DepressionDepression

Risk factors for depression

1 -Age: young patient are more prone to depression . Peak incidence from

20 – 402 -Sex: women are twice as men to

develop depression3 -Pregnancy: one in 10 of pregnant

women develop post partum depression

4 -Family history of depression

Risk factors for depression

Nutritional status is often a symptom of depression. Depressed patient often either under or overeating.

Nutritional intake in itself

not considered a risk facto

Do women depression more easily diagnosed?

Yes it is easily diagnosed more than men, children or adolescent,

Because they declare their emotional state and report it easily during a

medical visit. It is not because the symptoms are more sever among

women .

Why it is difficult to diagnose depression in men?

1 -Men feel stigmatized of being depressed.

2 -Men believe that it is not socially appropriate for them to report

depression symptoms and to seek help.

3 -Also males are more likely than females to mask a depression mood

and they may more likely to appear as they are using drugs or alcohol than

being depressed (outlook with chemical abuse).

Why identifying depression in children and adolescents is often difficult in family practice?

Is it because there is no screening tests for depression in such groups?

No, there are plenty of screening tests to screen depression in children and adolescents but even with those it is

difficult. Why?

Adolescents and children often report quite different signs. They describe

internalizing symptoms that not necessarily specific to depression

like feeling , like a failure ,not being able to succeed anymore,

or always being in a bad mood.

Examples of what can be said by them:

Children say:I do not like anyone in my class?I do not want to go out with my

friends anymore.

Parents say:He is gotten lazy and is not studying

anymoreShe is becoming so moody I can not

even talk to her without losing her temper with me .

How depression is presented in children?

Change in behavior and decline at school and extracurricular activities

symptoms . But those are not recognized as potential signs

of depression.

Feeling like a failure and not being able to succeed anymore.

How depression is presented in adolescents?

It is more likely to present with irritability, social withdrawal,

oppositional attitude and substance abuse more than

present with sadness or depressed mood. They are

atypical symptoms and thus missed .

Types of depression

1 -Major depressive disorder

2 -Dysthymic disorder3 -Manic Depression (now known

as Bipolar Disorder)4- Post Partum Depression

5 -Seasonal Affective Disorder (SAD)

6 -Anxiety Depression

Diagnosis of Major depressive disorder (MDD)

During the same 2 week period every day five out of nine symptoms must be present but one and two

must be present.1 -depressed mood most of the day, nearly every day,

as indicated by either the patient or observation by others (appears tearful).

2 -lose interest in all activities.3 -undesired weight change4 -sleep disturbance (less or more) 5 -agitation or retardation6 -fatigue or loss of energy7 -Feeling of worthlessness or guilt8 -cognitive dysfunction9 -strong suicidal ideas , plan or attempt

The symptoms must not related to a medical condition (cancer), loss of a loved one, drug abuse or

medication)

A positive depression screen must be followed by an interview , because

depression screening measures do not diagnose depression

Depression screening can provide :

- critical information about severity of symptoms

- how they change in response to treatment or

- lack of treatment

but does not diagnose depressive illness.

Depressed patient are more likely to present with physical symptoms such

as : - insomnia , - hypersomnia (sleeping too much) , - loss of appetite , - pain and - fatigue

than to present with emotional

difficulties

Dysthymic Disorder is a chronic mood disorder that falls within the depression spectrum.

Dysthymia is a chronic long lasting form of depression sharing many characteristic

symptoms of major depressive disorder. However, these symptoms tend to be less severe but do fluctuate in intensity. To be

diagnosed an adult must experience 2 or more of the following symptoms "for most of the day more days than not for at least 2 years without

interruption of symptoms for longer than 2 months

Feelings of hopelessness Insomnia or hypersomnia Poor concentration or difficulty making decisions Low energy or fatigue Low self-esteem Poor appetite or overeating

Manic Depression (now known as Bipolar Disorder)

This kind of depression includes periods of mania and depression. Cycling between these two states can be rapid or only mania can

be present without any depressive episodes. A manic episode consists of a persistent elevated or irritable mood that is

extreme, which lasts for at least one week. At least three (four if only irritable mood) other features are also present:

inflated self-esteem or self-importance decreased need for sleep more talkative than usual or compelled to keep talking easily distracted increase in goal-oriented activity (social, work, school, sexual) or

excessive movement excessive involvement in potentially risky pleasurable behavior

(e.g. over spending, careless sexual activity, unwise business investments)

Symptoms can be severe enough to warrant hospitalization to prevent harm to self or others or include psychotic features (e.g.

hallucinations, delusions).

4 -Post Partum Depression – Major depressive episode that occurs after

having a baby. Depressive symptoms usually begin within four weeks of giving

birth and can vary in intensity and duration .

5 -Seasonal Affective Disorder (SAD) It is MDD with a seasonal pattern – A type of depressive disorder which is characterized

by episodes of major depression which reoccur at a specific time of the year (e.g.

fall, winter). In the past two years, depressive periods occur at least two

times without any episodes that occur at a different time .

6 -Anxiety Depression - Not an official depression type (as defined by the DSM).

However, anxiety often also occurs with depression. In this case, a depressed

individual may also experience anxiety symptoms (e.g. panic attacks) or an

anxiety disorder.

