Depression in Community Dr Pradip Mate

(Masters In Pharmaceutical Medicine)

Introduction • Depressive disorders are common mental disorders that occur

in people of all ages across all world regions• Depressive disorders are common mental disorders, occurring

as early as 3 years of age and across all world regions• Global Burden of Disease (GBD) 2010 identified

depressive disorders as a leading cause of burden. • MDD was also a contributor of burden allocated to suicide and

ischemic heart disease. • These findings emphasize the importance of including

depressive disorders as a public-health priority and implementing cost-effective interventions to reduce its burden.

PLoS Med 10(11): e1001547.

Overview • Depressive disorders were the second leading cause of YLDs in

2010. • MDD accounted for 8.2% (5.9%–10.8%) of global YLDs and dysthymia for

1.4% (0.9%–2.0%).• There was more regional variation in burden for MDD than for

dysthymia; with higher estimates in females, and adults of working age. • Whilst burden increased by 37.5% between 1990 and 2010• MDD explained 16 million suicide DALYs and almost 4 million

ischemic heart disease DALYs. • This attributable burden would increase the overall burden of depressive

disorders from 3.0% (2.2%–3.8%) to 3.8% (3.0%–4.7%) of global DALYs.

PLoS Med 10(11): e1001547.

PLoS Med 10(11): e1001547.

Problem is at our doorstep

Epidemiology in India

• Many studies have estimated the prevalence of depression in community samples and the prevalence rates have varied from 1.7 to 74 per thousand population.

• Reddy and Chandrasekhar carried out a metanalysis, which included 13 studies on epidemiology of psychiatric disorders which include 33572 subjects from the community and reported prevalence of depression to be 7.9 to 8.9 per thousand population and the prevalence rates were nearly twice in the urban areas.

Indian J Psychiatry. Jan 2010; 52(Suppl1): S178–S188

Epidemiology in India

• large population-based study from South India, which screened

more than 24,000 subjects in Chennai using Patient Health

Questionnaire (PHQ)-12 reported overall prevalence of depression

to be 15.1% after adjusting for age using the 2001 census data

• Studies done in primary care clinics/center have estimated a

prevalence rate of 21-40.45%.

• Studies done in hospitals have shown that 5 to 26.7% of cases

attending the psychiatric outpatient clinics have depression

Indian J Psychiatry. Jan 2010; 52(Suppl1): S178–S188

• Studies on the elderly population, either in the community, inpatient, outpatient and old age homes have shown that depression is the commonest mental illness in elderly subjects.

• An epidemiological study from rural Uttar Pradesh showed that psychiatric morbidity in the geriatric group (43.32%) was higher than in the nongeriatric group (4.66%) and most common psychiatric morbidity was neurotic depression, followed by manic-depressive psychosis depression, and anxiety state.

Indian J Psychiatry. Jan 2010; 52(Suppl1): S178–S188

Epidemiology in India

Age-standardized DALYs per 100,000 population 2004 WHO figures for India

Indian J Psychol Med. 2010 Jan-Jun; 32(1): 1–2.

DEPRESSION & SUICIDALITY

• Depression is associated with high suicidality.

• About 50% of individuals who have committed suicide carried a

primary diagnosis of depression.

• Because mood disorders underlie 50-70% of all suicides,

effective treatment of these disorders on a national level should,

in principle, drastically reduce this major complication of mood

disorders.

Indian J Psychol Med. 2010 Jan-Jun; 32(1): 1–2.

DEPRESSION & SUICIDALITY

• Indian union health ministry estimates state that 120,000 people commit suicide every year in India.

• Also over 400,000 people attempt suicide. • A significant percentage of people who commit suicide in India

(37.8%) are below 30 years of age. • Ministry officials state that majority of those committing

suicide suffer from depression or mental disorder

Indian J Psychol Med. 2010 Jan-Jun; 32(1): 1–2.

Depression & Ischemic heart disease

• The pooled relative risk of developing IHD in those with major depression was 1.56 (95% CI 1.30 to 1.87).

• Globally there were almost 4 million estimated IHD disability-adjusted life years (DALYs), which can be attributed to major depression in 2010; 3.5 million years of life lost and 250,000 years of life lived with a disability.

• Major depression may be responsible for approximately 3% of global IHD DALYs warrants assessment for depression in patients at high risk of developing IHD or at risk of a repeat IHD event

Charlson et al. BMC Medicine 2013, 11:250

Cumulative burden of disease of major depression, 2010.

Charlson et al. BMC Medicine 2013, 11:250

Depression in neurological diseases ● Studies have found high rates of depression in neurological

disorders.

● Prevalence of depression after stroke range from 20% to 72%

● In Parkinson’s disease 40-50% ● In Multiple sclerosis 19-54%

● In epilepsy, up to 55%

J Neurol Neurosurg Psychiatry 2011;82:914e923.

Hypothetical Model of depression in MS

Journal of the International Neuropsychological Society (2008), 14, 691–724.

Rheumatoid disorder & depression

• Psychological disorders such as anxiety or depression are common among patients suffering from RA

• It has been calculated that 13.4% have a diagnosis of anxiety and 41.5% are diagnosed with depression.

• In the case of ankylosing spondylitis, anxiety is present in 25% of all patients and depression in 15%-30%.

M. Freire et al / Reumatol Clin. 2011;7(1):20–26

Patients with psoriatic arthritis who reported problems for each of the dimensions on the HRQoL EQ-5D questionnaire according to the presence or absence of symptoms for each disorder.

M. Freire et al / Reumatol Clin. 2011;7(1):20–26

Classification • Depression classifications include ;

•Major depressive disorder (MDD), • Depression with melancholic or catatonic features, • Atypical depression, • Psychotic features, • Bipolar depression, • Single or recurrent episode, • Dysthymia• seasonal affective disorder (SAD).

