INTRODUCTION TO PRIMARY CARE: A COURSE OF THE CENTER OF POST GRADUATE STUDIES N FM

DR WEDAD BARDISI

PO Box 27121 Riyadh 11417 Tel: 4912326 Fax: 4970847

Module 5Depression in primary care

ObjectivesKnow thhe prevalence of depression in KSA know the size of the problem in primary health care.Encourage trainee to use DSM IV diagnostic criteria.Encourage recognition of depression and determine its cause & classification.know proper history taking and physical examination. know evidence based management options. Know methods of screening for depression in family practice. know how to do proper follow up. know when to refer.

Size Of The ProblemThe World Health Organization ranks major depression among the most burdensome diseases in the world

Approximately 5 to 10 percent of primary care patients meet DSM-IV criteria for major depression, 3 to 5 percent for dysthymia, and 10 percent for minor depression.

About 70%-80% of all psychiatric patients had been firstly visit their Family physician or primary care doctors before seen by psychiatrist.

Depression often Goes Undetected

PrevalenceDepression symptoms are very common. 13 to 20% of the population being affected at any one time.In KSA the prevalence is similar to that of world wide i.e 20%.The prevalence of major depression is estimated at 10 to 20 percent in patients with medical illnesses such as diabetes and heart disease. Women are affected more than men.

Major Depressive Disorder(MDD)Major depression is a relapsing, remitting illness in most patients.Recurrence rate is 40% following the first episode over two years. After two episodes, the risk of recurrence within five years is approximately 75 percent.

10 to 30 % of patients treated for a major depressive episode will have an incomplete recovery, with persistent symptoms or dysthymia

Depression if untreated or inadequately treated , is a disease associated with high mortality, morbidity and economic costs, and danger serious disorder 15% of the patient commit suicide.

Many patients find a diagnosis of depression difficult to accept

Suicide rate by age and gender. 2004 data compiled from CDC. The mean suicide rate for the entire population was 12.8/100,000/year.

Classification according to DSM IV

Major depressive disorder ( Unipolar).Dysthymic disorder (mild sepression)- At least 2 years of lower-level depressive symptoms Bipolar depression - A major depressive episode arises in a patient with a history of hypomanic, manic, or mixed episodes Adjustment disorder - Emotional or behavioral symptoms that arise in response to an identifiable stressor and that cease once the stressor has terminated

Predisposing Factors(1) Genetic & familial factors. (2) Impaired social supports (3) Loneliness. (4) Bereavement. (5) Negative life events.(6) Childhood abuse and neglect.(7) postpartum. As well as cumulative load of stressors like:- Unhappy marriage. - Problems at work.- Unsatisfactory housing. - Lack of employment. - Lack of confiding relationship.

OTHER ILLNESSES CAN CAUSE DEPRESSIVE SYMPTOMS

Clinical PictureCATEGORIES OF DEPRESSIVE SYMPTOMPSSadDepressed anhedoniaGreif

Suicidal Ideas.Guilt Feeling Low Self EsteemLack Of Concentration

RetardationAgitation.Negligence Of WorkNegligence Of Social Activity

Disturbed sleep pattern.Appetite change.Weight change.Decreased sexual drive.Loss of energy, fatigue.

MOST COMMON PRESENTING SYPMTOMS

Sleep disturbance.Fatigue Pain.Anxiety.Irritability Gastrointestinal disorders.

Unexplained Somatic symptoms:

C.V.SPalpitationPseudoanginal pain.Respiratory :DyspneaHyperventilation .Gastrointestinal VomitingBowel disturbanceColicsMusculosklettalLow backacheGenitourinaryFrequency micuritionImpotence Vs premature ejaculationDysparonia frigidity

Diagnostic criteria for major depressive episode (adapted from DSM-IV-TR 17 )

At least 5 of the following symptoms have been present during the same 2-week period and represent a change from previous functioning.At least 1 of the symptoms is either #1 or #2. Depressed mood most of the day, nearly every day Markedly diminished interest or pleasure in all, or almost all, activities most of the day ( TWO SCREENING QUESTIONS) Significant weight loss when not dieting, or weight gain, or decrease or increase in appetite Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy Feelings of worthlessness or excessive or inappropriate guilt Diminished ability to think or concentrate, or indecisiveness Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

Screening of depression in primary care

Key symptoms: persistent sadness or low mood; and/or loss of interests or pleasure

fatigue or low energy. At least one of these, most days, most of the time for at least 2 weeks.

