Major Depressive Disorder Psychiatry.pptx

MDD

1. APPROACH TO MAJOR DEPRESSIVE DISORDER (CPG MDD 2 nd edition) Presenter: DR. MOHD FARIS SUPERVISOR: DR AMEERAH

2. CASE SCENARIO A 24 years old Malay girl, NKMI/NKDFA presented to ED department She was brought by her mother for alleged suicide attempt Self mutilating behaviour / alleged cut over the wrist Noticed by her mother when patient suddenly scream and cried in pain at 2am in the morning At that time, patient was alone in the room, locked up and her mother had to break in the room as patient refused to open up her door When her mother saw her, patient was already bleeding out blood from the wrist, lying down on the floor and semi unconscious.

3. Otherwise, Patient had no fever No traumatic injury to head prior to this/ no stroke No signs and symptoms of meningitis Denies taking substances/high risk behaviour Denies having illusion/delusion No hypo/hyperthyroid symptoms No previous surgical hx No h/o malignancy No h/o epilepsy No h/o mental illness in the family

4. O/e: GCS full, not tachypneic, not tachycardic, good PV, warm peripheries, well perfused Noted multiple superficial traces of cuts and scars over bilateral wrist - Toileting done, no deep wound, no active bleed L igature marks over the neck Otherwise Lungs: clear CVS: DRNM PA: soft non tender

5. Vital signs: BP: 118/72 PR: 95 SPO2: 99% under RA T: 36.5C ECG: Sinus rhythm Blood Ix: FBC, RP, ELECTROLYTES, LFT all normal Urine drug test: all panels negative

6. DASS SCORE: Depression: 27 Anxiety: 7 Stress: 27

7. What is your list differential diagnosis?

8. How do you approach in making your final diagnosis?

9. Upon further history from patient For the past few months: She had been having low moods Frequent episodes of crying spells Does not want to mingle with other people, prefer isolation Loss of interest, no more interested in doing her hobbies (likes to draw pictures) Loss of ability to focus and concentrate in class, affecting her studies Unable to get good sleep, always sleep late in the morning Difficult to get out from bed and feeling lethargic and sleepy at daytime Feeling of hopelessness Passive suicidal thoughts every once in a while Self mutilating behaviour , scratch her head bite her arms, slit her wrist, strangle her neck - Claims she felt relieved after doing so

10. Upon further history from patient Patient is a 5 th year medical student in a well known university in Malaysia. Her excellent results in SPM and matriculation granted her a place in the medical school. Even though she was a medical student, she never really wanted to take medical subject. She felt she was forced to take this course by her family. Although she was bright and scored good marks in every year exam, she always feel empty and that she never really had any interest in the medical field itself. Her parents was a divorcee, currently living with her mother and her brother Her mother work as a cleaner and the sole breadwinner in the family, her father left their mother when she was just a newborn. Patient had 3 other siblings, elder brother aged 29 y/o who are a drug addict. Her brother had physically abused her mother and patient in search of money. Her 2 nd brother is in prison after involved in robbery since 5 years ago and her 3 rd sister left their family at the age of 17 years old, currently married to a Thai gentleman and never returned to Malaysia.

11. Patient claimed she was the child of hope in her family Her mother had high expectation for her and that she was very strict in raising her since she was a child. She described her relationship with her mother as not in good term. Her mother never really showed any love towards her and that she was always focused for her to excel in her studies. They rarely meet at home and claimed her mother is verbally and physically abusive when she was young Patient claimed her moral support comes from her grandmother who lives beside their house, claim that only her grandmother understands her.

12. Patient claimed that she was stressed with her brother who is a drug addict and kept taking money from patient and her mother. Due to this her mother would reflect her anger towards patient and she will get the end of the rope Previously she was able to resist due to having good support from friends However her friends had isolated her after knowing her brother was a drug addict and that she came from a troubled family

13. AS A MEDICAL OFFICER IN CHARGE, WHAT WOULD YOU DO?

14. Contents Assessment and Diagnosis of MDD DSM-5 Criteria and ICD-10 Criteria Suicide Risk Assessment Treatment of MDD Follow Up and Monitoring

15. Screening of MDD Do we screen the general population? In most of the studies, women had higher rates of depression than men. Studies in clinical setting found a prevalence of depression to be 20.7% in post-partum women, 36% in post-stroke patients and 19.1% in breast cancer patients. [1]

16. High Risk Individuals for MDD first-degree relative with history of depression chronic diseases obesity chronic pain (e.g. backache, headache) impoverished home environment financial strain experiencing major life changes pregnant or postpartum period socially isolated sleep disturbance substance abuse e.g. alcohol, illicit drugs loss of interest in sexual activity old age

17. How to Screen? The common tools used in Malaysia for screening of depression are; Beck Depression Inventory (BDI) Depression, Anxiety and Stress Scale (DASS) Patient Health Questionnaire-9 (PHQ 9) Hospital Anxiety Depression Scale (HADS) Whooley Questions is a shorter tool which has been validated locally .

