DEPRESSION

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

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

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

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

TYPES OF DEPRESSIONTypes of depressionMajor depressive disorder

Dysthymia

Depressive disorder, not otherwise specified

Minor depressive disorderPremenstrual dysphoric disorder

Severity of depression

Mild

Moderate

Severe

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

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

MINOR DEPRESSIVE DISORDER Episodes of at least 2 weeks of depression

Fewer than five items required for major depressive disorder

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

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

DIFFERENTIAL DIAGNOSIS Substance induced mood disorder

Bereavement

Mood disorder due to a general medical condition

COMMON DRUGS OF ABUSE CAUSING DEPRESSION Alcohol Amphetamines Anti-anxiety drugs Cocaine Hallucinogens Hypnotics Inhalants Opioids Sedatives

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

MANAGEMENT OF DEPRESSION Phase 1: Acute phase - to achieve full remission of

depressive symptoms

Phase 2: Maintenance phase - to prevent relapse and recurrence

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

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

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

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

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

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)

SELECTING AN ANTIDEPRESSANT Efficacy

Side effect profile

Concurrent medication

Comorbidity

Subtype of depression

Simplicity of use

Cost

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

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

OTHER EVIDENCE BASED THERAPIES FOR DEPRESSIONElectro Convulsive therapy (ECT)

Exercise, wake therapy and light therapy

PsychotherapyCognitive Behaviour therapy

Family therapy

Interpersonal psychotherapy

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