Transcript depression 2012 slide show
Slide 1
K.E. .Badoe MBChB., FRCPC
Medical Director, Trellis Mental Health and Developmental
Services, Guelph
MEDICAL FIESTA August 9th 2012
Slide 2
Review an approach to diagnosis of Depressive
Disorders
Examine the clinical course of MDD
Consider the rationale behind the drive to
achieve remission
Evidence-based selection of treatment options
Slide 3
“ Depression”
Slide 4
“Doctor, I am depressed”
because...
My lotto numbers did not “drop” this
week
My wife left me last week
My husband died three years ago
There is no reason for me to feel this
way
Slide 5
Diagnosis
and treatment of
“depression”
depended on the clinician’s
perspective
Slide 6
Psychological
biological
- nurture
- nature
Slide 7
Causation -life events, “stressors”
Diagnosis – Reactive depression,
Neurotic depression
Treatment - psychotherapy “tell me
about your mother.... Your finances,
your husband, boss
Slide 8
One man’s stress, is another man’s pleasure
“If I look hard enough, I will find stress”
e.g. travelling to Ghana, jet lag, preparing
for a presentation, carrying back kobe
Slide 9
Diagnosis – Endogenous depression
Treatment - Biological –medication,
ECT
Slide 10
No one would consider putting someone on
an antidepressant because of a lotto ticket
What about the man who has lost 30 pounds,
cannot sleep, has been thinking of suicide for
the past two months, because of the lotto
ticket?
And on what basis would one decide which
treatment?
Slide 11
Somewhere
in between
Slide 12
Symptoms clusters that responded biological
interventions
Mood disturbance that seemed to be
autonomous, impairment in in parametres
such as sleep, energy, appetite, concentration
Precipitants/stressors – not relevant to the
diagnosis of MDD (except bereavement)
Slide 13
A. At least Five
of the following
symptoms
present during the same 2-week
period
represent a change from previous
functioning
Slide 14
Of five at least one of the symptoms is
EITHER
(1) depressed mood most of the day, nearly
every day, either subjective report (e.g., feels
sad or empty) or observation by others (e.g.,
appears tearful). In children and adolescents,
can be irritable mood.
OR
(2) markedly diminished interest or pleasure in
all, or almost all, activities most of the day,
nearly every day .
Slide 15
(3) significant weight loss when not dieting
or weight gain (e.g., a change of more than
5% of body weight in a month), or decrease
or increase in appetite nearly every day.
Note: In children, consider failure to make
expected weight gains.
(4) insomnia or hypersomnia nearly every
day
Slide 16
(5) psychomotor agitation or retardation
nearly every day (observable by others, not
merely subjective feelings of restlessness or
being slowed down)
(6) fatigue or loss of energy nearly every
day
Slide 17
(7) feelings of worthlessness or excessive or
inappropriate guilt (which may be delusional) nearly
every day (not merely self-reproach or guilt about
being sick)
(8) diminished ability to think or concentrate, or
indecisiveness, nearly every day (either by subjective
account or as observed by others)
(9) recurrent thoughts of death (not just fear of
dying), recurrent suicidal ideation without a specific
plan, or a specific plan for committing suicide or a
suicide attempt
Slide 18
B. The symptoms do not meet criteria for a
Mixed Episode.
C. The symptoms cause clinically significant
distress or impairment in social, occupational,
or other important areas of functioning.
D. The symptoms are not due to the direct
physiological effects of a substance (e.g., a
drug of abuse, a medication) or a general
medical condition (e.g., hypothyroidism).
Slide 19
E. The symptoms are not better accounted
for by Bereavement, i.e., after the loss of a
loved one, the symptoms persist for longer
than 2 months or are characterized by
marked functional impairment, morbid
preoccupation with worthlessness, suicidal
ideation, psychotic symptoms, or
psychomotor retardation.
Slide 20
Major depressive disorder
◦ Major depressive disorder, single episode
◦ Major depressive disorder, recurrent - (two or
more episodes)
Dysthymic disorder
Depressive Disorder NOS
(Adjustment Disorder – depressed mood)
Slide 21
Major depressive disorder
◦ Major depressive disorder, single episode
◦ Major depressive disorder, recurrent - (two or
more episodes)
Slide 22
Mild
Moderate
Severe without psychotic features
Severe with psychotic features
In partial remission
In remission
Slide 23
Melancholic depression - loss of pleasure in most or all
activities,, a quality of depressed mood more pronounced
than that of grief or loss,
a worsening of symptoms in the morning hours, earlymorning waking, psychomotor retardation, excessive weight
loss, excessive guilt.
