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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

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



  • 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

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



  • 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 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

Po box 27121 riyadh 11417 tel 4912326 fax 4970847

  • 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

Po box 27121 riyadh 11417 tel 4912326 fax 4970847

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

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

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

Clinical Picture



  • Sad

  • Depressed

  • anhedonia

  • Greif

  • Suicidal Ideas.

  • Guilt Feeling

  • Low Self Esteem

  • Lack Of Concentration




  • 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

Unexplained Somatic symptoms:


  • Palpitation

  • Pseudoanginal pain.

    Respiratory :

  • Dyspnea

  • Hyperventilation .


  • Vomiting

  • Bowel disturbance

  • Colics


  • Low backache


  • Frequency micurition

  • Impotence Vs premature ejaculation

  • Dysparonia

  • frigidity

Diagnostic criteria for major depressive episode adapted from dsm iv tr 17

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

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

Po box 27121 riyadh 11417 tel 4912326 fax 4970847

  • 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

Po box 27121 riyadh 11417 tel 4912326 fax 4970847

  • 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.

Po box 27121 riyadh 11417 tel 4912326 fax 4970847

  • 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.

Po box 27121 riyadh 11417 tel 4912326 fax 4970847

  • 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.

Po box 27121 riyadh 11417 tel 4912326 fax 4970847

  • 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

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

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 (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 disorder dsm iv

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 disorder dsm iv

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

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 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.



  • 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

Pharmacological treatment1


  • Tricyclic antidepressant.(side effects are problem)

  • MAOI ( not used frequently)

  • SSRI

Side effects of tca

: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

Examples of TCA

Po box 27121 riyadh 11417 tel 4912326 fax 4970847

  • 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

The SSRIs All share several characteristics

Examples of ssri

Examples of SSRI

St john s wort hypericum perforatum

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

    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 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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