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Depression-An under-recognized condition

Non- attendance

(A) The Epidemiological Catchment Area Study carried out in theUSAsuggests that

approximately one third of people suffering from depression do not seek help or

treatment

(B) A European sur veyof 80,000 people also revealed third of people with major

depression had not consulted a health-care specialist.

Men were less likely to consult a medical specialist than women.

Many believed --------They would get better by themselves

Some--------------------Too embarrassed to seek help

Other reasons why patients dont consult doctors include: They may not recognise they have an illness

They may regard their symptoms as appropriate in their circumstances

Many people do not know depression can be treated easily

Misconceptions over treatment

Poor recognition

GPs manage about 80 per cent of all mental illness, but evidence suggests that

depression is frequently missed in general practice.

1. Half of patients severe depression -----------not recognised at the first consultation.

2. A further 10%------------- Recognised in subsequent consultations.

3. 20%--------------------------Remit during this time.

4. The remaining 20%-------- may remain unrecognised even after six months

5. Recognising difficulty -----------presentations with somatic symptoms -

70% cases - and of depression related to physical disorders

1. Other factors include an aversion on the part of both GPs and patients to

talk about psychological problems and inadequate time forconsultations

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MAJOR DEPRESSIVE DISORDEROR

AFFECTIVE DISORDER( DEPRESSIVE EPISODE)

INCIDENCE

Male 5-12%

Female 10-25%

More in females, the ratio 2:1

Age 20-50 years

Average 40 years

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Lifetime Prevalence of Various Mood Disorders

Mood Disorder Lifetime Prevalence

Depressive disord ersMajor depressive disorder (MDD) 1025% for women

512% for men

Recurrent, without full 2530% of persons with MDD

interepisode recovery,

superimposed on dysthymic disorder (double depression)

Dysthymic disorder 36%

Bipolar disordersBipolar I disorder 0.41.6%

Bipolar II disorder


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ICD-10 Criteria fo r Depressiv e Episode

A. Five (or more)of the following symptoms have been

present during the same 2-week period and representa change from previous functioning;

At leastone of the symptoms is either (1) depressed

mood or (2) loss of interest or pleasure.

.(1)Depressed mood most of the day, nearly every day,

Either subjective report (e.g., feels sad or empty) or

Observation made by others (e.g., appears tearful).

Note: in children and adolescents, can be irritable mood.

(2) Markedly diminished interest or pleasure in all, or almost all,

activities most of the day, nearly every day

(as indicated either by subjective account or observation made by others)

(3) Significant weight loss when not dieting or

Weight gain (e.g., a change of more than 5% of body

weight in a month), or

Decrease or increase in appetite nearly every day.

Note: in children, consider failure to make expected

weight gains.

(4) Insomnia or hypersomnia nearly every day

(5) Psychomotor agitation or retardation nearly every day5


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6) Fatigue or loss of energy nearly every day

7) Feelings of worthlessness or excessive or inappropriate

guilt (which may be delusional) nearly every day

8) Diminished ability to think or concentrate, or

indecisiveness, nearly every day

(either by subjective account or as observed by others)9) Recurrent thoughts of death (not just fear of dying),

recurrent suicidal ideation without a specific plan, or

A suicide attempt or a specific plan for committing

suicide

B. The symptoms do not meet criteria for a mixed episode.

C. Significant distress or impairment in social,

occupational, or other important areas of functioning.

D. Not due to the direct physiological effects of a

Substance

General medical condition(e.g., hypothyroidism).

E. Not better accounted for by bereavement,6


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Somatic syndrome

Some depressive symptoms are widely regarded as having special

clinical significance and are here called "somatic." (Terms such as

biological, vital, melancholic, or endogenomorphic are used for thissyndrome in other classifications.)

