Assessment and management of depression

Depression is the leading cause of disability world wide and is a major contributor to the overall global burden of diseases .At its worst depression can cause suicide .
There are effective psychological and pharmacological treatments for depression

1. ASSESSMENT AND MANAGEMENT OF DEPRESSION DR OGECHUKWU MBANU FAMILY MEDICINE DEPARTMENT AKTH KANO 24 / 10 / 2018

2. 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

3. 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 “(7 th April)

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. RISK FACTORS FOR DEVELOPING DEPRESSION

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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)

29. 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

30. 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

31. SCREENING TESTS AND SCALES

32. Interpretation of PHQ 9 Test score Depression severity 1 to 4 minimal 5 to 9 mild 10 to 14 moderate 15 to 19 Moderately severe 20 to 27 severe 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 )

33. 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

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

35. 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

36. 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

37. 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

38. ANTI DEPRESSANTS 2 1 ST 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 ) 2 ND GENERATION ANTIDEPRESSANTS Selective serotonin reuptake inhibitors (SSRIs) :- Fluoxetine (Prozac ) fluvoxamine ( luvox ) sertraline (Zoloft ) , paroxetine ( paxil ) , citalopram ( celexa ) , Ecitalopram ( cilantro

39. 3 rd 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 )

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. Mirtazapine -- NaSSA Noradrenaline and specific serotonin – anti depressants They cause sedation Increase appetite Weight gain These effects are beneficial if biological symptoms of depression (insomnia ,  appetite , weght loss ) are present AGOMELATIN Agonists of MT1 / MT2 melatonin receptors Melatonin , secreted by the pineal gland is important for sleep Side effects includes Acute liver failure Regular LFTs are important

48. NATURAL REMEDIES Some have been shown to be more effective than placebos and are in some cases as effective as fluoxetine and imipramine (Dwyer , Withtten , and Hawrelak ,2011) They include :- St john’s wort Saffron stigma and petal Lavender Rodiola Not much study on side effects Not to be combined with any of the other drugs

49. PERI - PARTUM DEPRESSION – MANAGEMENT Begins at pre-conception counseling for women with a personal history of mental health problems . Strategies includes Prevention Decision-making related to relapse risk, follow-up plans, psycho-education re: need for sleep and good social support Treatment Safety Assessment Risk-benefit analysis: safety of treatment during pregnancy/lactation vs. risks of untreated illness Options: Psychotherapy, Psychotropic Medication ,ECT(rarely done) SSRI or SNRI is first line treatment for moderate to severe depression( most safety data on older SSRI/SNRIs) Sertraline and Paroxetine usually undetectable in serum of breastfed infants, Others < 10% passage but no adverse events reported

50. Discontinuation syndrome Common with antidepressants with relatively short – half lives eg Venlafaxine and paroxetine Unusual with anti depressants with long half – life e.g. fluoxetine The shorter the half life the more severe the symptoms Symptoms includes : - insomnia , nausea , anxiety , dizziness , paresthesia , mood changes , and diarrhoea

51. SEROTONIN SYNDROME A result of acute spike in serotonergic transmission Can be caused by SSRIs alone More common when taken with other serotogenic drugs such as :- Other antidepressants Cocaine Amphetamines Its best to allow sufficient`` wash out ‘’ time when switching from one antidepressant to the another especially fluoxetine(Prozac) Features are similar to neuroleptic malignant syndrome Disorientation , agitation , confusion , Nausea , vomiting , diarrhoea Sweating hyperpyrexia , shivering , Autonomic instability

52. GENERAL PRINCIPLES WHEN USING ANTIDEPRESSANTS Start at a low dose and increase dose gradually Review mental state regularly Monitor for side effects Avoid using more than one antidepressants at the same time Takes at least 2 to 3 weeks for the anti – depressants effect to manifest If improvement continue for several months If stable withdraw gradually to avoid ` rebound ‘ relapse If no improvement gradually change to another anti depressants If repeated relapse consider long term ( possible life long ) maintenance treatment

