depression

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Slide 1 : DEPRESSION Afshar Hospital Case conference Dr.M.Rafi.B.Sina 7/7/2011
Slide 2 : OBJECTIVE INTRODUCTION ETIOLOGY CLINICAL PICTURE DIAGNOSIS DDX COURSE OF DEPRESSION PROGNOSIS TREATMENT
Slide 3 : INTRODUCTION Sadness sever enough to interfere with function & often by decrease interest or pleasure in activities. Is a major public health problem & leading predictor of functional disability & mortality.
Slide 4 : ETIOLOGY Multi factorial. Psychological/social factors Predisposing factors Precipitating factors Perpetuating factors Biological factors Genetic factors
Slide 5 : CLINICAL PICTURE ICD-10 Key symptoms: low mood lack of enjoyment lack of energy
Slide 6 : CLINICAL PICTURE Additional typical symptom Cognitive symptoms Difficulties in concentrating Low self esteem Feeling of guilt Hopelessness
Slide 7 : CLINICAL PICTURE Biological symptoms : Lack of enjoyment Loos of appetite Early morning weakness Loos of libido Psychomotor retardation Reduced emotional reactivity
Slide 8 : CLINICAL PICTURE Most serious signs : Psychotic symptom Suicidal ideas stupor
Slide 9 : DIAGNOSIS ICD-10 Mild 4 symptoms are needed. Moderate 6 symptom are needed. Sever 8 symptoms (all 3 symptom of group A + 5 of the group B)
Slide 10 : DX & CLASSIFICATION (DSM-4) Depressed mood Loos of interest Insomnia or hypersomonia Change in appetite Psychomotor retardation or agitation Low energy Poor concentration Worthlessness or guilt suicide
Slide 11 : DX & CLASSIFICATION (DSM-4) Major depression : 5 of that symptoms Most of the day For tow consecutive weeks Depressed mood or loose of interest Minor depression 2 to 4 of that 9 symptoms Present nearly every day Depressed mood is necessary.
Slide 12 : DDX Dysthymia. Bipolar disorder. Adjustment disorder. Depressive symptom in other psychiatric disorder Depressive symptom in other medical disorder. Parkinson, CVA , head injury , Cushing disease. Hypo –Hyperthyroidism. Depressive symptoms due to drugs.
Slide 13 : COURSE OF DEPRESSION First untreated episode lasts 6-12 month. Relapse & chronic course are frequent Risk of suicide is 20 times higher than general population.
Slide 14 : PROGNOSIS Negative prognostic factor are: More sever episode Psychotic symptom Presence of other psychiatric disorder Lack of close person
Slide 15 : GENERAL ADVICES Encouraging to some activities. Give hope to the patient Talk him serious, listen to him Encourage him to express his feeling Holiday are not helpful for depressed people Marrying will not cure their mental illness but it might get worse Help & support his family members.
Slide 16 : GENERAL ADVICES Before starting medication always asses the patient Suicidality. Explain the possible side effect of the drug. Encourage the patient & give him hope.
Slide 17 : TREATMENT Psychotherapy pharmacotherapy
Slide 18 : PSYCHOTHERAPY Is an option for mild to moderate major depression. 12 week after fail of psychotherapy anti depressant should be start. Combination of psycho-pharmaco therapy for sever Chronic , recurrent cases
Slide 19 : PHARMACOTHERAPY 50- 60% response rate. MAOIs phenelzine TCAs Imeperamin, amitriptylin, nortriptline SSRIs Fluoxetin, sertaline, paroxetin, SNRIs Venlafexin, dulextine
Slide 20 : CHOICE OF ANTIDEPRESSANT The choice of antidepressant is likely to be less Important than treating patients with medication that they can tolerate & with doses sufficient to achieve symptom remission.
Slide 21 : CHOICE OF ANTIDEPRESSANT ACP recommend to initiate Tx with one of the following. Fluoxetine,paroxotine,sertraline,citalopram,ecitalopram,bupropoin,mirtazapine,trazodone,nefazodone,duloxetine,venlafexin. Consider side effect.
Slide 22 : SIDE EFFECT SNRI: similar side effect to SSRI+ dizzness,sweating,HTN. TCA: Anticholinergic side effect. SSRI: Headache, insomnia, restlessness, GI symptom. agitation ,agitation. sexual dysfunction.
Slide 23 : DOSAGE Paroxetine 5-10 mg Sertraline 12,5-25 mg Fluoxetine 5mg Citalopram 10 mg
Slide 24 : TIMING OF RESPONSE & FOLLOW UP Initially every 1-2 Ws for 6 & 8 weeks . Treatment time to maximal response is 6 week or longer. We suggest (up-to date, not me) maintenance therapy > 2y to patients with Hx of more than 3 episode. Medication should be taken for a minimum of 6- 9 months after a first episode of depression.
Slide 25 : TIMING OF RESPONSE & FOLLOW UP If no response to antidepressant by 8 W , the medication should switch to another antidepressant. If second antidepressant become fail, refer to psychiatrist (out of hospital) for further medication adjustment.
Slide 26 : SUMMARY & RECOMMENDATION Major depression is defined by presence of 5 symptom of 9 symptom.(DSM-4). Diagnosis is based on patient Hx & mental status examination.
Slide 27 : SUMMARY & RECOMMENDATION Goal of Tx is remission of symptoms. Up-to date recommend treat mild to moderate cases with psycoterapy or pharmacotherapy. Pharmacotherapy as initial therapy for sever depression. Combination therapy for chronic & recurrent episode. Use SSRI,SNRI,MAOIs,TCAs
Slide 28 : SUMMARY & RECOMMENDATION Side effect can be minimized by starting at low doses. Do not stop antidepressant abruptly. If the psychotic symptom present add a neuroleptic. In order to prevent a relapse or recurrence continue Tx for 6 month after the symptoms have disappeared.
Slide 29 : REFERANCES Notes from my psychiatric rotation Up- to date 2011.

 


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