depression feb2012

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Mood Disorders (18.19-2-2010)


  • 1. Major Depression..The Story and TreatmentProf. Yaser Abdel Razek Professor of Psychiatry Institute of Psychiatry, Ain Shams University WHO Collaborative center for training and research

2. Unipolar Major Depression /2010 Number of6,865,820,500population Life time prevalence 1,513,322,000 of UMD Point prevalence 450,088,420 UMD (WHO- 2008 ) 15% will try suicide 67,513,263 Died by suicide 426.463(2010) 3. Worldwide, 450 million patient, with high comorbid, social and economic costs ( WHO 2008) Prevalence of Unipolar depressive disorders is 17% (NCS-R Kessler et al,2003) Average life time prevalence from studies 19-21% ( Kaplan and Sadock, 2005) 4. In the UK and in 2005 there were in excessof 29 million prescriptions for ADD. The direct cost of treatment for depressionin the National Health Service (887million) > both that for hypertension and diabetes combined (439 and 300 millionrespectively). In 1994 an estimated 1.5 million disability- adjusted life years were lost each year in the developed world as the result of depression. 5. In the U.S., more than 21 million adults sufferfrom some kind of depressive disorder, according to the National Institute of MentalHealth. Most patients who have one major depressive episode are likely to have another within 5years. Overall, as many as 20% of patients with major depression do not respond to 2 or moreadequate treatment regimens for depression. 6. Prevalence of depressive disorders will increase !!!!!!! More industrialization and urbanization Globalization Increasing Stress ( education , competition, unemployment, delayed marriage, economicproblems) Increase life span Genetic anticipation Substance abuse 7. Thats Why Findingan effective treatment for depressionis therefore a key consideration for the health service 8. Some Facts and Figures about Depression 3/10 employees will have a mental healthproblem in any one year, mainlydepressive and anxiety disorders. By the year 2020, major depression will besecond only to chronic heart disease as an international health burden (this is measured by its cause of death, disability,incapacity to work and the medicalresources it uses). 9. L e a d in g C a u s e s o f D A L Ys in2020( D is a b ilit y A d ju s t e d f o r L if e Ye a r s ) Both sexes MalesFemalesDisease or injuryDisease or injury Disease or injury All causesAll causesAll causesIschaemic heartIschaemic heart Unipolar major1-diseasedisease depressionUnipolar major Road trafficIschaemic heart2-depression accidents diseaseRoad traffic Cerebravascular Cerebravascular3-accidentsdisease disease Chronic ChronicCerebravascularobstructive obstructive4-diseasepulmonary pulmonary disease diseaseChronic obstructiveUnipolar majorRoad traffic5-pulmonary diseasedepressionaccidents Ustun et al (2004) Brit. J. Psychiat. 10. Why depression? (cont.) 15% of depressive disorders cases attempt suicide 50% of completed suicidal cases are major depression Prevalence of depressive disorders is 20% in women and 12% in men Prevalence of Unipolar Major depressive disorder isincreasing 1% for those born before 1905 6% for those born after 1955 Many persons with Depression are disabled and have abad quality of life It is an expensive disorder 11. Recognition of general practicepatients Up to 50% of general practice patients may have somedepressive symptoms.Approximately 5% of thesewill have major depressiondefined by DSM-III-Rcriteria.Freeling and Tylee (1992); Regier et al (1988); Vazquez-Barquero et al (1987) 12. M DepressionDysthymia Mixed anxiety depression Adjustment disorders with depressive symptomsDepressive symptoms 13. Prevalence of depressive disorders willincrease due to: More industrialization and urbanization Globalization Increasing Stress ( education , competition, unemployment, delayed marriage, economicproblems) Increase life span Genetic anticipation Substance abuse 14. Bed days: depression vs chronic medical condition No chronic condition Back problem Lung problemGI problemArthiritis Angina onlyCoronary artery diseaseDiabetesHypertensionDepressive symptoms 0 0.51 1.52 2.5 Bed days / past monthWells et al., 1989 15. The Effects of Depression Beyond SymptomsDisability of Daily Functioning: DepressionCompared with Chronic Medical ConditionsPhysical SocialRoleBed Days Hypertension Diabetes Heart Arthritis LungDepression has more disability (P < 0.05)Depression has less disability (P < 0.001)No difference (P > 0.05) Wells et al. JAMA. 1989; 262 (7): 914-919 16. Work-Loss Days by Health Condition3 2.77 2.51.7821.74 1.6 1.41Days 1.51.21 0.831 0.50 DepressionDiabetes History of Immune Heart iseaseDisorderGrzywacz JG. SL. TEN. 2000; 2(6): 41-46. 