1 Depression in adults Yousuf Al Farsi
2 Objectives 1. Aetiology 2. Classification 3. Major depression 4. Screening 5. Differential diagnosis 6. Treatment approach 7. When to refer 8. Complication 9. Prognosis
3 Introduction Depression is a major public health problem and a leading predictor of functional disability and mortality. The annual economic consequences of depression have been estimated at 83 billion dollars in the United States and 118 billion euros in Europe. Optimal depression treatment improves outcomes for most patients.
4 Introduction Although most adults with clinically significant depression never see a mental health professional, they often see a primary care physician. Yet substantial numbers of depressed primary care patients remain undiagnosed or under-treated, reflecting practices of physicians, patients, families, and health care systems. A systematic review of 36 studies found that nonpsychiatric physicians missed the diagnosis of depression in over one half of patients seen Cepoiu, M, McCusker, J, Cole, MG, et al. Recognition of depression by non-psychiatric physicians--a systematic literature review and metaanalysis. J Gen Intern Med 2008; 23:25.
5 Aetiology The aetiology of depression remains poorly understood. Integrative models, taking into account biological and social variables, most effectively reflect the complex aetiology. Susceptibility to a depressive disorder is 2 to 4 times greater among the first-degree relatives of patients with a mood disorder than among other people.
6 Aetiology It is unclear whether a gene X environment interaction can help explain susceptibility to depression or predict response to treatment. A meta-analysis in 2009 show that stressful life events have a potent relationship with the risk of depression
7 Classification Diagnostic and statistical manual of mental disorders, 4th edition (dsm-iv). 1. Major depression 2. Minor depression 3. Dysthymia.
8 Major depression 1. Depressed mood 2. Loss of interest or pleasure in most or all activities 3. Insomnia or hypersomnia 4. Change in appetite or weight 5. Psychomotor retardation or agitation 6. Low energy 7. Poor concentration 8. Thoughts of worthlessness or guilt 9. Recurrent thoughts about death or suicide
9 Major depression Eight of these symptoms (all but depressed mood) may be more readily recalled using the mnemonic "SIG: E CAPS" SCAP, SIGE S: Suicide C: Concentration A: Appetite P: Psychomotor S: Sleep I: Interest G: Guilt E: Energy
10 Major depression A major depressive syndrome or episode manifests with five or more of these symptoms, present most of the day nearly every day for a minimum of two consecutive weeks. At least one symptom is either depressed mood or loss of interest or pleasure.
11 Major depression 1. Depressed mood 2. Loss of interest or pleasure in most or all activities 3. Insomnia or hypersomnia 4. Change in appetite or weight 5. Psychomotor retardation or agitation 6. Low energy 7. Poor concentration 8. Thoughts of worthlessness or guilt 9. Recurrent thoughts about death or suicide
12 Major depression In addition, these symptoms: 1. Do not meet criteria for a mixed episode (a state in which a patient simultaneously has symptoms of depression and mania for at least 1 week) 2. Are not related to substance abuse 3. Are not related to a grief reaction. 4. Cause functional impairment (e.g., social, occupational)
13 Major depression There are 3 subcategories of major depression: 1. Mild: 2. Moderate: 3. Severe:
14 Major depression There are 3 subcategories of major depression: 1. Mild: symptoms more than number required for diagnosis of major depression with minor functional impairment 2. Moderate: more than required number of symptoms for diagnosis of depression with greater intensity and moderate impairment in functioning 3. Severe: many more symptoms than required for diagnosis of depression with intense functional impairment; psychotic features such as hallucinations or paranoia may be present.
15 CLASSIFICATION Diagnostic and statistical manual of mental disorders, 4th edition (dsm-iv). 1. Major depression 2. Minor depression 3. Dysthymia.
16 Minor depression The patient suffers from 2 to 4 depressive symptoms, including either sad mood or anhedonia for at least 2 weeks.
17 Minor depression Terminology used in the literature for these has varied, including 1. Minor 2. Sub-syndromal 3. Sub-threshold depression
18 Dysthymic disorder The patient has 3 or 4 dysthymic symptoms, including depressed mood, for 2 years. Dysthymic symptoms are as follows: 1. Depressed mood 2. Appetite changes 3. Sleep changes 4. Low self-esteem 5. Fatigue 6. Poor concentration 7. Hopelessness.
