Depression PP FV.ppt

8/14/2019 Depression PP FV.ppt

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Guyana Primary Health CareDepression Guidelines


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What are todays Objectives??

by the end of the day, you should be able to

Understand the risk factors for depression

Screen for depression

Understand the factors that play a role in the

development of depression

Appreciate the widespread effects of depression

Differentiate the types of depression

Understand the natural course of depression

Understand the treatment options for depression


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What is

Depression?

Depression is a medical illness that affects the way one

feels, thinks and acts.


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What is Depression?

There are many symptoms associated with depression including:

Emotional numbnessor emptiness

Difficulty concentrating Moving or speaking

slower than usual

Thinking life is notworth living

Sadness

Sleep changes Weight and appetite

changes

Lack of energy Feeling guilty or worthless


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How is Depressiondifferent from Sadness?

SadnessIn response to stressful, life-changing events such as the death of a loved

one, the loss of a relationship or employment, the natural reaction is

sadness, discouragement and frustration. These emotions shouldgradually dissipate on their own after a few days or weeks.

DepressionWhen these feelings last for two weeks or longer and start to interferewith the activities of daily living such as work, family or relationships,

this low mood may be clinical depression.


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How Common is Depression?

Depression is common, with a lifetime risk for majordepressive disorder

Men 7-12%

Women 20-25%

Depression is projected to become the leading cause

of disability and the second leading contributortothe global burden of disease by the year 2020.

Depression occurs in persons of allgenders, ages, and

backgrounds.


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Depressionmatters because Treatable cause of pain, suffering, disability Recurrent and chronic course Major public health concern

Increased absenteeism from work Affects family members and caregivers Increased use of medical services and emergency

services/ increased length of stay in hospital for co-

existing medical conditions

Increased mortality rates


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What Causes Depression?

Depression

BiochemistryMedical

Conditions

Triggers

Genetics

Environment

Gender Personality


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What is the Onset

and Natural Course of Depression?

Depression can present at anyage, but most commonlyit first presents in the early 20s to 30s.

It is an illness that is chronic, characterized by frequent

episodes of recurrencesduring a patients lifetime.

After a Major Depressive Episode 85%of patientsexperience a recurrence within 15 years.


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What Disorders co-occur with

Depression?

anxiety disorders substance abuse/ dependence

personality disorders (avoidant, obsessive-compulsive and self-defeating) migraine headaches cancer cerebral accidents myocardial infarctions


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Who is at risk for

Major Depressive Disorder ?

Sex:female > male Age:onset in 25-50 age group Family History:depression, alcohol abuse, sociopathy Childhood Experiences:loss of parent before 11 years

old, negative home environment (abuse, neglect)

Personality:avoidant, dependent, or obsessivecompulsive

Recent Stressors:financial, legal, migration, illness(chronic insomnia, chronic pain, diabetes, arthritis,myocardial infarction, stroke, recent trauma)

Postpartum < 6 months Lack of intimate, confiding relationship or social isolation


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DETECTION ANDDIAGNOSIS


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How do you Detect and Diagnose Depression?

For patients at risk for major depressive disorder,you can use this 2-question screening test:

Have you felt sad, low , dow n depressed or hop eless?Have you los t interest or p leasure in th ings you usual ly l ike to do?

* The symptoms must be present most of the day, nearly every day, during

the same two-week period.

If the patient answersYESto either question,

you should proceed with a further assessment.


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Detect and Diagnose

There are 5 criteria that determine whether a person is suffering

from major depressive disorder.

1) In addition to the depressed mood or loss of interest, the

person must have symptoms including three or more of the

following:

Significant weight loss/gain or an increased/decreased appetite.

Problem sleeping (insomnia or hypersomnia).

Psychomotor agitation or retardation.

Fatigue or loss of energy. Feelings of worthlessness or excessive guilt.

Diminished ability to think or concentrate, indecisiveness.

Recurrent thoughts of death, recurrent suicidal ideation without a

specific plan, or a suicide attempt or specific plan for committing

suicide


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Detect and Diagnose

2) These symptoms must cause functional impairment.

3) These symptoms do not meet criteria for a mixed

mood episode (an episode with symptoms of maniaand depression occurring simultaneously.)

4) The symptoms are not due to the effects of a

substance or general medical condition.

5) The symptoms are not better explained bybereavement.


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Subtypes of Depression

and how are they diagnosed?

a) Major Depressive Disorder, characterized by

Major Depressive Episodes

b) Dysthymic Disorder

c) Depressive Disorder, not otherwise specified


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What else to study in a

Depressive Episode?