Atypical depression - mood reactivity (paradoxical
anhedonia) and positivity, significant weight gain or increased
appetite (comfort eating), hypersomnia ,), a sensation of
heaviness in limbs known as leaden paralysis, and significant
social impairment as a consequence of rejection
hypersensitivity
Slide 24
Catatonic depression - rare and severe form of major
depression involving disturbances of motor behavior and
other symptoms. Patient is mute and almost stuporous,
immobile or engages in purposeless or even bizarre
movements.
Rule out schizophrenia /neuroleptic malignant syndrome .
Post partum depression -10–15% among new mothers onset
occur within one month of delivery
Seasonal affective Disorder (SAD) – onset fall/autumn
subsides following spring ,at least two episodes have
occurred in colder months with none at other times, over at
least a two-year period
Slide 25
Normal bereavement – 2 months
Bipolar depression - previous (hypomanic)
episode
DYTHYMIC DISORDER Chronic “Low grade” 2
years
Adjustment Disorder- depressed mood
Other mental disorders e.g. schizoaffective
Substance induced
Medical – e.g. Hypothyroidism,
Slide 26
$15 billion / yr (USA)
2030 - second leading cause of disability
(WHO) after HIV
Morbidity – presenteeism, absenteeism,
relationship, occupational, obesity, diabetes,
cancers
Comorbidity ( worse prognosis)– anxiety
disorders, substance use disorders,
personality disorders,
Slide 27
Mortality - lifetime risk of suicide in the US
estimated at “3.4%”,
Men -almost 7%
Women- 1%
The estimate is substantially lower than a
previously accepted figure of 15%, which had
been derived from older studies of
hospitalized patients -15%
Slide 28
Mortality – lifetime risk of suicide in
untreated major depressive disorder 20%
Less than 25% of those with MDD adequately
treated
Slide 29
smoking and obesity -increased likelihood
cardiovascular disease
-1.5- to 2-fold increased risk, independent of
other known risk factors
colorectal cancer
- Up to 43% greater risk in depressed women
- "dose-response" relationship observed
- overweight women had highest
Slide 30
Higher incidence in medical conditions
e.g. obesity, chronic pain , diabetes
neurological conditions such as strokes,
Parkinson's disease, MS
Slide 31
Lifetime prevalence (8% -12%)
Gender differential
Adolescent and adult females : males - 2:1
Age of onset
rare before puberty
average age at onset is the late 20s.
may begin at any age, but peak 25-44
Slide 32
Clinical course
Initial episode may be triggered by stressor
develop over days to weeks
Prodromal symptoms -generalized anxiety,
panic attacks, phobias, or depressive
symptoms that do not meet the diagnostic
threshold may occur over the preceding
several months.
Slide 33
Clinical course
mean duration of a major depressive episode
16 weeks
Untreated -6 months or longer
median time to recovery from a major
depressive episode is approximately 20
weeks
Slide 34
Recurrence risk
After one episode – 50-60% for 2nd
After 2nd episode – 70% for 3rd
After 3rd episode - 90% +
Slide 35
Episodes may become
more frequent
More prolonged
Less treatment responsive
More spontaneous/autonomous
Slide 36
Partial remission - higher risk for relapse
Longer episode duration- poorer prognosis
More episodes – poorer prognosis
Maintenance of full therapeutic dose for 6-12
months reduces relapse risk by 50%
Slide 37
Implications
Treat Early
Aim for remission
Maintain treatment dose for 6-12
months in remission or indefinitely
Slide 38
Response
Relapse
Remission
Recurrence
Return to premorbid functioning
Slide 39
Symptom
remission
Treat comorbid disorders
Restore premorbid functioning
Attempt to limit disease
progression.