Pathophysiology

• Clinical and preclinical trials suggest a disturbance in central nervous

system serotonin (5-HT) activity as an important factor.

• Other neurotransmitters implicated include norepinephrine (NE), dopamine

(DA), glutamate, and brain-derived neurotrophic factor (BDNF).

• Functional neuroimaging studies support the hypothesis that the depressed

state is associated with decreased metabolic activity in neocortical

structures and increased metabolic activity in limbic structures.

• Serotonergic neurons implicated in affective disorders are found in the

dorsal raphe nucleus, the limbic system, and the left prefrontal cortex.

Stressors

• Although major depressive disorder can arise without any precipitating

stressors, stress and interpersonal losses certainly increase risk.

• Chronic pain, medical illness, and psychosocial stress

• Older adults may find medical illness psychologically distressing, and

these illnesses may lead to increased disability, decreased independence,

and disruption of social networks.

•  Chronic aversive symptoms such as pain associated with chronic medical

illness may disrupt sleep and other biorhythms leading to depression

Psychosocial risk factors for depression in late life

• Impaired social supports• Caregiver burden• Loneliness• Bereavement• Negative life events

Risk factors for suicide

• In addition to older age and male sex, risk factors for suicide include the following :• Diagnosis of major depression• Previous history of suicide attempts• Depressive symptoms with agitation or distress• Burden of medical disease and the presence of a current serious medical condition• Recent stressful life events, especially family discord• Lack of social support• Being widowed or divorced• Unexplained weight loss• High levels of anxiety• Lack of a reason not to commit suicide• Presence of a specific plan that can be carried out• Rehearsal of the plan

DSM V• A major depressive episode is defined as a syndrome in which at least 5 of

the following symptoms have been present during the same 2-week period :• Depressed mood (for children and adolescents, this can also be an irritable mood)• Diminished interest or loss of pleasure in almost all activities (anhedonia)• Significant weight change or appetite disturbance (for children, this can be failure to

achieve expected weight gain)• Sleep disturbance (insomnia or hypersomnia)• Psychomotor agitation or retardation• Fatigue or loss of energy• Feelings of worthlessness• Diminished ability to think or concentrate; indecisiveness• Recurrent thoughts of death, suicidal• A pattern of long-standing interpersonal rejection ideation, suicide attempt, or

specific plan for suicide

Depression With Melancholic Features• In depression with melancholic features, either a loss of

pleasure in almost all activities or a lack of reactivity to usually pleasurable stimuli is present.

• Additionally, at least 3 of the following are required:• A depressed mood that is distinctly different from the kind that is felt when

a loved one is deceased• Depression that is worse in the morning• Waking up 2 hours earlier than usual• Observable psychomotor retardation or agitation• Significant weight loss or anorexia• Excessive or inappropriate guilt

Depression With Catatonic Features

• Diagnosis of depressive episodes with catatonic features requires at least 2 of the following, according to the DSM-IV-TR:•Motoric immobility in the form of catalepsy or stupor•Motor overactivity that seems purposeless and not in response to external stimuli• Extreme negativism or mutism• Voluntary movement peculiarities such a posturing, grimacing, stereotypy, and mannerisms• Echolalia or echopraxia

D/D• Adjustment Disorders• Anemia• Chronic Fatigue Syndrome• Dissociative Disorders• Hypochondriasis• Hypoglycemia• Hypopituitarism (Panhypopituitarism)• Schizoaffective Disorder• Schizophrenia• Somatoform Disorders

Screening Tests

• Longer self-report screening instruments for depression include the following:

• PHQ-9 – The 9-item depression scale of the Patient Health Questionnaire;

each item is scored 0 to 3, providing a 0 to 27 severity score

• Beck Depression Inventory (BDI) – A 21-question symptom-rating scale

• BDI for primary care – A 7-question scale adapted from the BDI

• Zung Self-Rating Depression Scale – A 20-item survey

• Center for Epidemiologic Studies-Depression Scale (CES-D) – A 20-item

instrument that allows patients to evaluate their feelings, behavior, and

outlook from the previous week

Laboratory Studies to Rule Out Organic Causes• Complete blood cell (CBC) count• Thyroid-stimulating hormone (TSH)• Vitamin B-12• Rapid plasma reagin (RPR)• HIV test• Electrolytes, including calcium, phosphate, and magnesium levels• Blood urea nitrogen (BUN) and creatinine• Liver function tests (LFTs)• Blood alcohol level• Blood and urine toxicology screen• Dexamethasone suppression test (Cushing disease, but also positive in

depression)• Cosyntropin (ACTH) stimulation test (Addison disease)

THE PROBLEM OF AWARENESS

• Less than 25% of those affected by depression receive treatment.

• Barriers to effective care include the lack of resources, lack of trained providers, and the stigma.

• Nearly half of the patients with depression, as in diabetes, remain undiagnosed for years or inadequately treated.

• Large numbers of patients from rural areas remain under care of religious healers and may never receive correct treatment.

• The majority of patients do not receive evidence-based treatments.

Indian J Psychol Med. 2010 Jan-Jun; 32(1): 1–2.

Clinical implication

• Primary-care-based depression interventions have the potential

to reduce the current burden of depression by 10 - 30%.

• Proactive care strategies incorporating maintenance treatment

for recurrent depression yield considerably greater population-

level health gain than episodic depression

• On efficiency grounds alone, interventions using older

antidepressants are currently more cost-effective than those

using newer antidepressants, particularly in lower-income regionsBRITI SH JOURNA L O F P SYCHIATRY BRI TI SH JOURN A L O F P SYCHI AT RY (20 04), 184, 393^4 03 (2004), 184, 393^4 03