Mild

514 PHQ-9

Moderate1519 PHQ-9

Severe

20 o higher PHQ-9

- with Psychotic Features

-without Psychotic Features

Catatonic

Marked psychomotor disturbance (motoric immobility,

excessive motor activity, negativism, mutism)

Melancholic

Loss of interest in all activities or lack of reactivity to

pleasurable stimuli

Atypical

Significant weight gain or increase in appetite &

hypersomnia

Postpartum

Onset of episode within 4 weeks postpartum


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Adolescent Depression

Adolescence comprises the years from puberty to the

mid-twenties

Major depressive disorder (MDD) affects 6-8% of

adolescents

Most people who develop MDD experience their first

episode between the ages of 14-24

Youth onset of MDD usually develops into a chroniccondition with substantial morbidity, poor economic/

vocational/ interpersonal outcomes and increased

morbidity (from suicide and, in the long term, from

other chronic illness: diabetes, heart disease, etc)


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Effective treatments that can be provided by first

contact health providers are available

Early identification and early effective treatment can

decrease short-term morbidity and improve long-term

outcomes (including decreased mortality)


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Diagnosis of MDD in Adolescence

Mood States in young people may changerapidly and are often strongly influencedby their environment.

It is important to distinguish a depressive

disorderfrom depressive distress.


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Differentiation of Distressand Disorder

Always associated with a

precipitating event

Functional impairment is

usually mild

Transientwill usually

ameliorate with change in

environment

Professional intervention not

usually necessary

May be associated with aprecipitating event

Functional impairment may

range; mildsevere

Long lasting or may be chronic,environment may modify butnot ameliorate

External validation (syndromal)

Professional intervention isusually necessary

Distress Disorder


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Differentiation of Distressand Disorder:

important for outcome and intervention

Can be a positive factor in life

person learns new ways to deal

with adversity

Social supports such usual

friendship and family networks

help

Counseling and other technicalpsychological interventions can

help but may not be needed

Medications should not be used

May increase adversity due to its

effect on creation of negative life

events (low mood can lead to

relationship loss)

May lead to long term negative

outcomes (substance abuse, job

loss, etc.)

Social supports and otherpsychological interventions are

often helpful

Medications may be needed but

must be used properly

Distress Disorder


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Risk Factors for MDD in Youth:

1. Family history of MDD

2. Family history of suicide

3. Family history of a mental illness

(especially a mood disorder,

anxiety disorder, substance

abuse disorder)4. Childhood onset anxiety disorder


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A Memory AidM= mood

S= sleep

I= interest

G= guilt

E= energy

C= concentration

A= appetiteP= psychomotor agitation/ retardation

S= suicide


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Dysthymic Disorder

Depressed mood for most of the day, for more days than not, as

indicated by either subjective account or observation by others, for at

least 2 years.

Note:In children and adolescents, mood can be irritable andduration must be at least 1 year.

Presence, while depressed, or 2 or more of the following:

poor appetite or overeating insomnia or hypersomnia low energy or fatigue poor concentration or difficulty making decisions feelings of hopelessness


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Dysthymic Disorder

During the 2-year period (1 year for children and adolescents) of the

disturbance, the person has never been without the symptoms in the

first two criteria for more than 2 months at a time.

No MDE has been present during the first two years of the

disturbance, that is, the disturbance is not better accounted for by

chronic MDD, or MDD in partial remission.

The symptoms cause clinically significant distress or impairment in

social, occupational, or other important areas of functioning.


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Depressive Disorders:not otherwise specified

Premenstrual Dysphoric Disorder:in most menstrual cycles during the past

year, symptoms regularly occurred during the last week of the luteal phase

and remitted within a few days of the onset of menses

Minor Depressive Disorder:episodes of at least 2 weeks of depressive

symptoms but with fewer than the 5 items required for MDD

Recurrent Brief Depressive Disorder of schizophrenia: depressive episode

lasting from 2 days to 2 weeks, occurring at least once a month for 12

months and not associated with the menstrual cycle

An MDE superimposed on the following:delusional disorder, psychotic

disorder not otherwise specified, or the active phase of schizophrenia

Situations in which the clinician has concluded that a depressive disorder is

present but is unable to determine whether it is primary, due to a general

medical condition, or substance- induced


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What is mood?Mood is the ongoing inner

feeling experienced by an

individual.

+ 10

+ 7

+ 3

0

- 3

- 7

- 10

0

How am I feeling inside?


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How to ask the questions for anhedonia

Have you lost interest in or do you get less pleasure

from the th ings you used to enjoy?

IF YES:

What do you normally enjoy doing? (Television? Reading? Sports?

Shopping? Socializing? Eating? Hobbies? Sex?)

What do you still enjoy?

What have you lost interest in?

For how long have you not enjoyed these things like you used to?

It is like that nearly every day?


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How to ask the questions for appetite

Has there been any change in your appetite?

IF INCREASED OR DECREASED:

How much more/less have you been eating?

Is it like that nearly every day? For how long has your appetite been increased/ decreased?

Have you gained/lost any weight?

