TeCLA - GHANA (Capacity building for health workers in managing NCDs)

Topic: Depression in various age groups and subpopulations

Date: 9th May 2023

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LESSONS LEARNT FROM TeCLA SESSION 2
(DIABETES IN PREGNANCY)

DR. BENEDICTA AFRIFA TOTTIMEH

NOTRE DAME CLINIC, NSAWAM
LESSONS LEARNT

► We have learnt that hyperglycemia in pregnancy is classified into types.ie pregestational

diabetes, diabetes in pregnancy, and gestational diabetes.
► Gestational diabetes-usually developed going into the 3rd trimester, few risks factors
are,-overweight ,obesity, previous delivery of macrosomic baby, previous history of gdm.
► We have also learnt that every pregnant woman is to be screened for gdm at 24-28 wks
gestation with ogtt.
► We have learnt that in the diagnosing of gdm at anytime during pregnancy should be based on
these values,
► fbs—5.1-6.9mmol/l, 1-hour post 75g oralglucose load->10.0mmol/l and 2h post 75g oral glucose
load-8.5-11.0mmol/l
Application At Notre Dame Clinic

- We are going to screen every pregnant woman at 24-28wks

- We are also using the hba1c for our diagnosis and also ogtt is done the first and
second trimester.
- Other labs like buecr and usg assessment is also done
- We are also using metformin and modified lifestyle for the management of gdm.
- Also we counsel and educate them on their condition ,complications and the
need to take their medication.
 Dr. Amma Mpomaa Boadu is a specialist psychiatrist, and Deputy Director ,
Mental Health for the Ghana Health Service. She has in the last three years
been working to minimize the mental health treatment gap by leading the
development of training programs and training both mental health and
non-mental health practitioners pre and in service.

She also continues to lead in developing training programs, and lead

facilitator for Mental Health And Psychosocial Support Skills (MHPSS) training
for different categories of emergency responders apart from health workers
across the country to address the ever growing need for psychosocial
support which is almost always forgotten in emergency situations as the
COVID-19 pandemic and outbreaks of other diseases such VHFs, and other
other emergency situations.

Prior to her role in the Ghana Health Service, she had been providing
specialist psychiatrist care to people with lived experience in underserved
areas of Ghana through her work with an NGO BasicNeeds Ghana apart from
providing services in different capacities at the Accra Psychiatric Hospital for
seven years.

Dr. Amma Boadu She is a member of the Ghana College of Physicians and Surgeons, and
Deputy Director, Mental Health pursuing a fellowship in Psychiatry in the same college.
Ghana Health Service
 Dr. Adwoa Mintaah Kusi-Kyere is a psychiatrist and medical educator
with extensive experience in mental health service delivery. She is a
member of both the Ghana College of Physicians and Surgeons and
the West African College of Physicians, and she plays an important role
in training and mentoring psychiatry junior residents.

She also trains medical and physician assistant students and provides
guidance and support to primary care professionals and mental health
nurses to recognize, evaluate, and manage prevalent mental,
neurological, and substance use disorders.

Dr. Kusi-Kyere currently works at the Mental Health Department of the

Ghana Health Service's Institutional Care Division, where she helps to
coordinate, monitor, and develop mental health services in both facility-
and community-based settings in Ghana.

Dr. Adwoa Kusi-Kyere

Psychiatrist
Ghana Health Service
 DR. AMMA BOADU

Depressions in Various Age-groups and Sub-populations

 Introduction

OUTLINE
Identification and
Assessment of Depression

Sub-populations Across
Different Levels of Care

Suicide Risk Assessment in

Different Age Groups

Conclusion
INTRODUCTION
 It causes
persistent
Depression is a feelings of
mental health sadness, loss of
disorder energy, and loss
of interest in daily
activities
Definition of depression
Leads to
emotional and
It affects how you physical problems
feel, think, and which can
behave significantly
impair
functioning.
 Depression can affect anyone, regardless of
age or background.

Experience of depression is different due to

Importance of discussing cultural, social, or environmental factors.
depression in different
age-groups and
sub-populations
To identify unique risk factors and develop
tailored interventions.

Prevent more severe symptoms and

improve overall quality of life.
Why do we need to scale up assessment and care for
depression in PHC?

