Ten Leading Causes of DALYs in 2020

(Disability Adjusted for Life Years)

In the World

Both sexes Disease or injury

Males Disease or injury

Females Disease or injury

All causes All causes All causes

1-Ischaemic heart disease

Ischaemic heart disease

Unipolar major depression

2-Unipolar major depression

Road traffic accidents

Ischaemic heart disease

3-Road traffic accidents

Cerebravascular disease

Cerebravascular disease

4-Cerebravascular disease

Chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease

5-Chronic obstructive pulmonary disease

Unipolar major depression

Road traffic accidents

Ustun et al (2004) Brit. J. Psychiat.

Prevalence of depression

WHO - Fact Sheet N° 265, December 2001

Copeland et al (1987); Gräsbeck (1996); Hagnell et al (1982)

9.5% of

women

5.8% of men

10-15% of elderly 65

years

15

“ICEBERG” PHENOMENON”

Depressed patients

seen by psychiatrists

Depressed patients seen in

primary care practice

Treatment of depression

Tylee A et al, Int Clin Psychopharmacol,1999,14(3):139–51;Lépine, JP et al.,

Int Clin Psychopharmacol, 1997,12:19–29.

- Do not seek help

- Undiagnosed

- Diagnosed but untreated

- Treated but non compliant*

Receive antidepressant

(4.4%)

Adequately treated

(?%)

Untreated patients

(95.6%)

Depressed Patients

(100%)

The hidden cost of not treating Mood

Disorders

Dysfunctional families

Absenteeism

Decreased productivity

Job-related injuries

Adverse effect on quality control in the workplace

Key symptoms

Emotional Physical

Sad mood

Loss of interest or pleasure

Feelings of worthlessness or

excessive guilt

Thoughts of death, suicide

Diminished ability to think or

concentrate

Psychomotor retardation or

agitation

Sleep disturbances

Weight loss or weight gain

Fatigue or loss of energy

American Psychiatric Association (1994)Other key symptoms

Don‟t chase symptoms –

treat the core

Tachycardia/irregular heart beat

Presenting complaint

Cardiological

Chest pain

Neurological

Headache

Dizziness

Syncope/seizures

Gastrointestinal

Epigastric pain

Diarrhoea

„Asthma‟

Pulmonary

Dyspnoea

0 10 20 30 40 50 60

% patients

Wayne Katon (1984)* DSM-IV-TR™ 2000

Medical Condition Frequency of Major Depression

Coronary Artery Disease 30-60%

Emphysema 20-40%

HIV infection 20-35%

Hypothyroidism 10-30%

Stroke 10-25%

Diabetes Mellitus 10-20%

Renal Failure 5-20%

Kaplan HI, 1994

The association between depression

and medical illness

69

What are we trying to achieve for

our depressed patients?

To return them to „health‟

“Health is a state of complete physical, mental and

social well-being and not merely the absence of

disease or infirmity”

World Health Organisation

Preskorn SM. J Clin Psychiatry 1997;58 (suppl 6):3-8.

S

T

E

P

S

STEPS: Factors to Consider in

Antidepressant Selection

Safety

Drug-drug interaction potential

Tolerability

Acute and long term

Efficacy

Onset of action

Treatment and prophylaxis

Payment

Cost effective

Simplicity

Dosing

Need for monitoring

73

Comparison of SSRI and Benzodiazepine

Drugs

SSRI BZ

Broad spectrum Yes No

Rapid onset No Yes

Tolerability Fair Good

CYP 460 interactions Yes No

Discontinuation sx Yes Yes

Abuse potential No Yes

Early activation Yes No

SSRIs/SNRIs bind only to the

primary site

The net result is

an intermittent

blockade of the

serotonin transporter

protein

Cipralex binds both to the primary

and the allosteric site

The net result is

Stronger and longer

binding to the serotonin

transporter protein

1. Von Moltke et al. Drug Metab Dispos 2001;29:1102-9

2. Greenblatt et al. J Clin Psychiatry 1998;59:19-27

3. Albers et al. Psychiatry Res 2000;96:235-243

Low potential for drug-drug

interactions

3A4 2D6 1A2 2C19 2C9

Escitalopram1 0 + 0 0 0

Citalopram2 0 + + 0 0

Fluoxetine2 ++ +++ + ++ ++

Paroxetine2 + +++ + + +

Venlafaxine3 + + 0 0 0

Fluvoxamine2 ++ + +++ +++ ++

Sertraline2 + + + ++ +0 = Negligible

+ = Very weak interaction

Cytochrome P450 Isozyme Inhibition In Vitro/In Vivo

++ = Moderate interaction

+++ = Strong interaction

•Ca+ antagonists

•Erythromycin

•Ketoconazole

•Lidocaine

•Cancer therapies

•Anti-Arrhythmic

•B-blockers

•Haloperidol

•Neuroleptics

•Caffeine

•Ciprofloxacin

•Theophylline

•Verapamil

•Diazepam

•Propranolol

•Moclobemide

•Imipramine

•Miconazole

•Phenytoin

•S-warfarin

•NSAIDs

Cipralex® is the true SRI

SRI

NRI

Fluoxetine1

SRIFluvoxamine1

DRI

SRISertraline1

SRICipralex3

SRI

NRI

Paroxetine1

DRI

SRIVenlafaxine2

Stahl SM. Using secondary binding properties to select a not so selective reuptake inhibitor. J Clin. Psychiatry 1998;59:642n3

Conclusions :

• Cipralex is an extremely selective serotonin reuptake

inhibitor .

• Cipralex has no effect on 140 receptors , Enzymes or

Ion channels .

THANK

YOU

Nameer

Mohamed