d epression. e pidemiology and burden depression is a highly prevalent condition about one in a...
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DEPRESSION
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EPIDEMIOLOGY AND BURDEN Depression is a highly prevalent condition
About one in a seven will experience depression during their lifetime
Many people with depression will have a recurrent or chronic course
Depression is the fourth leading cause of disability worldwide
Depression results in work absence and loss of productivity leading to significant economic loss
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AETIOLOGY OF DEPRESSION Biological (genetics), psychological (life events),
and social factors (lack of social support) are involved in the etiology and pathophysiology of depression
Stressful life events and stress reactivity can modify genetic and biological processes
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FACTORS PREDICTING PROLONGED COURSE OF DEPRESSIVE EPISODE
• Severe depression
• Alcohol and drug abuse
• Comorbid illness
• Psychotic features
• Poor social support
• Early age of onset
• Long duration
• Low levels of functioning prior to depression
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CLINICAL FEATURES OF DEPRESSIONDepressive symptom Presentation
Sleep Insomnia or hypersomnia
Interest/pleasure Decreased (anhedonia)
Guilt Increased; Irrational thoughts
Energy Decreased (fatigue)
Concentration Decreased (indecisive)
Appetite Decreased or increased
Psychomotor activity Agitation or retardation
Suicide Thoughts, plans, attempts
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TYPES OF DEPRESSIONTypes of depressionMajor depressive disorder
Dysthymia
Depressive disorder, not otherwise specified
Minor depressive disorderPremenstrual dysphoric disorder
Severity of depression
Mild
Moderate
Severe
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MAJOR DEPRESSIVE DISORDERFive or more of the following for at least 2 weeks:1. Depressed mood2. Loss of interest in pleasure3. Significant weight loss4. Insomnia or hypersomnia5. Psychomotor agitation or retardation6. Fatigue7. Excessive guilt or feelings of worthlessness8. Diminished ability to think or concentrate9. Recurrent thoughts of death
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DYSTHYMIAA. Depressed mood for at least 2 years
B. Two or more of the following:1. Poor appetite or overeating2. Insomnia or hypresomnia3. Low energy or fatigue4. Low self esteem5. Indecisive or poor concentration6. Feelings of hopelessness
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MINOR DEPRESSIVE DISORDER Episodes of at least 2 weeks of depression
Fewer than five items required for major depressive disorder
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RISK FACTORS FOR SUICIDEEPISODE RELATED Current suicidal plans Prior attempts Severe depression Hopelessness and guilt Bipolarity Mixed state (with agitation) Psychotic features Substance abuse Serious medical condition Anxiety
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RISK FACTORS FOR SUICIDEDEMOGRAPHICS Male Adolescent or elderly Early onset of mood disorder Family history of suicide Adverse childhood experiences Adverse life circumstances Recent stressor Lack of social support
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DIFFERENTIAL DIAGNOSIS Substance induced mood disorder
Bereavement
Mood disorder due to a general medical condition
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COMMON DRUGS OF ABUSE CAUSING DEPRESSION Alcohol Amphetamines Anti-anxiety drugs Cocaine Hallucinogens Hypnotics Inhalants Opioids Sedatives
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DEPRESSION DUE TO GENERAL MEDICAL CONDITIONS• Diabetes• Cardiovascular disease• Neurological
– CNS infections– Epilepsy– Sleep apnoea
• Systemic disorders– Viral and bacterial infections
• Endocrine disorders– Thyroid disorders
• Vitamin deficiencies (B12/Folate; Vitamin C; Niacin; Thiamine)• Others
– AIDS– Cardiopulmonary disease
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MANAGEMENT OF DEPRESSION Phase 1: Acute phase - to achieve full remission of
depressive symptoms
Phase 2: Maintenance phase - to prevent relapse and recurrence
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ACUTE PHASE MANAGEMENT OF DEPRESSION 8-12 weeks of treatment
Goal: remission of symptoms
Establish therapeutic alliance
Educate patients and relatives
Aid self management
Choose treatment(s)
Manage side effects
Monitor and follow-up
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MAINTENANCE PHASE MANAGEMENT OF DEPRESSION 6-24 months or longer of treatment
Goal: prevention of relapse and recurrence
Educate patients and relatives
Aid self management
Manage side effects
Rehabilitate work and social function
Monitor for recurrence
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PHARMACOTHERAPY RECOMMENDATIONS Minimum six months treatment after full remission of
symptoms
At least 2 years (for some lifetime) Severe episodes Chronic episodes Comorbidity Difficult-to-treat episodes Frequent episodes
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PATIENT/FAMILY EDUCATION Explain depression in terms of biochemical basis:
“Depression is an illness, not a weakness”
Early diagnosis and treatment is important for recovery
Reducing and stopping medications without medical advice is wrong
Monitor weight; advise exercise and food plans
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PATIENT EDUCATION MESSAGES TREATMENT
Antidepressants are not addictive
Medications daily, as prescribed
It may take 2-3 weeks before any relief is seen
Mild side effects are common, they get better over time
Medications should not be stopped without medical advice
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SELECTING AN ANTIDEPRESSANT The first line medications are selective serotonin reuptake
inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs)
They are preferred over tricyclic antidepressants (TCAs)
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SELECTING AN ANTIDEPRESSANT Efficacy
Side effect profile
Concurrent medication
Comorbidity
Subtype of depression
Simplicity of use
Cost
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SSRISMechanism of action
Common side effects
Drug Daily dose
Selective inhibition of serotonin reuptake
GI distress, nausea, vomiting, diarrhoeaHeadache, agitation, sleep disturbance, drowsiness, dry mouth, sexual side effects
Escitalopram
5-20 mg
Fluoxetine 20-80 mg
Sertraline 50-200 mg
Paroxetine 20-60 mg
Fluvoxamine
100-300 mg
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TCASMechanism of action
Common side effects
Drug Daily dose
Inhibition of serotonin and norepinephrine reuptake
Dry mouth, blurred vision, constipation, urinary retention, confusiondrowsiness, sedation, weight gain, nausea, tremor, headache, seizures, sexual dysfunction
Imipramine 75-300 mg
Amitryptaline 75-300 mg
Cloimipramine
75-300 mg
Dothiepin 75-300 mg
Nortrptaline 75-150 mg
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OTHER EVIDENCE BASED THERAPIES FOR DEPRESSIONElectro Convulsive therapy (ECT)
Exercise, wake therapy and light therapy
PsychotherapyCognitive Behaviour therapy
Family therapy
Interpersonal psychotherapy
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CONCLUSION Depression a disabling illness
Can be recurrent and chronic
There are cognitive, emotional and physical symptoms of depression
Suicide in a important risk of depression
Depression can be treated effectively with evidence based therapies such as antidepressants, ECT and psychotherapy