17. Public perceptions of Mental 71% Due to emotional weakness illness 65% Caused by bad parenting 43% Incurable 35% Consequence of sinful behaviour 10% Has a biological basis; Involves the brain 18. Etiology of major depression Major Depression has no environmental cause or disproportional to the cause Neurotransmitter disturbance Genetic factors Neuroendocrinal disturbance Disturbed immune function Disturbed sleep cycle Environmental stressors may play role but alone are notenough to cause depression 19. Treatable DiseaseDepression is one of the most treatable untreated diseases80% can be successfully treated with medication, psychotherapy or a combination of the two 20. TreatmentofdepressionDepressed Patients (100%) ReceiveUntreated patients antidepressant (95.6%)(4.4%)- Do not seek helpAdequately- Undiagnosedtreated- Diagnosed but untreated(?%)- Treated but non compliant*Tylee A et al, Int Clin Psychopharmacol,1999,14(3):13951;Lpine, JP etal., Int Clin Psychopharmacol, 1997,12:1929. 21. cost of not treating MoodDisorders Dysfunctional families Absenteeism Decreased productivity Job-related injuries Adverse effect on quality control in the workplace Although suicide is rare in our countries it is commonin depression 22. Clinical features To diagnose depression We should have two criteria out of each group ofthe following symptoms 23. First group1-Depressed mood Continuous unexplained bad mood with spontaneous crying from time to time 2-Loss of interest Loss of all pleasurable activities like sports, watching TV, reading, spending, visitingfriends, etc. 3-Easy fatigability patients complained of inability to do anythingwith marked reduction of energy and easyfatigability on minor effort 24. Second Group 1-Change of appetite 2-Change of sleep 3-Change of psychomotor activity 4-Guilt 5-Death wishes 6-Lack of concentration, indecisiveness 7-Loss of confidence 25. Other key symptoms Irritability and anxiety in addition or instead of pure depression symptoms Predominant somatic symptoms Headache General aches and pains Libido decrease 26. How do patients with major depression usually present in primary care?Presenting complaint% patients010203040 50 60Cardiological Chest painTachycardia/irregular heart beat NeurologicalHeadacheDizzinessSyncope/seizures GastrointestinalEpigastric painDiarrhoea Pulmonary Dyspnoea Asthma* DSM-IV-TR 2000Wa yn e K a to n 27. Types of depression There are more than 50 type of depressivedisorder, all types share some symptoms and differ in some other symptoms 28. Different forms Unipolar Bipolar Major depressive Bipolar I disorder DysthymiaBipolar II Cyclothymia Mixed statesAdjustment disorder withAmerican Psychiatric Association (1994)depressive sym 29. Dysthymia A less severe type of depression. It involves long-term, continuous symptoms However, people with dysthymia do notfunction well Many people with dysthymia also experience major depressive episodes at some time in their lives. 30. Bipolar depression Depression is alternating with episodes of hypomania or mania. 31. Major depression Adjustment disorder Previous manic features (BP) No manic F Stress May not present Stressor Must be present Early morning awakening 2 Delayed sleep onsethours Diurnal variation (bad at May be worst at the night morning) Marked Change of Not marked psychomotor activity No delusions or Delusions and hallucinations hallucinations Worse just before menses Not related to menses Post partum attacks No postpartum attacks Recovery may be delayed Recovery within 6 months 32. Differential Diagnosis Debilitating physical illness Organic depression Substance induced depression 33. Debilitating physical illness ascancers may be presented by Loss of weight Easy fatigability Disturbed sleep Somatic symptoms 34. Medical disorders with Depression(organic)AIDS Cancer Intracranial tumors, Pancreatic Ca., and others Diabetes Heavy metal toxicity Lead, Mercury etc Hypo and hyperthyroidism Hyperadrenalism (Cushings disease) Adrenocortical insufficiency (Addisons disease) Hypoparathyroidism Pernicious anaemia Systemic lupus erythemetosis Viral infections; Hepatitis, Pneumonia. 35. The association betweendepression and medical illness M e d ic a lF r equenc y ofC o n d it io n M a j o r De p r e s s io n x Coronary Artery Disease 30-60% x Emphysema 20-40% x HIV infection 20-35% x Hypothyroidism 10-30% x Stroke 10-25% x Diabetes Mellitus10-20% x Renal Failure5-20%Kaplan HI, 1994 36. Neurological disorders Parkinsons 50% Post stroke 20% Dementia 20-30% major depression Seizure20-50% in recurrent seizure Huntingtons 30% Multiple sclerosis 50% 37. Drugs that can cause depression All substances of abuse Beta blockers Some antihypertensive drugsContraceptive pills 38. Co-morbidity 39. Comorbid major depression and INTRODUCTION TO ANXIETY DISORDERS anxiety disordersLifetime comorbidity48% of patients with PTSD1 50% to 65% of patients with PD2PTSDPanic disorder Major depression GAD SAD8% to 39% ofpatients with GAD5 OCD34% to 70% ofpatients with SAnD4, 667% of patients with OCD3 1. Kessler et al (1995); 2. APA, DSM-IV; 3. Rasmussen & Eisen (1988); 4. Van Ameringen et al