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Transcript of The Practical Management of Depression Dr Frans A Korb Psychiatrist and Clinical Psychologist...
The Practical Management of Depression
Dr Frans A KorbPsychiatrist and Clinical Psychologist
Private PracticeFourways Intercare
• The Background
• The Facts
• Some Biology
• Making the Diagnosis
• Measuring Depression
• Management – Pharmaceutical
• Management – Other
• The Final Word
Overview : Depression
Definition : Depression
‘Mood is a sustained emotional tone perceived alonga normal continuum of sad to happy. Mood disordersare characterized by abnormal feelings of depression
or euphoria with associated psychotic features in somesevere cases. Mood disorders are divided into bipolar
and depressive disorders’
Kaplan & Sadock
Depression: Impact on Society
Murray CJL, Lopez AD, eds. The Global Burden of Disease. Boston: Harvard University Press; 1996.
Rank 1990 2020 (Estimated)
1 Lower respiratory infections Ischemic heart disease
2 Perinatal conditions Unipolar major depression
3 HIV/AIDS Road traffic accidents
4 Unipolar major depression Cerebrovascular disease
5 Diarrheal diseases Chronic obstructive pulmonary disease
A Major Cause of Disability Worldwide
DEPRESSIVE DISORDERS
• DSM-IV vs ICD-10
• Major Depressive Disorder
• Dysthymic Disorder
• Bipolar Disorder
• Cyclothymic Disorder
Depression – The Facts
1. Zung WW, et al. J Fam Pract. 1993;37:337-344.2. Kessler RC, et al. J Affect Disord. 1993;29:85-96.3. Solomon DA, et al. Am J Psychiatry. 2000; 157:229-233.
The Epidemiology of Depression
• Approximately 20% of primary care patients present with depressive symptoms.1
• Depression is almost twice as prevalent in females as in males.2
• Nearly two-thirds of MDD patients have multiple episodes. The risk of recurrence progressively increases with each successive episode and decreases as the duration of recovery increases.3
• Prevalence rates for MDD are unrelated to race, (religion),education, income, or civil status.4
4. U.S. Agency for Health Care Policy and Research. Depression in Primary Care: Vol. 1. Detection and Diagnosis. Rockville, MD: 1993: 23.
39.0%
45.0%
47.0%
42.0%
33.0%
36.0%
33.0%
9.4%
5.8%
0% 10% 20% 30% 40% 50%
Parkinson's Disease
MI
Stroke
Cancer Inpatients
Cancer Outpatients
Older Inpatients
Hospitalized
Chronically Ill
General Population
Adapted from: WPA/PTD Educational Program on Depressive Disorders. Gavard JA, et al. Diabetes Care. 1993;16(8):1167-1178.
Prevalence Rates of Depression in Chronic Medical Disorders
Gender Demographics1
0.0000
0.0020
0.0040
0.0060
0.0080
0.0100
0.0120
0.0140
0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54
FemaleMale
Age Category
Hazard
Rate
s
1. Kessler RC, et al. J Affective Disord. 1993;29:85-96.
MDE Hazard Rates by Age and Sex
Depression – Some Biology
Neurotransmission
Neurotransmission is the process of sending signals from one component of the nervous system to another
5-HT and NA at the Synaptic Level: Healthy vs. Depressed
DepressedHealthy
NA
5-HT5-HT Reuptake Transporter
NAReuptake Transporter
Theoretical Representation
Depression -- Making the Diagnosis
Depressed moodTraurigkeit
Slowed thinkingGedankenhemmung
Slowed movingBewegungshemmung
DepressionDepression
Weygandt “Uber die Mischzustande des manisch-depressiven Irreseins” (Munchen, 1899)
What is Depression ?
Depression. It’s not only a state of mind.
Reference: Adapted fromAmerican Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition,Text Revision. Washington, DC; American Psychiatric Association. 2000:345-356,489.
The emotional and physical symptoms of depression
Emotional Symptoms Include:
Always feeling sad
Loss of interest or pleasure
Worrying
Anxiety
Diminished ability to think or concentrate, indecisiveness
Excessive or inappropriate guilt
Physical Symptoms Include:
Vague aches and pains
Headache
Sleep disturbances
Fatigue
Vague back pain
Significant change in appetite resulting in weight loss or gain
TiredUnmotivated
Anxious
35%
34%
31%
35% have low mood, fatigue, low energy, and lack
of motivation.