NICE Guideline depression (amended April 2007) 61

If any of above present, ask about associated symptoms: disturbed sleep poor concentration or indecisiveness low self-confidence poor or increased appetite suicidal thoughts or acts agitation or slowing of movements guilt or self-blame

Then ask about past, family history, associated disability and availability of social support 1. Factors that favour general advice and watchful waiting: four or fewer of the above symptoms no past or family history social support available symptoms intermittent, or less than 2 weeks duration not actively suicidal

little associated disability.

2-Factors that favour more active treatment in primary care: five or more symptoms past history or family history of depression low social support suicidal thoughts associated social disability.

3. Factors that favour referral to mental health professionals: poor or incomplete response to two interventions recurrent episode within 1 year of last one patient or relatives request referral

self-neglect.

4-Factors that favour urgent referral to a psychiatrist: actively suicidal ideas or plans psychotic symptoms severe agitation accompanying severe (more than 10) symptoms

severe self-neglect.

ICD-10 definitions

Mild depression: four symptoms Moderate depression: five or six symptoms Severe depression: seven or more symptoms, with or without psychotic features

NICE Guideline depression (amended April 2007)

Physical Examination

The physical examination of a patient with depression may reveal evidence of malnutrition or poor self-care.

The mental status examination is central to the diagnosis of depression, and includes the following components:Appearance and behavior.Mood and affect.Thought processes and speech.Thought contentCognition.

Dysthymia (mild depression)Dysthymia: is a chronic mood disorder with a duration of at least 2 years (1 year in adolescents and children). It is manifested as depressed mood accompanied by at least 2 of the following symptoms:

Poor appetite or overeating Insomnia or hypersomnia Low energy or fatigue Low self-esteem Poor concentration Difficulty making decisions Feelings of hopelessness

Bipolar affective disorderDSM IV Manic episodes are characterized by the following symptoms: At least 1 week of profound mood disturbance is present, characterized by elation, irritability, or expansivenessOR Hypomanic episodes are characterized by the following: An elevated, expansive, or irritable mood of at least 4 days' duration Alternating with major depressive episodes. .

Adjustment disorderDSM IVA "maladaptive reaction to an identifiable psychosocial stressor, or stressors, that occurs within 3 months after onset of that stressor..The condition is:Acute: If the disturbance lasts less than 6 months. Chronic: If the disturbance lasts 6 months or longer.

A typical presentationIn the primary care setting, the presenting complaints often can be somatic, such as fatigue, headache, abdominal distress, or change in weight. Patients may complain more of irritability than of sadness or low mood.

Elderly persons may present with confusion or a general decline in functioning. Children with major depressive disorder may also present with irritability, decline in school performance, or social withdrawal

Assessment of suicidal ideationAssessment for the presence of suicidal ideation is of paramount importance in all depressed patients.

Evaluation for suicide risk should include assessment of the following :

Presence of suicidal or homicidal ideation, intent, or plan Access to means for suicide and the lethality of those means Presence of psychotic symptoms, command hallucinations, or severe anxiety Presence of alcohol or substance use History and seriousness of previous attempts Family history of or recent exposure to suicide Evaluation in an emergency department and/or hospitalization should be considered for patients at significant risk of suicide.

Management A wide range of effective treatments is available for major depressive disorder. Brief psychotherapy (eg, cognitive behavioral therapy, interpersonal therapy). Patients who do not respond after 12 weeks of initial psychotherapy should be started on an antidepressant.However, the combined approach generally provides the patient with the quickest and most sustained response

Pharmacological Treatment

PHARMACOLOGICAL TREATMENT

Tricyclic antidepressant.(side effects are problem) MAOI ( not used frequently)SSRI

:Side effects of TCAAntimuscarinic side effects like: Dry mouth, blurring of vision, urinary retention, sweating and constipation.Postural hypotension .Arrhythmia.Convulsion Increase appetite and weight gain

Examples of TCA

MAOI : Less frequently used because of dangerous interactions with foods and drugs.Side effects:Postural hypotension, drwsiness, headache, dry mouth costipation, oedema tremors,hypereflexia, sexual disturbances, and blood and liver diorders.e.g Phenelzine ( Nadril) : dose 15 mg 3 times daily , max.30mg daily

The SSRIs All share several characteristics

Examples of SSRI

St. John's wort (Hypericum perforatum)St. John's wort is considered a first-line antidepressant in some countriesUsed to treat of mild-to-moderate depressive symptoms. It acts as an SSRI.The dose is 300 mg 3 times a day with meals to prevent GI upset.side effects include: gastrointestinal upset, increased anxiety, minor palpitations, fatigue, restlessness, dry mouth, headache, and increased depression.