Slide 40
Safety – where to treat (clinic, hospital)
How to treat
With whom to treat
Slide 41
I General
II Psychotherapy –CBT, IPT
III Biological -Medication, ECT
IV Other – TMS, VNS, deep brain
stimulation
Slide 42
Promote treatment adherence
Pschoeducation – re: illness, treatment
options, patient preference
Exercise – minimum 150 min/wk
Establishing a routine with modest goals
Slide 43
Cognitive behavioural therapy
Interpersonal therapy
Solution focused therapy
Slide 44
Antidepressants
Augmenting
agents
Combinations
Slide 45
SSRI - Fluvoxamine, Citalopram, Paroxetine ,
Escitalopram, Sertraline, Fluoxetine
SNRI - Duloxetine, Venlafaxine, Desvenlafaxine
RIMA - Moclobemide
Miscellaneous – Bupropion, Mirtazapine ,
Slide 46
Quetiapine
Tricyclic antidepressants – e.g. nortriptyline,
imipramine, chlomopramine
Slide 47
Monoamine oxidase inhibitors (MAOIs)
e.g phenelzine, tranylcipramine
Slide 48
Evidence
for superior
efficacy/safety/tolerability
Slide 49
Escitalopram,
Sertraline,
Venlafaxine
Slide 50
Duloxetine
Mirtazapine
Slide 51
Early indication of response after 2-4 weeks
With response allow for a further 2 – 4 weeks
If clear but inadequate response then ADD
If poor response then CHANGE
Slide 52
Previously - change classes e.g. SSRI’S
to SNRI
BUT
No evidence of benefit over change to
same class
Slide 53
Use other agents in the “superior “
group.
duloxetine,
escitalopram,
mirtazapine,
sertraline,
venlafaxine
Slide 54
lithium
triiodothyronine,
atypical
antipsychotic
Slide 55
venlafaxine/mirtazepine
“California Rocket fuel”
buproprion/SSRI
-
(Escitalopram/citalopram)
nortriptyline/SSRI’s
Slide 56
Commonly
done, but limited data
to support this practice
Slide 57
Create a controlled seizure
Right unilateral or bilateral
Increases mono amine neurotransmitters
ECT has the highest rates of response and
remission of any form of antidepressant
treatment, with 70%–90% of patients treated
showing improvement
Potential cognitive side effects
Slide 58
Transcranial Magnetic Stimulation
Light therapy ( even for non seasonal
affective disorder)
Deep brain stimulation
Vagus Nerve stimulation
Slide 59
Recurrence - Risk factors
◦ Persistence of subthreshold depressive symptoms
(relapse)
◦ Prior history of multiple episodes of major
depressive disorder
◦ Severity of initial and any subsequent episodes
◦ Earlier age at onset
◦ Presence of an additional nonaffective psychiatric
diagnosis
◦ Presence of a chronic general medical disorder
◦ Persistent sleep disturbances
Slide 60
common, occurring in 20% of patients
within 6 months following remission.
Slide 61
Remission rates (STAR*D)
First trial
- 36.8%,
Second trial - 30.6%,
Third trial
- 13.7%,
Fourth trial - 13.0%
Total
- 67% with trials, augmentation
and combination strategies
Slide 62
Depressed mood or appears depressed for two
years or more,
WITH two or more of:
◦ decreased or increased appetite
◦ decreased or increased sleep (insomnia or
hypersomnia)
◦ fatigue or low energy
◦ Reduced self-esteem
◦ Decreased concentration or problems making
decisions
◦ Feels hopeless or pessimistic
Slide 63
Symptoms never absent longer than two consecutive months.
No major depressive episode during first two years
No manic hypomanic or mixed episodes
The patient has never fulfilled criteria for cyclothymic
disorder.
The depression does not exist only as part of a chronic
psychosis
The symptoms not directly caused by a medical illness or by
substances, including drug abuse, or other medications.
The symptoms may cause significant problems or distress in
social, work, academic, or other major areas of life
functioning.
Slide 64
major depression,
anxiety disorders (up to 50%)
personality disorders (20–40% or more
among those with early-onset DD),
somatoform disorders (2.8%–45.2%),
substance abuse (up to 50%).
Slide 65
As per MDD but response may take
longer
More likely to maintain treatment
indefinitely
Slide 66
Criteria not met for MDD or DD
Exclude the exclusion criteria
Treatment options to consider as per
MDD
Slide 67
Common, more common in women than men
recurrent , progressive, chronic,
Associated with morbidity, comorbidity,
mortality
Repercussions –personal, relationship, societal
Goal of treatment – symptom relief, limit
disease progression, restore premorbid
function.
