Depressive Illness Dr. Sarma R V S N Consultant Physician visit : drsarma

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/ psychopharmacology%20and%20serotonin.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 Marked 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 frompure depression (evenly distributed between mild, moderate,and severe) Further 8% suffer from a mixture of anxietyand depression Patients with symptoms not severe enoughto qualify for diagnosis of either anxiety or depression..... ??? Impaired working and social lives and many unexplainedphysical 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 > 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 & Sadock’s Synopsis of Psychiatry, 8th ed., p 941 Harrison’s 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 ina first episode Many patients present with physicalsymptoms - Somatisation syndrome Some may show multiple symptoms ofdepression 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 (>2 hours early) Psychomotor retardation or agitation Marked loss of appetite Weight loss >5% 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 anxietyor depression • Mixed anxiety and depressionis now recognised • Presence of physical symptoms indicatesa somatic syndrome • Value of somatic features in predicting response to treatmentis not clear • Presence of psychotic features has major implicationsfor treatment • Brief episodes of more severe depression - brief recurrent depression • More prolongedrecurrence 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: • geneticand family predisposition • clinical course of concurrentmedical 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 oftencauses great distress for patients: mistakenly assumed • that symptoms (weakness or fatigue) are due to an underlyingmedical • 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) • Can’t replace systematic clinical assessment – LISTENING • Persistent low mood and lackof interest and pleasure in life cannot be • accounted for by severephysical 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 (MAOI’s) rare fatalities tyramine-free diet Selective Serotonin Re-uptake Inhibitors (SSRI’s) 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 (SSRI’s) - 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 (SSRI’s) – 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 treatedin primary care • Four main reasons for referral to specialist psychiatric services: • 1) Condition is severe • 2) Failingto 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 talkingtherapy • Most patients in primary caresettings would prefer a talking therapy • Effectivenessis limited to particular forms of psychotherapy • Mild-Mod. Depression: CBTand 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 compliancewith and outcome of physical treatment • facilitate the "appropriate"use of healthcare resources • Primarycare 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 • Forpatients with suicidal ideation / whose depression hasnot responded to initial management, specialist referral is thenext 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

37. “The good physician treats the disease, but the great physician treats the person.” William Osler

38. Thank You