53. COGNITIVE BEHAVIOR THERAPY How one thinks (cognition) and how one acts (behavior ) can affect how one feels (mood) Certain behaviors can cause one to feel low in mood Negative cognitions and maladaptive behaviors can cause one to feel low in mood CBT aims to help the patient correct negative cognitions and unhelpful behaviors that maintain the depression

54. INDICATIONS FOR ECT Severe , life threatening depression : patient not eating or drinking Depressive stupor Severe psychotic depression e.g. post partum psychosis In cases of life – threatening or intolerable side effects of psychopharmacological treatments Treatment resistant depression : when different antidepressants have been tried

55. RESISTANT DEPRESSION Refers to depression that has not responded to at least 2 different classes of anti depressants ,given at an adequate dosage for an adequate duration ( at least for 4 – 6 weeks) ASSESS Compliance Alcohol or drug abuse Interaction with other medications ( eg enzyme inducers ) Role of physical illness eg poorly controlled pain Psychological / social stressors

56. RESISTANT DEPRESSION -- treatment Combination strategies e.g. antidepressant  CBT Augmentation of antidepressants with another drug that is not an antidepressant e.g. antidepressant  lithium or T3 or atypical antipsychotics ECT Repetitive transcranial magnetic stimulation ( r TMS) Transcranial direct current stimulation (t DCS) Deep brain stimulation ( DBS ) Vagus nerve stimulation ( VNS) Lithium and clozapine are known to have anti suicidal effects

57. MANAGEMENT OF BIPOLAR DEPRESSION The atypical antipsychotic Quetiapine may be used Antiepileptics such as sodium valproate or lamotrigine can be used Additional anti depressant (usually SSRIs) may be needed in some but care must be taken due to possible switch to mania / hypomania ECT

58. DIFFERENTIAL DIAGNOSIS Endocrine disorders e.g. hypothyroidism Drug - related conditions e.g. cocaine abuse Side effects of some CNS depressants Infectious diseases e.g. infectious mononucleosis Sleep – related disorders Central nervous system diseases e.g. Parkinson's disease ,dementia , Multiple sclerosis , neoplastic lesions

59. PROGNOSIS Poor prognostic factors Earlier age of onset Longer duration / increased severity of episodes Poor initial response to treatment Or treatment resistance Suicidal behavior Co – morbid anxiety / personality disorders Alcohol and substance abuse Low levels of social support and social integration

60. RISK OF RECURRANCE At least 50% will have a recurrence after 1 st episode of depression Average number of episodes per decade is about 3 Risk of recurrence Greater with each successive episode Lower with increasing periods of recovery About 20% experience chronic depression ( ie low levels of depression for many years without return to previous level of normal mood

61. CONCLUSION Depression is a leading cause of disability worldwide wide and is a major contributor to the overall global burden of disease WHO recognizes the various forms of depression as real illness. At its worse depression can lead to suicide We should educate our patients properly about depression and about treatment options REMEMBER THAT DEPRESSION IS A DISEASE ,IT IS NOT WEAKNESS OF CHARACTER OR IMAGINATION

62. Thank you for listening

63. REFERENCE The ICD 10 Classification Of Mental And Behavioral Disorders Psychiatric Mental Health Medication Overview Presentation ,Accessed OCT 26 2018 Douglas M M ,Depression Screening ,American Academy Of Family Physicians JAN15 2012, Www.Aafp.Org / Afp WHO , Depression And Other Mental Disorders , Global Health Estimates Treating Depression In The Primary Care Setting , Presentation By Dr Sager Screening For Depression In Primary Care Presentation By Dr Bishop And Sarah Williams

64. REFERENCE Dr Rajagopal , May 23 2015 ,Psychiatric Lecture : Mood Disorder – Depression And Bipolar Disorder , Accessed SEP 30 2018 Update On Perinatal Mood Disorders ,Presentation By William Watson And Simone Vigod Depression Its Symptoms ,Causes And Treatment Presentation By Dr Adelbert Scholtz Psychopharmacology Hour Accessed October 26 2018 Dr Rajagopal Jan 21, 2015 ,Psychiatric Lecture ,Descriptive Psychopathology; Accessed October 24 2018