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PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax: 4970847. Module 5 Depression in primary care. Introduction to Primary Care: a course of the Center of Post Graduate Studies i n FM Dr Wedad bardisi. Objectives. Know thhe prevalence of depression in KSA

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PO Box 27121 – Riyadh 11417 Tel: 4912326 – Fax: 4970847

Module 5

Depression in primary care

Introduction to Primary Care:

a course of the Center of Post Graduate Studies in FM

Dr Wedadbardisi


Objectives

  • Know thhe prevalence of depression in KSA

  • know the size of the problem in primary health care.

  • Encourage trainee to use DSM IV diagnostic criteria.

  • Encourage recognition of depression and determine its cause & classification.

  • know proper history taking and physical examination.

  • know evidence based management options.

  • Know methods of screening for depression in family practice.

  • know how to do proper follow up.

  • know when to refer.


Size Of The Problem

  • The World Health Organization ranks major depression among the most burdensome diseases in the world

  • Approximately 5 to 10 percent of primary care patients meet DSM-IV criteria for major depression, 3 to 5 percent for dysthymia, and 10 percent for minor depression.

  • About 70%-80% of all psychiatric patients had been firstly visit their Family physician or primary care doctors before seen by psychiatrist.

  • Depression often Goes Undetected


Prevalence

  • Depression symptoms are very common. 13 to 20% of the population being affected at any one time.

  • In KSA the prevalence is similar to that of world wide i.e 20%.

  • The prevalence of major depression is estimated at 10 to 20 percent in patients with medical illnesses such as diabetes and heart disease.

  • Women are affected more than men.


Major Depressive Disorder(MDD)

  • Major depression is a relapsing, remitting illness in most patients.

  • Recurrence rate is 40% following the first episode over two years.

  • After two episodes, the risk of recurrence within five years is approximately 75 percent.

  • 10 to 30 % of patients treated for a major depressive episode will have an incomplete recovery, with persistent symptoms or dysthymia


  • Depression if untreated or inadequately treated , is a disease associated with high mortality, morbidity and economic costs, and danger serious disorder 15% of the patient commit suicide.

  • Many patients find a diagnosis of depression difficult to accept


Suicide rate by age and gender. 2004 data compiled from CDC. The mean suicide rate for the entire population was 12.8/100,000/year.


Classification according to DSM IV

  • Major depressive disorder ( Unipolar).

  • Dysthymic disorder (mild sepression)- At least 2 years of lower-level depressive symptoms

  • Bipolar depression - A major depressive episode arises in a patient with a history of hypomanic, manic, or mixed episodes

  • Adjustmentdisorder - Emotional or behavioral symptoms that arise in response to an identifiable stressor and that cease once the stressor has terminated


Predisposing Factors

  • (1) Genetic & familial factors.

  • (2) Impaired social supports

  • (3) Loneliness.

  • (4) Bereavement.

  • (5) Negative life events.

  • (6) Childhood abuse and neglect.

  • (7) postpartum.

  • As well as cumulative load of stressors like:

  • - Unhappy marriage.

  • - Problems at work.

  • - Unsatisfactory housing.

  • - Lack of employment.

  • - Lack of confiding relationship.


OTHER ILLNESSES CAN CAUSE DEPRESSIVE SYMPTOMS


Clinical Picture

MOOD SYMPTOMS

PSYCOLOGICAL SYMPTOMS

  • Sad

  • Depressed

  • anhedonia

  • Greif

  • Suicidal Ideas.

  • Guilt Feeling

  • Low Self Esteem

  • Lack Of Concentration

CATEGORIES OF DEPRESSIVE SYMPTOMPS

SOMATIC SYMPTOMS

BEHAVIOURAL SYMOPTOMS

  • Disturbed sleep pattern.

  • Appetite change.

  • Weight change.

  • Decreased sexual drive.

  • Loss of energy, fatigue.

  • Retardation

  • Agitation.

  • Negligence Of Work

  • Negligence Of Social Activity


MOST COMMON PRESENTING SYPMTOMS

  • Sleep disturbance.

  • Fatigue

  • Pain.

