Depression and management Guidelines

1. Depression and management Guidelines Prof. Dr. Momtaz AbdEl WahabProf. of psychiatry Cairo University

2. Face the Facts Depression is a Prevalent Disorder

3. Epidemiology

4. Epidemiology • The depression research in European society (DEPRES) study found that almost 16% of total population had suffered from depression in their life time. (lepin jp. etal 1979). • The incidence is almost identical in USA 17%(kessler R.C.etal 1994).

5. Depression is a Prevalent Disorder 121 Million People Suffer From Depression ATLAS (WHO 2001)

6. Face the Facts The Prevalence of Depression is Rising?!

7. Epidemiology(cont’d) • The incidence of depression appears to be increasing, although this may be explained by an increasing willingness to report psychological problems.

8. Anxiety Depression (DALYS, 2020) STRESS OVERLOAD Disasters Globalization Massive information Techno stress Individualization WARS Lack of support EVERYDAY LIFE Economic Noises Recession Time pressure Others Spouces Pollution Boss Excessive respondents Anticipation of danger

9. The Burden of Depression

10. Face the Facts Depression is a Burden

11. The burden of depression • Disability associated with depression is reportedly greater than that for chronic illnesses such as arthritis, back pain, diabetes gastrointestinal disease, hypertension and long diseases.

12. Leading causes of disability worldwide in years of life lived with disability

13. World Bank Reports Year 2000 is the world 2020 will be the Anxiety Depression 4th greatest health problem 2nd greatest health problem causing disability

14. Face the Facts Depression in an Expensive Disorder

15. The burden of depression • The disorder tends to become recurrent or chronic with time. • 50% of the life of depressed patients life span will be clouded by the illness. • The depressed patient is often isolated, the dysfunction has repercussion on: - family member - friends - colleagues Their relationships frequently being shattered

16. The burden of depression • Behavioral changes are common: - increased drinking - initiation drug abuse • Unfortunately, the patients themselves are often not aware of being clinically depressed, and thus will not actively seek help or treatment.

17. The burden of depression • Several studies has shown higher mortality risk in depressed individual: -suicidal risk is high 15%-19% -cardiovascular deaths • Depressive symptoms seem to be risk factors for mortality in pulmonary disorders and stroke.

18. The burden of depression • Depressed patient is less likely to sustain a demanding job or career or to achieve his or her potential. • If the depression arises during the formative years, an in evitable consequence is diminished performance at school, college, or educational training with life long consequences.

19. Economic implications for society • Reduced and lost productivity - absenteeism - wasted training • The increased strain and demands on health services. • The increased direct cost of treatment, particularly caused by hospital admissions.

20. Direct Recurrence Treatment Hospitalization COST • Indirect • Disability in work • Poor social function • Associated behavioral problems • Increase self destructive behaviors

21. Face the Facts Depression is a Recurrent Disorder

22. Face the Facts • Depression is too painful to be ignored. • Depression is unrecognized!! • Depression has many faces.

23. 20% of those with major depression have symptoms that persist beyond 2 years Keller et al., (1992) & Scot & Dicky (2003), B. J. Psychiat.

24. The need for treatment • Depression continue to be a silent epidemic because so few people with depression receive treatment. • 50% of depressed patients had not consulted physician. • Of those who had 70% had been given no medication for depression. • Less than 10% of those with major depressive disorder had been prescribed an antidepressant.

25. Face the FactsDepression is an Under-recognized Disorder • Stigma. • Masked depression. • Comorbid medical illness. • Time constraints. • Inadequate medical education.

26. The need for treatment • In addition, when antidepressants are prescript, dosage and duration of treatment are often mostly inadequate to achieve a response or maintain remission.

27. Reasons for under recognition/ under treatment of depression Provider • Inadequate training. • Depression not a real disorder (preoccupied with organicity ). • Time- consuming to evaluate (failure to elicit symptoms). • Restricted access to treatment options. • Failure to refer from G.P. when indicated.

28. Reasons for under recognition/ under treatment of depression Patient • Stigma. • Ignorance. • Effect of the symptoms. • Poor compliance. • Poor insurance coverage. • Presentation: somatization.

29. Why is it important to recognize depression? • High costs. • Suicide and other mortality. • Risk factor for co morbidity. • Very treatable.

30. Diagnosis and Symptoms

31. Many Faces of Depression Depressive symptoms Background Somatic symptoms Foreground

32. Face the Facts Depression is recorded in up to 30% of patients seen by other specialties • Oncology • Dermatology • GIT • CNS • C.V.S. • Others

33. Presenting Complaints inPrimary Care Practice (Widmer & Cadoret, 1978)

34. Depression in Primary Care

35. Okasha, 2003 “ICEBERG” PHENOMENON • Depressed patients seen by psychiatrists Depressed patients seen in primary care practice

36. Many Faces of Depression ? Why there is a Tendency for depression to manifest itself in the somatization sphere

37. Only about ½ of patients with MD are explicitly recognized as being depressed. Only about ½ of all depressed patients receive some form of therapy for their illness (Lepine et al 1997) Only about ¼ of depressed patient receive an adequate dose and duration of AD treatment (Katon et al 1992)

38. The understanding of the underlying neurobiology and neurochemical dysfunction in depression is an essential issue for the proper management

39. Neuobiology of Depression Khalia M (2005): Metabolism Clinical & experimental 54 Suppl(1).; 24-27

40. Linking Neurotransmitters and neurocirciuts with Symptoms of Depression

41. Neuroanatomical & Neurochemical Basis of Symptoms of Depression Malhi GS, et al., (2005): Acta Psychiatr. Scand.; 111:94-105

42. Functional Roles of Brain Monoamines Norepinephrine Serotonin Anxiety Irritability Energy Interest Social function Memory Impulse Control Mood, Emotion, Cognitive function Motivation Attention Sex & appetite Aggression Drive Reward Executive function Dopamine Modified from Healy & McMonagle. J Psychopharmacol 1997; 11 (suppl 4): S25-S31.

43. Scheme of Diagnosis

44. Symptoms Pattern of Symptoms: • Typical. • Atypical. • With melancholic.

45. Diagnostic Process 1) Common Presentations Usually the patient presents either of the following symptoms: 1- Multiple Somatic complaints. 2- Lack of Concentration and/or forgetfullness. 3- Increased fatigability.

46. The patient has multiple and excessive complaints, involving more than one system in the body. • The complaints are vague and ill defined and cannot be categorized as one identifiably disease. • The patient is easily predictable, giving yes as an answer to any question. • On physical examination, there are not enough signs to explain the symptoms described by the patient. • Results of investigations are always within the normal ranges. 2) Signs suggesting a depressive disorder:

47. 3) Diagnostic Criteria • A. At least one on the following symptoms has to prevail for at least two weeks. • 1- Depressed mood for most of the day and almost every day. • 2- loss of interest or pleasure in doing the activities that were normally pleasurable.

48. B) At least four of the following symptoms: • 1- change in appetite. • 2- Sleep Disturbance. • 3- Psychomotor disturbance. • 4- Increased fatigability or loss of energy. • 5- Feeling of worthlessness as well as excessive inappropriate guilt. • 6- Diminished ability to think and concentrate. • 7- a state of indecisiveness. • 8- Recurrent thoughts of death. • 9- Pessimistic views of the future.

49. C) The symptoms lead to significant distress or impairment in social, occupational or other important functional areas.

50. Atypical symptoms include: 1-vegetative symptoms of reserved polarity as:- -hypersomnia -increased appetite -weight gain. 2-marked mood reactivity. 3-sensitivity to emotional rejection.