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Depression PP FV
Depression PP FV
Depression PP FV
Depression Guidelines
What is
Depression?
What is
Depression?
Emotional numbness or emptiness Difficulty concentrating Moving or speaking slower than usual Thinking life is not worth living
Sadness
In response to stressful, life-changing events such as the death of a loved one, the loss of a relationship or employment, the natural reaction is sadness, discouragement and frustration. These emotions should gradually dissipate on their own after a few days or weeks.
Depression
When these feelings last for two weeks or longer and start to interfere with the activities of daily living such as work, family or relationships, this low mood may be clinical depression.
Men 7-12%
Women 20-25%
Depression is projected to become the leading cause of disability and the second leading contributor to the global burden of disease by the year 2020. Depression occurs in persons of all genders, ages, and backgrounds.
Treatable cause of pain, suffering, disability Recurrent and chronic course Major public health concern Increased absenteeism from work Affects family members and caregivers Increased use of medical services and emergency services/ increased length of stay in hospital for coexisting medical conditions
Increased mortality rates
Triggers
Depression
Gender Environment
Personality
anxiety disorders substance abuse/ dependence personality disorders (avoidant, obsessivecompulsive and self-defeating) migraine headaches cancer cerebral accidents myocardial infarctions
Sex: female > male Age: onset in 25-50 age group Family History: depression, alcohol abuse, sociopathy Childhood Experiences: loss of parent before 11 years old, negative home environment (abuse, neglect) Personality: avoidant, dependent, or obsessive compulsive Recent Stressors: financial, legal, migration, illness (chronic insomnia, chronic pain, diabetes, arthritis, myocardial infarction, stroke, recent trauma) Postpartum < 6 months Lack of intimate, confiding relationship or social isolation
For patients at risk for major depressive disorder, you can use this 2-question screening test:
Have you felt sad, low, down depressed or hopeless? Have you lost interest or pleasure in things you usually like to do?
* The symptoms must be present most of the day, nearly every day, during the same two-week period.
If the patient answers YES to either question, you should proceed with a further assessment.
3) These symptoms do not meet criteria for a mixed mood episode (an episode with symptoms of mania and depression occurring simultaneously.)
4) The symptoms are not due to the effects of a substance or general medical condition.
Subtypes of Depression
and how are they diagnosed?
a) Major Depressive Disorder, characterized by Major Depressive Episodes b) Dysthymic Disorder c) Depressive Disorder, not otherwise specified
Catatonic
Marked psychomotor disturbance (motoric immobility, excessive motor activity, negativism, mutism)
Moderate
15 19 PHQ-9
Melancholic
Loss of interest in all activities or lack of reactivity to pleasurable stimuli
Severe
20 o higher PHQ-9
Atypical
Significant weight gain or increase in appetite & hypersomnia
Postpartum
Onset of episode within 4 weeks postpartum
Adolescent Depression
Adolescence comprises the years from puberty to the mid-twenties Major depressive disorder (MDD) affects 6-8% of adolescents
Most people who develop MDD experience their first episode between the ages of 14-24
Youth onset of MDD usually develops into a chronic condition with substantial morbidity, poor economic/ vocational/ interpersonal outcomes and increased morbidity (from suicide and, in the long term, from other chronic illness: diabetes, heart disease, etc)
Adolescent Depression
Effective treatments that can be provided by first contact health providers are available Early identification and early effective treatment can decrease short-term morbidity and improve long-term outcomes (including decreased mortality)
Disorder
May be associated with a precipitating event
Differentiation of Distress and Disorder: important for outcome and intervention Distress
Can be a positive factor in life person learns new ways to deal with adversity Social supports such usual friendship and family networks help Counseling and other technical psychological interventions can help but may not be needed
Disorder
May increase adversity due to its effect on creation of negative life events (low mood can lead to relationship loss) May lead to long term negative outcomes (substance abuse, job loss, etc.)
Adolescent Depression
Risk Factors for MDD in Youth: 1. Family history of MDD 2. Family history of suicide 3. Family history of a mental illness (especially a mood disorder, anxiety disorder, substance abuse disorder) 4. Childhood onset anxiety disorder
M= mood
S= sleep I= interest G= guilt E= energy
A Memory Aid
C= concentration
A= appetite P= psychomotor agitation/ retardation S= suicide
Dysthymic Disorder
Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for at least 2 years.
poor appetite or overeating insomnia or hypersomnia low energy or fatigue poor concentration or difficulty making decisions feelings of hopelessness
Dysthymic Disorder
During the 2-year period (1 year for children and adolescents) of the disturbance, the person has never been without the symptoms in the first two criteria for more than 2 months at a time.
No MDE has been present during the first two years of the disturbance, that is, the disturbance is not better accounted for by chronic MDD, or MDD in partial remission.
The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
M= mood
S= sleep I= interest G= guilt E= energy
C= concentration
A= appetite P= psychomotor agitation/ retardation S= suicide
What is mood?
Mood is the ongoing inner feeling experienced by an individual.
+ 10 +7 +3
0
-3 -7
- 10
IF YES:
For how long have you been feeling this way? Do you feel that way nearly every day?
IF YES:
What do you normally enjoy doing? (Television? Reading? Sports? Shopping? Socializing? Eating? Hobbies? Sex?) What do you still enjoy?
appetite
sleep
IF INCREASED OR DECREASED:
Is it a problem nearly every day? For how long have you had sleep problems?
