Depression

1. ASSESSMENT AND MANAGEMENT OF DEPRESSION

2. Learned Helplessness (Women) • Efforts bear no results • Elderly: PseudoDementia: “I don’t remember” • Depression • Confabulations: making up stories: Dementia • Symptoms of the condition • 5 out of 9 symptoms, Low mood or Loss of interest • Low mood or loss of interest through out the day nearly everyday • Loss of weight • Insomnia • Psychomotor retardation • Fatigue • Feeling of worthlessness • Poor concentration • Recurrent thoughts of death or suicide (Idea, Plan Attempt) • Duration of the symptoms • 2 weeks • 13 to 18 months • Social and occupational disruption and other areas of functioning.

3. Becks Depression Inventory (BDI) • Mild (Therapy)(Motivational Talks or Interviewing) (Supportive Therapy) • Moderate: Medicine/ Therapy • CBT, IPT, Psychoanalysis, Art, Rational Emotive Behaviour Therapy REBT • Severe Medicine plus Therapy • SSRI (Serotonin) • Fluoxetine • Sertraline • Citalopram • TCA • Amitriptyline • 6 months • Electroconvulsive Therapy ECT: Rebooting the brain: Suicidal

4. OUTLINE • Introduction • Epidemiology • ICD – 10 • Aetiology • Risk factors • Depression in bipolar depression • Endogenous VS Reactive depression • Presentation at the GOPD • History and examination • Co – morbidities • Peripartum depression • Screening tests • Laboratory investigations • Management strategies • Types of treatment • Prognosis • conclusion

5. INTRODUCTION • Mental health disorder characterized by persistent low mood , loss of interest and pleasure in daily activities ,loss of energy ,causing significant impairment in daily life • `Deprimere ‘ (latin) meaning pressed down • Hippocrates used the term` melancholia ‘ – Greek for black bile • Emil Kraepelin : `Depressive states’ as part of `manic – depressive psychosis’ • Kurt Schneider :`endogenous (melancholic) and reactive (neurotic) types • Can be unipolar depression or part of other disorders such as BAD • Theme of world health day 2017 was depression – title was `` depression ,lets talk “(7th April)

6. EPIDEMIOLOGY • Lifetime prevalence is about 15% • There is an annual incidence of about 5% • Average age of onset is about 30 years • Peak age groups of onset : 30 – 44years and 18 – 29years • About 5 to 10 % of patients with untreated / inadequately treated unipolar depression commit suicide • More than 1.5 million cases are reported per year in Nigeria

7. EPIDEMIOLOGY • According to WHO Proportion of global population with depression as of 2015 is about 4.4 % • This is about 322million people living with depression in the world • An increase of more than 18% between 2005 and 2015 • Nearly half of these in south – east Asia region and western pacific regions • More common in females (5.1%) than males (3.6%) • Prevalence varies from a low 2.6% among males in the western pacific to 5.9% among females in African region • Despite known effective treatments < 10% of affected are treated in many countries

8. ICD – 10 • It is categorized under Mood [affective] disorders • F32 Depressive episode • F32.0 Mild depressive episode • .00 Without somatic syndrome • .01 With somatic syndrome • F32.1 Moderate depressive episode • .10 Without somatic syndrome • .11 With somatic syndrome • F32.2 Severe depressive episode without psychotic symptoms

9. ICD – 10 -- 2 • F32.3 Severe depressive episode with psychotic symptoms • F32.8 Other depressive episodes • F32.9 Depressive episode, unspecified • F33 Recurrent depressive disorder • F33 .0 Recurrent depressive disorder, current episode mild • .00 Without somatic syndrome • .01 With somatic syndrome • F33 .1 Recurrent depressive disorder, current episode moderate • .10 Without somatic syndrome • .11 With somatic syndrome

10. ICD – 10 - 3 • F33.2 Recurrent depressive disorder, current episode severe without psychotic symptoms • F33.3 Recurrent depressive disorder, current episode severe with psychotic symptoms • F33.4 Recurrent depressive disorder, currently in remission • F33.8 Other recurrent depressive disorders • F33.9 Recurrent depressive disorder, unspecified

