I N T R O D U C T I O N T O P R I M A R Y C A R E :A C O U R S E O F T H E C E N T E R O F P O S T G R A D U AT E S T U D I E S İ N F M

D R W E D A D B A R D I S I

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Module 5

Depression in primary care

Objectives

To 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 Problem

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

The 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

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 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 depression

The 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 Depression

Major 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 Studies

Parents, 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:

1. Major depressive disorder ( Unipolar).

2. Dysthymic disorder - At least 2 years of lower-level depressive symptoms

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

4. Adjustment disorder - Emotional or behavioral symptoms that arise in response to an identifiable stressor and that cease once the stressor has terminated

5. 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 SYMPTOMS

Endocrine 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

Clinical Picture

CATEGORIES OF DEPRESSIVE SYMPTOMPS

•SAD•DEPRESSED • ANHEDONIA•GREIF

MOOD SYMPTOMS

PSYCOLOGICAL SYMPTOMS

•Suicidal Ideas.•Guilt Feeling• Low Self Esteem•Lack Of Concentration

•Retardation•Agitation.•Negligence Of Work•Negligence Of Social Activity

 

BEHAVIOURAL SYMOPTOMS

SOMATIC SYMPTOMS

•Disturbed sleep pattern.•Appetite change.•Weight change.•Decreased sexual drive.•Loss of energy, fatigue.

MOST COMMON PRESENTING SYPMTOMS

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

Unexplained Somatic symptoms:

C.V.SPalpitationPseudoanginal pain.Respiratory :DyspneaHyperventilation .Gastrointestinal VomitingBowel disturbanceColics

MusculosklettalLow 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. 1. Depressed mood most of the day, nearly every day 2. Markedly diminished interest or pleasure in all, or almost all, activities

most of the day 3. Significant weight loss when not dieting, or weight gain, or decrease

or increase in appetite 4. Insomnia or hypersomnia 5. Psychomotor agitation or retardation 6. Fatigue or loss of energy 7. Feelings of worthlessness or excessive or inappropriate guilt 8. Diminished ability to think or concentrate, or indecisiveness 9. 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.

Dysthymia

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 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 Disorders

Cyclothymia- 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 talkative than normal, witty* Increased interest and involvement in sexual and other pleasurable activities.* Over-optimism and exaggeration of past

achievements.

Bipolar affective disorderDiagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR).9

Manic episodes are characterized by the following symptoms: At least 1 week of profound mood disturbance is present, characterized by

elation, irritability, or expansiveness. Three or more of the following symptoms are present:

Grandiosity Diminished need for sleep Excessive talking or pressured speech Racing thoughts or flight of ideas Clear evidence of distractibility Increased level of goal-focused activity at home, at work, or sexually Excessive pleasurable activities, often with painful consequences

The mood disturbance is sufficient to cause impairment at work or anger to the patient or others.

The mood is not the result of substance abuse or a medical condition.

Contd,Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR).9

Hypomanic episodes are characterized by the following: The patient has an elevated, expansive, or irritable mood of at

least 4 days' duration. Three or more of the following symptoms are present:

Grandiosity or inflated self-esteem Diminished need for sleep Pressured speech Racing thoughts or flight of ideas Clear evidence of distractibility Psychomotor agitation at home, at work, or sexually Engaging in activities with a high potential for painful consequences

The mood disturbance is observable to others. The mood is not the result of substance abuse or a medical

condition.

Contd, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR).9

Major depressive episodes are characterized by the following: For the same 2 weeks, the person experiences 5 or more of the

following symptoms, with at least 1 of them being either a depressed mood or characterized by a loss of pleasure or interest: Significant weight loss or gain or significant loss or increase in appetite Hypersomnia or insomnia Psychomotor retardation or agitation Loss of energy or fatigue Decreased concentration ability or marked indecisiveness Preoccupation with death or suicide patient has a plan or has attempted

suicide The symptoms cause significant impairment and distress. The mood is not the result of substance abuse or a medical

condition.

Contd, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR).9

Mixed episodes are characterized by the following: Persons must meet both the criteria for mania and

major depression; the depressive event is required to be present for 1 week only.

The mood disturbance results in marked disruption in social or vocation function.