Clinical course Is classified using six categories:Response Significant reduction (usually >50 percent) of depressive symptoms during the acute treatment phase. Remission A period of 2 weeks and

Referral Referral to a psychiatrist or to a treatment centre should be considered in the following circumstances:1- If the patient is expressing a suicidal intent or if there was a recent suicide attempt2- If the patient is elderly, confused and presentation of the history is unclear3- If the presenting symptoms of the disorder are severe, e.g., severe weight loss or weight gain , severe physical damage from drinking, severe withdrawal symptoms, several unsuccessful attempts to quit drinking.4- If the diagnosis is not clear5- If the treatment fails after the patient has received an appropriate medication trial6- If the management requires hospitalization or intensive treatment e.g. extreme hostility, aggression or homicide7- If there is one of comorbidity with severe physical or other mental disorders

Parents, siblings and children of patients of patients with severe depression have a10 to 15% morbidity risk.Concordance rates of 70% for monozygotic twins and 20% for dizgyotic twins in bipolar disorders.Concordance rate for unipolar depression in monozygotic twins is 40%.

*Appearance and behavior: Patients with depression may appear completely normal or may have evidence of poor self-care; patients with severe depression may appear dehydrated, thin, or even cachectic. Behaviors associated with depression include psychomotor slowing, poor eye contact, masked facies, tearfulness, furrowed brow, and hand wringing. Mood and affect:Mood is the subjective experience of an emotional state and is ascertained by asking the patient, who may describe feeling sad, blue, or depressed.Affect is the clinicians objective assessment of emotional state; typically, patients with depression have a restricted range of affect encompassing dysphoria and perhaps anxiety. Thought processes and speech: Speech is often delayed, slow, and monotonous.Thought poverty refers to a relative lack of spontaneity and content. Thought content: Patients may endorse helplessness, hopelessness, worthlessness, and/or suicidal ideation. Passive suicidal ideation refers to the belief that life is not worth living or that one would be better off dead. Active suicidal ideation refers to reporting a plan to harm oneself and/or the intent to harm oneself. Assessment of suicidal ideation is a critical and necessary component of the examination of patients with depression.Patients with psychotic depression may endorse hallucinations and/or delusions. Assessment of homicidal ideation is also necessary in this population.Cognition: Patients are generally alert, although may be inattentive and show evidence of short-term memory loss. Identifying cognitive impairment can be accomplished by routinely administering the Mini-Mental Status Examination (or other screening tool) to all depressed older adults.

*."2 The definition of maladaptive reaction is potentially broad and systemically relative depending on the racial, ethnic, and cultural identifications of the patient and psychiatrist. No guidelines are provided to help identify a psychosocial stressor. Additionally, the delineation between AD, anxiety not otherwise specified (NOS), and depression NOS are unclear*Amitryptaline ( Tryptizol): dose 25-75 mg daily either divided or one bed time single dose Clomipramine (Anafranil): dose 10 up to 150 mg either divided or one bed time single dose.Imipramine (Tofranil): dose initially up to 75 mg up to 200 mg as single bed time dose.Nortryptyline ( Ativan) :dose75-100 mg daily either divided or one bed time single dose.Doxepine (sinequan) dose: initially 75 mg up to 300mg daily in 3 divided doses

Amitryptaline ( Tryptizol): dose 25-75 mg daily either divided or one bed time single dose Clomipramine (Anafranil): dose 10 up to 150 mg either divided or one bed time single dose.Imipramine (Tofranil): dose initially up to 75 mg up to 200 mg as single bed time dose.Nortryptyline ( Ativan) :dose75-100 mg daily either divided or one bed time single dose.Doxepine (sinequan) dose: initially 75 mg up to 300mg daily in 3 divided doses

*The SSRIs all share several characteristics:They are all hepatically metabolized. They have relatively little affinity for histaminic, dopaminergic, alpha-adrenergic, and cholinergic receptors. They tend to have relatively mild side-effect profiles, although they can be associated with sexual dysfunction . They are relatively safe in overdose. They all produce changes in sleep architecture (increased REM latency and decreased total REM sleep).

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