18. Assessment of MDD Detailed history taking Mental state examination Physical examination Investigations where indicated

19. History Taking presenting symptoms mode of onset duration and severity of symptoms number and severity of past episodes response to treatment previous hospitalisations psychosocial stressors family history suicide attempts past history of manic or hypomanic episodes substance abuse or other psychiatric illnesses social history and social support social and occupational impairment relevant medical history drugs history (prescribed and over-the-counter medications)

20. Mental State Examination evaluation of depressive symptom severity presence of psychotic symptoms risk of harm to self and others

21. Diagnosis of MDD The diagnosis of MDD is made using internationally accepted diagnostic criteria i.e. either the American Psychiatric Association’s Diagnostic or Statistical Manual of Mental Disorders V (DSM-5) or the 10th Revision of the International Classification of Diseases (ICD-10).

22. DIFFERENTIAL DIAGNOSIS FOR MDD MOOD DISORDER DUE TO ANOTHER MEDICAL CONDITION SUBSTANCE/MEDICATION INDUCED DEPRESSIVE BIPOLAR DISORDER ATTENTION-DEFICIT / HYPERACTIVITY DISORDER ADJUSTMENT DISORDER WITH DEPRESSED MOOD SADNESS/GRIEF PERSISTENT DEPRESSIVE DISORDER

23. Persistent Depressive Disorder

24. Adjustment Disorder

25. How severe is severe ? Mild depression : five or more symptoms are present which cause distress but they are manageable and result in minor impairment in social or occupational functioning. Severe depression : most of the symptoms are present with marked impairment in functioning . It can present with or without psychotic symptoms. Moderate depression : both symptoms presentation and functional impairment are between mild and severe .

26. Suicide Risk Assessment A recent systematic review found that the suicide rate in Malaysia is approximately 6 - 8/100,000 population/year with a rising trend in the means of suicide and self-harm. [2]

27. Suicide Risk Assessment Form (Adapted from Becks Suicidal Intent Scale)

28. Criteria for Referral to Psychiatric Services In local setting, referral to the psychiatric services may be done through the Emergency and Trauma Department or directly to the Psychiatric Clinic. Indications for referral to psychiatric services include: unsure of diagnosis attempted suicide active suicidal ideas failure of treatment advice on further treatment clinical deterioration recurrent episode within one year psychotic symptoms severe agitation self-neglect

29. When to Admit? risk of harm to self psychotic symptoms inability to care for self lack of impulse control danger to others

30. Phases of Treatment Phases of Treatment of MDD

31. The acute phase is a period aiming to achieve remission. The maintenance phase is a period to prevent relapse and recurrence and, development of chronicity. Response is a ≥50% reduction in depressive symptoms and at least a moderate degree of global improvement. Non-response - ≤25% decrease in baseline symptom severity Partial response - >25% and <50% decrease in baseline symptom severity Remission is the absence of signs and symptoms in the current episode of depression and restoration of function. Relapse is the return of symptoms of the current episode within six months following remission. Recovery is when an individual is fully functional and has returned to premorbid functioning. Recurrence is a new episode of depression after recovery.

32. Treatment The modalities of treatment in MDD are: pharmacotherapy psychotherapy psychosocial intervention physical others These are offered based on the severity of the disease (mild, moderate and severe) in both acute and maintenance phases.

33. Treatment of MDD

34. Types of Antidepressants Examples Selective Serotonin Reuptake Inhibitors (SSRIs) Escitalopram, Citalopram, Fluoxetine, Paroxetine, Sertraline Serotonin Noradrenaline Reuptake Inhibitors (SNRIs) Venlafaxine, Desvenlafaxine, Duloxetine Noradrenergic & Specific Serotonergic Antidepressants ( NaSSAs ) Mirtazapine Melatonergic Agonist & Serotonergic Antagonist Agomelatine Multimodal Serotonin Modulator Vortioxetine Tricyclic Antidepressants Amitriptyline, Clomipramine, Dosulepine , Imipramine, Maprotiline and Nortriptyline Noradrenaline/Dopamine Reuptake Inhibitor (NDRI) Bupropion Monoamine Oxidase Inhibitors (MAOIs) Isocarboxazid , Phenelzine, Selegiline, Tranylcypromine

35. Continuation and Maintenance Phase Non-pharmacological Approach Psychosocial Intervention and Psychotherapy CBT Mindfulness-based Cognitive Therapy (MBCT) IPT Pharmacological Approach Aim: prevent relapse and recurrence. Duration: 6 to 9 months after remission. NB: ≥2 years if there is a high risk of relapse and recurrence.

