Depression- An Approach for physicians .

Includes definition and clinical features of depression, risk assessment of suicide and studies quoting relationship of physicians and approach to depression and its effective management

1. Understanding and treating depression – Physicians task

2. Objectives Definition of depression Clinical features of depression knowing its impact on population Role of primary care physicians Medical conditions presenting as depression Assessing depression by physicians Management/ approach of depression Physician- psychiatrist practical scenarios

3. Definition Depression (major depressive disorder) is a common and serious illness that negatively affects, How you feel The way you think How you act Leads to a variety of emotional and physical problems Decrease your ability to function at work and at home.

4. Statistics of depression Globally 300 million affected by 2015 ( WHO) National Mental Health Survey 2015-16 15% Indian adults need active intervention for one or more mental health issues  1in 20 suffers from depression

5. Risk factors ( Indian context) Women are twice likely affected than men. More likely occurs in unmarried, divorced, widowed or separated. Nuclear families urban area residence Elderly Medical disorders

6. Depression will become the leading cause of disease burden by the year 2030

7. Why physicians should know about depression? Primary care physicians are usually the point of first contact with health care system. Majority of patients with mental health problems land in physician’s OPD There is less stigma to see physician than a psychiatrist Early diagnosis can be made and treated appropriately or refer to psychiatrist Depression can present as medically unexplained somatic symptoms Many medical illness can present as depression.

8. 60% of mental health care delivery occurs at primary care setting. 79% prescriptions are written by non psychiatrists

9. Assessment

10. Assessment never ends without assessing suicide risk

11. When to Refer to psychiatrist Risk of suicide Severe depression Psychotic symptoms Non response to medication Chronic resistant depression Multiple comorbidities Need for psychotherapy Special population- adolescent, child, pregnancy Diagnostic difficulty Family history of psychiatric disorder

12. Management Antidepressants are mainstay of treatment. Start low dose and slow titration advised. Pharmacokinetics differ in elderly population. Liver and kidney parameters to be considered. Abrupt stoppage of drugs can cause discontinuation syndromes. Drug interactions to be considered.

13. Antidepressant induced mania Patient A was a 50-year-old woman presented with moderate depression following which she was prescribed escitalopram at a dosage of 10 mg/day. After 14 days, she exhibited mild improvement in her depressive symptoms. However, as this effect was insufficient, the dose was increased to 20 mg/day. After an additional 14 days, the patient developed hypomania lasting more than 4 days, exhibiting arrogant and aggressive behavior , inflated self-esteem, uncharacteristic talkative behavior and overspending, as well as a decreased need for sleep. Symptoms of hypomania improved as escitalopram was tapered off. The patient is currently stable on a treatment regimen consisting of lithium at 800 mg/day, and she has exhibited no hypomanic symptoms since the cessation of escitalopram treatment.

14. SLE presenting as depression 24 year old female presented with low mood, decreased appetite, weight loss, decreased interest, guilt, negative thinking and generalised fatigue since 1 month. On physical examination she had malar rash. She was worked up for autoimmune profile.ANA was positive and anti ribosomal P was positive. All other investigations were normal . A diagnosis of SLE was made and referred to Rheumatologist.She was started on Prednisolone 60 mg per day along with sertraline 50 mg per day. She improved by 6 months on follow up.