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Depression and management Guidelines. Prof. Dr. Momtaz AbdEl Wahab Prof. of psychiatry Cairo University. Face the Facts. Depression is a Prevalent Disorder. Epidemiology. Epidemiology.

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Depression and management guidelines

Depression and management Guidelines

Prof. Dr. Momtaz AbdEl WahabProf. of psychiatry Cairo University


Face the facts

Face the Facts

Depression is a Prevalent Disorder



Epidemiology1
Epidemiology

  • The depression research in European society (DEPRES) study found that almost 16% of total population had suffered from depression in their life time. (lepin jp. etal 1979).

  • The incidence is almost identical in USA 17%(kessler R.C.etal 1994).


Depression is a prevalent disorder
Depression is a Prevalent Disorder

121 Million People Suffer From Depression

ATLAS (WHO 2001)


Face the facts1

Face the Facts

The Prevalence of Depression is Rising?!


Epidemiology cont d
Epidemiology(cont’d)

  • The incidence of depression appears to be increasing, although this may be explained by an increasing willingness to report psychological problems.


Anxiety

Depression

(DALYS, 2020)

STRESS

OVERLOAD

Disasters

Globalization

Massive information

Techno stress

Individualization

WARS

Lack of support

EVERYDAY LIFE

Economic

Noises

Recession

Time pressure

Others

Spouces

Pollution

Boss

Excessive respondents

Anticipation

of danger



Face the facts2

Face the Facts

Depression is a Burden


The burden of depression1
The burden of depression

  • Disability associated with depression is reportedly greater than that for chronic illnesses such as arthritis, back pain, diabetes gastrointestinal disease, hypertension and long diseases.



World Bank Reports lived with disability

Year

2000 is the world

2020 will be the

Anxiety Depression

4th greatest health problem

2nd greatest health problem causing disability


Face the facts3

Face the Facts lived with disability

Depression in an Expensive Disorder


The burden of depression2
The burden of depression lived with disability

  • The disorder tends to become recurrent or chronic with time.

  • 50% of the life of depressed patients life span will be clouded by the illness.

  • The depressed patient is often isolated, the dysfunction has repercussion on:

    - family member

    - friends

    - colleagues

    Their relationships frequently being shattered


The burden of depression3
The burden of depression lived with disability

  • Behavioral changes are common:

    - increased drinking

    - initiation drug abuse

  • Unfortunately, the patients themselves are often not aware of being clinically depressed, and thus will not actively seek help or treatment.


The burden of depression4
The burden of depression lived with disability

  • Several studies has shown higher mortality risk in depressed individual:

    -suicidal risk is high 15%-19%

    -cardiovascular deaths

  • Depressive symptoms seem to be risk factors for mortality in pulmonary disorders and stroke.


The burden of depression5
The burden of depression lived with disability

  • Depressed patient is less likely to sustain a demanding job or career or to achieve his or her potential.

  • If the depression arises during the formative years, an in evitable consequence is diminished performance at school, college, or educational training with life long consequences.


Economic implications for society
Economic implications for society lived with disability

  • Reduced and lost productivity

    - absenteeism

    - wasted training

  • The increased strain and demands on health services.

  • The increased direct cost of treatment, particularly caused by hospital admissions.


Direct lived with disability

Recurrence

Treatment

Hospitalization

COST

  • Indirect

  • Disability in work

  • Poor social function

  • Associated behavioral problems

  • Increase self destructive behaviors


Face the facts4

Face the Facts lived with disability

Depression is a Recurrent Disorder


Face the Facts lived with disability

  • Depression is too painful to be ignored.

  • Depression is unrecognized!!

  • Depression has many faces.


20% of those with major depression have symptoms that persist beyond 2 years

Keller et al., (1992) & Scot & Dicky (2003), B. J. Psychiat.


The need for treatment
The need for treatment persist beyond 2 years

  • Depression continue to be a silent epidemic because so few people with depression receive treatment.