Using pharmacotherapy, psychotherapy and
other strategies, the majority can be helped
K.E. .Badoe MBChB., FRCPC
Medical Director, Trellis Mental Health and Developmental
Services, Guelph
MEDICAL FIESTA August 9th 2012
Slide 2
Review an approach to diagnosis of Depressive
Disorders
Examine the clinical course of MDD
Consider the rationale behind the drive to
achieve remission
Evidence-based selection of treatment options
Slide 3
“ Depression”
Slide 4
“Doctor, I am depressed”
because...
My lotto numbers did not “drop” this
week
My wife left me last week
My husband died three years ago
There is no reason for me to feel this
way
Slide 5
Diagnosis
and treatment of
“depression”
depended on the clinician’s
perspective
Slide 6
Psychological
biological
- nurture
- nature
Slide 7
Causation -life events, “stressors”
Diagnosis – Reactive depression,
Neurotic depression
Treatment - psychotherapy “tell me
about your mother.... Your finances,
your husband, boss
Slide 8
One man’s stress, is another man’s pleasure
“If I look hard enough, I will find stress”
e.g. travelling to Ghana, jet lag, preparing
for a presentation, carrying back kobe
Slide 9
Diagnosis – Endogenous depression
Treatment - Biological –medication,
ECT
Slide 10
No one would consider putting someone on
an antidepressant because of a lotto ticket
What about the man who has lost 30 pounds,
cannot sleep, has been thinking of suicide for
the past two months, because of the lotto
ticket?
And on what basis would one decide which
treatment?
Slide 11
Somewhere
in between
Slide 12
Symptoms clusters that responded biological
interventions
Mood disturbance that seemed to be
autonomous, impairment in in parametres
such as sleep, energy, appetite, concentration
Precipitants/stressors – not relevant to the
diagnosis of MDD (except bereavement)
Slide 13
A. At least Five
of the following
symptoms
present during the same 2-week
period
represent a change from previous
functioning
Slide 14
Of five at least one of the symptoms is
EITHER
(1) depressed mood most of the day, nearly
every day, either subjective report (e.g., feels
sad or empty) or observation by others (e.g.,
appears tearful). In children and adolescents,
can be irritable mood.
OR
(2) markedly diminished interest or pleasure in
all, or almost all, activities most of the day,
nearly every day .
Slide 15
(3) significant weight loss when not dieting
or weight gain (e.g., a change of more than
5% of body weight in a month), or decrease
or increase in appetite nearly every day.
Note: In children, consider failure to make
expected weight gains.
(4) insomnia or hypersomnia nearly every
day
Slide 16
(5) psychomotor agitation or retardation
nearly every day (observable by others, not
merely subjective feelings of restlessness or
being slowed down)
(6) fatigue or loss of energy nearly every
day
Slide 17
(7) feelings of worthlessness or excessive or
inappropriate guilt (which may be delusional) nearly
every day (not merely self-reproach or guilt about
being sick)
(8) diminished ability to think or concentrate, or
indecisiveness, nearly every day (either by subjective
account or as observed by others)
(9) recurrent thoughts of death (not just fear of
dying), recurrent suicidal ideation without a specific
plan, or a specific plan for committing suicide or a
suicide attempt
Slide 18
B. The symptoms do not meet criteria for a
Mixed Episode.
C. The symptoms cause clinically significant
distress or impairment in social, occupational,
or other important areas of functioning.
D. The symptoms are not due to the direct
physiological effects of a substance (e.g., a
drug of abuse, a medication) or a general
medical condition (e.g., hypothyroidism).
Slide 19
E. The symptoms are not better accounted
for by Bereavement, i.e., after the loss of a
loved one, the symptoms persist for longer
than 2 months or are characterized by
marked functional impairment, morbid
preoccupation with worthlessness, suicidal
ideation, psychotic symptoms, or
psychomotor retardation.
Slide 20
Major depressive disorder
◦ Major depressive disorder, single episode
◦ Major depressive disorder, recurrent - (two or
more episodes)
Dysthymic disorder
Depressive Disorder NOS
(Adjustment Disorder – depressed mood)
Slide 21
Major depressive disorder
◦ Major depressive disorder, single episode
◦ Major depressive disorder, recurrent - (two or
more episodes)
Slide 22
Mild
Moderate
Severe without psychotic features
Severe with psychotic features
In partial remission
In remission
Slide 23
Melancholic depression - loss of pleasure in most or all
activities,, a quality of depressed mood more pronounced
than that of grief or loss,
a worsening of symptoms in the morning hours, earlymorning waking, psychomotor retardation, excessive weight
loss, excessive guilt.
