Depressive IllnessDepressive Illness

Dr. Sarma R V S NConsultant Physician

visit: www.drsarma.in

http://www.hcc.bcu.ac.uk/craig_jackson/psychopharmacology%20and%20serotonin.ppt

With thanks for the resource material from

Neurotics build castles in the air

Psychotics live in them and enjoy

Psychiatrists collect rent for those castles

PathogenPathogen DiseaseDisease (pathology)(pathology)

ModifiersModifiersLifestyleLifestyleIndividual susceptibilityIndividual susceptibility

Traditional model of Disease DevelopmentTraditional model of Disease Development

Dominance of the biopsychosocial modelDominance of the biopsychosocial model

Mainstream in last 15 yearsMainstream in last 15 years

Hazard Hazard

Psychosocial FactorsPsychosocial FactorsAttitudesAttitudesBehaviourBehaviourQuality of LifeQuality of Life

Illness Illness (well-being)(well-being)

Rise of the person as a Rise of the person as a “psychological entity”“psychological entity”

MDD and Anxiety Disorders

AnxietyDisorders

59%59%MajorDepression

MajorDepression

Association of Psychiatric Disorders

MDD: Indian Facts and FiguresMDD: Indian Facts and Figures

The World Health Report 2001 accessed from http://www.who.int/whr2001/2001/main/en/contents.htm. last accessed on 30.12.02WHR 2001: Box 3.8 Two national approaches to suicide prevention

Total populationapprox.103 crores (2001 census)

Total populationapprox.103 crores (2001 census)

Total no of depressed patients approx. 9 croresTotal no of depressed patients approx. 9 crores

Depressed patients per psychiatrist approx. 25,714 Depressed patients per psychiatrist approx. 25,714

Common disorderCommon disorder

Bangalore: 9.1% (WHR 2001)Bangalore: 9.1% (WHR 2001)

Spectrum of mood disturbanceSpectrum of mood disturbance

Mild Mild thru to thru to SevereSevere

Transience Transience thru to thru to Persistence Persistence

Continuous distribution in populationContinuous distribution in population

Clinically significant when:Clinically significant when:(1) interferes with normal activities(1) interferes with normal activities(2) persists for min. 2 weeks(2) persists for min. 2 weeks

Diagnosis of depression / depressive disorderDiagnosis of depression / depressive disorder““Persistent & pervasive low mood”Persistent & pervasive low mood”““Loss of interest or pleasure in activities”Loss of interest or pleasure in activities”

Depressive IllnessDepressive Illness

Usually treatableUsually treatable

CommonCommon

Marked disabilityMarked disability

Reduced survivalReduced survival

Increased costsIncreased costs

Depression may beDepression may be

Coincidental associationCoincidental association

Complication of physical illness Complication of physical illness

Cause of / Exacerbation of somatic symptomsCause of / Exacerbation of somatic symptoms

Depressive IllnessDepressive Illness

2% of population suffer from2% of population suffer from pure depressionpure depression(evenly distributed between mild, moderate,(evenly distributed between mild, moderate, and severe)and severe)

Further 8% suffer from a mixture of anxietyFurther 8% suffer from a mixture of anxiety and depressionand depression

Patients with symptoms not severe enoughPatients with symptoms not severe enough to qualify for diagnosis of either to qualify for diagnosis of either anxiety or depression..... ???anxiety or depression..... ???

Impaired working and social lives and many unexplainedImpaired working and social lives and many unexplained physical symptomsphysical symptoms

Greater use of medical servicesGreater use of medical services

EpidemiologyEpidemiology

2nd biggest cause of disability 2nd biggest cause of disability

worldwide by 2020 (WHO) worldwide by 2020 (WHO)

(IHD still the biggest)(IHD still the biggest)

Associated with increasedAssociated with increasedphysical illnessphysical illness

• 5% during lifetime have MDD5% during lifetime have MDD• 1 in 20 consultations1 in 20 consultations• MDD & Dysthymia > in femalesMDD & Dysthymia > in females• 20% develop chronic depression20% develop chronic depression• 30% of in-patients have depressive symptoms30% of in-patients have depressive symptoms

MDD and PhysiciansMDD 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)

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

PRIME MD TODAYTMPRIME MD TODAYTM

A Screening and

Diagnostic

Instrument

for Major Depressive

Disorder (MDD)

A Screening and

Diagnostic

Instrument

for Major Depressive

Disorder (MDD)

Primary Care Evaluation of Mental Disorders

Kaplan & Sadock’s Synopsis of Psychiatry, 8th ed., p 941 Harrison’s Principles of Internal Medicine, 15th ed., p 2543

SuicideSuicide

SuicideSuicide

Final clinical pathwayFinal clinical pathway

1 million deaths per year, 10-12 million attempts1 million deaths per year, 10-12 million attempts