11. ICD – 10 - 4 • In typical depressive episodes the individual usually suffers from • low mood • , loss of interest and enjoyment, and • reduced energy leading to increased fatiguability and diminished activity • Typical depressive episodes (mild (F32.0) , moderate (F32.1 ), and severe (F32.2 and F32.3)), involve two or more of the typical symptoms  • A variation of 2 to 4 or more of the other common symptoms • Then presence or absence of somatic symptoms for mild and moderate and presence or absence of psychotic symptoms for severe episodes

12. ICD – 10 - 5 • . Other common symptoms are: • Reduced concentration and attention; • Reduced self-esteem and self-confidence; • Ideas of guilt and unworthiness (even in a mild type of episode); • (d)bleak and pessimistic views of the future; • (e)ideas or acts of self-harm or suicide; • (f)disturbed sleep • (g)diminished appetite

13. ICD – 10 - 6 • F33 - Recurrent depressive disorder • The disorder is characterized by repeated episodes of depression as specified in depressive episode mild (F32.0), moderate (F32.1), or severe (F32.2 and F32.3)) • diagnosis based on current episode • No history of independent episodes of mood elevation and overactivity that fulfil the criteria of mania • If required, • the predominant type of previous episodes (mild, moderate, severe, uncertain) may be specified • delusions or hallucinations , specified as mood-congruent or mood incongruent

14. ICD – 10 -- 6 • For recurrent depressive disorder – F33.0 , F 33.1 , F33.2 , F33.3 • the criteria for recurrent depressive disorder (F33.-) should be fulfilled, • the current episode should fulfil the criteria for • Mild ,moderate ,severe depressive episodes • With or without somatic symptoms for F33 .0 and F 33.1 • With or without psychotic symptoms for F33.3 and F 33.4 • at least two episodes should have lasted a minimum of 2 weeks and should have been separated by several months without significant mood disturbance

15. ICD – 10 – 7 • F33.4 Recurrent depressive disorder, currently in remission • the criteria for recurrent depressive disorder (F33.-) should have been fulfilled in the past, • the current state should not fulfil the criteria for depressive episode of any degree of severity or for any other mood disorder • at least two episodes should have lasted a minimum of 2 weeks and should have been separated by several months without significant mood disturbance

16. AETIOLOGY OF DEPRESSION GENETIC FACTORS • Complex interaction of social , psychological and biological features • Two susceptibility loci MDD I and MDD 2 (on chromosomes 12 and 15 respectively) have been identified • Other potential genes are TPH2 ,HTR 3A , HTR 3B genes • Polymorphism of the serotonin transporter (SLC6A4) gene (on chromosome 17 ) – 5HTTLP : -- short allele homozygosity or heterozygosity is associated with increased risk of depression ,in response to stressful life events ,than long allele homozygosity • Genetic factor may also mediate drug response or side effects

17. AETIOLOGY OF DEPRESSION – 2 PSYCHOSOCIAL FACTORS • Recent stressful life events –especially a loss of e.g. bereavement , loss of job , psychological trauma • Loss of parents before age 10years • Living alone • Lack of social support • Chronic pain • Alcohol and substance misuse • Medication : steroids , antihypertensives etc • Vascular : stroke and CAD increases risk of depression and vice versa

18. RISK FACTORS FOR DEVELOPING DEPRESSION

19. DEPRESSION IN BIPOLAR DISORDER • Can be clinically indistinguishable from unipolar depression • In any first episode of depression the possibility of bipolar disorder needs to be borne in mind • Information from family members is very important as patient with significant depression may not be able to recall any happy memories (including hypomaniac / maniac episodes) • 40% of patients with bipolar disorder are initially diagnosed as unipolar depression • Depression accounts for much of long-term disability in bipolar disorder • Patients with bipolar disorder tend to have more ( and longer)depressive episodes in the course of their lifetime than patients with unipolar depression