36. Failed Response to Initial Treatment Treatment failure can be due to a number of factors: incorrect diagnosis (e.g. failure to diagnose bipolar disorder) psychotic depression organic conditions e.g. anaemia or hypothyroidism co-morbid psychiatric disorder e.g. substance abuse or dependence, panic disorder, obsessive-compulsive disorder and personality disorder adverse psychosocial factors non/poor compliance

37. These strategies can be used in cases of failure or inadequate response to initial treatment: optimisation (refers to increasing the dose of antidepressant to the standard maximum dose for 6 - 12 weeks) switching (refers to a change from one antidepressant to another) combination augmentation In patients who fail to show response to initial treatment, optimisation is recommended rather than switching as because of wide inter-individual variation in dosage and there was no clear dose-response relationship for most antidepressants.

38. Next Step Treatment/ Treatment Resistant Depression TRD has been defined as failure to respond to two or more antidepressants at an adequate dose for an adequate duration, given sequentially. [5]

39. The following strategies can be used in the next-step treatments: switching augmentation -refers to the addition of a non-antidepressant (atypical antipsychotics/ lithium/ antiepilectic agents/ esketamine ) to an ongoing antidepressant combination therapy (refers to the addition of another antidepressant to the ongoing antidepressant) physical treatment psychotherapy as an adjunct

40. Physical Treatment Physical treatments are non-invasive techniques using electrical or magnetic stimulation targeting specific regions of the brain. Most of these treatments have been studied and are used in patients with TRD who have failed to respond to standard treatments. ECT Repetitive Transcranial Magnetic Stimulation ( rTMS ) Transcranial Direct Current Stimulation (TDCS)

41. ECT A therapeutic procedure that induces seizure by applying an electrical stimulus to the brain. There is no absolute contraindication for ECT. However, the relative contraindications are: cerebral space-occupying lesion increased intracranial pressure recent cerebral haemorrhage recent myocardial infarction vascular aneurysm or malformation pheochromocytoma class four or five anaesthesia risk ECT is indicated in MDD with: acute suicidal ideation high degree of symptom severity and functional impairment psychotic symptoms/features catatonic features rapidly deteriorating physical status e.g. refusal to eat TRD repeated medication intolerance previous favourable response to ECT pregnancy, for any of the above indications patient’s preference

42. Pharmacotherapy of MDD

43. Follow Up and Monitoring

44. Ongoing monitoring during treatment of MDD

45. References Mukhtar F OTP. Review on the Prevalence of Depression in Malaysia. Current Psychiatry Reviews. 2011;7(3):1-5. Armitage CJ, Panagioti M, Abdul Rahim W, et al. Completed suicides and selfharm in Malaysia: a systematic review. Gen Hosp Psychiatry. 2015;37(2):153-165. Caddy C, Amit BH, McCloud TL, et al. Ketamine and other glutamate receptor modulators for depression in adults. Cochrane Database Syst Rev. 2015(9):CD011612. Kennedy SH, Lam RW, McIntyre RS, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 3. Pharmacological Treatments. Can J Psychiatry. 2016;61(9):540-560. 5. Ministry of Health, Malaysia. CPG Management of Major Depressive Disorder. Putrajaya: MoH; 2007. 6. National Collaborating Centre for Mental Health. National Institute for Health and Clinical Excellence: Guidance. Depression: The Treatment and Management of Depression in Adults (Updated Edition). Leicester (UK): The British Psychological Society & The Royal College of Psychiatrists; 2010.

46. 7. Milev RV, Giacobbe P, Kennedy SH, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 4. Neurostimulation Treatments. Can J Psychiatry. 2016;61(9):561-575. 8. Woody CA, Ferrari AJ, Siskind DJ, et al. A systematic review and metaregression of the prevalence and incidence of perinatal depression. J Affect Disord . 2017;219:86-92. 9. Klainin P, Arthur DG. Postpartum depression in Asian cultures: a literature review. Int J Nurs Stud. 2009;46(10):1355-1373. 10. Dennis CL, Dowswell T. Psychosocial and psychological interventions for preventing postpartum depression. Cochrane Database Syst Rev.2013(2):CD001134. 11. National Collaborating Centre for Mental Health. Antenatal and Postnatal Mental Health: Clinical Management and Service Guidance: Updated edition. Leicester (UK): British Psychological Society; 2014. 12. CLINICAL PRACTICE GUIDELINES 2019 MOH MANAGEMENT OF MAJOR DEPRESSIVE DISORDER . (2019) (2nd ed.).