(1) Marked loss of interest or pleasure in activities that are normally

pleasurable;

(2) Lack of emotional reactions to events or activities that normally

produce an emotional response;

(3) Waking in the morning 2 hours or more before the usual time;

(4) Depression worse in the morning;

(5) Objective evidence of marked psychomotor retardation or agitation

(remarked on or

reported by other people);

(6) Marked loss of appetite;

(7) Weight loss (5% or more of body weight in the past month);

(8) Marked loss of libido. 7


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Criteria for Seasonal Pattern

With seasonal pattern

can be applied to:-

Major depressive episodes in bipolar I disorder, bipolar II disorder,

or

Major depressive disorder, recurrent)

A. There has been a regular temporal relationship between the

onset of and a particular time of the year (e.g., regular appearance

of the major depressive episode in the fall or winter)

B. Full remissions (or a change from depression to mania or

hypomania) also occur at a characteristic time of the year (e.g.,

depression disappears in the spring).

C. In the last 2 years, two major depressive episodes have

occurred that demonstrate the temporal seasonal relationships

defined in criteria A and B, and no non seasonal major depressive

episodes have occurred during that same period.

D. Seasonal major depressive episodes (as described above)

substantially outnumber any non seasonal major depressive

episodes that may have occurred over the individual's lifetime.8


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Recurrent depressive disorder, current episode mild

Without somatic syndrome

With somatic syndrome

Recurrent depressive disorder, current episodemoderate

Without somatic syndrome

With somatic syndrome

Recurrent depressive disorder, current episodewithoutpsychotic symptoms

Recurrent depressive disorder, current episode severe

with psychotic symptoms

With mood-congruent psychotic symptomsWith mood-incongruent psychotic symptoms

Recurrent depressive disorder, currently in remission

Other recurrent depressive disorders

Recurrent depressive disorder, unspecified

Persistent mood [affective] disorders

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Diagnostic Criteria for Dysthymic Disorder

A Depressed mood for most of the day, for more days thannot, for at least 2 years.

B. Presence, while depressed, of two (or more) of the

following:

(1) Poor appetite or overeating

(2) Insomnia or hypersomnia

(3) Low energy or fatigue

(4) Low self-esteem

(5) Poor concentration or difficulty making decisions

(6) Feelings of hopelessness

C. Never without symptoms for more than two months during

the last 2-year period

D. No major depressive episode has been present during thefirst 2 years of the disturbance (1 year for children and

adolescent

Early onset------------Before 21 years of age

Late onset-------------21 years or older10


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ICD-10 Diagnostic Criteria for

Adjustment DisordersA. Onset of symptoms must occur within 1 month of

exposure to an identifiable psychosocial stressor, not

of an unusual or catastrophic type.

. Symptoms may be variable in both form and

severity.

The predominant feature of the symptoms may be

further specified as:-

Brief depressive reaction

A transient mild depressive state of a duration not

exceeding 1 month.

Prolonged depressive reaction

A mild depressive state occurring in response to a

prolonged exposure to a stressful situation but of a

duration not exceeding 2 years.

Mixed anxiety and depressive reaction

Both anxiety and depressive symptoms are

prominent, but at levels no greater than those

specified for mixed anxiety and depressive disorderor other mixed anxiety disorders.

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Bipolar affect ive diso rderEpisodes are demarcated by a switch to an episode of opposite or mixed

polarity

Bipolar affective disorder, current episode hypomanic

A. The current episode meets the criteria for hypomania.

B. There has been at least one other affective episode in the past, meeting the

criteria for hypomanic or manic episode, depressive episode, or mixed

affective episode.

Bipolar affective disorder, current episode manic without psychotic

symptoms

The current episode meets the criteria for mania without psychotic symptoms.

Bipolar affective disorder, current episode manic with psychotic symptoms

The current episode meets the criteria for mania without psychotic symptoms.

. With mood-congruent psychotic symptoms

With mood-incongruent psychotic symptoms

Bipolar affective disorder, current episode moderate or mild depression

A. The current episode meets the criteria for a depressive episode of either mild

or moderate severity.