● Annual prevalence
On average, about 5% in the community
Especially common among persons attending primary health
care

● Depression can affect physical disease. E.g.

It predisposes to myocardial infarctions
It reduces adherence to treatment for chronic diseases, incl.
HIV and TB

17
Identification and Assessment of Depression
SIGNS AND SYMPTOMS OF DEPRESSION

Persistent feelings of sadness, or low mood. ● Difficulty concentrating, making decisions, or

remembering things.
Loss of interest or pleasure in activities that were
once enjoyable. ● Thoughts of suicide or self-harm.

Fatigue, low energy, or a lack of motivation ● Irritability, restlessness, or anger.

Difficulty sleeping or sleeping too much. ● Withdrawal from friends and family or social
situations.
Changes in appetite or weight.

Feelings of emptiness, worthlessness or guilt. ● Note: Physical symptoms such as headaches,

stomachaches, or chronic pain could be present.
Reduced self esteem or self confidence

Hopelessness, bleak and pessimistic view of the

future

2 core and 3 other symptoms > 2 weeks +/- impairment of daily activities
Assessment tools for depression
(PHQ-9)

Used to identify
individuals in need of
further evaluation or Patient Health
treatment. Questionnaire-9
(PHQ-9) self
administered, rates
severity of depressive
symptoms on a scale
from 0 to 3. Scores of
10 or higher are
Should be used considered indicative
in conjunction of depression.
with a clinical
evaluation
 Prevents worsening symptoms and leads
to a better prognosis.
Effective treatments like medication and
Importance of early psychotherapy are available.
detection and treatment/
intervention Reduces the impact on social,
occupational, and academic functioning.
Prevents suicide

Reduces stigma and encourages

individuals to seek help
SUB-POPULATIONS ACROSS DIFFERENT LEVELS OF CARE
 Estimated around Presentations vary
3% of children and according to the age
13% of adolescents of the child

DEPRESSION IN CHILDREN AND Eating and sleeping

ADOLESCENTS
Children may
difficulties are
present with more
common in young
somatic symptoms
children

Older children may

Adolescents may
have trouble with
express feelings of
school performance
sadness, boredom or
or play less than
inadequacy
usual
● Tearfulness, or hopelessness
● Irritability, anger, or frequent
outbursts
● Refusal to participate in activities
or play with friends
● Loss of interest in toys or games
● Difficulty sleeping or sleeping too
much
● Changes in appetite, weight loss
or gain
● Fatigue, lack of energy, or
sluggishness
● Difficulty concentrating or paying
attention
● More physical complaints, such as
stomach aches or headaches
● Poor school performance
● Thoughts of death or suicide (in rare
cases)

DEPRESSION IN CHILDREN
Depression in older adults
Difficult to recognize, as symptoms may be attributed to other health problems or
dismissed as a normal part of aging.

Depression affects about 7% of older adults (WHO)

Factors increasing the risk of depression in the elderly

• Chronic medical conditions, such as heart disease, stroke, cancer, or diabetes

• Chronic pain or physical disability
• Cognitive decline or dementia
• Loss of independence or social support
• Bereavement or loss of a loved one
• Financial stress or instability
• Substance abuse or misuse of medications
• History of trauma or abuse
• Isolation or loneliness
Postpartum depression

Prevalence: about 10% of women after delivery

Onset: most common in the first few months after birth

Duration: from months to a year

Impact: may reduce the interaction between mother

26
and
child and delay child development
 ● Personal or family history of ● Lack of social support or
depression or other mental stressful life events
health disorders
● Relationship problems or
● Hormonal changes that domestic violence
occur during pregnancy
● Financial or employment
and childbirth
stress
Risk factors for
● Difficult pregnancy or
postpartum depression ● Having a baby with health
childbirth, such as
problems or special needs
premature delivery or
complications during ● Substance abuse or history
delivery of trauma or abuse
 One-third of individuals with chronic illnesses have
been estimated to experience depression.
Depression and suicide
risk in individuals with Suicide risk is higher among individuals with chronic
chronic illnesses illnesses, especially those with chronic pain.