  • Anxiety.

  • Irritability

  • Gastrointestinal disorders.


Unexplained Somatic symptoms:

C.V.S

  • Palpitation

  • Pseudoanginal pain.

    Respiratory :

  • Dyspnea

  • Hyperventilation .

    Gastrointestinal

  • Vomiting

  • Bowel disturbance

  • Colics

Musculosklettal

  • Low backache

    Genitourinary

  • Frequency micurition

  • Impotence Vs premature ejaculation

  • Dysparonia

  • frigidity


Diagnostic criteria for major depressive episode (adapted from DSM-IV-TR17 )

  • At least 5 of the following symptoms have been present during the same 2-week period and represent a change from previous functioning. At least 1 of the symptoms is either #1 or #2.

    • Depressed mood most of the day, nearly every day

    • Markedly diminished interest or pleasure in all, or almost all, activities most of the day ( TWO SCREENING QUESTIONS)

    • Significant weight loss when not dieting, or weight gain, or decrease or increase in appetite

    • Insomnia or hypersomnia

    • Psychomotor agitation or retardation

    • Fatigue or loss of energy

    • Feelings of worthlessness or excessive or inappropriate guilt

    • Diminished ability to think or concentrate, or indecisiveness

    • Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide


Screening of depression in primary care

  • Key symptoms:

  • • persistent sadness or low mood; and/or

  • • loss of interests or pleasure

  • • fatigue or low energy.

  • At least one of these, most days, most of the time for at least 2 weeks.

  • NICE Guideline – depression (amended April 2007) 61


  • If any of above present, ask about associated symptoms:

    • disturbed sleep

    • poor concentration or indecisiveness

    • low self-confidence

    • poor or increased appetite

    • suicidal thoughts or acts

    • agitation or slowing of movements

    guilt or self-blame


  • Then ask about past, family history, associated disability and availability of social support

    1. Factors that favour general advice and watchful waiting:

    • four or fewer of the above symptoms

    • no past or family history

    • social support available

    • symptoms intermittent, or less than 2 weeks duration

    • not actively suicidal

    • little associated disability.


  • 2-Factors that favour more active treatment in primary care:

  • • five or more symptoms

  • • past history or family history of depression

  • • low social support

  • • suicidal thoughts

  • • associated social disability.


  • 3. Factors that favour referral to mental health professionals:

  • • poor or incomplete response to two interventions

  • • recurrent episode within 1 year of last one

  • • patient or relatives request referral

  • • self-neglect.


  • 4-Factors that favour urgent referral to a psychiatrist:

  • • actively suicidal ideas or plans

  • • psychotic symptoms

  • • severe agitation accompanying severe (more than 10) symptoms

  • • severe self-neglect.


ICD-10 definitions

  • Mild depression: four symptoms

  • Moderate depression: five or six symptoms

  • Severe depression: seven or more symptoms, with or without psychotic features

  • NICE Guideline – depression (amended April 2007)


Physical Examination

  • The physical examination of a patient with depression may reveal evidence of malnutrition or poor self-care.

  •  The mental status examination is central to the diagnosis of depression, and includes the following components:

  • Appearance and behavior.

  • Mood and affect.

  • Thought processes and speech.

  • Thought content

  • Cognition.


Dysthymia (mild depression)

Dysthymia: is a chronic mood disorder with a duration of at least 2 years (1 year in adolescents and children).

  • It is manifested as depressed mood accompanied by at least 2 of the following symptoms:

  • Poor appetite or overeating

  • Insomnia or hypersomnia

  • Low energy or fatigue

  • Low self-esteem

  • Poor concentration

  • Difficulty making decisions

  • Feelings of hopelessness


Bipolar affective disorderDSM IV

Manic episodes are characterized by the following symptoms:

At least 1 week of profound mood disturbance is present, characterized by elation, irritability, or expansiveness

OR Hypomanic episodes are characterized by the following:

An elevated, expansive, or irritable mood of at least 4 days' duration

Alternating with major depressive episodes. .


Adjustment disorderDSM IV

  • A "maladaptive reaction to an identifiable psychosocial stressor, or stressors, that occurs within 3 months after onset of that stressor..