20. FEATURES POSSIBLY SUGGESTIVE OF BIPOLAR DEPRESSION • Atypical features - e.g. increased appetite , increased sleep , possibly weight gain • Psychomotor retardation • More frequent episodes • Family history of bipolar disorder • Lower age of onset • Male gender ( equal gender prevalence for bipolar) • More abrupt onset

21. ENDOGENOUS VS REACTIVE DEPRESSION • These subtypes are no longer included in ICD 10 and DSM 5 ENDOGENOUS DEPRESSION • Occurs spontaneously without any external stressor • Also called `melancholic’ depression or `psychotic ‘ depression • Characterized by prominent biological / somatic symptoms of depression • More severe symptoms e.g. psychomotor retardation ,psychotic symptoms • More likely to need antipsychotics / ECT

22. ENDOGENOUS VS REACTIVE DEPRESSION REACTIVE DEPRESSION • Depression occurring in response to a clearly identifiable external stressor e.g. bereavement ,loss of job • Also called neurotic depression • Less severe • More affective symptoms eg irritability ,anxiety , guilt etc. • Significant overlap with `adjustment disorder ‘ • Spontaneous recovery more common

23. ATYPICAL DEPRESSION • In `typical ‘depression there is reduced sleep ,reduced appetite and weight loss • In `atypical’ depression there is hypersomnia , increased appetite , and weight gain • Other features of atypical depression includes • Feeling of heaviness in arms legs ( LEADEN PARALYSIS) • Excessive sensitivity to interpersonal problems ( interpersonal rejection sensitivity) • Atypical features are commoner in seasonal affective disorder and bipolar depression than in unipolar depression • Atypical depression may respond better to MAOIs than to TCAs or SSRI s

24. PRESENTATION OF DEPRESSION AT THE GOPD • Patients usually do not walk into the office and say they have `` depression ‘’ • Doctor should have a high index of suspicion and screen as many people as possible Features to look out for includes : • > 5 office visits a year • Unexplainable symptoms • Work and home dysfunction • Poor follow up with treatment recommendations

25. PRESENTATION OF DEPRESSION AT THE GOPD 2 • Irritable bowel syndrome -- 15% with IBS have psychiatric co - morbidity • Unexplained weight gain or loss • Sleep disturbances • Fatigue • Cognition complaints ,difficulty making desitions

26. HISTORY AND EXAMINATION • Note your sources of information such as relatives ,neighbors ,referring doctor ,police etc. • Make a note on reliability of informant • Presenting complaints with correct durations • History of presenting complaints : this should include amongst other things • assessment of risks • To self e.g. suicide • To others • To being abused / exploited • Past psychiatric history

27. HISTORY AND EXAMINATION 2 • Past medical history • Personal history – pregnancy , delivery , neonatal history , early life experiences, education , employment , pre morbid personality , forensic history • Mental state examination • Systemic examination • Bio – psycho – social evaluation in terms of • Predisposing • Precipitating • Maintaining factors • Finally make a Diagnosis

28. Assessing risk of suicidality • Patients usually feel hopeless about the future • Suicide risk may paradoxically  as the severely depressed patient just starts to improve as he / she may now have the energy to be able to act out their plan • Inquire about specific suicidal thoughts , intent , plans , access to weapons’ • Recent suicidal behavior • Determine current stressors and protective factors ( reasons to live) • Protective factors include factors like having a spouse , children, sibblings , spirituality or religion • Determine family history of suicide • History of violence • Is there imminent risk to patient or to others

29. Mental state examination Appearance • Unkempt , withdrawn , reduced facial expression , no eye contact Mood • sad. , hopelessness , helpless Affect • Flat , blunted , Speech • Low volume voice , speaking slowly , long pauses Cognition • Orientation may be impaired • Attention and concentration and memory may all be impaired

30. CO - MORBIDITIES • Co – morbidity is common for both unipolar and Bipolar depressions • These include : • Anxiety disorder • Alcohol / substance misuse • Personality disorders • Eating disorders • ADHD Physical co – morbidities include • Thyroid dysfunction • Migraine • Metabolic sydrome ( in addition to that induced by antidepressants)