Risk factors for depression and suicide risk:

• Chronic pain or discomfort

• Loss of independence or mobility
• Financial stress or burden
• Difficulty managing symptoms or treatment
• Fear of worsening illness or death
• Social isolation or stigma
• Changes in body image or functioning
AVERAGE PREVALENCE OF DEPRESSION IN PEOPLE WITH PHYSICAL DISEASES (70 COUNTRIES)

29
 Children and Elderly with
Presentations that may adolescents with dementia-type
behavioural problems symptoms
be cases of depression

Caregivers of adults
People with and children with
self-harm, alcohol use mental, neurological
problems or epilepsy or substance use
disorders

30
 DR. ADWOA MINTAA KUSI-KYERE

Depressions in Various Age-groups and Sub-populations

SUICIDE RISK ASSESSMENT IN DIFFERENT AGE GROUPS
SUICIDE DATA
● Globally, about 700,000 - 800,000 people die by suicide
annually, i.e., 1 every 40 secs
● Suicide rate in Ghana: 1500 per year
■ Data from DHIMS: 470 attempts in the first quarter of
2022
● Suicide is under reported. For every attempted suicide,
there are 4 under reported, 10 more attempting, 10 more
with a plan, 10 more with thoughts
● Suicide rates tend to be highest among individuals aged
15-29 years and 65 years or older (WHO's 2016 global
report on suicide prevention)
SUICIDE DATA

Women attempt suicide 3-4x more than

men

Men die by suicide 3x more

Suicide decriminalized in Ghana

Asking about self-harm does NOT

provoke acts of self-harm.

Media reportage and copycat suicide

Factors that increase suicide risk in different age groups

● Suicide is complex, multiple factors can contribute to increased

risk.
● Some individuals may not exhibit any of these risk factors, while
others may exhibit multiple.
● Take all warning signs seriously.
● Risk factors common to all age groups and populations:
■ Mental health disorders such as depression, anxiety, and
bipolar disorder
■ Substance abuse
■ Previous suicide attempts
■ Access to lethal means such as weapons, poisons or
medications
SPECIFIC RISK FACTORS FOR SUICIDE
Adolescents
History of self-harm or suicidal
behavior in family members or
friends
Exposure to suicidal behavior or
suicide in peers or media
Bullying or social isolation
Adults
● Physical illness or chronic pain
● Relationship problems or divorce
● Financial difficulties or job loss
Older Adults
● Physical illness, or chronic pain
● Loss of a spouse or loved one
● Social isolation or loneliness
● Changes in cognitive function or
dementia
 Suicidal behavior can be difficult to
predict

Not everyone contemplating suicide will

Warning signs of exhibit these warning signs.
suicide

If you notice any of these behaviors, take

them seriously and seek help from a
mental health professional or use the crisis
hotline.
 Warning signs of suicide
● Talking about wanting to die or to kill
oneself
● Expressing feelings of hopelessness or
helplessness
● Talking about feeling trapped or being in
unbearable pain
● Increasing the use of alcohol or drugs
● Acting recklessly or engaging in risky
activities
● Withdrawing from friends, family, and social
activities
● Sleeping too much or too little
● Displaying extreme mood swings, including
rage or despair
● Giving away prized possessions or making
arrangements for the future
● Preoccupation with death, dying, or suicide in
conversations or behavior
 S- Sex (male)
Suicide risk assessment
A- Age (older than 44 or younger than 20)
tools (Sad Persons Scale)
D- Depression/ other mental illness

P- Previous suicide attempts

E- Excessive alcohol or drug use

Total Proposed clinical action R- Rational thinking loss

points

0 to 2 Send home with follow-up S- Social support lacking

3 to 4 Close follow-up; consider
hospitalization O- Organized plan/ lethal plan/ serious intent
Strongly consider hospitalization,
5 to 6 depending on confidence in the N- No significant other/ lack of a confiding relationship
follow-up arrangement

7 to 10 Hospitalize or admit S – Sickness (chronic, debilitating, severe)

Treatment and prevention of depression and suicide
Overview of different types of treatments for depression

Psychosocial
Psychotherapy
interventions

Antidepressant
ECT
medication
 Offer Offer the person an opportunity to talk in private

Ask about Ask about current stressors

Ask about Ask about available resources for support

Addressing
psychosocial stressors Assess Assess for abuse (e.g. domestic violence) and neglect

