Depressive Illness
Dr. Sarma R V S N
Consultant Physician
visit: www.drsarma.in
With thanks for the resource material from
http://www.hcc.bcu.ac.uk/craig_jackson/
psychopharmacology%20and%20serotonin.ppt
Neurotics build castles in the air
Psychotics live in them and enjoy
Psychiatrists collect rent for those castles
Traditional model of Disease Development
Pathogen
Modifiers
Lifestyle
Individual susceptibility
Disease (pathology)
Dominance of the biopsychosocial model
Mainstream in last 15 years
Hazard
Illness (well-being)
Psychosocial Factors
Attitudes
Behaviour
Quality of Life
Rise of the person as a
“psychological entity”
MDD and Anxiety Disorders
Major
Depression
59%
Anxiety
Disorders
Association of Psychiatric Disorders
MDD: Indian Facts and Figures
Total population
approx.103 crores (2001 census)
Common disorder
Total no of depressed patients
approx. 9 crores
Bangalore: 9.1% (WHR 2001)
Depressed patients per psychiatrist approx.
25,714
The World Health Report 2001 accessed from http://www.who.
int/whr2001/2001/main/en/contents.htm. last accessed on 30.12.02
WHR 2001: Box 3.8 Two national approaches to suicide prevention
Spectrum of mood disturbance
Mild
thru to
Severe
Transience
thru to
Persistence
Continuous distribution in population
Clinically significant when:
(1) interferes with normal activities
(2) persists for min. 2 weeks
Diagnosis of depression / depressive disorder
“Persistent & pervasive low mood”
“Loss of interest or pleasure in activities”
Depressive Illness
Usually treatable
Common
Marked disability
Reduced survival
Increased costs
Depression may be
Coincidental association
Complication of physical illness
Cause of / Exacerbation of somatic symptoms
Depressive Illness
2% of population suffer from pure depression
(evenly distributed between mild, moderate, and severe)
Further 8% suffer from a mixture of anxiety and depression
Patients with symptoms not severe enough to qualify for diagnosis of either
anxiety or depression..... ???
Impaired working and social lives and many unexplained physical symptoms
Greater use of medical services
Epidemiology
2nd biggest cause of disability
worldwide by 2020 (WHO)
(IHD still the biggest)
Associated with increased
physical illness
• 5% during lifetime have MDD
• 1 in 20 consultations
• MDD & Dysthymia > in females
• 20% develop chronic depression
• 30% of in-patients have depressive symptoms
MDD 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)
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 TODAYTM
Primary Care Evaluation of Mental Disorders
A Screening and
Diagnostic
Instrument
for Major Depressive
Disorder (MDD)
Kaplan & Sadock’s Synopsis of Psychiatry, 8th ed., p 941
Harrison’s Principles of Internal Medicine, 15th ed., p 2543
Suicide
Suicide
Final clinical pathway
1 million deaths per year, 10-12 million attempts
Males – most common in older
Female – most common in middle age
15 per 100,000 deaths males
6 per 100,000 deaths females
Almost 50% fail on first attempt
Previous attempters 23 times more likely to dies from suicide than those
without previous attempts
Internal stress
Pre-existing psychiatric morbidity
Demographics
Opportunities
Behavioural Indicators
- recent bereavement or other life-altering loss
- recent break-up of a close relationship
- major disappointment (failed exams or missed job promotion)
- change in circumstances (retire, redundant or children leaving home)
- physical illness
- mental illness
- substance misuse / addiction
- deliberate self-harm, (particularly in women)
- previous suicide attempts
- loss of close friend / relative by suicidal means
- loss of status
- feelings of hopelessness, powerlessness and worthlessness
- declining performance in work / activities (sometimes this can be reversed)
- declining interest in friends, sex, or previous activities
- neglect of personal welfare and hygiene
- alterations in sleeping habits (either direction) or eating habits
Epidemiology
Depression more common in those with:
•
Life threatened / limited / chronic physical illness
•
Unpleasant / demanding treatment
•
Low social support
•
Adverse social circumstances
•
Personal / family history of depression / psychological vulnerability
•
Substance misuse
•
Anti-hypertensive / Corticosteroid / Chemotherapy use
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 Features
• Adjustment
Disorders
mild
short-lived
reactive episodes
•
Major Depressive Disorder (MDD)
5 symptoms displayed in 14 days
•
Dysthymia
depressed mood for 2+ years
not severe
chronic depression
unhealthy lifestyle associations
•
Bipolar Disorder / manic depression
major depression & mania
Major depression (DSM IV-TR)
5 or more…..
• decreased interest / pleasure *
• depressed mood *
• reduced energy
• weight gain / loss
• insomnia / hypersomnia
• feeling worthless
• guilt
• recurrent morbid thought
• psychomotor changes
• fatigue
• poor concentration
• pessimism / bleak views
• self harm ideas / actions
• suicide ideation
Classification of Depression (ICD-10)
Primary
Unipolar
 Mixed anxiety and depressive disorder (prominent anxiety)
 Depressive episode (single episode)
 Recurrent depressive disorder (recurrent episodes)
 Dysthymia - Persistent and mild ("depressive personality")
Bipolar
Bipolar affective disorder - manic episodes ("manic depression")
Cyclothymia - Persistent instability of mood
Other primary
Seasonal affective disorder
Brief recurrent depression
Depressive episode may be
Moderate or severe
With/Without somatic syndrome
With/Without psychotic symptoms
Somatization Syndrome (DSM IV)
4 or more…..
Anhedonia (inability experience pleasure)
Loss of emotional reactivity
Early waking (>2 hours early)
Psychomotor retardation or agitation
Marked loss of appetite
Weight loss >5% of body mass in one month
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 Factors
Anxiety + Sadness + Somatic discomfort
Normal psychological response to life stress
Clinical depression is a “final common pathway”
Resulting from interaction of biological, psychological, and social factors
Likelihood of this outcome depends on many factors:
• genetic and family predisposition
• clinical course of concurrent medical illness
• nature of any treatment
• functional disability
• individual coping style
• social 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 assumed
that symptoms (weakness or fatigue) are due to an underlying medical
condition.
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 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 instruments
Beck Depression Inventory (BDI)
General Health Questionnaire (GHQ)
Hospital Anxiety Depression Scale (HAD)
Can’t replace systematic clinical assessment – LISTENING
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) - Newer
Sertraline
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:
• improve mood and quality of life
• reduce the risk of medical complications
• improve compliance with and outcome of physical treatment
• facilitate the "appropriate" use of healthcare resources
Primary care staff should be familiar with properties and use of:
1) common antidepressant drugs & brief psychological treatments
2) assessment of suicidal thinking and risk
Patients with more enduring or severe symptoms will usually require specific
treatment - usually drug therapy
For patients with suicidal ideation / whose depression has not responded to initial
management, specialist referral is the next 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
Summary
• Detection can be hard – symptom overlap and patient unaware
• Depression a natural occurrence in population
• Whole range of depressive conditions with varying severity
• Depression can be present in acute or chronic states
• Depression can have physiological, biological or social causes
• Depression may have a mixture of causes
• Depression co-exists with many other symptoms
• Depression is a natural reaction to disease diagnosis and presence
• Depression and symptomotology are highly related
“The good physician
treats the disease,
but the great physician
treats the person.”
William Osler
Thank You