Dr Kirthi Kumar
Psychiatrist
•Mercy
Mental Health Program
•Wyndham Private Clinic
•South West Specialist Centre
•Harvester Private Consulting
1
 Significance
 Overview
of depression
 Depression in men
 Management
 Extent of suicide
 Risk factors
 Management
 Prevention
2
 Misconceptions
 Under
recognised
 Medical profession have a duty to
identify depression
 One of the leading causes of disability
worldwide
 Prevalence rates – anxiety (9.7%),
affective disorders (5.8%), D & A (7.7%)
3
 Most
episodes are managed by GPs
 85% of antidepressant prescriptions are
by GPs
 4th most commonly managed problem in
general practice (McManus MJA 2000)
 2nd highest contributor of global disease
by 2020 (Harvard University Press 1996)
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 Major
depression
 Bipolar depression
 Dysthymia
 Adjustment disorder
 PTSD
 Substance use disorders
 Personality disorders
 Organic depression
 Post psychotic depression
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Features
Depression
Unhappiness
Anhedonia
++
▬
Loss of interest
++
+/-
Depressive cognition
++
▬
Loss of reactivity
++
▬
↓ Libido
++
▬
↓ Productivity
++
+/-
↓ Biological functions
++
▬
Psychotic Symptoms
++
▬
6
43 y o, male working as an admin officer presents sadness,
amotivation to work, apprehension, frustration, helplessness,
impaired sleep of 3months duration in the context of apparent
work place harassment and bullying by management for the last
5months. Gives a history office adapting new technology about
5months ago which he could not cope as he was computer
illiterate due to dyslexia. He has not been able to cope with
performance review. Manager has told given him 2months time to
‘pull up his socks’ Patient has been feeling the threat of job loss.
He has no past, family history. No major adverse personal or
childhood events.
On mental status examination, comes across as with depressed
mood, non reactive affect with reduced range, preoccupied with
state of affairs, apprehensive. Expresses helplessness. Not suicidal.
No psychotic or cognitive features. He is insightful.
Diagnosis: Adjustment disorder with depressive and anxiety
symptoms
7
45 y o single mother of two kids. Separated 8 years ago. Works
part time in a supermarket.
Presents with a 4 year history of sadness of mood, reduced
motivation, does not enjoy much, fatigue, minimal
socialisation, eats well, lack of sound sleep. No death wishes
or suicidality. No psychotic symptoms. Has been on
antidepressants for 3 years. Has not improved much nor has
deteriorated. Functionally, drops kids off to school and
attends work till 3 pm. Cooks for kids and self. Cleans the
house once a week. Drives adequately. No drug and alcohol
history.
MSE, stated age; well attired, talks slowly. No PMA ↓, depressed
mood but laughs at times. No psychotic or cognitive
pathology. Insightful
Diagnosis: Dysthymia
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


30 y o mother of 1 (2 y o), married house wife. Reports 3 months of
low mood, reduced interest, lack of pleasure, fatigue, increased
effort, minimal appetite, loss of weight (5 kgs), poor quality of
sleep, frequent disagreement with husband. Has been neglecting
household chores, has occasionally thought of suicide but no plans
or intent. Past history of PND, sister and mother have depression
on treatment. Unable to identify overt reasons but wonders if her
husband is not caring and son is demanding.
MSE: looks tired, walks slowly, low tone of speech, worthless,
fleeting suicidal thoughts, depressed mood, passively smiles at
times, fearful of what people think around her. No psychotic or
cognitive pathology. Some social judgement impairment.
Insightful.
Diagnosis: Major depression
Recurrent depressive disorder
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 Medications
alone
 Psychotherapy alone
 Combined medications and
psychotherapy
 ECT
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 Average
episode ► 9 months
 Most episodes remit in 2 years
 No prophylaxis ► 50% have another
episode
 RDD with >3 episodes ► 70-80% will
have another episode within 3 years
 Increasing number of episode ► ↑ risk of
suicide, chronicity and disability
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 Severe
symptoms
 Depression and physical comorbidity
 Depression and personality challenges
 Non response to treatment
 Suicidality
 Psychotic depression
 Bipolar depression
 Inability to treat
 Patient requests
 Legislative requirement.
