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Depression

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

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Depression

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  1. Depression

  2. 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

  3. 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

  4. 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

  5. Clinical features of depression

  6. Types of depression

  7. Major depressive disorder Five or more of the following for at least 2 weeks: • Depressed mood • Loss of interest in pleasure • Significant weight loss • Insomnia or hypersomnia • Psychomotor agitation or retardation • Fatigue • Excessive guilt or feelings of worthlessness • Diminished ability to think or concentrate • Recurrent thoughts of death

  8. Dysthymia • Depressed mood for at least 2 years • Two or more of the following: • Poor appetite or overeating • Insomnia or hypresomnia • Low energy or fatigue • Low self esteem • Indecisive or poor concentration • Feelings of hopelessness

  9. Minor depressive disorder • Episodes of at least 2 weeks of depression • Fewer than five items required for major depressive disorder

  10. Risk factors for suicideEpisode related • Current suicidal plans • Prior attempts • Severe depression • Hopelessness and guilt • Bipolarity • Mixed state (with agitation) • Psychotic features • Substance abuse • Serious medical condition • Anxiety

  11. Risk factors for suicideDemographics • 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

  12. Differential diagnosis • Substance induced mood disorder • Bereavement • Mood disorder due to a general medical condition

  13. Common drugs of abuse causing depression • Alcohol • Amphetamines • Anti-anxiety drugs • Cocaine • Hallucinogens • Hypnotics • Inhalants • Opioids • Sedatives

  14. Depression due to general medical conditions • Diabetes • Cardiovascular disease • Neurological • CNS infections • Epilepsy • Sleep apnoea • Systemic disorders • Viral and bacterial infections • Endocrine disorders • Thyroid disorders • Vitamin deficiencies (B12/Folate; Vitamin C; Niacin; Thiamine) • Others • AIDS • Cardiopulmonary disease

  15. Management of depression • Phase 1: Acute phase - to achieve full remission of depressive symptoms • Phase 2: Maintenance phase - to prevent relapse and recurrence

  16. 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

  17. 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

  18. 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

  19. 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

  20. Patient education messages Treatment • Antidepressants are not addictive • Medications daily, as prescribed • It may take 2-3 weeks before any relief is seen • Mild side effects are common, they get better over time • Medications should not be stopped without medical advice

  21. 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)

  22. Selecting an antidepressant • Efficacy • Side effect profile • Concurrent medication • Comorbidity • Subtype of depression • Simplicity of use • Cost

  23. SSRIs

  24. TCAs

  25. Other evidence based therapies for depression • Electro Convulsive therapy (ECT) • Exercise, wake therapy and light therapy • Psychotherapy • Cognitive Behaviour therapy • Family therapy • Interpersonal psychotherapy

  26. 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

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