* Do you have problems falling asleep, staying, or waking up too early in the morning?
Retardation: Have you felt slowed down, like you were moving in slow motion or stuck in mud? IF YES:
Have others noticed this?
engery
IF YES How long have you been feeling this way? Do you feel like this nearly every day?
guilt
guilt
About what? How hard is it to get your mind off of this? Do you think about things from the past and feel guilty about them?
*How often do you think of these things? Is it on your mind every day?*
concentration
Have you been having problems thinking or concentrating? IF YES: What does this interfere with? Are you able to read? Watch TV? Follow a conversation? (how often, nearly every day?) Is it harder to made decisions than before?
IF YES: What kind of decisions are harder to make? What about every day decisions? (how often, nearly every day?
suicide
Sometimes when a person feels down or depressed they might think about dying. Have you been having any thoughts like that? IF YES: Tell me about it. Have you thought about taking your life? IF YES:
Did you think of a way to do it? How close have you come to doing it?
IF NO: Do you wish you were dead? When you go to sleep, do you often wish you would not wake up?
Clinical cases
Case # 1
Kwesia, a 43 year old woman, presents to you complaining of not being able to concentrate as well as she used to.
On further questioning you learn that her husband died suddenly 3 months previously and she is now solely responsible for the care of his 4 children. She is still very upset about his husbands death and her mood is low most every day. She has very little energy necessary to care for her children and go to work each day. She is tired most of the day even though she is sleeping 8 hrs each night- a lot more than he is used to. She no longer has an appetite and says that sometimes she wishes to die alongside his husband.
Case # 1
Does Kwesia qualify as a major depressive episode? Or is she just grieving the death of her husband?
Case # 2
Priya, a 25 year old woman had a healthy pregnancy and a
normal delivery. She and her husband were happy to welcome a healthy baby girl into their family. Directly following the birth Priya was excited about her new role as a mother but, within two weeks, she became more and more sad and withdrawn. She felt as though she would never be a good mother. She would never catch up on her sleep and she felt hopeless about the future. What further questions would you like to ask her?
Case # 2
Mood? low most every day Sleep? unable to sleep between feedings Interest in normally pleasurable activities? doesnt want to leave the house Guilt? feels extremely guilty about being a bad mother Energy level? she has very little energy Concentration? (decreased) Appetite? she has no interest in food Psychomotor retardation/ agitation? she feels as though she is always moving in slow motion Suicide Ideation? sometimes she goes to bed wishing she wouldnt wake up in the morning
Case # 3
Raj is a 55 year old man who has been active and employed as a laborer all his life. He is married with 2 grown children. For the last 2-3 years he has had increasing troubles at work. He has become more and more irritable and difficult to work with ultimately leading to the loss of his job.
Case # 3
For the past 2 years. Sleep .. He has been unable to sleep more than one hour at a time and never feels rested. Energy .. He has had no energy and wants to spend his days in bed. Appetite .. He no longer has much of an appetite.
Mood .. His wife reports she hasnt seen him smile in over a year
and that his mood is chronically low.
TREATMENT
Goal of Treatment
Restoring brain neurochemical balance. Improving sleep. Raising the energy level. Returning to normal appetite. Restore mood, interest and concentration to functional levels.
#2 Anti-depressants
SSRI TCA
#2 Psychotherapy
Cognitive-behavioural therapy (CBT) Interpersonal therapy (ITP) Problem-solving therapy (PST).
It is always helpful to include the patient in the treatment of their illness and have them be aware of their symptoms and signs of a relapse.
It is also helpful to utilize any community resources that exist.
Establish baseline PHQ-9 and baseline sleep and sexual function status
Start Fluoxetine or Citalopram 10mg by mouth once a day, each morning for 5 days, if well tolerated increase to 20mg.
Adults
Patients should continue on anti-depressant medications for at least 6 months AFTER full remission of symptoms.
Establish baseline PHQ-9 and baseline sleep and sexual function status
Adults
Patients should continue on anti-depressant medications for at least 6 months AFTER full remission of symptoms.
GPAC: Guidelines and Protocols Advisory Committee. Depression (MDD)Diagnosis and Management. British Columbia Medical Association, 2004
GPAC: Guidelines and Protocols Advisory Committee. Depression (MDD)Diagnosis and Management. British Columbia Medical Association, 2004
References
American Psychiatric Association. Lets Talk Facts About Depression, 2005. American Psychiatric Association. Practice Guidelines for the Treatment of Patients with Major Depressive Disorder, 2002. British Columbia Partners for Mental Health and Addictions Information, compiled by Eric Macnaughton. Depression Toolkit: Information and Resources for Effective SelfManagement of Depression, 2006. Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety Treatments (CANMAT). Clinical Guidelines for the Treatment of Depressive Disorders. Canadian Journal of Psychiatry 2001; 46. GPAC: Guidelines and Protocols Advisory Committee. Depression (MDD)- Diagnosis and Management. British Columbia Medical Association, 2004. Identification, Diagnosis and Treatment of Adolescent Depression (Major Depressive Disorder)A Package for First Contact Health Providers. Stan Kutcher & Sonia Chehil, 2008. Zimmerman, Mark. Interview guide for evaluating DSM-IV Psychiatric Disorders and the Mental Status Examination, 1994.