  • 50% of depressed patients had not consulted physician.

  • Of those who had 70% had been given no medication for depression.

  • Less than 10% of those with major depressive disorder had been prescribed an antidepressant.


Face the facts depression is an under recognized disorder
Face the Facts persist beyond 2 yearsDepression is an Under-recognized Disorder

  • Stigma.

  • Masked depression.

  • Comorbid medical illness.

  • Time constraints.

  • Inadequate medical education.


The need for treatment1
The need for treatment persist beyond 2 years

  • In addition, when antidepressants are prescript, dosage and duration of treatment are often mostly inadequate to achieve a response or maintain remission.


Reasons for under recognition under treatment of depression
Reasons for under recognition/ under treatment of depression persist beyond 2 years

Provider

  • Inadequate training.

  • Depression not a real disorder

    (preoccupied with organicity ).

  • Time- consuming to evaluate (failure to elicit symptoms).

  • Restricted access to treatment options.

  • Failure to refer from G.P. when indicated.


Reasons for under recognition under treatment of depression1
Reasons for under recognition/ under treatment of depression persist beyond 2 years

Patient

  • Stigma.

  • Ignorance.

  • Effect of the symptoms.

  • Poor compliance.

  • Poor insurance coverage.

  • Presentation: somatization.


Why is it important to recognize depression
Why is it important to recognize depression? persist beyond 2 years

  • High costs.

  • Suicide and other mortality.

  • Risk factor for co morbidity.

  • Very treatable.


Diagnosis and symptoms

Diagnosis and Symptoms persist beyond 2 years


Many faces of depression
Many Faces of Depression persist beyond 2 years

Depressive symptoms Background

Somatic symptoms Foreground


Face the Facts persist beyond 2 years

Depression is recorded in up to 30% of patients seen by other specialties

  • Oncology

  • Dermatology

  • GIT

  • CNS

  • C.V.S.

  • Others


Presenting complaints in primary care practice
Presenting Complaints in persist beyond 2 yearsPrimary Care Practice

(Widmer & Cadoret, 1978)


Depression in primary care
Depression in Primary Care persist beyond 2 years


Okasha, 2003 persist beyond 2 years

“ICEBERG” PHENOMENON

  • Depressed patients seen by psychiatrists

Depressed patients seen in primary care practice


Many faces of depression1
Many Faces of Depression persist beyond 2 years

?

Why there is a Tendency for depression to manifest itself in the somatization sphere


Only persist beyond 2 years about ½ of patients with MD are explicitly recognized as being depressed.

Only about ½ of all depressed patients receive some form of therapy for their illness (Lepine et al 1997)

Only about ¼ of depressed patient receive an adequate dose and duration of AD treatment (Katon et al 1992)



Neuobiology of Depression neurochemical dysfunction in depression is an essential issue for the proper management

Khalia M (2005): Metabolism Clinical & experimental

54 Suppl(1).; 24-27



Neuroanatomical neurochemical basis of symptoms of depression
Neuroanatomical & Neurochemical DepressionBasis of Symptoms of Depression

Malhi GS, et al., (2005): Acta Psychiatr. Scand.; 111:94-105


Functional Roles of Brain Monoamines Depression

Norepinephrine

Serotonin

Anxiety

Irritability

Energy

Interest

Social function

Memory

Impulse

Control

Mood,

Emotion,

Cognitive function

Motivation

Attention

Sex & appetite Aggression

Drive

Reward

Executive function

Dopamine

Modified from Healy & McMonagle. J Psychopharmacol 1997; 11 (suppl 4): S25-S31.



Symptoms
Symptoms Depression

Pattern of Symptoms:

  • Typical.

  • Atypical.

  • With melancholic.


Diagnostic process
Diagnostic Process Depression

1) Common Presentations

Usually the patient presents either of the following symptoms:

1- Multiple Somatic complaints.

2- Lack of Concentration and/or forgetfullness.

3- Increased fatigability.


