Depressive Illness

1
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/ psychophar
macology20and20serotonin.ppt
2

• Neurotics build castles in the air
• Psychotics live in them and enjoy
• Psychiatrists collect rent for those castles

3
Traditional model of Disease Development
Pathogen
Disease (pathology)
Modifiers Lifestyle Individual susceptibility
4
Dominance of the biopsychosocial
model Mainstream in last 15 years
Hazard
Illness (well-being)
Psychosocial Factors Attitudes Behaviour Quality
of Life
Rise of the person as a psychological entity
5
MDD and Anxiety Disorders
Major Depression
AnxietyDisorders
59
6
Association of Psychiatric Disorders
7
MDD Indian Facts and Figures
Total population approx.103 crores (2001 census)
Common disorder
Total no of depressed patients approx. 9 crores
Bangalore 9.1 (WHR 2001)
Depressed patients per psychiatrist approx.
25,714
The World Health Report 2001 accessed from
http//www.who. int/whr2001/2001/main/en/contents.
htm. last accessed on 30.12.02 WHR 2001 Box 3.8
Two national approaches to suicide prevention
8

• Spectrum of mood disturbance
• Mild thru to Severe
• Transience thru to Persistence
• Continuous distribution in population
• Clinically significant when
• (1) interferes with normal activities
• (2) persists for min. 2 weeks
• Diagnosis of depression / depressive disorder
• Persistent pervasive low mood
• Loss of interest or pleasure in activities

9
Depressive Illness Usually treatable Common Mar
ked disability Reduced survival Increased
costs Depression may be Coincidental
association Complication of physical illness
Cause of / Exacerbation of somatic symptoms
10
Depressive Illness 2 of population suffer from
pure depression (evenly distributed between mild,
moderate, and severe) Further 8 suffer from a
mixture of anxiety and depression Patients with
symptoms not severe enough to qualify for
diagnosis of either anxiety or depression.....
??? Impaired working and social lives and many
unexplained physical symptoms Greater use of
medical services
11

• Epidemiology
• 2nd biggest cause of disability
• worldwide by 2020 (WHO)
• (IHD still the biggest)
• Associated with increased
• physical illness
• 5 during lifetime have MDD
• 1 in 20 consultations
• MDD Dysthymia gt in females
• 20 develop chronic depression
• 30 of in-patients have depressive symptoms

12
MDD 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)
The World Health Report 2001 accessed from
http//www.who. int/whr2001/2001/main/en/contents.
htm. last accessed on 30.12.02
13
PRIME MD TODAYTM
Primary Care Evaluation of Mental Disorders
A Screening and Diagnostic Instrumentfor Major
Depressive Disorder (MDD)
Kaplan Sadocks Synopsis of Psychiatry, 8th
ed., p 941 Harrisons Principles of Internal
Medicine, 15th ed., p 2543
14
Suicide
15

• Suicide
• Final clinical pathway
• 1 million deaths per year, 10-12 million attempts
• Males most common in older
• Female most common in middle age
• 15 per 100,000 deaths males
• 6 per 100,000 deaths females

16

• Almost 50 fail on first attempt
• Previous attempters 23 times more likely to dies
  from suicide than those without previous attempts
• Internal stress
• Pre-existing psychiatric morbidity
• Demographics
• Opportunities

17
Behavioural Indicators - recent bereavement or
other life-altering loss - recent break-up of a
close relationship - major disappointment
(failed exams or missed job promotion) - change
in circumstances (retire, redundant or children
leaving home) - physical illness - mental
illness - substance misuse / addiction -
deliberate self-harm, (particularly in women) -
previous suicide attempts - loss of close friend
/ relative by suicidal means - loss of status -
feelings of hopelessness, powerlessness and
worthlessness - declining performance in work /
activities (sometimes this can be reversed) -
declining interest in friends, sex, or previous
activities - neglect of personal welfare and
hygiene - alterations in sleeping habits (either
direction) or eating habits
18

• Epidemiology
• Depression more common in those with
• Life threatened / limited / chronic physical
  illness
• Unpleasant / demanding treatment
• Low social support
• Adverse social circumstances
• Personal / family history of depression /
  psychological vulnerability
• Substance misuse
• Anti-hypertensive / Corticosteroid /
  Chemotherapy use

