RECOGNITION & TREATMENT OF DEPRESSION

Prof. Fareed Aslam MinhasMB,MCPS,Dip.Psych,MSc,MRCPsych

HeadInstitute of Psychiatry

Rawalpindi Medical CollegeRawalpindi.

EVIDENCE FOR MENTAL DISORDERS CAUSING SUBSTANTIAL BURDEN GLOBALLY

• Estimated percent of DALY (Disability adjusted life years) for Neuropsychiatric disorders world-wide:

1990 – 10.5%1998 – 11.5%2020 – 15%

• 1990 estimate of DALY lost, range from 25% in Established Market Economies (EME) to 7% in developing countries.

• 1998 estimate range from 23.5% in high-income countries to 10.5% in low/medium income countries.

GLOBAL DISTRIBUTION OF HEALTH BURDENS, 1995:

Rank Cause %DALYs loss

• Lower respiratory diseases 7.3• Diarrhoeal diseases 6.5• Perinatal conditions 6.1• Unipolar Major Depression 4.2• Ischaemic Heart Disease 4.0• HIV 3.4• Cerebrovascular disease 3.2• Motor vehicle accidents 3.0• Malaria 3.0• Tuberculosis 3.0__________________________________________________________Major depression is estimated to become the second largest contributor to

DALYs by 2020

Disease Burden in Depression

• Functional disability is high 1

• Disability is greater when depression co-exists with other psychiatric conditions such as panic disorder or generalized anxiety disorder 2, 3

• The rate of attempted suicide is 15%; this figure rises when comorbid psychiatric disorders are present 4

Disease Profile

Depression…the most common psychiatric disorder that primary care clinicians

encounter.

• A prevalent and a serious psychiatric disorder

• Risk of suicide is high among individuals with depression

• Symptoms of depression are made more severe by the co-existence of anxiety

• People can experience depression at any time of life

THE BROAD IMPACT OF MENTAL ILLNESS

FearPersonal safetyTax burdenWider society

Staff moraleCriminal Justice

PsychiatryService system

Carer burdenLost employment

Travel cost, fees

Family

Quality costsLost employment

Service feesPatient

Intangible cost

Indirect costs

Direct cost

Examples of Impact Level

AFFECTIVE DISORDERSICD 10

• MANIC EPISODE

• BIPOLAR AFFECTIVE DISORDERS

• DEPRESSIVE EPISODE

• RECURRENT DEPRESSIVE DISORDERS

• PERSISTENT MOOD DISORDERS

• RECURRENT BRIEF DEPRESSION.

Types of Depression in Primary Care

• Anxious Depression

• Chronic Anxious Depression

• Depression with Somatic Symptoms

• Treatment Resistant Depression

• Bipolar Depression

Anxious depression

• Commonest kind of depressive disorder in general medical practice.

• Co-Morbid Depression and Generalized anxiety

• Often very severe disorder.

• Should be offered a sedating antidepressant.

• Depression without anxiety is less common in primary care

• May need an alerting antidepressant.

Chronic Anxious Depression

Some patients are usually well known to their doctors, have been symptomatic for many years.

Important not to treat with many different drugs and try to confine yourself only to those that are effective for that individual.

These patients often have • Intractable or insoluble life problems• It is unreasonable to suppose that these problems will

disappear with drug treatment.

• Arrange to see these patients at Regular Intervals

• If left to themselves, they often arrive more frequently.

• Spend time with them discussing their personal problems,

• Perform physical examinations for any physical disorders

• If new physical symptoms arise.

Depression with somatic symptoms

These can be divided into two groups

• Those whose physical symptoms are part of an undoubted physical illness.

• Those for whom no physical cause can be found, despite physical examination and any necessary investigations.

• Neither group consider themselves depressed. • They will readily admit to depressive symptoms if asked

directly• They improve considerably on anti-depressants.

• Doctors are typically distracted by the somatic symptoms, so that the psychiatric disorder goes undetected.

