Major Depressive Disorder Presenting Complaints

2. Major Depressive Disorder Presenting Complaints May present initially with one or more physical symptoms • Fatigue • Pain • Low mood, loss of interest or irritability. Symptoms must be present for at least 2 weeks, without a break.

3. LOW OR SAD MOOD. LOSS OF INTEREST OR PLEASURE. Associated symptoms include: Disturbed sleep Guilt or low self-worth Pessimism or hopelessness about future Fatigue or loss of energy Poor concentration Disturbed appetite Suicidal thoughts or acts Slowing of speech or movements or agitation Loss of confidence Sexual dysfunction Symptoms of anxiety or physical symptoms are a frequent presentation. Major Depressive Disorder Diagnostic Features

4. Major Depressive Disorder Differential Diagnosis • Anxiety • Bipolar Disorder • Thyroid Dysfunction • Substance-Induced Depression • Secondary to chronic physical illnesses

5. Major Depressive Disorder: Specific Counseling to Patient and Family • Involve the relatives in patient care. • Ask about risk of suicide. • Plan short-term activities • Resist pessimism and self-criticism. • Address physical symptoms if present • After improvement, discuss signs of relapse

6. Major Depressive Disorder Considerations for medication • Consider antidepressant drugs if • Sad mood or loss of interest is pervasively prominent for at least 2 weeks • Four or more of following symptoms are present: 1.Fatigue or loss of energy 2.Disturbed sleep 3.Guilt or self-reproach 4.Poor concentration 5.Thoughts of death or suicide 6.Disturbed appetite 7.Agitation OR slowing of movement and speech

7. Major Depressive Disorder: Considerations for medication • If good response to one drug in the past, use that again. • Use caution with older or medically ill patients • Build up to effective dose • Explain how medications should be used: • Continue antidepressant at least 6 months after symptoms improve.

8. Major Depressive Disorder: Consider Consultation with Specialist • If significant depression persists despite full course of treatment with at least two groups of antidepressants • If suicide risk is severe, consider immediate consultation and hospitalization.

9. Bipolar Disorder: Presenting Complaints • May present during a period of depression or separately as mania or excitement.

10. Periods of MANIA or HYPOMANIA lasting 4 – 7 days with Increased energy and activity level Rapid or loud speech Reports of racing thoughts Easily distracted Decreased Need for Sleep Grandiose ideas about self Elevated mood or irritability Loss of Inhibitions (over spending or hyper sexuality) Bipolar Disorder: Diagnostic Features

11. Bipolar Disorder: Diagnostic Features • Even a single Manic episode is treated as Bipolar Disorder. • Mixed states are very common • In severe cases, may have hallucinations or delusions during either period of mania or depression, but not in hypomania.

12. Bipolar Disorder: Differential Diagnosis • Alcohol or drug use can cause similar symptoms. • Schizophrenia presents with at least 6 month history of progressive deterioration, and no intervening period of normalcy.

13. Bipolar Disorder: Specific Counseling to Patient and Family • Involve relatives in patient’s care. • Ask about risk of suicide • During manic periods - Avoid confrontation, unless necessary to prevent harmful or dangerous acts. • During depressed periods - Resist pessimism and self-criticism. Do not make major financial decisions.

14. Bipolar Disorder: Medications • Drug treatment in acute phases is similar to treatment in acute psychotic disorder • Anticonvulsants, lithium, carbamazepine and sodium valporate are used as mood stabilizers • If hallucinations, delusions or disordered thinking are present, antipsychotic medication may be helpful • Anti-anxiety medication may also be used in conjunction with neuroleptics

15. Bipolar Disorder: Psychiatric Consultation • If suicide risk is present consider immediate referral and hospitalization • If agitation/hyperactivity is severe consider referral • If significant depression or mania continues, consider psychiatric consultation.

16. Sleep Problems: Diagnostic Features • Difficulty falling asleep • Restlessness or unrefreshing sleep • Early awakening • Frequent or prolonged awakenings • Primary sleep problems are relatively rare. They are usually indicative of some other physical or psychiatric condition.

17. Sleep Problems: Differential Diagnosis • Transient insomnia (several days’ duration, commonplace) • Short-term insomnia (lasting several weeks) • Chronic insomnia (lasting months or years)

18. Sleep Problems: Differential Diagnosis • If daytime anxiety is prominent, consider Generalized Anxiety Disorder. • If low or sad mood is prominent, consider Depression. • If loud snoring is present, consider sleep apnea • Consider medical conditions • heart failure • pulmonary disease • pain conditions • thyroid dysfunction

19. Sleep Problems: Essential Information for Patient and Family • Temporary sleep problems are common at times of stress or medical Illness and do not require treatment • 6 hours of sleep per day may be normal and sufficient, especially for older patients. • Improving sleep habits (not sedative medication) is the best treatment. • Worry about not being able to sleep can worsen insomnia. • Alcohol may help falling asleep but can lead to restless sleep and early awakening. • Stimulants (including coffee, tea or nicotine) can cause or worsen insomnia.

20. Sleep Problems: Specific Counseling to Patient and Family • Maintain a regular sleep routine: • Practice relaxation exercises to aid in falling asleep. • Avoid caffeine and alcohol. • If unable to fall asleep after 20 minutes, get up and try again later when feeling sleepy. • Daytime exercise may help, but evening exercise may contribute to insomnia. • Avoid daytime napping. • Ensure appropriate sleeping environment

21. Sleep Problems: Medication • Treat any underlying psychiatric or medical condition. • Make needed changes in medication. • Hypnotic medication not more than 14 days (benzodiazepines) • Risk of dependence increases significantly after 14 days of use.

22. Sleep Problems: Specialist Consultation • Consider consultation: • For narcolepsy or sleep apnea • If significant insomnia continues