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

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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. To know the prevalence of depression in KSA - PowerPoint PPT Presentation

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

PO Box 27121 Riyadh 11417 Tel: 4912326 Fax: 4970847

Introduction to Primary Care: a course of the Center of Post Graduate Studies in FM

Dr Wedad bardisi

PO Box 27121 Riyadh 11417 Tel: 4912326 Fax: 4970847

Module 5Depression in primary care

ObjectivesTo know the prevalence of depression in KSA To know the size of the problem in primary health care.To encourage trainee to use DSM IV diagnostic criteria.To encourage recognition of depression and determine its cause & classification.To know proper history taking and physical examination.To know evidence based management options.To know different antidepressant, uses, side effects, interaction, initiation, duration of treatment.To know how to to do proper followup.To know when to refer. Size Of The ProblemThe World Health Organization ranks major depression among the most burdensome diseases in the worldThe WHO in its last publication referred to some facts:About 40% of those attending for physicians regardless of their specialties suffer from somatic symptoms secondary to psychiatric problems. Major Depression Occurs in up to 30% of patients seen by physicians.About 70%-80% of all psychiatric patients had been firstly visit their Family physician or primary care doctors before seen by psychiatrist.But often Goes UndetectedWomen are affected more than men

PrevalenceDepression symptoms are very common. 13 to 20% of the population being affected at any one time.In KSA the prevalence is similar to the world wide , 20%.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 depressionThe prevalence of major depression is estimated at 10 to 20 percent in patients with medical illnesses such as diabetes and heart disease.psychiatric disorder are under diagnosed in General practice.

Major DepressionMajor depression is a relapsing, remitting illness in most patients. Following a first episode, there is a greater than 40 percent rate of recurrence over a two-year period . after two episodes, the risk of recurrence within five years is approximately 75 percent. Ten to 30 percent of patients treated for a major depressive episode will have an incomplete recovery, with persistent symptoms or dysthymia Many patient with untreated depression receive aggressive medical treatment and testing for vague somatic complaints. 49% of depressed cases in the community are not treated.Those who are treated receive low doses and a very short period of treatment.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.

Family StudiesParents, siblings and children of patients of patients with severe depression have a10 to 15% morbidity risk.Concordance rates of 70% for monozygotic twins and 20% for dizgyotic twins in bipolar disorders.Concordance rate for unipolar depression in monozygotic twins is 40%.The DSM-IV-TR includes the following psychiatric causes of depression:

Major depressive disorder ( Unipolar).Dysthymic disorder - 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 Adjustment disorder - Emotional or behavioral symptoms that arise in response to an identifiable stressor and that cease once the stressor has terminated Bereavement - A non pathological response to the loss of a loved one

Predisposing Factors(1) Impaired social supports. (2) Caregiver burden. (3) Loneliness. (4) Bereavement. (5) Negative life events.(6) Childhood abuse and neglect, as well as cumulative load of stressors- Unhappy marriage. - Problems at work.- Unsatisfactory housing.- Lack of employment.- Lack of confiding relationship.

OTHER ILLNESSES CAN CAUSE DEPRESSIVE SYMPTOMSEndocrine disorders: Cushing's disease, Addison's disease, dibetes mellitus, hypothyroidism, hyperthyroidism.Collagen disease: rheumatoid arthritis, temporal arthritis, polymyalgia rheumatic.Chronic infections: infectious mononucleosis, hepatitis, herpes zoster, tuberculosis.Neoplastic: cancer of lung, brain, or head of pancreas.Neurologic: parkinsonism, cerebrovascular accident, multiple sclerosis, Alzheimer's disease Pharmacologic: Steroids, beta blockers, reserpine, alcohol, antibiotics, barbiturates, alphamethydopa.Alcoholism. Drug addiction


MOOD SYMPTOMSPSYCOLOGICAL SYMPTOMSSuicidal Ideas.Guilt Feeling Low Self EsteemLack Of Concentration

RetardationAgitation.Negligence Of WorkNegligence Of Social Activity

BEHAVIOURAL SYMOPTOMSSOMATIC SYMPTOMSDisturbed sleep pattern.Appetite change.Weight change.Decreased sexual drive.Loss of energy, fatigue.


Sleep disturbance.Fatigue Pain.Anxiety.Irritability Gastrointestinal disorders.

Unexplained Somatic symptoms:

C.V.SPalpitationPseudoanginal pain.Respiratory :DyspneaHyperventilation .Gastrointestinal VomitingBowel disturbanceColicsMusculosklettalLow backacheGenitourinaryFrequency micuritionImpotence Vs premature ejaculationDysparonia frigidity

Diagnostic criteria for major depressive episode (adapted from DSM-IV-TR 17 )

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 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

The symptoms do not meet criteria for a mixed episode. The symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning. The symptoms are not due to the direct physiological effects of a substance or a general medical condition. The symptoms are not better accounted for by bereavement.

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 contentCognition.

Appearance and behavior: Patients with depression may appear completely normal or may have evidence of poor self-care; patients with severe depression may appear dehydrated, thin, or even cachectic. Behaviors associated with depression include psychomotor slowing, poor eye contact, masked facies, tearfulness, furrowed brow, and hand wringing. Mood and affect:Mood is the subjective experience of an emotional state and is ascertained by asking the patient, who may describe feeling sad, blue, or depressed.Affect is the clinicians objective assessment of emotional state; typically, patients with depression have a restricted range of affect encompassing dysphoria and perhaps anxiety. Thought processes and speech: Speech is often delayed, slow, and monotonous.Thought poverty refers to a relative lack of spontaneity and content. Thought content: Patients may endorse helplessness, hopelessness, worthlessness, and/or suicidal ideation. Passive suicidal ideation refers to the belief that life is not worth living or that one would be better off dead. Active suicidal ideation refers to reporting a plan to harm oneself and/or the intent to harm oneself. Assessment of suicidal ideation is a critical and necessary component of the examination of patients with depression.Patients with psychotic depression may endorse hallucinations and/or delusions. Assessment of homicidal ideation is also necessary in this population.Cognition: Patients are generally alert, although may be inattentive and show evidence of short-term memory loss. Identifying cognitive impairment can be accomplished by routinely administering the Mini-Mental Status Examination (or other screening tool) to all depressed older adults.

17 DysthymiaDysthymia 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 for most of the day, occurring more days than not, and 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

To diagnose dysthymia, any major depressive episodes must not have occurred in the first 2 years of the illness (the first 1 year in children) and history of mania should not exist

Persistent Affective DisordersCyclothymia- At least 2 years of instability of mood (depression / hypomania)- During depression:* Reduction of energy of activity.* Insomnia.* Loss of self-confidence or feelings of inadequacy. * Difficulty in concentration.* Social withdrawal.* Loss of interest.- During hypomania:* Increased energy or activity.* Decreased need for sleep.* Inflated self-esteem.* Sharpened or unusually creative thinking.* More talkat