19 Screening The National Institute for Health and Clinical Excellence (NICE), The Canadian Task Force on Preventative Care and the U.S. Preventive Services Task Force advocate screening for depression in primary care.
20 Screening There is no proven recommendation for screening frequency; however, clinicians should consider repeated screenings of patients with a history of depression,
22 SCREENING TOOL
23 Patient Health Questionnaire-2 (PHQ-2) The PHQ-2 is quickly and accurately screens for depression with only 2 questions: 1. "Over the past 2 weeks have you felt down, depressed, hopeless? 2. "Over the past 2 weeks have you felt little interest or pleasure in doing things? A positive response to either question warrants a thorough review of the DSM-IV-TR criteria or an equivalent tool.
24 Diagnostic tests 1. Edinburgh Postnatal Depression Scale 2. Geriatric Depression Scale 3. Cornell Scale for Depression in Dementia 4. FBC : normal 5. TFT : normal
25 Other Diagnostic tests
26 Differential Diagnosis Bipolar disorder Pre-menstrual dysphoric disorder(pmdd) Grief reaction Dementia Anxiety disorder Alcohol abuse Anorexia nervosa Hypothyroidism Medicine adverse effects Cushing s disease Vitamin B12 deficiency
27 Treatment Approach The goals of treatment are: 1. To eradicate symptoms of depression. 2. Improve daily functioning and quality of life. 3. Reduce suicidality. 4. Minimize treatment adverse effects. 5. Prevent relapse.
28 When To Refer 1. Severe depression that is endangering the life of the patient (ie, suicidality or inability to care for self) or others (aggressivity or inability to care for dependent others). 2. Depression that has failed to respond to initial treatment trials. 3. Psychotic depression. 4. Depression that is part of the course of bipolar disorder, schizoaffective disorder, or another major psychiatric illness
29 When To Refer 5. Patients for whom the diagnosis of depression (or its comorbidities) is uncertain 6. Desire to treat with psychotherapy, light therapy, electroconvulsive therapy, or other modalities requiring specialty expertise.
30 Treatment approach Treatment modalities include : 1. Medication. 2. Psychotherapies. 3. Supportive interventions. 4. Electroconvulsive therapy (ECT).
31 Treatment approach 1. Psychotic, suicidal, or severe psychomotor retardation 2. Severe disease without psychotic symptoms, suicidal ideation, or severe psychomotor retardation 3. Mild to moderate disease
32 1. Psychotic, suicidal, or severe psychomotor retardation ECT is generally considered the first-line treatment for depressed patients with psychotic features or active suicidal thoughts. ECT is performed under general anaesthesia, twice or three times a week for a total of 6 to 12 treatments. Alternative first-line options are the psychotherapy and antidepressant regimens recommended for severe disease
33 2. Severe disease without psychotic symptoms, suicidal ideation, or severe psychomotor retardation Fist line: 1. Second or third generation antidepressant 2. Psychotherapy 3. Supportive interventions Second line: 1. Switch to tricyclic antidepressant or combination therapy
34 2. Severe disease without psychotic symptoms, suicidal ideation, or severe psychomotor retardation Severely depressed patients derive the greatest benefit from the combination of antidepressants and psychotherapy. [B Evidence]
35 2. Severe disease without psychotic symptoms, suicidal ideation, or severe psychomotor retardation The choice of medication should be based on patient preference, tolerability, and past evidence of effectiveness in the patient or in a family member. 1. Selective serotonin-re-uptake inhibitor (SSRI)(e.g., Fluoxetine, paroxetine) 2. Serotonin-noradrenaline (norepinephrine) reuptake inhibitor (SNRI), ( venlanfaxine) 3. Dopamine re-uptake inhibitor (e.g., Bupropion), 4. 5-ht2 receptor antagonist (e.g., Mirtazapine)
36 Psychotherapy With concomitant psychotherapy is considered first-line therapy. 1. Cognitive behavioral therapy (CBT) 2. Interpersonal psychotherapy (ITP) 3. Problem solving therapy (PST)
37 2. Severe disease without psychotic symptoms, suicidal ideation, or severe psychomotor retardation Patients should be seen in follow-up 1 to 2 weeks after initiating therapy, then monthly for the next 12 weeks. to monitor symptoms over time. adverse effects, suicidality, and acceptance of medicine taking, and to reinforce educational messages Patients who experience a partial response to antidepressants after 2 to 4 weeks should have the dose titrated to the maximum tolerated. Treatment should be continued for 4 to 9 months following remission.[a Evidence]
38 2. Severe disease without psychotic symptoms, suicidal ideation, or severe psychomotor retardation If the response to first-line therapy is inadequate, switching to an alternative antidepressant regimen should be considered. [B Evidence]
39 2.Severe disease without psychotic symptoms, suicidal ideation, or severe psychomotor retardation Alternative options include monotherapy with a tricyclic antidepressant e.g. Amitriptyline, [B Evidence] Desipramine, doxepin, imipramine, or nortriptyline or combination therapy (i.e., SSRI or SNRI plus bupropion or mirtazapine).