. Without somatic syndrome

. With somatic syndrome

Bipolar affective disorder, current episode severe depression without

psychotic symptoms

Bipolar affective disorder, current episode severe depression with psychotic

symptoms

. With mood-incongruent psychotic symptoms

. With mood-congruent psychotic symptoms

Bipolar affective disorder, current episode mixed

Both manic and depressive symptoms must be prominent most of the time

during a period of at least 2 weeks.

Bipolar affective disorder, currentlyin remission

The current state does not meet the criteria for depressive or manic episode of any severity or

for any other mood [affective] disorder (possibly because of treatment to reduce the risk of

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M

A

N

I

A

D

E

P

R

E

S

S

I

ON

Normal State

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BIPOLAR AFFECTIVE DISORDERS

MA

N

I

A

D

E

P

R

E

S

SI

O

N

NORMALSTATE

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ICD-10 Diagnostic Criteria for Mood [Affective] Disorders

Manic episode

Mania without psychotic symptoms

A. Mood must be predominantly elevated, expansive, or ir r i table,

Change must be prominent and sustained for at least 1 week (unless it is

severe enough to require hospital admission).

B. At least threeof the following signs must be present (four if the mood is

merely irritable), leading to severeinterference with personal

functioning in daily living:1) increased activity or physical restlessness;

2) increased talkativeness ("pressure of speech");

3) flight of ideas or the subjective experience of thoughts racing;

4) loss of normal social inhibitions, resulting in behavior that is inappropriateto the circumstances;

5) decreased need for sleep;

6) inflated self-esteem or grandiosity;

7) distractibility or constant changes in activity or plans;8) behavior that is foolhardy or reckless

e.g., spending sprees, foolish enterprises, reckless driving;

9) Marked sexual energy or sexual indiscretions.

C. There are no hallucinationsor delusions, although perceptualdisorders may occur

D.The episode is not attributable to psychoactive substanceuse or to any

organic mental disorder.

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Mania wi th psychot ic symp toms

.

Delusions or hallucinations are present,

The commonest examples are those with grandiose, self-

referential, erotic, or persecutory content.

.

Congruent with the mood:

With mood-congruent psychotic symptoms

Example: -Grandiose delusions or voices telling the

individual that he or she has superhuman powers)

With mood-incongruent psychotic symptoms

Example:-voices speaking to the individual about affectively

neutral topics, or delusions of reference or persecution)

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Hypomania

A. The mood is elevated or irritableto a degree that is

definitely abnormal forThe individual concerned and

Sustained for at least 4 consecutive days.

B. At least three of the followingsigns must be present,

leading to

some interferencewith personal functioning in dailyliving:

(1) Increased activity or physical restlessness;

(2) Increased talkativeness;

(3) Distractibility or difficulty in concentration;

(4) Decreased need for sleep;

(5) Increased sexual energy;

(6) Mild overspending, or other types of reckless or

irresponsible behavior;

(7) Increased sociability or overfamiliarity.

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Table 14.6-7. DSM-IV Criteria for Manic Episode

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood,

asting at least 1 week (or any duration if hospitalization is necessary).

. During the period of mood disturbance, three (or more) of the following symptoms have

ersisted

1) inflated self-esteem or grandiosity

2) decreased need for sleep (e.g., feels rested after only 3 hours of sleep)

3) more talkative than usual or pressure to keep talking

4) flight of ideas or subjective experience that thoughts are racing

5) distractibility (i.e., attention too easily drawn to unimportant or irrelevant externalimuli)

6) increase in goal-directed activity (either socially, at work or school, or sexually) or

sychomotor agitation

7) excessive involvement in pleasurable activities that have a high potential for painful

onsequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish

usiness investments)

. The symptoms do not meet criteria for a mixed episode.

D. The mood disturbance is sufficiently severe to cause marked impairment in

ccupational functioning or in usual social activities or relationships with others, or to

ecessitate hospitalization to prevent harm to self or others, or there are psychotic features.

. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug

f abuse, a medication, or other treatment) or a general medical condition (e.g.,

yperthyroidism).

Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment

e.g., medication, electroconvulsive therapy, light therapy) should not count toward a

iagnosis of bipolar I disorder.18


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BIO-PSYCHO-SOCIAL VIEW

BIOLOGICAL

SOCIAL PSYCHOLOGICAL

Age

Sex

Neurotransmitters

Hormones

Genetic

Brain structure

Family Stability

Social Support

Sex

Nurture

Place of living

Minority class

Social & religious values

StressNurture

Cognitions

Personality

Painful childhood

Psychoanalysis

AETIOLOGY OF DEPRESSION

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Medical Conditions Physiologically Associated With Affective Disorders

Endocrine Disorders

Hypothyroidism

Hyperthyroidism

Parathyroid disorders

Cushing's syndrome

Neurologic Disorders

Cerebrovascular accidents

Central nervous system (CNS) lesions

Neurosyphilis

Mul tiple sclerosis

Neurosarcoidosis

CNS vascul i tis

HIV-associated CNS pathology

Other Disorders

Vitamin def iciencies (e.g, folate and vitamin B12)

Anemia

Hypoxia

End-stage renal disease

Systemic lupus erythematosus and other connective tissue

diseases

Occult malignancy (eg, pancreatic cancer)

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Differentiating Characteristics of Bipolar and Unipolar Depressions

Bipolar Unipolar

History of mania or hypomania Yes No

(definitional)

Temperament/personality Cyclothymic/extroverted Dysthymic/introverted

Sex ratio Equal More women than men

Age of onset Teens, 20s, and 30s 30s, 40s, 50s

Postpartum episodes More common Less common

Onset of episode Often abrupt More insidious

Number of episodes Numerous Fewer

Duration of episode 3 to 6 months 3 to 12 months

Psychomotor activity Retardation > agitation Agitation > retardation

Sleep Hypersomnia > insomnia Insomnia > hypersomnia

Family history

Bipolar disorder Yes

Unipolar disorder Yes Yes

Alcoholism Yes

Pharmacological response

Cyclic antidepressants Induce hypomania-mania

Lithium carbonate Acute antidepressant effects Ineffective

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Basic principles of prescribing in depression

Discuss with the patient: -

1) Choice of drug and2) utility/availability of other, non-pharmacological

treatments

Discuss with the patient likely outcomes. e.g.

Gradual relief from depressive symptoms over several

weeks

Prescribe a dose of antidepressant (after titration, if

necessary) that is likely effective

Continue treatment for at least 46 months after

resolution of symptoms

Withdraw antidepressants gradually;

Always inform patients of the risk and nature of

discontinuation symptoms

Treatment o f affect ive i l lness

Depression

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Episode: A period lasting longer than 2 weeks (as defined

by the DSM-IV-R) during which the patient is consistently

within the fully symptomatic range of a sufficient number of

ymptoms to meet syndromal criteria for the disorder.

Part ial rem ission: A period during which an improvement o

ufficient magnitude is observed that the individual is no

onger fully symptomatic

Response: The point at which a partial remission begins. A

esponse, unlike a partial remission, does require treatment

and thus implies that the cause of the change in the patient's

ondition is known, which may not be a valid assumption.

Ful l rem ission: A relatively brief period during which an

mprovement of sufficient magnitude is observed that the

ndividual is asymptomatic

Recovery: A remission that lasts for a specified period of

me. Relapse: A return of symptoms satisfying the fullyndrome criteria for an episode that occurs during the period

of partial or full remission, but before recovery as defined

above. A relapse signals a need for treatment intervention or

modification of ongoing treatment.

Recurrence: The appearance of a new episode of majorepressive disorder occurring during a recovery.

