Transcript Depressionx
DEPRESSION EPIDEMIOLOGY AND BURDEN Depression is a highly prevalent condition About one in a seven will experience depression during their lifetime Many people with depression will have a recurrent or chronic course Depression is the fourth leading cause of disability worldwide Depression results in work absence and loss of productivity leading to significant economic loss AETIOLOGY OF DEPRESSION Biological (genetics), psychological (life events), and social factors (lack of social support) are involved in the etiology and pathophysiology of depression Stressful life events and stress reactivity can modify genetic and biological processes FACTORS PREDICTING PROLONGED COURSE OF DEPRESSIVE EPISODE • Severe depression • Alcohol and drug abuse • Comorbid illness • Psychotic features • Poor social support • Early age of onset • Long duration • Low levels of functioning prior to depression CLINICAL FEATURES OF DEPRESSION Depressive symptom Presentation Sleep Insomnia or hypersomnia Interest/pleasure Decreased (anhedonia) Guilt Increased; Irrational thoughts Energy Decreased (fatigue) Concentration Decreased (indecisive) Appetite Decreased or increased Psychomotor activity Agitation or retardation Suicide Thoughts, plans, attempts TYPES OF DEPRESSION Types of depression Major depressive disorder Severity of depression Dysthymia Moderate Depressive disorder, not otherwise specified Severe Minor depressive disorder Premenstrual dysphoric disorder Mild MAJOR DEPRESSIVE DISORDER Five or more of the following for at least 2 weeks: 1. Depressed mood 2. Loss of interest in pleasure 3. Significant weight loss 4. Insomnia or hypersomnia 5. Psychomotor agitation or retardation 6. Fatigue 7. Excessive guilt or feelings of worthlessness 8. Diminished ability to think or concentrate 9. Recurrent thoughts of death DYSTHYMIA Depressed mood for at least 2 years Two or more of the following: A. B. 1. 2. 3. 4. 5. 6. Poor appetite or overeating Insomnia or hypresomnia Low energy or fatigue Low self esteem Indecisive or poor concentration Feelings of hopelessness MINOR DEPRESSIVE DISORDER Episodes of at least 2 weeks of depression Fewer than five items required for major depressive disorder RISK FACTORS FOR SUICIDE EPISODE RELATED Current suicidal plans Prior attempts Severe depression Hopelessness and guilt Bipolarity Mixed state (with agitation) Psychotic features Substance abuse Serious medical condition Anxiety RISK FACTORS FOR SUICIDE DEMOGRAPHICS Male Adolescent or elderly Early onset of mood disorder Family history of suicide Adverse childhood experiences Adverse life circumstances Recent stressor Lack of social support DIFFERENTIAL DIAGNOSIS Substance induced mood disorder Bereavement Mood disorder due to a general medical condition COMMON DRUGS OF ABUSE CAUSING DEPRESSION Alcohol Amphetamines Anti-anxiety drugs Cocaine Hallucinogens Hypnotics Inhalants Opioids Sedatives DEPRESSION DUE TO GENERAL MEDICAL CONDITIONS • • • Diabetes Cardiovascular disease Neurological – – – • Systemic disorders – • • Viral and bacterial infections Endocrine disorders – • CNS infections Epilepsy Sleep apnoea Thyroid disorders Vitamin deficiencies (B12/Folate; Vitamin C; Niacin; Thiamine) Others – – AIDS Cardiopulmonary disease MANAGEMENT OF DEPRESSION Phase 1: Acute phase - to achieve full remission of depressive symptoms Phase 2: Maintenance phase - to prevent relapse and recurrence ACUTE PHASE MANAGEMENT OF DEPRESSION 8-12 weeks of treatment Goal: remission of symptoms Establish therapeutic alliance Educate patients and relatives Aid self management Choose treatment(s) Manage side effects Monitor and follow-up MAINTENANCE PHASE MANAGEMENT OF DEPRESSION 6-24 months or longer of treatment Goal: prevention of relapse and recurrence Educate patients and relatives Aid self management Manage side effects Rehabilitate work and social function Monitor for recurrence PHARMACOTHERAPY RECOMMENDATIONS Minimum six months treatment after full remission of symptoms At least 2 years (for some lifetime) Severe episodes Chronic episodes Comorbidity Difficult-to-treat episodes Frequent episodes PATIENT/FAMILY EDUCATION Explain depression in terms of biochemical basis: “Depression is an illness, not a weakness” Early diagnosis and treatment is important for recovery Reducing and stopping medications without medical advice is wrong Monitor weight; advise exercise and food plans PATIENT EDUCATION MESSAGES TREATMENT Antidepressants Medications It are not addictive daily, as prescribed may take 2-3 weeks before any relief is seen Mild time side effects are common, they get better over Medications should not be stopped without medical advice SELECTING AN ANTIDEPRESSANT The first line medications are selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) They are preferred over tricyclic antidepressants (TCAs) SELECTING AN ANTIDEPRESSANT Efficacy Side effect profile Concurrent medication Comorbidity Subtype of depression Simplicity of use Cost SSRIS Mechanism Common Drug of action side effects Selective inhibition of serotonin reuptake GI distress, nausea, vomiting, diarrhoea Headache, agitation, sleep disturbance, drowsiness, dry mouth, sexual side effects Daily dose Escitalopra 5-20 mg m Fluoxetine 20-80 mg Sertraline 50-200 mg Paroxetine 20-60 mg Fluvoxamin 100-300 mg e TCAS Mechanism Common Drug of action side effects Inhibition of serotonin and norepinephrin e reuptake Dry mouth, blurred vision, constipation, urinary retention, confusion drowsiness, sedation, weight gain, nausea, tremor, headache, seizures, sexual dysfunction Imipramine Daily dose 75-300 mg Amitryptaline 75-300 mg Cloimipramin 75-300 mg e Dothiepin 75-300 mg Nortrptaline 75-150 mg OTHER EVIDENCE BASED THERAPIES FOR DEPRESSION Electro Convulsive therapy (ECT) Exercise, therapy wake therapy and light Psychotherapy Cognitive Behaviour therapy Family therapy Interpersonal psychotherapy CONCLUSION Depression a disabling illness Can be recurrent and chronic There are cognitive, emotional and physical symptoms of depression Suicide in a important risk of depression Depression can be treated effectively with evidence based therapies such as antidepressants, ECT and psychotherapy