IF YES:

How much more/less?

Since when?


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How to ask the questions for sleep

How have you been sleeping?

How many hours per night have you been sleeping?

How does th is compare to normal?

IF INCREASED OR DECREASED:

Is it a problem nearly every day?

For how long have you had sleep problems?

* Do you have problems falling asleep, staying, or waking up too

early in the morning?


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How to ask the questions for

psychomotor agitation/ retardation

Agitation:

Have you been mo re f idgety and having p roblems s i t t ing s t i ll?

IF YES: Do you pace back and forth?

Have others noticed your restlessness?

Retardation:

Have you fel t slowed dow n, like you were moving in slowmot ion or stuck in mud?

IF YES:

Have others noticed this?


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How to ask the questions for engery

How has your energy level been?

Have you been feel ing t i red o r worn ou t?

IF YES

How long have you been feeling this way?

Do you feel like this nearly every day?


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How to ask the questions for guilt

How have you been feel ing abou t you rsel f?Whats your self-esteem been lik e?

IF LOW:

What type of thoughts do you have about yourself?

Do you feel like you are worthless or a failure?

IF YES:

Tell me about it.

Have you been b laming yoursel f for th ings?

IF YES:

Like what?


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How to ask the questions for guilt

Do you feel gui l ty?

IF YES:

About what?

How hard is it to get your mind off of this? Do you think about things from the past and feel guilty about them?

IF YES:

Like what?

*How often do you think of these things?

Is it on your mind every day?*


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concentration

Have you been having problems th ink ing or c oncentrat ing?

IF YES:

What does this interfere with?

Are you able to read? Watch TV? Follow a conversation? (how often, nearly every day?)

Is i t harder to made decision s than before?

IF YES:

What kind of decisions are harder to make?

What about every day decisions? (how often, nearly every day?


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suicide

Somet imes when a person feels down o r depressed they m ight

th ink about dying. Have you been h aving any thou ghts l ike that?

IF YES:

Tell me about it. Have you thought about taking your life?

IF YES:

Did you think of a way to do it?

How close have you come to doing it?

IF NO:

Do you wish you were dead?

When you go to sleep, do you often wish you would not wake up?


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Every depressed patient

should be assessed for suicide.

Questions should include:

Do you ever feel hop eless, or feel as tho ugh l i fe is no t wo rth l iv ing?

Have you ever though t of commit t ing suic ide?

Have you ever attempted su icide before?

How do you Assess Suicide Risk?


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Lets meet some patients

Kwesia, a 43 year old woman, presents toyou complaining of the inability to

concentrate

Priya, a 25 year old woman, gave birth to herfirst child 3 weeks ago and she presents to

you for a health check up

Raj, a middle aged man, presents tooutpatients complaining of feeling tired most

of the time

C # 1


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Case # 1

Kwesia, a 43 year old woman, presents to you complaining of

not being able to concentrate as well as she used to.

On further questioning you learn that her husband died suddenly 3 months

previously and she is now solely responsible for the care of his 4 children.

She is still very upset about his husbands death and her mood is low most

every day. She has very little energy necessary to care for her children and

go to work each day.

She is tired most of the day even though she is sleeping 8 hrs each night- alot more than he is used to.

She no longer has an appetite and says that sometimes she wishes to die

alongside his husband.


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Does Kwesia qualify as a major depressive episode?

Or is she just grieving the death of her husband?

What is the diagnosis?

Case # 1


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Case # 2Priya, a 25 year old woman had a healthy pregnancy and a

normal delivery.

She and her husband were happy to welcome a healthy baby girl

into their family.

Directly following the birth Priya was excited about her new role as a

mother but, within two weeks, she became more and more sad and

withdrawn.

She felt as though she would never be a good mother. She would

never catch up on her sleep and she felt hopeless about the future.

What fur ther quest ions would y ou l ike to ask her?


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Case # 2

Mood?low most every day

Sleep?unable to sleep between feedings

Interest in normally pleasurable activities?doesnt want to leave the

house

Guilt?feels extremely guilty about being a bad mother

Energy level?she has very little energy

Concentration?(decreased)

Appetite?she has no interest in food

Psychomotor retardation/ agitation?she feels as though she is always

moving in slow motion

Suicide Ideation?sometimes she goes to bed wishing she wouldnt wakeup in the morning

What is the Diagnosis?


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Case 3 For the past 2 years.

Sleep.. He has been unable to sleep more than one hour at a time

and never feels rested.

Energy.. He has had no energy and wants to spend his days in bed.

Appetite.. He no longer has much of an appetite.

Mood.. His wife reports she hasnt seen him smile in over a year

and that his mood is chronically low.

What is the Diagnosis?


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TREATMENT


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Goal of Treatment

Restoring brain neurochemical balance.

Improving sleep.

Raising the energy level.