    The condition is:

  • Acute: If the disturbance lasts less than 6 months.

  • Chronic: If the disturbance lasts 6 months or longer.


A typical presentation

  • In the primary care setting, the presenting complaints often can be somatic, such as fatigue, headache, abdominal distress, or change in weight.

  • Patients may complain more of irritability than of sadness or low mood.

  • Elderly persons may present with confusion or a general decline in functioning.

  • Children with major depressive disorder may also present with irritability, decline in school performance, or social withdrawal


Assessment of suicidal ideation

  • Assessment for the presence of suicidal ideation is of paramount importance in all depressed patients.

  • Evaluation for suicide risk should include assessment of the following :

  • Presence of suicidal or homicidal ideation, intent, or plan

  • Access to means for suicide and the lethality of those means

  • Presence of psychotic symptoms, command hallucinations, or severe anxiety

  • Presence of alcohol or substance use

  • History and seriousness of previous attempts

  • Family history of or recent exposure to suicide

  • Evaluation in an emergency department and/or hospitalization should be considered for patients at significant risk of suicide.


Management

  • A wide range of effective treatments is available for major depressive disorder.

  • Brief psychotherapy (eg, cognitive behavioral therapy,

  • interpersonal therapy).

  • Patients who do not respond after 12 weeks of initial psychotherapy should be started on an antidepressant.

  • However, the combined approach generally provides the patient with the quickest and most sustained response


Pharmacological Treatment


PHARMACOLOGICAL TREATMENT………

  • Tricyclic antidepressant.(side effects are problem)

  • MAOI ( not used frequently)

  • SSRI


:Side effects of TCA

  • Antimuscarinic side effects like:

  • Dry mouth, blurring of vision, urinary retention, sweating and constipation.

  • Postural hypotension .

  • Arrhythmia.

  • Convulsion

  • Increase appetite and weight gain


Examples of TCA


  • MAOI :

    Less frequently used because of dangerous interactions with foods and drugs.

    Side effects:

    Postural hypotension, drwsiness, headache, dry mouth costipation, oedematremors,hypereflexia, sexual disturbances, and blood and liver diorders.

  • e.gPhenelzine ( Nadril) : dose 15 mg 3 times daily , max.30mg daily


The SSRIs All share several characteristics


Examples of SSRI


St. John's wort (Hypericum perforatum)

  • St. John's wort is considered a first-line antidepressant in some countries

  • Used to treat of mild-to-moderate depressive symptoms.

  • It acts as an SSRI.

  • The dose is 300 mg 3 times a day with meals to prevent GI upset.

  • side effects include:

  • gastrointestinal upset, increased anxiety, minor palpitations, fatigue, restlessness, dry mouth, headache, and increased depression.


  • Clinical course

    Is classified using six categories:

    • Response — Significant reduction (usually >50 percent) of depressive symptoms during the acute treatment phase.

    • Remission — A period of ≥2 weeks and <2 months with no clinically significant depressive symptoms.

    • Partial remission — A period of ≥2 weeks and <2 months with one or more clinically significant depressive symptom(s).

    • Relapse — An episode of depression during the period of remission.

    • Recovery — A asymptomatic period of more than two months.

    • Recurrence — The emergence of symptoms of MDD during the period of recovery (a new episode).


    Referral

    • Referral to a psychiatrist or to a treatment centre should be considered in the following circumstances:

    • 1- If the patient is expressing a suicidal intent or if there was a recent suicide attempt

    • 2- If the patient is elderly, confused and presentation of the history is unclear

    • 3- If the presenting symptoms of the disorder are severe, e.g., severe weight loss or weight gain , severe physical damage from drinking, severe withdrawal symptoms, several unsuccessful attempts to quit drinking.

    • 4- If the diagnosis is not clear

    • 5- If the treatment fails after the patient has received an appropriate medication trial

    • 6- If the management requires hospitalization or intensive treatment e.g. extreme hostility, aggression or homicide

    • 7- If there is one of comorbidity with severe physical or other mental disorders


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