Management of depression in primary health care

1. Management of depression in primary health care Dr. Tarik S. Khammas Consultant Psychiatrist New Psychiatry Hospital Abu Dhabi

2. INTRODUCTION • It is estimated that depressive disorders will affect one of five patients in general practice. • These patients may be unaware of their mental state & its influence, seeking treatment for a somatic disorder. • In depressed patients, the associated somatic complaints may be also be gender related. • Information regarding these symptoms may be difficult to obtain, often only becoming apparent with gentle questioning. If further information is needed, relative & a friend are often a valuable source.

3. Affective Disorders • The word ‘affect’ is a synonym for mood. • Affective disorders are so named because their main feature is an abnormality of mood, namely depression or elation. • ICD-10 classification (Manic episode, Depressive episode- mild, moderate & severe, Bipolar affective disorder, Persistent mood states- cyclothymic & dysthymia ). • DSM-IV classification ( Manic episode, Major depressive episode, Bipolar disorders, Cyclothymia & dysthymia ). • Both depression & elation can be secondary to other psychiatric syndromes & also accompany physical illness.

4. Depressive disorder • The central features of depression are low mood, pessimistic thinking, lack of enjoyment, reduced energy, slowness, poor concentration & low self-esteem. • Depressive disorder is frequent in general & hospital practice but is often undetected, especially when there are physical symptoms. • Unrecognized depressive disorder is a common cause of distress & slow recovery from physical illness. • All doctors should be able to recognize the condition, treat the less severe cases, identify those requiring specialist care. • They are classified as single or recurrent episodes & less severe form (dysthymia).

5. General clinical features • Sadness is a normal emotion commonly experienced by healthy people in response to misfortunes, especially losses(grief). It is often accompanied by anxiety, lack of energy & poor sleep. • More severe unhappiness associated with low mood, depressive thinking & biological symptoms. • Depressive symptoms also occur in many other psychiatric disorders such as schizophrenia & dementia. • Many anxiety depression seen in primary health care are due to depressive disorder. • Sometimes the symptoms of depressive disorders is denied & patient smiles a condition described as masked depression.

6. Mild depressive disorder • Complains of low mood, lack of energy & enjoyment and poor sleep. • Other symptoms include anxiety, phobia & obsessional symptoms. • Sleep disturbance is often difficult to fall asleep, restless with period of waking during the night followed sound sleep before waking. • Mood may vary during the day; worse in the evening than in the morning in contrast to more severe cases. • Biological features are uncommon.

7. Moderately severe depressivedisorder • Appearance-sad appearance & psychomotor retardation • Low mood-misery, worse in the morning & irritability and agitation. • Lack of interest & enjoyment-reduced energy, poor concentration & memory. • Depressive thinking-pessimistic & guilty thoughts, self-blame, suicidal ideas & hypochondriacal ideas. • Biological symptoms-early wakening, weight loss reduced appetite& reduced sexual drive. • Other symptoms-obsessional symptoms, depersonalization etc.

8. Severe depressive disorder • All the features described under moderate depressive disorder occur with greater intensity. • There may be additional symptoms; namely delusions & hallucinations ( psychotic depression ). • Delusion namely; worthlessness, guilt, ill-health, poverty,hypochodriacal delusions, delusion of impoverishment, nihilistic delusions & delusion of persecution. • Perceptual disturbances; fall short of hallucinations but few experience true hallucinations usually auditory. • Suicidal ideas & rarely homicidal ideas; particularly important when related to young children.

9. Variants of depression • Agitated depression: is applied to depressive disorders in which agitation is severe, common in middle-aged & elderly. • Retarded depression: is applied to depressive disorders in which psychomotor retardation is prominent, may lead to depressive stupor. • Depressive stupor: is a rare variant of severe depression, the patient is motionless, mute& refusing tp eat & drink. • Atypical depression: a minority of patients have severe anxiety, severe fatigue, increased sleep & increased appetite. • Seasonal affective disorder (SAD): some people develop depression at the same time of the year.

10. Who develops depression? • Certain events in life are known to precipitate depression; reaction to loss of a parent in early childhood, a limb or another part of the body ( mastectomy), miscarriage,or loss of self-esteem, divorce or separation. • Women more prone to depression premenstrually, after childbirth & at menopause. • A prepubertal child may develop depression as a reaction to organic or environmental ( familial or scholastic ) conditions. • The confusing social, emotional & physical changes experienced in adolescence may cause depression. • Depression is common in the elderly especially when there is loneliness, isolation or bereavement.

11. What somatic symptoms are suggestive of depression ? • The more insightful & articulate patient may help in the diagnosis of depression. • In depressed patient many physical discomforts are often of a psychosomatic in nature. • Complaints of gastrointestinal disturbance, headache, muscular pains, backache, menstrual disturbances, thoracic pain, etc. are common. • Physical examination & laboratory procedures need to be conducted to exclude possible organic causes. These may include anaemia, hypothyroidism, neoplasm, chronic fatigue syndrome, cardiac diseases, peptic ulcer, bowel disease as well as other somatic diseases.

12. Management • A full psychiatric & physical examination should be completed & any underlying organic cause identified & treated. • If no organic cause exists, the best approach to treatment will often be individualized & global in nature integrating pharmacotherapy, psychotherapy & prophylactic measures. • Medication may be particularly necessary when the depression is associated with genuine somatic condition

13. Psychopharmacology • Anxiolytics such as benzodiazepines are effective in treating anxiety. • Antidepressants of choice would be an agent which has been demonstrated to be safe & effective without sedation & other adverse effects including anticholinergic, potentiation with alcohol, drug interaction & toxicity in case of suicide attempt. • In general practice, tricyclic antidepressants are widely prescribed ( Imipramine & amitryptyline). • New agents have been developed which act more rapidly, are less toxic & nonsedating (Prozac,seroxat, zoloft, faverin, effexsor & cipram ).