Atypical depression - mood reactivity (paradoxical
anhedonia) and positivity, significant weight gain or increased
appetite (comfort eating), hypersomnia ,), a sensation of
heaviness in limbs known as leaden paralysis, and significant
social impairment as a consequence of rejection
hypersensitivity
Slide 24
Catatonic depression - rare and severe form of major
depression involving disturbances of motor behavior and
other symptoms. Patient is mute and almost stuporous,
immobile or engages in purposeless or even bizarre
movements.
Rule out schizophrenia /neuroleptic malignant syndrome .
Post partum depression -10–15% among new mothers onset
occur within one month of delivery
Seasonal affective Disorder (SAD) – onset fall/autumn
subsides following spring ,at least two episodes have
occurred in colder months with none at other times, over at
least a two-year period
Slide 25
Normal bereavement – 2 months
Bipolar depression - previous (hypomanic)
episode
DYTHYMIC DISORDER Chronic “Low grade” 2
years
Adjustment Disorder- depressed mood
Other mental disorders e.g. schizoaffective
Substance induced
Medical – e.g. Hypothyroidism,
Slide 26
$15 billion / yr (USA)
2030 - second leading cause of disability
(WHO) after HIV
Morbidity – presenteeism, absenteeism,
relationship, occupational, obesity, diabetes,
cancers
Comorbidity ( worse prognosis)– anxiety
disorders, substance use disorders,
personality disorders,
Slide 27
Mortality - lifetime risk of suicide in the US
estimated at “3.4%”,
Men -almost 7%
Women- 1%
The estimate is substantially lower than a
previously accepted figure of 15%, which had
been derived from older studies of
hospitalized patients -15%
Slide 28
Mortality – lifetime risk of suicide in
untreated major depressive disorder 20%
Less than 25% of those with MDD adequately
treated
Slide 29
smoking and obesity -increased likelihood
cardiovascular disease
-1.5- to 2-fold increased risk, independent of
other known risk factors
colorectal cancer
- Up to 43% greater risk in depressed women
- "dose-response" relationship observed
- overweight women had highest
Slide 30
Higher incidence in medical conditions
e.g. obesity, chronic pain , diabetes
neurological conditions such as strokes,
Parkinson's disease, MS
Slide 31
Lifetime prevalence (8% -12%)
Gender differential
Adolescent and adult females : males - 2:1
Age of onset
rare before puberty
average age at onset is the late 20s.
may begin at any age, but peak 25-44
Slide 32
Clinical course
Initial episode may be triggered by stressor
develop over days to weeks
Prodromal symptoms -generalized anxiety,
panic attacks, phobias, or depressive
symptoms that do not meet the diagnostic
threshold may occur over the preceding
several months.
Slide 33
Clinical course
mean duration of a major depressive episode
16 weeks
Untreated -6 months or longer
median time to recovery from a major
depressive episode is approximately 20
weeks
Slide 34
Recurrence risk
After one episode – 50-60% for 2nd
After 2nd episode – 70% for 3rd
After 3rd episode - 90% +
Slide 35
Episodes may become
more frequent
More prolonged
Less treatment responsive
More spontaneous/autonomous
Slide 36
Partial remission - higher risk for relapse
Longer episode duration- poorer prognosis
More episodes – poorer prognosis
Maintenance of full therapeutic dose for 6-12
months reduces relapse risk by 50%
Slide 37
Implications
Treat Early
Aim for remission
Maintain treatment dose for 6-12
months in remission or indefinitely
Slide 38
Response
Relapse
Remission
Recurrence
Return to premorbid functioning
Slide 39
Symptom
remission
Treat comorbid disorders
Restore premorbid functioning
Attempt to limit disease
progression.