The mood is not the result of substance abuse or a medical condition.

The mixed symptomology is quite common in patients presenting with bipolar symptomology. 

Adjustment disorder

Diagnostic and Statistical Manual, Fourth Edition, Text Revision (DSM-IV-TR) description of AD as:

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

The DSM-IV-TR diagnostic criteria for adjustment disorder

The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurs within 3 months of the onset of the stressor(s).

These symptoms or behaviors are clinically significant, as evidenced by either of the following: Marked distress in excess of what is expected from

exposure to the stressor Significant impairment in social or occupational

(academic) functioningThe stress-related disturbance does not meet criteria for

another specific axis I disorder and is not merely an exacerbation of a preexisting axis I or axis II disorder.

The symptoms do not represent bereavement. Once the stressor (or its consequences) has

terminated, the symptoms do not persist for more than an additional 6 months.

Specify whether the condition is acute or chronic, as follows:

Acute: If the disturbance lasts less than 6 months, it is considered acute.

Chronic: If the disturbance lasts 6 months or longer, it is considered chronic.

Recurrent Depression Disorder

80% of depression is recurrent only 29% single episode.

Modification at gene level seem to occur that lead to

Sensitization (spontaneous occurrence of episodes).

Immediate and long-term treatment ensures that this

sensitization does not occur.

Discontinuation of long-term treatment could lead drug

refractoriness.

A typical presentation

In the primary care setting, where many of these patients first seek treatment, 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) has been shown in clinical trials to be an effective treatment option, either alone or in combination with medication.

Patients who do not respond after twelve weeks of initial psychotherapy should be started on an antidepressant, as part of a combined treatment approach

Medication alone also can relieve symptoms. However, the combined approach generally provides the patient with the quickest and most sustained response

Pharmacological Treatment

3 Phases

- 1st Treatment of the acute phase. 4-6 weeks.- 2nd Consolidation treatment to ensure that episode has been adequately treated 4-6 months.- 3rd Prophylactic to reduce risk of recurrence after

a period to symptom free.

Tricyclic antidepressant

Most effective for treating moderate to sever

endogenous depression associated with psychomotor and

physiological changes such as loss of appetite and sleep

disturbance.

sleep disturbance is the first thing to improve.

About 10-20% fail to respond to TCA due to low doses.

High doses can cause dangerous cardiotoxicity.

In elderly should initiate low doses.

There are two types sedative and stimulant.

Cloimipramin and amotryptyline are sedative.

Amoxapine , imipramin , nortryptyline are less sedative .

Prtotriptyline are stimulant.

Imipramine and amitryptlin are safe and effective but

they have more marked antimuscarinic or cardiac side

effects

:Side effects

Antimuscarinic side effects like, dry mouth, blurring of vision, urinary retention, sweating and constipation.

Postural hypotension , tachycardia, syncope. Arrhythmias and heart blocks, occasionally sudden death. Convulsion especially in known epileptics., headache and fine

tremors. Hepatic and hematological reactions. Interference with sexual function. Blood sugar changes, and abnormal LFT. Increase appetite and weight gain. Endocrine side effects such as testicular enlargement,

gynecomastia and galactorrhea. Movement disorders and dykinesia.

Examples of TCA

Amitryptaline ( Tryptizol): dose 25-75 mg daily either divided or one bed time single dose

Clomipramine (Anafranil): dose 10 up to 150 mg either divided or one bed time single dose.

Imipramine (Tofranil): dose initially up to 75 mg up to 200 mg as single bed time dose.

Nortryptyline ( Ativan, Motival) :dose75-100 mg daily either divided or one bed time single dose.

Doxepine (sinequan) dose: initially 75 mg up to 300mg daily in 3 divided doses

Other related antidepressant

Maprotiline ( ludimoil): has sedative effect Dose:25-75 daily in 3 divided doses or single dose at bedtime , max.150 mg Mianserin(mianserin):has sedative effect Dose:30-40 daily in 3 divided doses or single dose at bedtime , max.90 Mg. Mirtazapine ( Romeron, organon): Dose 15mg up to 45mg as single or 2 divided doses MAOI : Less frequently used because of dangerous interactions with foods and

drugs.Side effects:Postural hypotension, drwsiness, headache, dry mouth costipation, oedema

tremors,hypereflexia, sexual disturbances, and blood and liver diorders. e.g Phenelzine ( Nadril) : dose 15 mg 3 times daily , max.30mg daily

SSRI

The SSRIs all share several characteristics:They are all hepatically metabolized. They have relatively little affinity for histaminic,

dopaminergic, alpha-adrenergic, and cholinergic receptors.