  • The patient has multiple and excessive complaints, involving more than one system in the body.

  • The complaints are vague and ill defined and cannot be categorized as one identifiably disease.

  • The patient is easily predictable, giving yes as an answer to any question.

  • On physical examination, there are not enough signs to explain the symptoms described by the patient.

  • Results of investigations are always within the normal ranges.

2) Signs suggesting a depressive disorder:


3) Diagnostic Criteria more than one system in the body.

  • A. At least one on the following symptoms has to prevail for at least two weeks.

    • 1- Depressed mood for most of the day and almost every day.

    • 2- loss of interest or pleasure in doing the activities that were normally pleasurable.


  • B) At least more than one system in the body.four of the following symptoms:

    • 1- change in appetite.

    • 2- Sleep Disturbance.

    • 3- Psychomotor disturbance.

    • 4- Increased fatigability or loss of energy.

    • 5- Feeling of worthlessness as well as excessive inappropriate guilt.

    • 6- Diminished ability to think and concentrate.

    • 7- a state of indecisiveness.

    • 8- Recurrent thoughts of death.

    • 9- Pessimistic views of the future.


C) The symptoms lead to significant distress or impairment in social, occupational or other important functional areas.


Atypical symptoms include
Atypical symptoms include: in social, occupational or other important functional areas.

1-vegetative symptoms of reserved polarity as:-

-hypersomnia

-increased appetite

-weight gain.

2-marked mood reactivity.

3-sensitivity to emotional rejection.


Severity
severity in social, occupational or other important functional areas.

  • Mild episode characterized by:

  • Minimum diagnostic requirements

  • Minor function impairment

  • Moderate episode

  • The symptoms present exceed the bare diagnostic requirements

  • Greater degrees of functional impairment


Severe episode
Severe Episode in social, occupational or other important functional areas.

  • Presence of several symptoms beyond the minimum required to make diagnoses.

  • Marked interference with social and/or occupational functioning.


Severe episode1
Severe Episode in social, occupational or other important functional areas.

In extreme cases,individuals might be unavailable to function socially, occupationally, un-able to feed and clothe themselves, or to maintain minimal personal hygiene.

  • Presence of suicidal ideation and attempt.

  • Presence of psychotic symptoms.

  • Presence of catatonic symptoms.

  • Presence melancholic symptoms.


Psychosis
Psychosis in social, occupational or other important functional areas.

  • Psychosis is considered when there is:

  • Delusions

  • Hallucinations

  • Catatonic symptoms


Catatonic symptoms
Catatonic symptoms in social, occupational or other important functional areas.

Characterized by at least two of the following:

  • Motor immobility (catalepsy or stupor)

  • Extreme agitation

  • Extreme negativism

  • Posturing

  • Stereotyped movements, mannerisms or grimacing

  • Echolalia or echopraxia


Melancholic symptoms
Melancholic Symptoms in social, occupational or other important functional areas.

1- Loss of pleasure in all, or almost all activities.

2-Lack of reactivity to pleasurable stimuli (anhedonia).

3- Distinct quality of depressed mood.

4- Diurnal variation (depression regularly worse in the morning).


Melancholic symptoms1
Melancholic Symptoms in social, occupational or other important functional areas.

5-Early morning awakening.

6- Marked psychomotor retardation or agitation.

7- Significant anorexia or weight loss.

8- Excessive or inappropriate guilt.


OTHER FORMS OF DEPRESSIVE DISORDERS in social, occupational or other important functional areas.

  • Dysthymia

  • Postpartum depression

  • Recurrent brief depression

  • Mixed anxiety-depression syndrome

  • Sub-threshold depression

  • Premenstrual Dysphoric Disorder

  • Post menopausal Depression


SPECIAL FORMS OF DEPRESSIVE DISORDERS in social, occupational or other important functional areas.

  • Psychotic depression

  • Somatic depression

  • Atypical depression


SPECIAL FORMS OF in social, occupational or other important functional areas.DEPRESSIVE DISORDERS (cont’d)

  • Seasonal depressive disorder.