40 2. Severe disease without psychotic symptoms, suicidal ideation, or severe psychomotor retardation ECT is an option for those who have not responded to or cannot tolerate antidepressants. [B Evidence]
41 3. Mild to moderate disease The initial choice of therapy should be guided by patient preference and includes: 1. Psychotherapy 2. Antidepressants 3. Supportive interventions: self-help books, yoga, relaxation training, light therapy, and acupuncture.
42 3. Mild to moderate disease Patients with mild to moderate depression do equally well with either cognitive behavioural therapy B Evidence]. or antidepressants. [C Evidence]. Psychotherapy is considered as first line option in mild to moderate depression. Usually time response is 12 weeks Combination psychotherapy and medication offers no demonstrated short-term advantage in this group
43 3. Mild to moderate disease Antidepressants may be preferable in some patients as they may offer a more rapid response than self-help or psychotherapy. The most commonly prescribed antidepressant medicines, SSRIs and SNRIs, offer similar response rates and can be used first line as monotherapy in mild to moderate disease. [C Evidence]
44 3. Mild to moderate disease Patients should be seen in follow-up 1 to 2 weeks after initiating therapy, then monthly for the next 12 weeks. to monitor symptoms over time. adverse effects, suicidality, and acceptance of medicine taking, and to reinforce educational messages Patients who experience a partial response to antidepressants after 2 to 4 weeks should have the dose titrated to the maximum tolerated. Treatment should be continued for 4 to 9 months following remission.[a Evidence]
45 3. Mild to moderate disease If response to first-line therapy is inadequate, switching to an alternative antidepressant regimen should be considered.[ B Evidence] Alternative options include monotherapy with a tricyclic antidepressant (e.g., amitriptyline, desipramine, doxepin, imipramine, or nortriptyline) or combination therapy (i.e., SSRI or SNRI plus bupropion or mirtazapine).[ B Evidence].
46 3. Mild to moderate disease Supportive interventions Self-help books are popular and bibliotherapy has demonstrated more effectiveness than no treatment. Yoga interventions may have a beneficial effect on depressive disorders, [C Evidence] Other supportive intervention include relaxation training
47 3.Mild to moderate disease St. John's wort is a herb that is considered to be effective for the treatment of mild to moderate depression. [C Evidence] It may also be used as an alternative therapy (as monotherapy only) if there is no response to first- and second-line treatments.
48 Recurrent episodes Recurrent episodes of depression should be treated with the same antidepressant therapy that previously led to remission, provided that the recurrences do not occur while under adequate maintenance treatment with such medication. Maintenance therapy for at least 3 to 5 years or lifetime maintenance treatment should be considered for patients on their third episode of depression.
49 Recurrent episodes Patients with a first recurrence and risk factors for further recurrences (i.e., family history of bipolar disorder, recurrence within 1 year, onset in adolescence, severe depression, or suicidal attempt, and sudden onset of symptoms) may also benefit from long-term maintenance therapy.
50 Emerging treatments 1. Transcranial magnetic stimulation (TMS) 2. Vagus nerve stimulation (VNS) 3. Methylphenidate and thyroid hormone 4. Folic acid 5. Computer-based treatment
51 Complication 1. sexual adverse effects of SSRIs and SNRIs 2. undesired weight gain from antidepressants 3. agitation or excessive activation from antidepressants 4. unmasking mania 5. mania due to antidepressant withdrawal 6. risk of suicide with SSRI treatment
52 Prognosis Depression recurs in about one third of patients within 1 year of discontinuing treatment and in more than 50% of patients during their lifetime. After 15 years, 87% will experience a recurrence. For patients with 3 recurrent depressive episodes, many experts advocate long-term maintenance therapy.