They tend to have relatively mild side-effect profiles, although they can be associated with sexual dysfunction .

They are relatively safe in overdose. They all produce changes in sleep architecture

(increased REM latency and decreased total REM sleep).

Examples of SSRIFluoxetine (prozac): Dose is 20 mg daily ,if no response dose increased by 10 to

20 mg as tolerated up to 80 mg daily It is safe and convenient alternative to the tricyclic

antidepressants (TCAs) and MAOIs. The clinical antidepressant effect may be delayed from three

to six weeks from the start of treatment.The most common initial side effects of fluoxetine are nausea,

insomnia, and anxiety, tend to resolve over one to two weeks.Fluoxetine like all of the SSRIs, is relatively safe in overdose. Deaths attributed to overdose of fluoxetine alone have been

very rare

Flufoxamine( faverin) : The usual starting dose is 50 mg daily up to 150 to 250 mg. Fluvoxamine should be taken at bedtime for doses up to 100 mg

daily, and in divided doses (twice a day) for higher dosing. It can cause gastrointestinal upset such as nausea and vomiting.Paroxetine ( seroxat): Is indicated for the treatment of depression, panic disorder,

generalized anxiety disorder, and social phobia. It has a mild affinity for muscarinic receptors and can cause

more anticholinergic side effects than the other SSRIs.Sertralin( Lustral): Initial dose 50-200 mg daily maintenance 100 mg .used only for

8 weeks

CITALOPRAM (cipram)

1. As effective as other TCAs.2. More effective in sever depression3. Rapid onset of action.4. Short elimination half-life and no active metabolites

(17-22 hours).5. Lower level of side effects than TCAs6. Not cardiotoxic.7. Reduce suicidal thoughts.8. Not toxic in over dosage.9. Minimal quantities in breast milk.10. Does not need to be adjusted in elderly patients.11. Less likely to cause convulsion

12. Can be given in depression with other disorders: OCD PA Eating disorders.

13. Effective in Dysthymia.14. less sexual dysfunction15. Effective as prophylactic.

The usual starting dose of citalopramis 20 mg daily raised up to 40 mg daily in a single morning dose.

St. John's wort (Hypericum perforatum)

While St. John's wort is considered a first-line antidepressant in many European countries, it has gained popularity in the United States only recently.

Uses include treatment of mild-to-moderate depressive symptoms.

Research indicates that it acts as an SSRI and not as a monoamine oxidase inhibitor (MAOI) as previously believed.

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

If no clinical response occurs after 3-6 months, encouraging the use of another medication is essential.

side effect of St. John's Wort

Transient photosensitivity is generally the most common and occurs more commonly at higher dosages.

Other side effects include: gastrointestinal upset, increased anxiety, minor

palpitations, fatigue, restlessness, dry mouth, headache, and increased depression.

Atypical antidepressants

Bupropion (Wellbutrin), nefazodone (Serzone), mirtazapine (Remeron), and trazodone (Desyrel).

This group also shows low toxicity in overdose and may have an advantage over the SSRIs by causing less sexual dysfunction and GI distress. Bupropion is associated with a risk of seizure at higher doses,

especially in patients with a history of seizure or EDs. Mirtazapine is a potent antagonist at 5-HT2, 5-HT3, alpha2-,

and histamine (H1) receptors and, thus, can be very sedating. Adverse effects such as drowsiness and weight gain may tend

to improve over time and with higher doses. Trazodone is very sedating and usually is used as a sleep aid

rather than as an antidepressant

Clinical course

Is classified using six categories:

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

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

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

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

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

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

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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

Referrences

Rakel text book of family medicine Clinical evidence 2009Up to date .2009e. medicine .2009NICE guidelines of depressionNational manual for primary mental course.British National Formulary