31. PERI - PARTUM DEPRESSION • Perinatal period is generally defined as from onset of pregnancy until ~ 1 year postpartum • NOTE: DSM-5 defines perinatal onset for mood disorders as being onset during pregnancy or within 4 weeks postpartum • An important public health issue • Risk of a Major Depressive Episode is up to 10% in pregnancy, • 15% postpartum (higher than age-matched point prevalence in the non-pregnant population) • Risk of bipolar disorder relapse is high in pregnancy and very high in the postpartum period

32. PERI - PARTUM DEPRESSION – 2 • Potential Impact of untreated mood disorders on • mother, • baby and • family can be profound: • Pregnancy: • spontaneous abortion, poor prenatal care, substance use, poor fetal growth, preterm labour, suicide • Postpartum: • poor attachment/parenting, delayed infant motor, language and cognitive development, child behavior problems, suicide/infanticide

33. SCREENING TESTS AND SCALES

36. Interpretation of PHQ 9 Other screening tools include :- Hamilton rating scale for depression (HAM – D) Beck depression inventory (BDI) Mainly used in research Geriatric depression scale (GDS -5 and GDS – 15 )

37. SCREENING TOOLS FOR PERIPARTUM DEPRESSION NATIONAL INSTITUTES FOR CLINICAL EXCELLENCE (NICE) • During the past month, have you often been bothered by feeling down, depressed or hopeless? • During the past month, have you often been bothered by having little interest or pleasure in doing things? If the woman answers 'Yes' to both questions a further question should be asked: • Is this something you feel you need or want help with? EDINBURGH POSTNATAL DEPERSSION SCALE (EPDS) In the past seven days: • I have been able to laugh and see the funny side of things • I have looked forward with enjoyment to things • I have blamed myself unnecessarily when things went wrong • I have been anxious or worried for no good reason • I have felt scared or panicky for no very good reason • Things have been getting on top of me • I have been so unhappy that I have had difficulty sleeping • I have felt sad or miserable • I have been so unhappy that I have been crying • The thought of harming myself has occurred to me Scored 0-30. Scores > 13 associated with 10x likelihood that patient has major depression

38. LABORATORY INVESTIGATIONS • Routine tests :- • FBC • LFT • E/U/CR • TFT • FBS • LIPID STUDIES • Baseline ECG • Neuroimaging and EEG may not be done routinely

39. MANAGEMENT STRATEGIES • Develop a treatment plan • Form a therapeutic alliance • Clarify the realistic and unrealistic aspects of the patients expectations of effectiveness from the medication • Inform patient that there other medications to choose from should the present one not work • Build Collaboration (``we’’ instead of ``I‘’ • Discuss possible side effects • Plan for follow up • Stay on medication for at least 6 months -- if possible

40. TYPES OF TREATMENT Different types of treatment includes:- • Psychotherapy – for mild depression • Anti depressants • ECT • Acupuncture • Yoga • Exercise programmes • Patient should be counciled to stop alcohol • Also to reduce coffee intake • Psychotherapy includes :- • Cognitive based therapy • Positive mood induction, mindfulness therapy • Behavioral activation • Interpersonal psychotherapy (IPT) • Exposure to light

41. ANTI DEPRESSANTS Monoamine hypothesis of depression :- • Depression is due to a deficiency of monoamines : namely serotonin and noradrenaline • By increasing the levels of one or both of these monoamines depression can be managed • This is the basis for the action of most antidepressants • They can be classified into • Older or first generation antidepressants and • second generation antidepressants • Third generation antidepressants

42. ANTI DEPRESSANTS 2 1ST GENERATION ANTIDEPRESSANTS : • Monoamine oxidase inhibitors (MAOIs) . • phenelzine (Nardil) , tranylcypromine (pariate), moclobemide( ludomil) • Tricyclics antidepressants (TCAs) • Imipramine (Tofranil) • Amitriptyline (Elavil) • Desipramnine (norpramin) • Nortriptyline ( Aventyl) • Dexapine (Adepin) 2ND GENERATION ANTIDEPRESSANTS • Selective serotonin reuptake inhibitors (SSRIs) :- • Fluoxetine (Prozac ) fluvoxamine ( luvox ) sertraline (Zoloft ) , paroxetine ( paxil) , citalopram (celexa) , Ecitalopram ( cilantro