Brainstorm Brainstorm together for solutions or for ways of coping

Involve Involve supportive family members as appropriate

Encourage Encourage involvement in support groups

42
 Identify the Prioritize the
problems problems

Problem solving Select the Think about all

problem to be possible solution
techniques addressed to the problem

Select the most

Implement the
appropriate
solution
solution

43
Reactivate social networks

Identify social activities that provide psychosocial support

family outings visiting community

sports
gatherings with friends neighbors activities

Encourage the person and family to pursue these

44
activities
as they can be effective in helping a person overcome
depression
How do you address psychosocial stressors in children and
adolescents

1 2 3 4
Assess parent’s Assess and manage If there are school Provide
psychosocial maltreatment, performance parent/care giver
stressors and exclusion and problems, discuss education and
manage them to the bullying (ask child
extent possible with with the teacher skills training if
or adolescent on how to support available
the help of available directly about it)
community resources the student
 SSRIs (fluoxetine), TCA (amitriptyline)

Time of onset is 4-6 weeks

Treatment should continue for 9 - 12 months

Antidepressants Taper slowly if ceasing medication

treatment Do not prescribe anti-depressants to
• A functioning person (mild depression)
• Someone recently bereaved, physical cause
• Children, pregnant, breastfeeding mothers

Avoid TCAs if
• The person is elderly, suicidal, has dementia or cardiovascular
disease
 Crisis intervention:
hotlines, emergency
departments, and Psychotherapy
psychiatric hospitals
can help.
Overview of different
types of treatments for Safety planning,
suicide identifying triggers,
Medications coping strategies,
and sources of
support.
 No one-size-fits-all

Provide tailored interventions

Importance of Address specific symptoms, causes, and

personalized treatment risk factors
plans
Help individuals feel heard, validated,
and supported
Increase an individual's sense of agency
and control over their mental health
CONCLUSION
Recap of key points
Depression and suicide are major public health concerns affecting all
ages and backgrounds.
Risk factors include biological, psychological, and environmental
factors.
Using tools like PHQ-9, Sad persons score aid in identifying those at
risk for further assessment, management and referral.
Management involves pharmacological and non-pharmacological
interventions.

Call to action for
supporting individuals with
depression and suicide
risk.
Recognize
• Recognize that mental health is just as important as
physical health
Listen and provide
• Actively listen and provide support to those in need
Work
• Work together to break the stigma surrounding
depression and suicide
• Promote a culture of openness and non-judgmental
support within healthcare settings
Prioritize
• Prioritize mental health screenings during routine medical
visits
Thank You
References
● World Health Organization. (2019). Depression. https://www.who.int/news-room/fact-sheets/detail/depression

● World Health Organization. (2016). International Classification of Diseases, 10th Revision (ICD-10).
https://icd.who.int/browse10/2016/en

● World Health Organization. (2016). International Classification of Diseases, 10th Revision (ICD-10).
https://icd.who.int/browse10/2016/en

● World Health Organization (2017). Suicide: Key Facts. . Available

at: https://www.who.int/news-room/fact-sheets/detail/suicide

● Daily Graphic (2015.). Interview with the Chief Executive Officer (CEO) of the Mental Health Authority (MHA) of
Ghana. Available
at: http://ghheadlines.com/agency/citifm/20170405/38741183/world-health-day-depression-and-spate-of-suicid
e-in-ghana-article

● Mental Health Authority of Ghana (MHAG) (2016). Statement on the recent spate of suicide among university
students in Ghana. Available
at: http://ghheadlines.com/agency/citifm/20170405/38741183/world-health-day-depression-and-spate-of-suicid
e-in-ghana-article

● World Health Organization. (2010). mhGAP Intervention Guide for Mental, Neurological and Substance Use
Disorders in Non-Specialized Health Settings: Mental Health Gap Action Programme (mhGAP).
https://www.who.int/publications/i/item/mhgap-intervention-guide---version-1.0
References
● National Institute of Mental Health. (2021). Depression.
https://www.nimh.nih.gov/health/topics/depression/index.shtml

● American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.).
https://doi.org/10.1176/appi.books.9780890425596

● Centers for Disease Control and Prevention. (2021). Depression.

https://www.cdc.gov/mentalhealth/depression/index.htm

● National Alliance on Mental Illness. (2021). Depression.

https://www.nami.org/About-Mental-Illness/Mental-Health-Conditions/Depression

● American Psychological Association. (2019). Depression: How psychotherapy and other treatments can help
people recover. https://www.apa.org/topics/depression/treatment-recovery

● National Institute of Mental Health. (2021). Suicide prevention.

https://www.nimh.nih.gov/health/topics/suicide-prevention/index.shtml
Case Presentation
Case Presentation

LAURA NYARKO AKUAMOAH

SDA HOSPITAL
 Case Presentation
Bio Data

Name: Madam X.R.