Males – most common in olderMales – most common in older

Female – most common in middle ageFemale – most common in middle age

15 per 15 per 100,000 deaths males100,000 deaths males

6 per 6 per 100,000 deaths females100,000 deaths females

Almost 50% fail on first attemptAlmost 50% fail on first attempt

Previous attempters 23 times more likely to dies from suicide than those Previous attempters 23 times more likely to dies from suicide than those without previous attemptswithout previous attempts

Internal stressInternal stress

Pre-existing psychiatric morbidityPre-existing psychiatric morbidity

DemographicsDemographics

OpportunitiesOpportunities

Behavioural IndicatorsBehavioural Indicators

- recent bereavement or other life-altering loss - recent bereavement or other life-altering loss

-- recent break-up of a close relationship recent break-up of a close relationship

-- major disappointment (failed exams or missed job promotion) major disappointment (failed exams or missed job promotion) - change in circumstances (retire, redundant or children leaving home) - change in circumstances (retire, redundant or children leaving home) - physical illness- physical illness- mental illness - mental illness - substance misuse / addiction- substance misuse / addiction- deliberate self-harm, (particularly in women)- deliberate self-harm, (particularly in women)- previous suicide attempts - previous suicide attempts - loss of close friend / relative by suicidal means- loss of close friend / relative by suicidal means- loss of status- loss of status- feelings of hopelessness, powerlessness and worthlessness- feelings of hopelessness, powerlessness and worthlessness- declining performance in work / activities (sometimes this can be reversed)- declining performance in work / activities (sometimes this can be reversed)- declining interest in friends, sex, or previous activities- declining interest in friends, sex, or previous activities- neglect of personal welfare and hygiene- neglect of personal welfare and hygiene- alterations in sleeping habits (either direction) or eating habits- alterations in sleeping habits (either direction) or eating habits

EpidemiologyEpidemiology

Depression more common in those with:Depression more common in those with:

• Life threatened / limited / chronic physical illnessLife threatened / limited / chronic physical illness

• Unpleasant / demanding treatmentUnpleasant / demanding treatment

• Low social supportLow social support

• Adverse social circumstancesAdverse social circumstances

• Personal / family history of depression / psychological vulnerabilityPersonal / family history of depression / psychological vulnerability

• Substance misuseSubstance misuse

• Anti-hypertensive / Corticosteroid / Chemotherapy useAnti-hypertensive / Corticosteroid / Chemotherapy use

Q o LQ o L

Different Reasons

Most depressions have triggering life events - Reactive depression

Especially in a first episode

Many patients present with physical symptoms - Somatisation syndrome

Some may show multiple symptoms of depression 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

Clinical FeaturesClinical Features

• Adjustment DisordersAdjustment Disorders mildmild short-livedshort-lived reactive episodesreactive episodes

• Major Depressive Disorder (MDD)Major Depressive Disorder (MDD) 5 symptoms displayed in 14 days5 symptoms displayed in 14 days

• DysthymiaDysthymia depressed mood for 2+ yearsdepressed mood for 2+ years not severenot severe chronic depressionchronic depression unhealthy lifestyle associationsunhealthy lifestyle associations

• Bipolar Disorder / manic depressionBipolar Disorder / manic depression major depression & maniamajor depression & mania

Major depression (DSM IV-TR)Major depression (DSM IV-TR)

5 or more…..5 or more…..

• decreased interest / pleasure * decreased interest / pleasure * • depressed mood *depressed mood *• reduced energyreduced energy• weight gain / lossweight gain / loss• insomnia / hypersomniainsomnia / hypersomnia• feeling worthlessfeeling worthless• guiltguilt• recurrent morbid thoughtrecurrent morbid thought• psychomotor changespsychomotor changes• fatiguefatigue• poor concentrationpoor concentration• pessimism / bleak viewspessimism / bleak views• self harm ideas / actionsself harm ideas / actions• suicide ideationsuicide ideation

Classification of Depression (ICD-10)Classification of Depression (ICD-10)

PrimaryPrimaryUnipolarUnipolar

Mixed anxiety and depressive disorder (prominent anxiety) Mixed anxiety and depressive disorder (prominent anxiety) Depressive episode (single episode) Depressive episode (single episode) Recurrent depressive disorder (recurrent episodes) Recurrent depressive disorder (recurrent episodes) Dysthymia - Persistent and mild ("depressive personality") Dysthymia - Persistent and mild ("depressive personality")

BipolarBipolar Bipolar affective disorder - manic episodes ("manic depression") Bipolar affective disorder - manic episodes ("manic depression") Cyclothymia - Persistent instability of mood Cyclothymia - Persistent instability of mood

Other primaryOther primary Seasonal affective disorder Seasonal affective disorder Brief recurrent depression Brief recurrent depression

Depressive episode may beDepressive episode may beModerate or severe Moderate or severe With/Without somatic syndrome With/Without somatic syndrome With/Without psychotic symptomsWith/Without psychotic symptoms

Somatization Syndrome (DSM IV)Somatization Syndrome (DSM IV)

4 or more…..4 or more…..