43. 3rd generation antidepressants • Atypical antidepressants • Bupropion – an NDRI ( Wellbutrin ,forfivo XL , Aplenzin) Bupropion under the name Zyban is used to aid in smoking cessation • Mirtazapine - NaSSA (Remeron ) • Reboxetine – NARI • Trazodone – also used to treat insomnia • Vortrioxetine (Trintellix ) • Agomelatine • Amoxapine ( Ascendin ) • Esketamine ( ketamine derivative) • SNRIs :- Desvenlafaxine (Prisca ) • Duloxetine (Cymbalta ) • Milnacipran (savella ) • Venlafaxine ( effecxor ) • Levomilnacipran (Fetzima )

44. Tricyclic antidepressants • One of the oldest drugs , has three ring structure • Potentiates the effect of serotonin and norepinephrine in the CNS • Significant anticholinergic effects blocking muscarinic acetylcholine • Antagonizes histamine and adrenergic receptors • Main role is in treatment resistant /atypical depression • Serotonin syndrome is a risk when given with SAMe or st john‘s wort • Cardiotoxic in overdose

45. Tricyclic antidepressants • Side effects includes : - • weight gain ,sedation , • Drowsiness ,memory impairment • Impaired cognitive function • Anticholinergic side effects includes • Dry mouth , blurred vision , • Constipation , sweating • Urinary retention

46. Monoamine oxidase inhibitors (MAOIs) • Monoamine oxidase is an enzyme which breaks down the neurotransmitters namely • Dopamine • Norepinephrine • Epinephrine • Serotonin • MAOIs prevents the breakdown of these neurotransmitters thus their activities • It has prolonged duration of action in the post synaptic cells • Also one of the older medications

47. Monoamine oxidase inhibitors (MAOIs) – 2 • It is associated with hypertensive crisis or `` CHEESE REACTION” • This is due to inhibition of tyramine metabolism in the gut ( contained in some foods e.g. cheese ,alcohol certain meats ,wine, beer, chocolates ,etc.) • The newer MAOIs are selective in the monoamines they block • They don't block MAO – B found in the intestines which metabolise tyramine • Can be potentially fatal when taken with other antidepressants • A time interval of about 2 weeks is needed when stopping MAOIs before starting other drugs • For Prozac up to 5 weeks is needed

48. Monoamine oxidase inhibitors (MAOIs) – 3 • It is hepatotoxic in overdosage • They interact with opiods ,amphetamines , decongestants • Side effects includes :- • Hypertensive crisis , seizures , • serotonin syndrome , dizziness , • Headaches , insomnia , restlessness , • blurred vision , arrythmias • Orthostatic hypotension , diarrhoea

49. Selective serotonin reuptake inhibitors • Serotonin infuences mood • SSRIs treat depression by inhibition of serotonin reuptake • Appetite and nutritional intake should be monitored regularly • Suicidal tendencies should also be monitored regularly • Not to be taken with other SSRIs ,SAMe and st johns wort • It is associated with weight loss so sometimes prescribed for obesity • Side effects includes • Serotonin syndrome , Seizures , sexual dysfunction , • Mood changes ,  risk of suicidal behaviors , Loss of appetite , insomnia

50. Serotonin and norepinephrine reuptake inhibitors -SNRIs • Norepinephrine affects energy levels as well as alertness • The drugs increase the amount of serotonin and norepinephrine available • Patients to avoid alcohol • Side effects includes :- • Serotonin sydrome , suicidal ideation, seizures , • Insomnia , anxiety , agitation , weight loss , • Sexual dysfunction , fatigue , drowsiness , loss if appetite’ • Constipation , dry mouth , dysuria , increased sweating , • Difficulty urinating