Age: 22 YEARS

Marital Status: Single

Tribe: Akan

Religion: Christian

Occupation: Shop Attendant

Level of Education: Senior High

 Case Presentation

Presenting Complaint
- Headache, Sharp pains in the stomach, inability to sleep, loss of
appetite
 Case Presentation
History of Presenting Complaint

- Patient complains of having headaches and sharp pains in the epigastric of the stomach for 2 weeks.

- She has not been able to sleep and has lost appetite for 16 days.

- It was mild initially and intensified.

- Pain is exhibited after meals. there is no hematopezia

- According to the patient, after completing senior high school in 2021, she had the desire

to enroll in a nursing school but her brother who was her caretaker asked her to wait

for her other siblings to complete school since he had financial difficulties.
 Case Presentation

History of Presenting Complaint

- She has refused to eat and been fasting and praying for financial breakthrough.

- She has withdrawn from every social activity she once engaged in.

- She has been crying every day and refused to talk to everyone.
 Case Presentation
Past Medical History - A KNOWN PEPTIC ULCER PATIENT For Three years, NO
hypertension, NO DIABETES.
Past surgical history - NO MYOMECTOMY NO CAESARIAN SECTION NO
LAPAROTOMY
Past O&G History: Patient does not remember her last menstrual cycle. She
menstruates for five days and has 31 days cycle. She had menarche at sixteen
years.
Sexual Activity: Patient has no partner and doesn’t have any children
 Case Presentation

Drug History
- Tap paracetamol 1 gram start and tap omeprazole 20mg bd was administered at
the opd to relieve patient from pain

- Patient is currently not on any medication because of the acute state of

the condition to allow for further assessment
 Case Presentation
Allergy: NO Allergies
Family History: There is no family history of depression and any other
condition
Social History: Client is second born of four siblings to both parent who are alive.
Three siblings are currently staying with both parent at the Northern Region. Client
stays with her caretaker who is an employer to her. Client is a Christian who attends
one of the Pentecostal Churches (Faith Chapel)
 Case Presentation

Examination Findings (general examination):

- She is not warm to touch
- Not pale
- Anicteric
- Hydration is normal
 Case Presentation
Systemic Exam
Cardiovascular system- Heart rate 82 bpm Bp 110/70 mmhg Heart sounds 1
and 2 where present with no louder sound.`

Respiratory system- Chest is clinically clear

Abdominal exam- No Abdominal Tenderness

 Case Presentation
Systemic Exam
Mental Status Examination

APPEARANCE- patient neatly dress in an African

short dress with a slippers to match. hair well kept ,no deformity on her body and eye contact is normal.

ORIENTATION - patient is oriented to time ,place and persons

MOOD - depressed

PERCEPTION- patient has no form of visual or auditory hallucination .

THOUGHTS - suicidality-none
- delusion-religious
.
BEHAVIOUR - Patient is cooperative

INSIGHT - patient has insight about her condition.

JUDGEMENT- patient has good judgement. she was able to differentiate between a nurse and a doctor
 Case Presentation

Diagnosis: DEPRESSION/ STOMACH ULCER

- BECK DEPRESSION INVENTORY WAS USED TO ACCESS THE PATIENT
AND THE SCORE WAS 6 SIGNIFYING MILD DEPRESSION
 Case Presentation
Management

1.COUNSELLING

2.COGNITIVE BEHAVIOURAL THERAPY

3.FAMILY THERAPY
 Case Presentation
Laboratory Investigations

*FBC

*WIDAL TEST

*H.PYLORI TEST

*PREGNANCY TEST

*LIVER FUNCTION TEST

 Case Presentation
Status of Patient / Update
- Patient is currently doing well , she is responding to treatment and had started
business to gather funds to pursue her education.
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