Anhedonia (inability experience pleasure)Anhedonia (inability experience pleasure)

Loss of emotional reactivity Loss of emotional reactivity

Early waking (>2 hours early) Early waking (>2 hours early)

Psychomotor retardation or agitation Psychomotor retardation or agitation

Marked loss of appetite Marked loss of appetite

Weight loss >5% of body mass in one month Weight loss >5% of body mass in one month

Loss of libido (important and often ignored)Loss of libido (important and often ignored)

Classification

• Many patients do not fit neatly into categories of either anxiety or depression

• Mixed anxiety and depression is now recognised

• Presence of physical symptoms indicates a somatic syndrome

• Value of somatic features in predicting response to treatment is not clear

• Presence of psychotic features has major implications for treatment

• Brief episodes of more severe depression - brief recurrent depression

• More prolonged recurrence is now termed recurrent depressive disorder

Risk FactorsRisk Factors

Anxiety + Sadness + Somatic discomfortAnxiety + Sadness + Somatic discomfort

Normal psychological response to life stressNormal psychological response to life stress

Clinical depression is a “final common pathway”

Resulting from interaction of Resulting from interaction of biologicalbiological, , psychologicalpsychological, and , and social factorssocial factors

Likelihood of this outcome depends on many factors:Likelihood of this outcome depends on many factors:• geneticgenetic and family predispositionand family predisposition• clinical course of concurrentclinical course of concurrent medical illnessmedical illness• nature of any treatmentnature of any treatment• functional disabilityfunctional disability• individual coping styleindividual coping style• social and other supportsocial and other support

Recognition & Diagnosis

Depressive illness is often under-diagnosed and under-treated

Especially if it coexists with physical illness

This often causes great distress for patients: mistakenly assumedthat symptoms (weakness or fatigue) are due to an underlying medicalcondition.

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.

Screening QuestionnairesScreening 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 instrumentsSelf-report screening instrumentsBeck Depression Inventory (BDI) General Health Questionnaire (GHQ)

Hospital Anxiety Depression Scale (HAD)

Can’t replace systematic clinical assessment – Can’t replace systematic clinical assessment – LISTENINGLISTENING

Persistent low mood and lack of interest and pleasure in life cannot be accounted for by severe physical illness alone

Simplified Algorithm

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

Drug Treatment

Selective Serotonin Re-uptake Inhibitors (SSRI’s) - NewerSertraline 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

Comparative Tolerability

Treatment

Much depressive illness of all types is successfully treated in primary care

Four main reasons for referral to specialist psychiatric services:

1) Condition is severe

2) Failing to 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 talking therapy• Most patients in primary care settings would prefer a talking therapy• Effectiveness is limited to particular forms of psychotherapy• Mild-Mod. Depression: CBT and antidepressants are equally effective• Severe Depression: antidepressant drugs are more effective

Management

The main aims of treatment:The main aims of treatment:• improve mood and quality of lifeimprove mood and quality of life• reduce the risk of medical complicationsreduce the risk of medical complications• improve complianceimprove compliance with and outcome of physical treatmentwith and outcome of physical treatment• facilitate the "appropriate"facilitate the "appropriate" use of healthcare resourcesuse of healthcare resources

PrimaryPrimary care staff should be familiar with properties and use of:care staff should be familiar with properties and use of:1) common antidepressant drugs & brief psychological treatments1) common antidepressant drugs & brief psychological treatments

2) assessment of suicidal thinking and risk2) assessment of suicidal thinking and risk

Patients with more enduring or severe symptoms will usually require specific Patients with more enduring or severe symptoms will usually require specific treatment - usually drug therapytreatment - usually drug therapy

ForFor patients with suicidal ideation / whose depression haspatients with suicidal ideation / whose depression has not responded to initial not responded to initial management, specialist referral is themanagement, specialist referral is the next stepnext step

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

SummarySummary

• Detection can be hard – symptom overlap and patient unawareDetection can be hard – symptom overlap and patient unaware

• Depression a natural occurrence in populationDepression a natural occurrence in population

• Whole range of depressive conditions with varying severityWhole range of depressive conditions with varying severity

• Depression can be present in acute or chronic statesDepression can be present in acute or chronic states

• Depression can have physiological, biological or social causesDepression can have physiological, biological or social causes

• Depression may have a mixture of causesDepression may have a mixture of causes

• Depression co-exists with many other symptomsDepression co-exists with many other symptoms

• Depression is a natural reaction to disease diagnosis and presenceDepression is a natural reaction to disease diagnosis and presence

• Depression and symptomotology are highly relatedDepression and symptomotology are highly related

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

William Osler William Osler

Thank YouThank You