Transcript The Practical Management of Depression

The Practical Management of
Depression
Dr Frans A Korb
Psychiatrist and Clinical Psychologist
Private Practice
Fourways Intercare
Overview : Depression
• The Background
• The Facts
• Some Biology
• Making the Diagnosis
• Measuring Depression
• Management – Pharmaceutical
• Management – Other
• The Final Word
Definition : Depression
‘Mood is a sustained emotional tone perceived along
a normal continuum of sad to happy. Mood disorders
are characterized by abnormal feelings of depression
or euphoria with associated psychotic features in some
severe cases. Mood disorders are divided into bipolar
and depressive disorders’
Kaplan & Sadock
Depression: Impact on Society
A Major Cause of Disability Worldwide
Rank
1990
2020 (Estimated)
1
Lower respiratory infections
Ischemic heart disease
2
3
4
5
Perinatal conditions
HIV/AIDS
Unipolar major depression
Diarrheal diseases
Unipolar major depression
Road traffic accidents
Cerebrovascular disease
Chronic obstructive
pulmonary disease
Murray CJL, Lopez AD, eds. The Global Burden of Disease. Boston: Harvard University Press; 1996.
DEPRESSIVE DISORDERS
• DSM-IV vs ICD-10
• Major Depressive Disorder
• Dysthymic Disorder
• Bipolar Disorder
• Cyclothymic Disorder
Depression – The Facts
The Epidemiology of Depression
• Approximately 20% of primary care patients present with
depressive symptoms.1
• Depression is almost twice as prevalent in females as in
males.2
• Nearly two-thirds of MDD patients have multiple episodes.
The risk of recurrence progressively increases with each
successive episode and decreases as the duration of
recovery increases.3
• Prevalence rates for MDD are unrelated to race,
(religion),education, income, or civil status.4
1. Zung WW, et al. J Fam Pract. 1993;37:337-344.
2. Kessler RC, et al. J Affect Disord. 1993;29:85-96.
3. Solomon DA, et al. Am J Psychiatry. 2000; 157:229-233.
4. U.S. Agency for Health Care Policy and Research. Depression in Primary Care:
Vol. 1. Detection and Diagnosis. Rockville, MD: 1993: 23.
Prevalence Rates of Depression in Chronic Medical Disorders
General Population
5.8%
Chronically Ill
9.4%
Hospitalized
33.0%
Older Inpatients
36.0%
Cancer Outpatients
33.0%
Cancer Inpatients
42.0%
Stroke
47.0%
MI
45.0%
Parkinson's Disease
39.0%
0%
10%
20%
30%
Adapted from: WPA/PTD Educational Program on Depressive Disorders.
Gavard JA, et al. Diabetes Care. 1993;16(8):1167-1178.
40%
50%
Gender Demographics1
MDE Hazard Rates by Age and Sex
0.0140
Female
Male
Hazard Rates
0.0120
0.0100
0.0080
0.0060
0.0040
0.0020
0.0000
0-4
5-9
10-14 15-19 20-24
25-29
30-34
35-39
Age Category
1. Kessler RC, et al. J Affective Disord. 1993;29:85-96.
40-44
45-49
50-54
Depression – Some Biology
Neurotransmission
Neurotransmission is the
process of sending
signals from one
component of the nervous
system to another
5-HT and NA at the Synaptic Level: Healthy vs. Depressed
Healthy
Depressed
5-HT Reuptake
Transporter
NA
Reuptake
Transporter
5-HT
NA
Theoretical Representation
Depression -- Making the Diagnosis
What is Depression ?
Depressed mood
Traurigkeit
Depression
Slowed thinking
Gedankenhemmung
Slowed moving
Bewegungshemmung
Weygandt “Uber die Mischzustande des manisch-depressiven Irreseins” (Munchen, 1899)
Depression. It’s not only a state of mind.
The emotional and physical symptoms of depression
Emotional Symptoms Include:
Physical Symptoms Include:
Always feeling sad
Vague aches and pains
Loss of interest or pleasure
Headache
Worrying
Sleep disturbances
Anxiety
Fatigue
Diminished ability to think or
concentrate, indecisiveness
Vague back pain
Excessive or inappropriate guilt
Significant change in appetite
resulting in weight loss or gain
Reference: Adapted from
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders.
