Assessment for the presence of suicidal ideation is of paramount
importance in all depressed patients.
 Evaluation for suicide risk should include assessment of the
following :
 Presence of suicidal or homicidal ideation, intent, or plan
 Access to means for suicide and the lethality of those means
 Presence of psychotic symptoms, command hallucinations, or severe
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anxiety
Presence of alcohol or substance use
History and seriousness of previous attempts
Family history of or recent exposure to suicide
Evaluation in an emergency department and/or hospitalization should
be considered for patients at significant risk of suicide.
Management
 A wide range of effective treatments is available for major
depressive disorder.
 Brief psychotherapy (eg, cognitive behavioral therapy,
 interpersonal therapy).
 Patients who do not respond after 12 weeks of initial
psychotherapy should be started on an antidepressant.
 However, the combined approach generally provides the
patient with the quickest and most sustained response
Pharmacological Treatment
Phase 1 • Treatment of the acute phase 4-6 weeks.
• Consolidation treatment to ensure that episode
Phase 2 has been adequately treated 4-6 months
• Prophylactic to reduce risk of recurrence after
Phase 3 a period of symptom free
PHARMACOLOGICAL TREATMENT………
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Tricyclic antidepressant.(side effects are problem)
 MAOI ( not used frequently)
 SSRI
Side effects of TCA:
 Antimuscarinic side effects like:
 Dry mouth, blurring of vision, urinary retention, sweating and
constipation.
 Postural hypotension .
 Arrhythmia.
 Convulsion
 Increase appetite and weight gain
Examples of TCA
Amitryptaline
( Tryptizol)
dose 25-75 mg daily
Clomipramine
(Anafranil)
Imipramine
(Tofranil)
dose: 10 mg - 150mg
dose :75-200 mg
Nortryptyline
( Ativan)
Dose :75-100 mg daily.
Doxepine
(sinequan)
dose: 75 m- 300mg daily
in 3 divided doses
 MAOI :
Less frequently used because of dangerous interactions with foods and drugs.
Side effects:
Postural hypotension, drwsiness, headache, dry mouth costipation, oedema
tremors,hypereflexia, sexual disturbances, and blood and liver diorders.
 e.g Phenelzine ( Nadril) : dose 15 mg 3 times daily , max.30mg daily
The SSRIs
All share several characteristics
Low
side
effects
Safe in
over dose
SSRI
Low affinity
for histamin&
cholinergic
receptors
Hepatically
metabolized
Examples of SSRI
Fluoxetine (prozac)
Dose 20mg up to
80mg
Paroxetine
( seroxat)
Dose 50 mg up t0
200mg
Sertralin
( Lustral)
Dose 50- 200mg
Flufoxamine
( faverin)
Dose 50 mg up to
250
Venlafaxine
(Efexor)
50-200 mg
St. John's wort (Hypericum perforatum)
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St. John's wort is considered a first-line antidepressant in
some countries
Used to treat of mild-to-moderate depressive symptoms.
It acts as an SSRI.
The dose is 300 mg 3 times a day with meals to prevent GI
upset.
 side effects include:
 gastrointestinal upset, increased anxiety, minor
palpitations, fatigue, restlessness, dry mouth, headache,
and increased depression.
Clinical course
Is classified using six categories:
1.
Response — Significant reduction (usually >50 percent) of depressive
symptoms during the acute treatment phase.
2.
Remission — A period of ≥2 weeks and <2 months with no clinically
significant depressive symptoms.
3.
Partial remission — A period of ≥2 weeks and <2 months with one or
more clinically significant depressive symptom(s).
4.
Relapse — An episode of depression during the period of remission.
5.
Recovery — A asymptomatic period of more than two months.
6.
Recurrence — The emergence of symptoms of MDD during the period of
recovery (a new episode).
Referral
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Referral to a psychiatrist or to a treatment centre should be considered in the following
circumstances:
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1- If the patient is expressing a suicidal intent or if there was a recent suicide attempt
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2- If the patient is elderly, confused and presentation of the history is unclear
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3- If the presenting symptoms of the disorder are severe, e.g., severe weight loss or
weight gain , severe physical damage from drinking, severe withdrawal symptoms,
several unsuccessful attempts to quit drinking.
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4- If the diagnosis is not clear
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5- If the treatment fails after the patient has received an appropriate medication trial
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6- If the management requires hospitalization or intensive treatment e.g. extreme
hostility, aggression or homicide
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7- If there is one of comorbidity with severe physical or other mental disorders