  • Rapid-cycling bipolar disorder, depressive episode.

  • Secondary depressive disorder.


Depression due to a general medical conditions
Depression Due to a General in social, occupational or other important functional areas.Medical Conditions

1-Depression due to general medical condition

  • Endocrine disorders (D.M., hypothyroidism, Cushing's disease).

  • Diseases of CNS, CVS, chest disease.

  • Collagen disease ( Rheumatoid arthritis, SLE)

  • Chronic infections ( hepatitis, T.B.)

  • Neurological diseases ( Parkinsonism, CVS)

  • Neoplasm( cancer lung, cancer GIT).

    2-Depression secondary to other nonpsycho-active drugs (steroids, & reserpine).


Prevalence of Depressive Disorders in social, occupational or other important functional areas.

In Different Patient Populations*

Prevalence

*There is a range of percentages depending on the study.


Depression Adversely Affects Medical Diseases in social, occupational or other important functional areas.

  • Play a role in:

    • Exacerbation.

    • Delayed recovery.

    • Prolonged course.

    • Poor outcome.

    • Prolonged Hospitalization.


General Medical Disorders and Depression in social, occupational or other important functional areas.

The Myth & The Reality

MYTH

Depression is obvious and easily recognized and expressed by the patient

REALITY

Depression disorders are overlapping, hardly expressed by the patient and constitute a major problem in symptom exaggeration


General Medical Disorders and Depression in social, occupational or other important functional areas.

The Myth & The Reality

MYTH

Depression is Secondary to GMD activity

Treatment of the medical disorder will relief Depression.

REALITY

DEPRESSION REQUIRES TREATMENT intervention and do not remit with relieve of symptoms


DIAGNOSIS: THE CLINICAL INTERVIEW in social, occupational or other important functional areas.

  • Listen

  • Facilitate

    • “Go on.”

    • “What else?”

  • Demonstrate concern

  • Summarize

  • Try to put the patient at ease

  • Begin with open-ended questions

  • Probe for symptoms, e.g.

    • “Any trouble with your nerves?”

    • “How have you been sleeping?”

    • “What do you do to enjoy yourself?”


M in social, occupational or other important functional areas.

I

N

I

MINI INTERNATIONAL NEUROPSYCHIATRIC INTERVIEW

  • The MINI is a brief structured interview for the major Axis I psychiatric diorders in DSM-IV & ICD-10.

  • Compared to the SCID-P (structured interview developed by the WHO ), the MINI has acceptably high validation and reliability scores, but can be administered in a much shorter time.


Depressed mood or loss of feeling
Depressed mood or loss of feeling? in social, occupational or other important functional areas.

  • هل أحسست بالأكتئاب أو أن حالتك النفسية سيئة فى معظم أوقات اليوم و بصورة متكررة خلال الأسبوعين الماضيين؟

  • خلال الأسبوعين الماضيين هل كنت أقل اهتماما أو أقل استمتاعا بالأشياء التى كنت تتمتع بها أغلب الوقت ؟


Markedly diminished interest or pleasure or enjoyment or anhedonia
Markedly diminished interest or pleasure or enjoyment or anhedonia?

  • هل عمرك حسيت إن ملكش نفس في أى حاجة أومش قادر تتمتع بأي شيء حلو كنت قبل كده بـتتمتع به (مثلا الفرجة على التلفزيون ، قراءة الجريدة أو زيارة حد، أو هواية كنت بتمارسها ، أو الخروج مع الأصحاب ، أو حتى أكلة حلوة)

  • هل استمر هذا الاحساس معظم اليوم تقريبا فى معظم أيام الأسبوع ولمدة لا تقل عن أسبوعين كاملين؟


اذا كانت الأجابة على أى من السؤالين ”بنعم“ استمر فى الاجابة على الأسئلة التالية:

3. عندما شعرت أنك مكتئب أو مهموم أو حزين خلال الأسبوعين الماضيين:


Weight loss gain decreased increased appetite

3.(أ) السؤالين ”بنعم“ استمر فى الاجابة على الأسئلة التالية:

Weight loss – gain; decreased / increased appetite?