There is a type called adjustment disorder with depressed mood which

is defined as a reaction to some identifiable psychosocial stressors that

occur within 3 months of the onset of the depressed mood. Treatment of this case

by counseling and stress management.

The cause of these conditions

A neurotransmitter imbalance that appears to be caused by a relative deficiency of the neurotransmitter

serotonin ( the new SSRIs add confirming evidence to this

hypothesis)

The most important question to ask a patient who presents with signs and symptoms of depression

Asking about suicide.The following questions are useful in

exploring suicidality:1 -You seem so terribly unhappy. Have you

had any thoughts about hurting yourself?2 -If you have, have you thought of the

means by which you would do it? Have you considered a specific plan for ending your life? Under what circumstances would you

carry it out?3 -What would it take to stop you from killing

yourself?4 -Do you feel that your situation is

hopeless?

Techniques used by family physician in the outpatient clinics1- BATHE technique

B - Background - What happening that of concern to the patient or what is going in your life ?

A- Affect - How the patient feels about what is

happening?T- Trouble - What troubles you the most?H- Handling – How the patient is handling

the situation?

E- Empathy – An empathic or supportive statement

to conclude the sequence.

It is recommended to use this test in every patient encountered by family

physician.It takes from 5 – 7 minutesIndications for using this technique:

- basic level of counseling - little time for counseling - patient has psychosocial issues

Contraindication for BATHE technique:

Suicidal patientFamily violenceDrug abusePersonality disorders

SPEAK technique

It is used by family physician as a therapeutic tool. It is five steps

counseling.S – schedule each day – activate

patient to prepare a written daily schedule.

P – pleasant – it indicate that family physician

encourage depressed patient to have at

least one of the daily activities pleasant to

himself

E – exercise – exercise has shown to be beneficial in

alleviating depression symptoms .A – assertion- family physician should

encourage their depressed patient to assume more control in their lives to

regain their previous sense of self reliance

and self confidence as expression of anger

should be avoided

K- kind – thinking kind thoughts about oneself

Depressed patients usually focus on negative perceptions of themselves ,

their ongoing experiences in the future. See the empty half of a glass of water. They should be encouraged to identify positive coping abilities and strengths.

The SPEAK technique is used to motivate depressed patients and it is

more effective when it is used in conjunction with the BATHE technique.

The BATHE technique can be used as the assessment part of the visit ( a screening test)

because it helps define issues where SPEAK technique is part of the plan because it

helps design a plan to activate the patient.

DIG technique

Its aim to assist patent in constructing solutions for their

problem.It is used to help patient create

solutions to their problems.It is not a screening or diagnostic

tool but rather a therapeutic tool to create solutions for problems of the

depressed patients

DIG technique

D - Dream – the first step is to have patient dream of the miracle that would solve

their problem

I- Initiate – the next step is for patient to initiate a process that will make that

miracle happen and to make changes in themselves that miracle would happen

G- Get going – the third step is getting going and implementing activities to have

the process of change occur. This test takes 15 minutes to be

completed

Management of depression

Medication generally provide rapid response to depression in outpatient

settings. However, this response does not reduce the risk of relapse,

after medication is withdrawn.Depression generally responds more

slowly to behavioral therapy but it is as effective as medications.

Usually a combination of behavioral therapy and medication is good for

chronic patients

Cognitive behavioral therapy

It is shown to reduce the subsequent risk for relapse of depression.

It is based on that maladaptive thoughts and behavior are learned from experience and that they can

be modified through corrective experiences

It is a well documented and effective approach to the treatment of

depression

It employs a short term, good- oriented approach.

The thought of the dysfunctional thinking can be modified and ,therefore, the

emotions produced by the dysfunctional thinking will be changed.

Those vulnerable to depression harbor negative core beliefs and those stable

beliefs trigger distorted automatic thoughts that induce depressogenic effect and behaviour ( if there is a stressor or an

experience that caused a negative feeling, the approach to this stressor can be

changed.

Who treats depression?

Most patient with depression are treated by primary care provider and

most of them never see a mental health provider.

The majority of antidepressant medications are prescribed by family physicians but sometimes there is a need for consultation with a mental

health provider

Causes of referral

Combined psychiatric diseasePersonality disorderWhen at least two trials of

medications have failedWhen patient request that help

Serotonin & the Serotonergic System

FunctionInduction & maintenance of sleepRegulation of body temperaturePerception of sensations (hunger, mood,

behaviourAlso the regulation of muscle contraction,

and some cognitive functions including memory and learning.

Treatment

Medications for 6 monthsCognitive psychotherapy ( it reduce

recurrence)ExerciseRelaxation therapy is used for

treatment of anxiety than for depression

Drugs as 1 -Tricyclic antidepressant as Tofranil

it is presented in 10 or 25 mg . SSRIs (serotonin reuptake inhibitor) It has a short half life example

Fluoxetine

Side effect: Sexual dysfunction

SSRIs discontinuation syndrome: is characterized by flue like syndrome and

ca be avoided by tapering SSRI over 1 to 2 weeks.

( flue like symptoms as nausea, dizziness, headache, anxiety and crawling sensation under the skin.

Exercise has been shown to lower level of depression. Some studies

have shown it to be as effective as individual or group psychotherapy or

cognitive therapy. It is also effective in anxiety.