Q o L
19
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
20

• Clinical Features
• Adjustment Disorders
• mild
• short-lived
• reactive episodes
• Major Depressive Disorder (MDD)
• 5 symptoms displayed in 14 days
• Dysthymia
• depressed mood for 2 years
• not severe
• chronic depression
• unhealthy lifestyle associations
• Bipolar Disorder / manic depression
• major depression mania

21

• Major depression (DSM IV-TR)
• 5 or more..
• decreased interest / pleasure
• depressed mood
• reduced energy
• weight gain / loss
• insomnia / hypersomnia
• feeling worthless
• guilt
• recurrent morbid thought
• psychomotor changes
• fatigue
• poor concentration
• pessimism / bleak views
• self harm ideas / actions
• suicide ideation

22

• Classification of Depression (ICD-10)
• PrimaryUnipolar
• Mixed anxiety and depressive disorder (prominent
  anxiety)
• Depressive episode (single episode)
• Recurrent depressive disorder (recurrent
  episodes)
• Dysthymia - Persistent and mild ("depressive
  personality")
• Bipolar
• Bipolar affective disorder - manic episodes
  ("manic depression")
• Cyclothymia - Persistent instability of mood
• Other primary
• Seasonal affective disorder
• Brief recurrent depression
• Depressive episode may be
• Moderate or severe
• With/Without somatic syndrome
• With/Without psychotic symptoms

23

• Somatization Syndrome (DSM IV)
• 4 or more..
• Anhedonia (inability experience pleasure)
• Loss of emotional reactivity
• Early waking (gt2 hours early)
• Psychomotor retardation or agitation
• Marked loss of appetite
• Weight loss gt5 of body mass in one month
• Loss of libido (important and often ignored)

24

• 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

25

• Risk Factors
• Anxiety Sadness Somatic discomfort
• Normal psychological response to life stress
• Clinical depression is a final common pathway
• Resulting from interaction of biological,
  psychological, and social factors
• Likelihood of this outcome depends on many
  factors
• genetic and family predisposition
• clinical course of concurrent medical illness
• nature of any treatment
• functional disability
• individual coping style
• social and other support

26

• 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 assumed
• that symptoms (weakness or fatigue) are due to an
  underlying medical
• condition.
• 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.

27
Screening 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 instruments Beck
Depression Inventory (BDI) General Health
Questionnaire (GHQ) Hospital Anxiety Depression
Scale (HAD) Cant replace systematic clinical
assessment LISTENING Persistent low mood and
lack of interest and pleasure in life cannot be
accounted for by severe physical illness alone
28
Simplified Algorithm
29
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 (MAOIs) rare fatalities tyramine-free
diet Selective Serotonin Re-uptake Inhibitors
(SSRIs) fluoxetine lack sedation -
no anticholinergic effects improved compliance
less immediate benefit for disturbed sleep safe
in overdose single or narrow range of doses works
30
Drug Treatment Selective Serotonin Re-uptake
Inhibitors (SSRIs) - Newer Sertraline
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 (SSRIs) 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
31
Comparative Tolerability
32

• 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

33

• Management
• The main aims of treatment
• improve mood and quality of life
• reduce the risk of medical complications
• improve compliance with and outcome of physical
  treatment
• facilitate the "appropriate" use of healthcare
  resources
• Primary care staff should be familiar with
  properties and use of
• 1) common antidepressant drugs brief
  psychological treatments
• 2) assessment of suicidal thinking and risk
• Patients with more enduring or severe symptoms
  will usually require specific treatment - usually
  drug therapy
• For patients with suicidal ideation / whose
  depression has not responded to initial
  management, specialist referral is the next step

34
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

35

• Summary
• Detection can be hard symptom overlap and
  patient unaware
• Depression a natural occurrence in population
• Whole range of depressive conditions with
  varying severity
• Depression can be present in acute or chronic
  states
• Depression can have physiological, biological or
  social causes
• Depression may have a mixture of causes
• Depression co-exists with many other symptoms
• Depression is a natural reaction to disease
  diagnosis and presence
• Depression and symptomotology are highly related

36
(No Transcript)
37
The good physician treats the disease, but
the great physician treats the person.
William Osler
38
Thank You