  • هل لاحظت إنك خسيت جامد أو زاد وزنك زيادة ملحوظة؟

  • هل لاحظت أن شهيتك للأكل زادت أو نقصت عن الطبيعي و كان ذلك لمعظم اليوم تقريبا معظم أيام الأسبوع.


Insomnia or hypersomnia sleep disturbances

3.(ب) السؤالين ”بنعم“ استمر فى الاجابة على الأسئلة التالية:

Insomnia or hypersomnia, sleep disturbances?

  • هل لاحظت أن هناك صعوبة في النوم (صعوبة في الدخول إلي النوم أو تصحى كذا مرة بالليل أو تقوم بدري قوي عن الطبيعي)؟

  • هل لاحظت أنك بتنام أكثر بكثير من الطبيعي بتاعك معظم الأيام في خلال هذه الفترة؟


Psychomotor agitation or retardation

3.(ج) السؤالين ”بنعم“ استمر فى الاجابة على الأسئلة التالية:

Psychomotor agitation or retardation

  • هل لاحظت انك متململ ومش قادر تقعد في مكان واحد معظم الأيام في هذه الفترة؟

  • هل لاحظت ان عندك بطئ في الحركة و الكلام معظم الأيام في هذه الفترة؟


Fatigue or loss of energy

3.(د) السؤالين ”بنعم“ استمر فى الاجابة على الأسئلة التالية:

Fatigue or loss of energy

  • هل حسيت أنك مرهق وتعبان على طول و مش قادر على عمل أى حاجة وماعندكش طاقة ولا حيوية معظم الأيام في هذه الفترة؟


Feeling of worthlessness or excessive or inappropriate guilt self blame and reproach

3.(ه) السؤالين ”بنعم“ استمر فى الاجابة على الأسئلة التالية:

Feeling of worthlessness or excessive or inappropriate guilt, self blame and reproach,

  • هل كان بيجيلك إحساس داخلي إن روحك المعنوية منخفضة أو انك أقل من الناس وانك مالكش قيمة في معظم الأيام في هذه الفترة؟

  • هل كان بيجيلك إحساس داخلي بالذنب و تأنيب الضمير بدون سبب واضح في معظم الأيام في هذه الفترة؟

  • هل بتميل إنك تلوم نفسك على حاجات انت عملتها أو فكرت فيها؟


Diminished ability to think and concentrate indecisiveness

3.(و) السؤالين ”بنعم“ استمر فى الاجابة على الأسئلة التالية:

Diminished ability to think and concentrate, indecisiveness

  • هل كنت في هذه الفترة غير قادر على التركيز والتفكير بوضوح أو أنك كثير التردد؟


Thoughts of death catastrophe suicidal ideation attempt plan or self harm

3.(ز) السؤالين ”بنعم“ استمر فى الاجابة على الأسئلة التالية:

Thoughts of death, catastrophe, suicidal ideation, attempt, plan or self harm

  • هل حسيت أن الحياة ما تستهلش الواحد يعيش فيها أو أنه مش حايفرق معاك انك ما تصحاش تانى يوم الصبح؟

  • هل فكرت في هذه الفترة أن تؤذى نفسك بأي طريقة ؟

  • هل كنت في هذه الفترة بتفكر كثير في الموت أو تتمناه أو بيجيلك أفكار عن الانتحار ؟

  • هل أنت ميال انك تقعد تفكر فى مصايب ممكن تحصل زى الموت أو خراب البيوت أو أي كارثة؟


Diagnosis
Diagnosis: السؤالين ”بنعم“ استمر فى الاجابة على الأسئلة التالية:

اذا حصلت على 5 اجابات أو أكثر ”بنعم“ على الأسئلة من 3.أ الى 3.ز

اذا فالمريض يعانى من

نوبة اكتئاب حالية

Current Depressive Episode


Check for recurrent episodes
Check for Recurrent Episodes السؤالين ”بنعم“ استمر فى الاجابة على الأسئلة التالية:

4. (أ) خلال سنوات حياتك الماضية هل مررت بفترات أخرى (مدتها أسبوعين أو أكثر) أحسست خلالها بالاكتئاب أو أنك غير مهتم بمعظم الأشياء أو عانيت خلالها بنفس الأعراض السالف ذكرها؟

4.(ب) هل مرت عليك مدة لا تقل عن شهرين بدون اكتئاب أو احساس بعدم الاهتمام فى فترة ما بين نوبتين للاكتئاب؟

نوبة اكتئاب متكررة


Not due to a substance or a general medical condition
Not due to a substance or a general medical condition السؤالين ”بنعم“ استمر فى الاجابة على الأسئلة التالية:

  • هل قبل هذه الأعراض كنت مريض بأي مرض أو اتعرضت على دكاترة تانيين؟

  • هل أخذت أي أدوية أو علاجات قبل هذه الأعراض ؟

  • هل قبل هذه الأعراض أخذت مكيفات أو كحوليات؟


Questions
Questions السؤالين ”بنعم“ استمر فى الاجابة على الأسئلة التالية:

1- The DSM-IV classification of mood disorders encompasses all of the following except

  • Bipolar disorders

  • Dysthymia

  • Posttraumatic stress disorder

  • Cyclothemia

  • Major depression


2- which of the following statements is true of السؤالين ”بنعم“ استمر فى الاجابة على الأسئلة التالية:dysthymic disorders?

  • Symptoms less intense and invasive than major depression.

  • Symptoms have both characteristics of both depressive and manic syndromes.

  • Hypomanic features must be of at least two years duration.

  • It’s a variety of bipolar disorder.

  • None of the above is true.


3- Which of the following statements isn’t true of bipolar disorders?

  • It occurs in 0.4% to 1.2% of the adult population

  • It has a familial pattern associated with it

  • The first episode usually occurs between 20 & 40 years of age

  • Depression occurs more frequently than mania

  • Forty percent of patient with typical bipolar disorder respond to lithium.


4- The concept of uncomplicated bereavement includes all of the following except

  • It isn’t a mental disorder under DSM-IV

  • It isn’t categorized as a major depressive episode under DSM-IV

  • It’s a normal reaction

  • It’s of varied duration among different cultural groups

  • It’s an exacerbation of a previous mental disorder


5- All of the following are characteristics of melancholia except

  • Loss of interest or pleasure in all or almost all activities.

  • Lack of reactivity to pleasure stimuli

  • Depression regularly worse in morning

  • Endogenous origin

  • Consistent early morning awakening


6- an individual whose exceptsymptomatology fulfills the criteria for dysthymic disorder , but who have intermittent periods of normal mood which last more than a few months is BEST classified as having

  • Depressive disorder, otherwise not classified.

  • Dysthymic disorder

  • Cyclothemic disorder

  • Major depressive disorder

  • None of the above


7- All of the following are symptoms of a major depression except :

  • disorientation to time .

  • Delusions involving concern of AIDS.

  • Failure to care to personnel hygiene.

  • Overemphasis on the bad things of life.

  • Thought blocking .


8- The following statements are true regarding atypical depression.

  • Increase in food intake and sleeping is common.

  • Mood is unreactive.

  • Personality issues are prominent.

  • Delusions are systematized.


9- sleep disturbance in depression. depression.

  • Is most typically early awaking.

  • Not important sign.

  • Nightmare aren’t common.

  • Sleep is refreshing.


10- treatment with SSRIs : depression.

  • Not associated with sleep disturbance.

  • Not associated with nausea and vomiting.

  • Can result in orgasmic impotence.

  • Complicated dosing regimen.


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