Major and Minor DEPRESSION power point presentation

A short ppt on depression

1. MAJOR DEPRESSION – AN OVERVIEW

2. Central theme: depressed mood Chronic Recurrent - substantial impairment - suicide Frequent in general and hospital practice - unrecognized WHAT IS DEPRESSION?

3. CLASSIFICATION Major Depression Disorder -Unipolar Depression Dysthymia – sub-threshold depression (chronic) SAD

4. EPIDEMIOLOGY Depression is common, affecting about 163 million people worldwide. Risk for depression in general population is 1-2 % It is a leading cause of disability Fewer than 25 % of those affected have access to adequate treatment Age: All age groups (age influence nature of symptoms, 30’s) Sex: 2:1 ratio for women and men respectively Socioeconomic Status: No correlation has been found

5. CO-MORBIDITY Individuals with major depression are at an increased risk of having one or more. Alcohol abuse or dependence (Men) OCD Other Anxiety disorders Other illicit substance abuse

6. AETIOLOGY Genetic: hereditary evidence is overwhelming 1. One parent - child has risk 10-25 % 2. Both parents - then child risk is roughly doubled 3. Twin studies; concordance rate MZ twins is 70-90 % compared to same-sex DZ twins is 16-35 %. Life events and Environmental stress 1. Death of a loved one 2. Loss of employment 3. Unsupportive marriage

7. MEDIATING PROCESS Psychological processes – gloomy and negative thinking 1. Remember unhappy events more easily than happy ones 2. Unrealistic beliefs (I cannot be happy unless I am liked by everyone) 3. Illogical thinking (I failed in a relationship, I will never be loved by anyone) 4. gloomy intrusive thoughts (I am a failure as a mother) Biochemical processes – Reduced levels of neurotransmitters like serotonin , norepinephrine, dopamine,

8. DSM V-CRITERIA FOR MAJOR DEPRESSIVE EPISODE DSIGECAPS A Symptoms present during same 14 DAYS period Depressed mood *** Marked diminished interest or pleasure *** weight loss Insomnia or hyper-insomnia Fatigue or loss of energy Diminished ability to think or concentrate Psychomotor agitation or slowness Feelings of worthlessness or inappropriate guilt Recurrent thought of death (not just fear of death) Five or more of the above and must include either depressed mood or loss of interest / pleasure.

9. DSM V CRITERIA (continuation) B. Exclude mixed episode C. The symptoms cause clinically significant distress, or impairment in social, occupational, or other important areas of functioning. D. Symptoms are not due to the direct physiological effects of a substance (drug of abuse, medication) or a general medical condition (hypo-thyroidism) E. Bereavement, the symptoms > 2 months

10. MANAGEMENT OF DEPRESSION PSYCHOTHERAPY PHARMACOLOGY PHYSICAL TREATMENT – Electroconvulsive Therapy (ECT)

11. PSYCHOTHERAPY All patients with depression Psychotherapy effective in mild depression Used in combination with pharmacological treatment in severe illness Refer to slide 7 above Cognitive therapy, Interpersonal therapy, Behaviour therapy, Psychoanalytical Oriented therapy, and Family therapy.

12. OVERVIEW OF PHARMACOLOGICAL TREATMENT Anti-depressants are more effective with correct diagnosis Adequate dosage for an adequate duration of time (>6 months) Explanation of the treatment to the patient is essential Response rate of about 60-80 % compared with 20-30 % for placebo Different neurotransmitter systems including serotonin, noradrenalin, dopamine reuptake inhibition and MOI Action appears as soon the medication is first taken. Long half life and most can be given once a day Only differ in the range of side-effects

13. ANTIDEPRESSANT MEDICATION-TRICYCLICS Effectiveness in primary care is well recognized. Many of the side-effects occur even at low doses Dosage need to increased gradually to effective level The drop-out rate in primary care is in the region of 30 %

14. ANTIDEPRESSANT MEDICATIONS Noradrenalin and Serotonin Reuptake Inhibitors (available for over 40 yrs ) Amitriptyline Imipramine Venlafaxine Serotonin Reuptake Inhibitors Citalopram / escitalopram Fluoxetine Paroxetine Setraline

15. SIDE –EFFECTS OF TCA Anticholinergic Dry mouth Constipation Impaired visual accommodation Difficulty in micturition Worsening of glaucoma Confusion (elderly) Alpha-adrenergic blocking effect Drowsiness Postural Hypotension Sexual dysfunction Cardiovascular effects Tachycardia Hypotension cardiac conduction deficits cardiac arrhythmias Others Seizures and weight gain

16. TRICYCLICS Tricyclics account for 15 % of total deaths resulting from overdose; a further 7 % of fatal doses occurred where TCA was part of the cocktail. (source of litigation) TCA’s are relatively inexpensive, but the question of cost-effectiveness in the area of antidepressant therapy is a complex one The major expense is not the price of the antidepressants but that of untreated depression, with higher expenditure on doctors and health services, more days lost at work and more time spent in hospital

17. SPECIFIC SEROTONIN REUPTAKE I NHIBITORS (SSRI’s) SSRI’s were discovered as a result of systematic attempts to find ‘cleaner’ and more selective n their activity. As effective as TCAs in the treatment of severe depression, but not cardio-toxic No anti-cholinergic and antihistaminic side-effects Drop-out is 11 % Full dose can be instituted from the outset Most common reason for withdrawal are gastro-intestinal effects Suitable for elderly who tolerate TCAs poorly

18. INDICATIONS FOR SSRIs IN TREATMENT OF DEPRESSION Concomittant cardiac disease Intolerance to anti-cholinergic side-effects of TCAs Significant risk of deliberate self-harm Excessive weight gain with previous TCAs Sedation undesirable (e.g drivers) OCD with depression

19. SOME SSRIs Specific Serotonin Reuptake Inhibitors Citalopram 20mg-60mg Escitalopram Flouxetine 10mg-40mg Paroxentine 20mg-50mg Sertraline 50mg-150mg Noradrenaline and Serotonin Reuptake Inhibitor Venlafaxine 150mg-375mg

20. SIDE – EFFECTS OF SSRIs Gastrointestinal Nausea Flatulence Diarrhoea Central Nervous System Insomnia ( give in the morning) Restlessness Irritability Agitation Tremor Headache Sexual Ejaculatory delay (premature) ejaculation) Reduced libido

21. SPECIAL CONSIDERATIONS CHILDREN Often unrecognized “Moodiness” seen as developmental stage Reluctant to label a chid with psychiatric diagnosis Fear of psychotropic drugs in this age group (SSRIs safe) Belief that children do not have emotional capability to experience enduring depression Expression of symptoms is influenced by the developmental stage of child.

22. POSTPARTUM DEPRESSION (PPD) Majority opinion: PPD clinically distinguishable from Major Depression Not a different disease

23. PREGNANCY All anti-depressant cross placenta SSRIs better but new on the market therefore need long term studies As much as possible avoid all drugs in the first trimester. However, if the depressive symptoms are severe then treat the patient (TCAs – been available >40 years) Always consult manufacturers insert

24. FUTURE Mapping of the genes on human DNA responsible for depression

25. THANK YOU