Fourth Edition,Text Revision. Washington, DC; American Psychiatric Association. 2000:345-356,489.
Tired
Unmotivated
35
%
35% have low mood,
fatigue, low energy,
and lack of
motivation.
(Agitated)
Anxious
(Retarded)
34%
31%
34% have mild
symptoms of fatigue,
low energy, and
excessive worry, and are
easily overwhelmed
31% have primary
anxiety complaints
Adelphi Neurosis Market Research Study. 1997. A. Gupta 2000 (n=1590).
SPECIAL FORMS OF DEPRESSIVE DISORDERS
• Psychotic Depression
• Somatic Depression
• Atypical Depression
• Seasonal Depressive Disorder
• Rapid-cycling Bipolar Disorder
• Secondary Depressive Disorder
OTHER FORMS OF DEPRESSIVE DISORDERS
• Dysthymia
• Postpartum Depression
• Recurrent Brief Depression
• Mixed Anxiety-Depression Syndrome
• Subthreshold Depression
Measuring Depression
Depression Management -- Pharmaceutical
Depression: Current Treatment Patterns
• Only about 1/3 of patients with major depression seek care
for their depression (1)
• Less than 1/2 of patients with major depression are explicitly
recognised as being depressed (2,3)
• Only about 1/2 of all depressed patients receive some form
of therapy for their illness (2,3)
• Only about 1/4 of depressed patients receive an adequate
dose and duration of antidepressant treatment (4)
1) Shapiro S, et al. Arch Gen Psychiatry. 1984;41:971-78.
2) Wells KB, et al. JAMA. 1989;262(23):3298-3302.
3) Lepine C, et al. Intl Clin Psychopharm. 1997;12:19-29.
4) Katon W, et al. Medical Care. 1992;39(1):67-76.
Classes of Antidepressants
• Tricyclic and Tetracyclic Antidepressants (TCAs) Imipramine,
clomipramine
• Monoamine Oxidase Inhibitors (MAOIs + RIMAs) tranylcypromine,
moclobemide
• Selective Serotonin Reuptake Inhibitors (SSRIs) fluoxetine, citalopram
• Selective Noradrenaline Reuptake Inhibitor (NRI) reboxetine
• Serotonin-Noradrenaline Reuptake Inhibitors (SNRIs) duloxetine,
venlafaxine
• Serotonin-2 Antagonist and Reuptake Inhibitors (SARIs) trazodone,
nefazodone
• Noradrenergic and Specific Serotonergic Antidepressants (NaSSA)
mirtazapine
• Dopamine and Noradrenalin Reuptake Inhibitors (DNRI) Bupropion
AHCPR, 1993
Depression: Treatment Goals
Recovery
Remission
No Depression
Recurrence
Relapse
X
X
Relapse
X
Severity Symptoms
Response
Syndrome
Treatment Phases
Acute
6-12 weeks
Time
Reprinted with permission from Kupfer, 1991
WPA/PTD Educational Program on Depressive Disorders
Continuation
Maintenance
4-9 months
1 or more years
Switching Strategies
Pharmacological Strategies for
Treatment-Resistant Depression (TRD)
Optimization
(monotherapy)
Increase the dose or duration, or alter the timing
of the primary antidepressant.
Substitution
(switching)
Stop first medication, start next one as
monotherapy. New drug can be within or across
class.
Augmentation
Add a second drug (adjunct) that is not an
antidepressant to the antidepressant that has
not produced and adequate response.
Combination
Two antidepressants used together, typically for
synergistic mechanisms.
Depression Management -- Other
Patient Programmes
www.sadag.co.za
mySupport Programme
www.bouncingback.co.za
Depression – The Final Word
Social-Endocrine-Psychological Interactions
Depression: Treatment Goals
Treatment
Reduce/Remove
Signs, Symptoms
Restore
Role/
Function
Minimise Relapse/
Recurrence Risk
AHCPR Guidelines: Depression in Primary Care, Vol 2. US Dept. of Health and Human Services; 1993.
Depression Is ...
• Prevalent worldwide
• Common in primary care setting
• Often unrecognized, inadequately treated
• Associated with high morbidity,
mortality, cost
• PCP can provide effective treatment
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