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 Good
at hiding
 Higher rate of under recognition
 Higher rate of physical symptoms →
fatigue, pain, loss of weight
 Irritability
 Higher preexisting D & A issues,
antisocial behaviour
 Better coping strategies such physical
activities, instruments
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 Variable
attitude towards suicide
 Way to end the suffering
 Suicidal thoughts = underlying pathology
 Planned or impulsive
 ‘Chronic suicide’
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 2nd
leading cause of death < 30 y o after
MVA.
 Highest in Eastern European countries
(0.027%)
 Lowest in Latin American and Muslim
countries (0.0065%)
 Australia ranked 13th (WHO 1996)
 ♂ = 23.7/100,000
 ♀ = 3.7/100,000
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Rates per 100,000
10%
9%
8%
7%
6%
5%
4%
3%
2%
1%
0%
completed
suicide attempts
suicide (0.02%)
(2.5%)
DSH (6%)
suicidal ideation
(9%)
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120
100
80
60
40
20
0
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 Past
suicide/DSH attempts
 Psychiatric diagnosis
 Substance abuse
 Family history – suicide/self harm
 Male
 Younger group (16-25)
 Older age > 75
 Victim of child abuse
 Victim of violence as adult
18
 Major
physical illness
 Social isolation
 Multiple psychiatric conditions
 Significant anniversary
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 Current
intent or plan (self harm/suicide)
 Hopelessness
 Active symptoms
 Expressing distress
 Lack of impulse control
 Low frustration tolerance
 Active D & A use
 Recent stress
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 Recent
psychiatric admission
 Recent loss of relationship (separation,
divorce, death)
 Retirement
 Access to method
 Poor adherence to treatment
 Lack of treatment response
 Insomnia
 Hostility
 Concerned family/carers
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 Sex: ♂ complete more than ♀
(about 4:1)
 Age: Highest for 15-24 y o, > 60 y o
 Depression
 Past
Attempt
 Ethanol & Drug abuse
 Rational thinking is
impaired
 Support networks
(limited)
 Organised plan
 No
Spouse
 Sickness
 Experiences of
adversity
 Sexual abuse
 Co morbidity
 Anxiety disorder
 Personality
disorders
 Event: stressful
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 Higher
the social state, higher the risk (??)
 Physicians, especially ♂
 Among physicians psychiatrists,
ophthalmologists, Anesthetists
 Musicians, dentists, law enforcements officers,
lawyers & Insurance agents
 Unemployment
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 Positive
self esteem
 Adequate problem solving
 Spirituality
 Supports
 Children
 Adequate self control
 Pregnancy
 Sense of responsibility (towards
family/pets)
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 No
risk factors = absent
 Static + protection = low
 Static = some risk - moderate
 Static + dynamic = moderate to high
25
 Must
be offered to every patient
 A routine practice
 Share the knowledge, improve the
knowledge
 2nd opinion when in doubt
 Combined approach – clinician + patient
+ carer
26
 Routine
clinical care
 Crisis management plan in place
 Triage contact details provided
 Ascertain patient’s ability to understand
crisis plan; involve others if needed
27
 Treat
(initiate/optimise) mental disorder
 Alert triage if necessary
 Refer to mental health follow up
 Check if someone can stay with patient
 Crisis management plan discussed
 Review again within a week
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 As
per management of moderate risk
+
 Contact triage for further input
 Admission if needed
 Involve the carers
 Notify other clinicians
(psychologist/nurse/social worker)
+
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General public
- helps to identify risk
- encourages help seeking
- reduces stigma
 General practitioners
- most suicidal patients contact GP within a
month prior to death
- if unrecognised, untreated the
risk worsens
- opportunity to make a difference
 Gate keepers (eg, PCA, school cousellors, priests)
- increase awareness
- gate keepers are 1st point of contact to many
- lesser level of stigma; more attached to gate
keepers

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 Screen
for mental illness, D & A use, suicidal
behaviour
 Include youth, juvenile offenders, high
school students
 Use screening instruments
 Treat underlying conditions
- a health care plan
- medications
- psychotherapy (CBT, DBT, problem
solving, IPT)
- family therapy
- post suicide attempt follow up
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 Multimodal
approach
 Must be repetitive to be effective
 Must be part of orientation in health care
 Must include information on
- improving help seeking behaviour
- access to care
- reducing stigma
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