• • These group are best managed with Re-Attribution

Treatment-Resistant Depression

Refers to any patientDoes not respond to drug treatment given at the proper

dosage for an adequate time

About one third of depressed patients fall into this category.

Have to think of an antidepressant in another category; if this is not effective, a combination of drugs may be necessary.

Alternately refer to a psychiatrist.

Bipolar depression

• These are relatively rare is general practice.

• They have experienced episodes of mania or hypomania at some time in their past.

• They merit a psychiatric opinion,

• As antidepressants will sometimes precipitate an episode of hypomania.

USEFUL TERMS

• DEPRESSED MOOD

• DEPRESSIVE SYNDROME

• DEPRESSIVE ILLNESS

CORE SYMPTOMS OF MAJOR DEPRESSION

• Depressed mood.• Diminished interest or pleasure in activities.• Significant change in appetite and/or weight.• Insomnia or hypersomnia. • Psychomotor agitation or retardation.• Fatigue or loss of energy.• Lack of concentration or indecision. • Thoughts of death or suicide. • Anxiety, Pain and GI Symptoms.

SOMATIZATION

• Because it hurts.

• Indicates serious physical illness.

• Differential reinforcement by doctors.

• Differential reinforcement by relatives.

• Social stigma attached to emotional illness.

• Does not need to blame himself.

SOMATIC PRESENTATION IN MEDICAL SETTINGS.

• In primary care 1 in 5 new consultations are for somatic symptoms for which no specific cause is found. ( Goldberg & Bridges 1998)

• In hospital settings, medically unexplained somatic complaints are among the most common reasons for referral from primary care.

• Specific symptoms tend to cluster in medical specialties according to the organ system.

• The somatic symptoms of 1/3 of all patients seen in these clinics remain medically unexplained at the time of discharge. (Hamilton et al. 1996)

Depression with Anxiety

• 60 to 90% of depressed patients have anxiety symptoms

• Coexistent anxiety and depression results in

• more severe symptomology

• reduced treatment response

• worse prognosis

Profile of the Anxious Depressed Patient

• More impaired functioning compared with primary depression

• Increased agitation, hypochondriasis, depersonalization, chronic depression

• Reduced response to drug therapy and psychosocial intervention

• More severe and chronic illness

Stavrakaki C, The relationship of anxiety and depression: a review of the literature. British journal of Psychiatry 1986: 149: 7-16

PATHWAYS TO CAREGoldberg & Huxley

Level 1. Morbidity in Random Community Samples___________________________________________________________

Level 2. Total Psychiatric Morbidity in Primary Care.___________________________________________________________

Level 3. Conspicuous Psychiatric Morbidity___________________________________________________________

Level 4. Total Psychiatric Patients___________________________________________________________

Level 5. Psychiatric in-Patients

STRESS & PSYCHIATRIC DISORDERS IN RURAL PUNJAB.

British Journal Of Psychiatry(1997),170,473-478

• 66% of women, 25% of men suffered from Depressive and Anxiety disorders.

• Levels of emotional distress increased with age in both genders.

• Women living in unitary households reported more distress than those living in extended or joint families.

• With younger men and women, lower levels of education were associated with greater risk of Psychiatric disorders.

• Social disadvantage was associated with more emotional distress.

STRESS & PSYCHIATRIC DISORDERS IN URBAN RAWALPINDI

British Journal of Psychiatry (2000)-177,557-562

• 25% of women, 10 % of men suffered from Depressive and anxiety disorders.

• Levels of emotional distress increased with age.

• Women living in joint households reported more distress than those living in unitary families.

• Higher levels of education were associated with lower risk of common mental disorders.

• Emotional distress was negatively correlated with socio economic variables among women.

PRIMARY CARE SETTING.Gujar Khan

• 20-40% suffered from Depression and anxiety.

• More in females.

• Primary care physicians diagnosed depression in 58% of cases.

• 87% of patients presented with aches and pains .