Slide 40
Safety – where to treat (clinic, hospital)
How to treat
With whom to treat
Slide 41
I General
II Psychotherapy –CBT, IPT
III Biological -Medication, ECT
IV Other – TMS, VNS, deep brain
stimulation
Slide 42
Promote treatment adherence
Pschoeducation – re: illness, treatment
options, patient preference
Exercise – minimum 150 min/wk
Establishing a routine with modest goals
Slide 43
Cognitive behavioural therapy
Interpersonal therapy
Solution focused therapy
Slide 44
Antidepressants
Augmenting
agents
Combinations
Slide 45
SSRI - Fluvoxamine, Citalopram, Paroxetine ,
Escitalopram, Sertraline, Fluoxetine
SNRI - Duloxetine, Venlafaxine, Desvenlafaxine
RIMA - Moclobemide
Miscellaneous – Bupropion, Mirtazapine ,
Slide 46
Quetiapine
Tricyclic antidepressants – e.g. nortriptyline,
imipramine, chlomopramine
Slide 47
Monoamine oxidase inhibitors (MAOIs)
e.g phenelzine, tranylcipramine
Slide 48
Evidence
for superior
efficacy/safety/tolerability
Slide 49
Escitalopram,
Sertraline,
Venlafaxine
Slide 50
Duloxetine
Mirtazapine
Slide 51
Early indication of response after 2-4 weeks
With response allow for a further 2 – 4 weeks
If clear but inadequate response then ADD
If poor response then CHANGE
Slide 52
Previously - change classes e.g. SSRI’S
to SNRI
BUT
No evidence of benefit over change to
same class
Slide 53
Use other agents in the “superior “
group.
duloxetine,
escitalopram,
mirtazapine,
sertraline,
venlafaxine
Slide 54
lithium
triiodothyronine,
atypical
antipsychotic
Slide 55
venlafaxine/mirtazepine
“California Rocket fuel”
buproprion/SSRI
-
(Escitalopram/citalopram)
nortriptyline/SSRI’s
Slide 56
Commonly
done, but limited data
to support this practice
Slide 57
Create a controlled seizure
Right unilateral or bilateral
Increases mono amine neurotransmitters
ECT has the highest rates of response and
remission of any form of antidepressant
treatment, with 70%–90% of patients treated
showing improvement
Potential cognitive side effects
Slide 58
Transcranial Magnetic Stimulation
Light therapy ( even for non seasonal
affective disorder)
Deep brain stimulation
Vagus Nerve stimulation
Slide 59
Recurrence - Risk factors
◦ Persistence of subthreshold depressive symptoms
(relapse)
◦ Prior history of multiple episodes of major
depressive disorder
◦ Severity of initial and any subsequent episodes
◦ Earlier age at onset
◦ Presence of an additional nonaffective psychiatric
diagnosis
◦ Presence of a chronic general medical disorder
◦ Persistent sleep disturbances
Slide 60
common, occurring in 20% of patients
within 6 months following remission.
Slide 61
Remission rates (STAR*D)
First trial
- 36.8%,
Second trial - 30.6%,
Third trial
- 13.7%,
Fourth trial - 13.0%
Total
- 67% with trials, augmentation
and combination strategies
Slide 62
Depressed mood or appears depressed for two
years or more,
WITH two or more of:
◦ decreased or increased appetite
◦ decreased or increased sleep (insomnia or
hypersomnia)
◦ fatigue or low energy
◦ Reduced self-esteem
◦ Decreased concentration or problems making
decisions
◦ Feels hopeless or pessimistic
Slide 63
Symptoms never absent longer than two consecutive months.
No major depressive episode during first two years
No manic hypomanic or mixed episodes
The patient has never fulfilled criteria for cyclothymic
disorder.
The depression does not exist only as part of a chronic
psychosis
The symptoms not directly caused by a medical illness or by
substances, including drug abuse, or other medications.
The symptoms may cause significant problems or distress in
social, work, academic, or other major areas of life
functioning.
Slide 64
major depression,
anxiety disorders (up to 50%)
personality disorders (20–40% or more
among those with early-onset DD),
somatoform disorders (2.8%–45.2%),
substance abuse (up to 50%).
Slide 65
As per MDD but response may take
longer
More likely to maintain treatment
indefinitely
Slide 66
Criteria not met for MDD or DD
Exclude the exclusion criteria
Treatment options to consider as per
MDD
Slide 67
Common, more common in women than men
recurrent , progressive, chronic,
Associated with morbidity, comorbidity,
mortality
Repercussions –personal, relationship, societal
Goal of treatment – symptom relief, limit
disease progression, restore premorbid
function.
Using pharmacotherapy, psychotherapy and
other strategies, the majority can be helped