34% have mild symptoms of
fatigue, low energy, and excessive worry,
and are easily overwhelmed
31% have primary anxiety
complaints
Adelphi Neurosis Market Research Study. 1997. A. Gupta 2000 (n=1590).
(Retarded)
(Agitated)
SPECIAL FORMS OF DEPRESSIVE DISORDERS
• Psychotic Depression
• Somatic Depression
• Atypical Depression
• Seasonal Depressive Disorder
• Rapid-cycling Bipolar Disorder
• Secondary Depressive Disorder
OTHER FORMS OF DEPRESSIVE DISORDERS
• Dysthymia
• Postpartum Depression
• Recurrent Brief Depression
• Mixed Anxiety-Depression Syndrome
• Subthreshold Depression
Measuring Depression
Depression Management -- Pharmaceutical
Depression: Current Treatment Patterns
• Only about 1/3 of patients with major depression seek care for their depression (1)
• Less than 1/2 of patients with major depression are explicitly recognised as being depressed (2,3)
• Only about 1/2 of all depressed patients receive some form of therapy for their illness (2,3)
• Only about 1/4 of depressed patients receive an adequate dose and duration of antidepressant treatment (4)
1) Shapiro S, et al. Arch Gen Psychiatry. 1984;41:971-78.2) Wells KB, et al. JAMA. 1989;262(23):3298-3302.3) Lepine C, et al. Intl Clin Psychopharm. 1997;12:19-29.4) Katon W, et al. Medical Care. 1992;39(1):67-76.
AHCPR, 1993
Classes of Antidepressants
• Tricyclic and Tetracyclic Antidepressants (TCAs) Imipramine, clomipramine
• Monoamine Oxidase Inhibitors (MAOIs + RIMAs) tranylcypromine, moclobemide
• Selective Serotonin Reuptake Inhibitors (SSRIs) fluoxetine, citalopram
• Selective Noradrenaline Reuptake Inhibitor (NRI) reboxetine
• Serotonin-Noradrenaline Reuptake Inhibitors (SNRIs) duloxetine, venlafaxine
• Serotonin-2 Antagonist and Reuptake Inhibitors (SARIs) trazodone, nefazodone
• Noradrenergic and Specific Serotonergic Antidepressants (NaSSA) mirtazapine
• Dopamine and Noradrenalin Reuptake Inhibitors (DNRI) Bupropion
Depression: Treatment Goals
Reprinted with permission from Kupfer, 1991WPA/PTD Educational Program on Depressive Disorders
SeveritySeverity
TimeTime
X
ResponseResponse
RelapseRelapseRecurrenceRecurrence
MaintenanceMaintenanceContinuationContinuationAcuteAcute
Treatment PhasesTreatment Phases
SymptomsSymptoms
RemissionRemission
SyndromeSyndrome
RelapseRelapse
Progression
Progression
to disorder
to disorder
No DepressionNo Depression
RecoveryRecovery
X
X
6-12 weeks 4-9 months 1 or more years
Switching Strategies
Pharmacological Strategies for Treatment-Resistant Depression (TRD)
Optimization
(monotherapy)
Increase the dose or duration, or alter the timing of the primary antidepressant.
Substitution
(switching)
Stop first medication, start next one as monotherapy. New drug can be within or across class.
Augmentation Add a second drug (adjunct) that is not an antidepressant to the antidepressant that has not produced and adequate response.
Combination Two antidepressants used together, typically for synergistic mechanisms.
Depression Management -- Other
Patient Programmes
www.sadag.co.za
mySupport Programme
www.bouncingback.co.za
Depression – The Final Word
Social-Endocrine-Psychological Interactions
Depression: Treatment Goals
TreatmentTreatment
Reduce/RemoveReduce/RemoveSigns, SymptomsSigns, Symptoms
Minimise Relapse/Minimise Relapse/Recurrence RiskRecurrence RiskRestoreRestore
Role/Role/FunctionFunction
AHCPR Guidelines: Depression in Primary Care, Vol 2. US Dept. of Health and Human Services; 1993.
Depression Is ...
• Prevalent worldwide
• Common in primary care setting
• Often unrecognized, inadequately treated
• Associated with high morbidity,
mortality, cost
• PCP can provide effective treatment