THE PREVALENCE, CLASSIFICATION AND TREATMENT OF MENTAL DISORDERS AMONG ATTENDERS OF

NATIVE HEALERS IN RURAL PAKISTAN.Soc Psychiatry Psychiat Epidemiol(2000) 35: 480-485

• 61% of the attenders had psychiatric disorders.

• 29% female and 15 % males suffered from major depressive episode.

• 15% suffered from generalized anxiety disorder

• 8% suffered from dissociative disorders.

• 9% suffered from epilepsy.

PERCENTAGE OF MAJOR DIAGNOSTIC CATEGORIES DURING FOUR YEARS IN IOP

Journal of CPSP (2001)

Fig.3 Percentage of major diagnostic categories.

0.00%5.00%

10.00%15.00%20.00%25.00%30.00%35.00%40.00%

overall%

Males

Females

overall% 8.40% 37% 11.40% 4.80% 10.60% 1.50% 1.43% 4.80%

Males 5.70% 18% 4.15% 2.90% 10.60% 0.92% 0.95% 0.60%

Females 2.70% 19% 7.20% 1.90% 0% 0.66% 1.90% 4.20%

Scizophr

enia

Depressi

onBipolar Mania

Drug

Depende

Personal

ityOCD

Conversi

on

Postnatal depression in developing countries

Goa, IndiaPrevalence 23%

Patel et al., 2002. American Journal of Psychiatry; 159: 43-47

Dubai, United Arab EmiritesPrevalence 15.8%

Ghubash & Abou-Saleh, 1997. British Journal of Psychiatry; 171: 65-68

Khayelitsha, South AfricaPrevalence 34.7%

Cooper et al., 1999. British Journal of Psychiatry; 175: 554-58

Antenatal and Postnatal depression in a rural community

Rawalpindi, PakistanRahman, et al 2003. Psychol Med 33:1161-67

• Rural, community-based sample of 670 women• Single phase, SCAN • Prevalence 25% in antenatal period; 28% in postnatal

period• Depressed mothers significantly more disabled• Risk factors include husband’s unemployment,

relationship difficulties, 2 or more young children• Protective factors include family support in child care,

presence of infant’s grandmother, able to complete ‘chilla’ period, financial autonomy

Can maternal depression increase infant risk of illness and growth impairment in

developing countries?Rahman et al. 2002. Child: Care, Health &

Development 28: 51-56

Conclusion

Maternal depression is a major determinant of

infant growth and well-being

MEAN DURATION OF STAY IN DAYS FOR MAJOR DIAGNOSTIC CATEGORIES.

15.93

18.3

19.3

18.94

7.6 Depression

Schizophrenia

Hypomania

Bipolar

Drug Dependence

Measuring Improvement

• Improvement can be measured in terms of – symptoms,

– comorbid disorders,

– functional disability,

– and overall quality of life.

• Several clinician-rated scales exist for depression to measure severity of symptoms, and response to therapeutic intervention. – Hamilton rating scale for depression (HAM-D) - symptoms

Looking Up:Improving the

Management of Depression

0

20

40

60

80

100

ReceivingAntidepressant

Receiving AdequateDose

Wells KB et al. Am J Psychiatry. 1994;151:694-700.

% ofDepressed Patients

Depression Is Underdiagnosed and Undertreated

22.713.7

Medical Outcomes Study

90%80%

50%

0%

50%

100%

After 1 Episode After 2

Episodes

After 3

Episodes

Kupfer DJ. J Clin Psychiatry. 1991;52:(suppl 5):28-34.

Probability ofRecurrent Episodes

Depression Is a Chronic Illness

Defining outcomes and phases

of treatment

Adapted from Kupfer. J Clin Psychiatry 1991; 52 (Suppl 5): 28-34.