Definitions of terms related to the course of depression

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Panic Disorder50%-65%

Social AnxietDisorder 70%

OCD

67%

PTSD48%

GAD8%-39%

COMORBID MOOD & ANXIETY DISORDERS

DEPRESSION

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STRATEGIES FOR TREATMENT

When initiating acute-phase treatment, practitioners decide where the

patient should be treated (e.g., outpatient, day hospital, or

inpatient). Treatment location is dictated by factors such as

1) the imminent risk of suicide,

2) the capacity of the patient to recognize and follow instructions or

recommendations (adherence, psychosis),

3) the level of psychosocial resources,

4) the level of psychosocial stressors, and

5) the level of functional impairment.

Next, one chooses among the four common acute-phase

treatments

A) Medication

B) The combination of medication and psychotherapy.

C) Electroconvulsive therapy [ECT]).

D) For some, light therapy alone or in combination with medicationsmay also be an option.

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Treatment Plan

A treatment plan for depression consists of three

distinct phases

Phase 1: - Acu te treatment,relieves the immediate

symptoms of depression.

Phase 2, Cont inuat ion treatment,preserves the gains

achieved initially and protects the patient

from sliding back into depression.

Phase 3, Maintenance treatmen t,guards against

future episodes.

Treatment Phases and Goals

Phase Length Treatment goal

Acute 612 weeks Achieve remission

Continuation 1624 weeks Prevent relapse

Maintenance Varies Protect against recurrence

Remission= Return to level of symptoms and functioning that

existed before illness.

Relapse = Re-emergence of significant depressive symptoms.

Recurrence= Another major depressive episode.26


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Relation of Diagnosis to Treatment Selection

Diagnosis Treatment Recommendations

Major depressive Episode Medication or time-limited

(mild-to-moderate severity) psychotherapies*

No maintenance-phase treatment

Major depressive disorder, recurrent Consider maintenance-phase treatment

Major depressive disorder Antipsychotic plus antidepressant

with psychotic features medications

Electroconvulsive therapy

Major depressive disorder with melancholic Medications essential

or severe features

Depression with atypical features Nontricylic drugs preferred

Monoamine oxidase inhibitors

Depression with seasonal pattern Light therapy or medications

Dysthymic disorder Medications; time-limited, depression-

targeted psychotherapies; or theircombination

Consider maintenance-phase therapy

Complex or chronic depressions Medication plus psychotherapy

Interpersonal psychotherapy,

cognitive therapy, or behavior therapy.27


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SSRIsb

Citalopram 20 20-60 c

Fluoxetine 20 20-60 c

Fluvoxamine 50 50-300 c

Paroxetine 20 20-60 c

Sertraline 50 50-200 c

Dopamine-nor epinephrine reuptake inhibitors

Bupropionb

150 300

Bupropion, sustained release 150 300

Serotonin-norepinephrine reuptake inhibitors

Venlafaxineb 37.5 75-225

Venlafaxine, extended release 37.5 75-225

Serotonin modulators

Nefazodone 50 150-300

Trazodone 50 75-300

Nor epinephrine-serotonin modulator

Mirtazapine 15 15-45

MAOIs

Irreversible, nonselective

Phenelzine 15 15-90

Tranylcypromine 10 30-60

Reversible MAOI-A

Moclobemide 150 300-600

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MAOI Drug Incompatibilities

Generally Contraindicated Hazardous Potentiation

Stimulants Weight-reducing or antiappetite drugs; amphetamine, cocaine

Decongestants Sinus, hay fever, and cold tablets; nasal sprays or drops;

asthma tablets or inhalants, cough preparations (or any

products containing ephedrine, phenylephedrine, or

phenylpropanolamine

Antihypertensives Methyldopa, guanethidine, reserpine

Tricyclics Migraine, desipramine, clomipramine

MAOIs Tranylcypromine, after other MAOIs

Sympathomimetics Dopamine, Metaraminol

Amine precursors L-dopa, L-tryptophan

Narcotics Meperidine (Demerol)

Some Potentiation Possible

Opioids Morphine, codeine

Sedatives Alcohol, barbiturates, benzodiazepines

Local anesthetics containing vasoconstrictors

Sympathomimetics Ephedrine, norepinephrine, isoproterenol

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