Returning to normal appetite.

Restore mood, interest and concentration to

functional levels.

H d t l t t


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How do you acutely treat

depression?

Mild to Moderate MDD

#1 Psychotherapy Cognitive-behavioural therapy (CBT)

Interpersonal therapy (ITP)

Problem-solving therapy (PST)

#2 Anti-depressants

SSRI

TCA

H d t l t t


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How do you acutely treat

depression?

Moderate to Severe MDD

#1 Anti-depressants

SSRI

TCA

#2 Psychotherapy Cognitive-behavioural therapy (CBT)

Interpersonal therapy (ITP)

Problem-solving therapy (PST).


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In Depressive illness self-management and supportive interventionsare very helpful.

It is always helpful to include the patient in the treatment of their illnessand have them be aware of their symptoms and signs of a relapse.

It is also helpful to utilize any community resources that exist.

Supportive interventions include:

Arrange regular follow-up visits

Use the power of the prescription pad to prescribe one brief walk per

day, one nutritious meal per day, and one pleasurable activity per day Encourage the patient to keep a simple daily mood chart

Encourage and promote patient self-management


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Start Fluoxetine or Citalopram 10mg by mouth once a day, each morning for 5 days, if well

tolerated increase to 20mg.

Diagnosis of moderate to severe Major Depressive Disorder

Establish baseline PHQ-9 and baseline sleep and sexual function status

Treatment Flowsheet for SSRI Fluoxetine Citalopram

Monitor patient weekly for signs of side effects

Children and Adolescents Adults

Patients should continue on anti-depressant medications for at least 6 months

AFTERfull remission of symptoms.


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Start TCA 25mg by mouth once a day, at bedtime

Diagnosis of moderate to severe Major Depressive Disorder

Establish baseline PHQ-9 and baseline sleep and sexual function status

Treatment Flowsheet for TCAsAmitriptyline Imipramine Clomipramine

Monitor patient weekly for signs of side effects

Children and Adolescents Adults

Patients should continue on anti-depressant medications for at least 6 months

AFTERfull remission of symptoms.

I t t M b t


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Be sure to relay these messages to patients about

anti-depressants to promote compliance:

Antidepressants are not addictive.

Take your antidepressants daily.

It may take 2 to 4 weeks to start noticing improvement. Do not stop antidepressants without talking to your physician,

even if you are feeling better.

Mild side effects are common, but are usually temporary.

Contact your physician with any questions.

Important Message about

Anti-Depressant

Medications

H d it th t t t


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How do you monitor the treatment

of depression?

Since depression is a chronic and recurrent illness it is important to

closelymonitor the patients symptoms and be awareofpotential relapses.

The PHQ-9 is a good tool to monitor the response to treatment.

It is important to initially meet with patients at least once every

weekor two weeks until there is a clear improvement. At this pointit is appropriate to meet with patients each month.

.GPAC: Guidelines and Protocols Advisory Committee. Depression (MDD)-

Diagnosis and Management. British Columbia Medical Association, 2004


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H d t ?


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How do you managepoor outcome?

Improvement in the depression scores should see in 3-4 weeks.

If there is no improvement, the medications should be increased every 2-4weeks until the maximum dose is reached.

If there is still no improvement seen consider the following options:

Re-evaluatediagnostic issues (example: mania/hypomania, medical orpsychiatric co-morbidity, alcohol and substance abuse, personality traits/disorders)

Re-assesstreatment issues (example: compliance with medications, side-effects)

Addpsychotherapy

Switchto another antidepressant in the same class (if on SSRI) or in a

new class Referto a specialist or second level. Severe depressive symptoms (active

suicidality, psychosis); diagnostic uncertainty, significant psychiatric/medical co-morbidity; and unsatisfactory response to adequate trials of twoor more antidepressants.


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References

American Psychiatric Association. Lets Talk Facts About Depression, 2005.

American Psychiatric Association. Practice Guidelines for the Treatment of Patients

with Major Depressive Disorder, 2002.

British Columbia Partners for Mental Health and Addictions Information, compiled by

Eric Macnaughton. Depression Toolkit: Information and Resources for Effective Self-

Management of Depression, 2006. Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety

Treatments (CANMAT). Clinical Guidelines for the Treatment of Depressive

Disorders. Canadian Journal of Psychiatry 2001; 46.

GPAC: Guidelines and Protocols Advisory Committee. Depression (MDD)- Diagnosis

and Management. British Columbia Medical Association, 2004.

Identification, Diagnosis and Treatment of Adolescent Depression (Major DepressiveDisorder)A Package for First Contact Health Providers. Stan Kutcher & Sonia

Chehil, 2008.

Zimmerman, Mark. Interview guide for evaluating DSM-IV Psychiatric Disorders and

the Mental Status Examination, 1994.

Depression PP FV.ppt

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