Euthymia

Symptoms

Syndrome

Treatment phases

Pro

gre

ssion

to d

isord

er

Acute(6-12 weeks)

Continuation(4-9 months)

Maintenance(>1 year)

Relapse

Response

RecurrenceRelapse

Remission

TIME

STEPS: Factors to Consider in Antidepressant Selection

• Safety– Drug-drug interaction potential

• Tolerability– Acute and long term

• Efficacy– Onset of action– Treatment and prophylaxis– Activity in subpopulations

• Payment (cost-effectiveness)

• Simplicity– Dosing– Need for monitoring

ANTIDEPRESSANTS GROUPS AND NAMES

• TCAs Tricyclic Antidepressants. • SSRI Selective Serotonin Reuptake Inhibitor• RIMA Reversible Inhibitor of Mono Amino Oxidase• SNRI Serotonin and Noradrenalin Reuptake Inhibitor• NaSSA Noradrenergic and Specific Serotonergic

Antidepressant• DSA Daul Serotonergic Antidepressant• NARI NorAdrenalin Reuptake Inhibitor• (SNRI) Selective Noradrenalin Reuptake Inhibitor

ANTIDEPRESSANTS GROUPS AND PHARMACOLOGY (1)

• TCAs Amitriptyline, Doxepine, Trimipramine, Clomipramine and other.

• SSRI Fluvoxamine, Fluoxetine, Paroxetine, Sertraline, Citalopram

• RIMA Moclobemide – Reversible inhibitor, selective inhibition of MAO type A

• SNRI Venlafaxine– Reuptake inhibition NA/5-HT, no affinity to other systems

(?)

ANTIDEPRESSANTS GROUPS AND PHARMACOLOGY (2)

• NaSSA Mirtazapine 2 antagonist, 5-HT2 and 5-HT3 antagonist. H1 antagonist.

• DSA Nefazodone– 5-HT2 antagonist and 5-HT reuptake inhibitor

• NARI (SNRI) Reboxetine– Selective NA reuptake inhibitor

Side Effects of Concern With Antidepressant Therapy

CNS• Activation

– Insomnia– Anxiety– Nervousness– Agitation– Tremor– Seizures

• Sedation– Somnolence– Fatigue

GI• Nausea• Constipation• Diarrhea• Dyspepsia• Weight gain• Anorexia

Sexual function• Decreased libido• Impotence• Ejaculation disorder• Anorgasmia

Cardiovascular• Hypertension• Orthostatic hypotension• Arrhythmias

Other• Dry mouth• Increased sweating• Asthenia

OTHER THERAPIES FOR DEPRESSION

• Psychotherapy

• Electroconvulsive therapy

WHEN TO INVOLVE A SPECIALIST

• Persistent suicidal ideation or plan of action

• Development of psychotic or manic symptoms

• Poor or partial response to antidepressant

• Refusal of pharmacotherapy

• Complicating illness or concurrent medication

PATIENT FOLLOW-UP

• Regular monitoring of mental state

• Inform patients that improvement may not be apparent for 2 weeks on antidepressants

• Clear instructions regarding medication and importance of compliance

ANSWERS TO FREQUENTLY ASKED QUESTIONS

• Sleep disturbances may resolve relatively quickly with some agents

• Somatic complaints may resolve in a few weeks

• Other symptoms may take several weeks to resolve

• Compliance is essential

PSYCHOTHERAPY MAY BE INDICATED

• As an adjunct to drug therapy but is not a substitute for it

• In patients with milder depression who do not need or do not want drugs

LIFE-STYLE CHANGES

• Suggestions for life-style changes are not useful while patients are significantly depressed

• Patients should avoid alcohol and substances with potential for abuse while being treated

FOLLOW-UP THERAPY

• Continue antidepressants for several months or longer

• See patients frequently to assess mood and side effects

• When discontinuation is indicated, antidepressant dosages should be tapered

SUMMARY

• Affective disorders are as common in Pakistan as elsewhere in the world.

• Present with predominant Somatic symptoms.

• Not picked up by health professionals.

• Unnecessary investigations.

SUMMARY 2

• Even if recognized, treated with only Anti depressants.

• Teaching of Psychiatry at under & postgraduate levels.

• Integration into Primary Health Care System.

• Integration has positive effect on the utilisation of general health services.