Anxiety and Depressive Disorder

Represented by:

Rudy Salam
Fakultas Kedokteran UB
Prodi Farmasi
Dr. Sarma R V S N
Consultant Physician
visit: www.drsarma.in
With thanks for the resource material from
http://www.hcc.bcu.ac.uk/craig_jackson/
psychopharmacology%20and%20serotonin.ppt
Neurotics build castles in the air
Psychotics live in them and enjoy
Psychiatrists collect rent for those castles
Traditional model of Disease Development

Pathogen Disease (pathology)

Modifiers
Lifestyle
Individual susceptibility
Dominance of the biopsychosocial model

Mainstream in last 15 years

Hazard
Illness (well-being)

Psychosocial Factors
Attitudes
Behaviour
Quality of Life Rise of the person as a
“psychological entity”
The Stress Hormone Cycle

Hypothalamus
CRF Stress
Stress
StressResponses
Responses
Responses
Pituitary Stress
StressResponses
Responses
Gland

ACTH
CORTISOL
Adrenal
Glands

CRF:
Corticotropin
Kidneys
Releasing
Factor
Depression

• It is a vague complaint
Depression: and the patient cannot
cope with ordinary stress.

• Psychic depression:
Decrease concentration
of noradrenaline and
Amine serotonin in the brain.
Hypothesi • Elevated mood: Increase
of noradrenaline and
s of Mood serotonin in the brain.
• Schizophrenia: increased
dopamine in the brain
Anxiety

Normal anxiety is Pathologic anxiety is

adaptive. It is an anxiety that is
inborn response to excessive, impairs
threat or to the function.
absence of people or
objects that signify
safety can result in
cognitive (worry) and
somatic (racing heart,
sweating, shaking,
freezing, etc.)
symptoms.
General considerations for anxiety disorders
• Often have an early onset- teens or
early twenties
• Show 2:1 female predominance
• Have a waxing and waning course over
lifetime
• Similar to major depression and chronic
diseases such as diabetes in functional
impairment and decreased quality of
life
The differential diagnosis of anxiety. Psychiatric and Medical disorders. Psychiatr Clin North Am 1985 Mar;8(1):3-23
• Anxiety may be due to one of the
primary anxiety disorders OR
secondary to substance abuse
(Substance-Induced Anxiety Disorder),
a medical condition (Anxiety Disorder
Due to a General Medical Condition),
another psychiatric condition, or
psychosocial stressors (Adjustment
Disorder with Anxiety)
MDD and Anxiety Disorders

Major
Major Anxiety
59%
Depression Disorders
Association of Psychiatric Disorders
Anxiety Disorder

• Exposure to the feared situation almost invariably provokes anxiety

Social Anxiety Disorder • The anxiety lasts more than 6 months
(SAD)
• Causes significant disability Increased depressive disorders
• Recurrent unexpected panic attacks and for a one month period or more of:
• Persistent worry about having additional attacks
• Worry about the implications of the attacks
Panic Disorder
• Significant change in behavior because of the attacks
• Palpitations or rapid heart rate; Sweating; Shortness of breath; Feeling of
choking; Chest pain or discomfort; Nausea
• Excessive worry more days than not for at least 6 months about a number of
events and they find it difficult to control the worry.
Generalized Anxiety • 3 or more of the following symptoms:
Disorder • Restlessness or feeling keyed up or on edge, easily fatigued, difficulty
concentrating, irritability, muscle tension, sleep disturbance
• Causes significant distress or impairment

Obsessive-Compulsive • recurrent and persistent thoughts, impulses or images that are intrusive and
Disorder (OCD) unwanted that cause marked anxiety or distress
Posttraumatic Stress • Exposure to actual or threatened death, serious or sexual violence in one or
Disorder more of the following ways
Anxiety Treatment

Obsessive-
Social Anxiety Generalized Posttraumatic
Panic Disorder Compulsive
Disorder (SAD) Anxiety Disorder Stress Disorder
Disorder (OCD)
• Social skills • Education, • Medications • 40-60% • Debriefing
training, reassurance, including treatment immediately
behavior elimination of buspirone, response following
therapy, caffeine, benzodiazepine • Serotonergic trauma is NOT
cognitive alcohol, drugs, s, antidepressants necessarily
therapy OTC stimulants antidepressants • Behavior effective
• Medication – • Cognitive- (SSRIs, therapy • Cognitive-
SSRIs, SNRIs, behavioral venlafaxine, • Adjunctive behavioral
MAOIs, therapy imipramine) antipsychotics, therapy,
benzodiazepine • Medications – • Cognitive- psychosurgery exposure
s, gabapentin SSRIs, behavioral • Group therapy
venlafaxine, therapy • Medications –
tricyclics, antidepressants,
MAOIs, mood
benzodiazepine stabilizers, beta-
s, valproate, blockers,
gabapentin clonidine,
prazosin,
gabapentin
What Is Depression?

A Continuum

Normal Mood Lowering

Abnormal Mood Lowering

Abnormal mood lowering and loss of function

5-HT and NA at the Synaptic Level: Healthy vs. Depressed

Healthy Depressed
5-HT 5-HT
Reuptake
Transporter

NA
Reuptake
Transporter
NA
Theoretical Representation
Spectrum of mood disturbance

Mild thru to Severe

Transience thru to Persistence

Continuous distribution in population

Clinically significant when:

(1) interferes with normal activities
(2) persists for min. 2 weeks

Diagnosis of depression / depressive disorder

“Persistent & pervasive low mood”
“Loss of interest or pleasure in activities”
Depressive Illness

Usually treatable

Common
Marked disability
Reduced survival
Increased costs

Depression may be
Coincidental association
Complication of physical illness
Cause of / Exacerbation of somatic symptoms
 w/ seasonal pattern
w/ mood-[congruent, incongruent]
w/ anxious distress psychotic features

Major depressive disorder

w/ mixed features w/ peripartum onset

w/ catatonia
w/ atypical features
w/ melancholic features

≥2 of the following:
• keyed-up/tense
• unusually restless
• can’t concentrate b/c of worry
• fear something awful may happen
• might lose control
 w/ seasonal pattern w/ mood-[congruent, incongruent]
w/ anxious distress psychotic features

Major depressive disorder w/ peripartum onset

w/ mixed features

w/ catatonia
w/ atypical features w/ melancholic features

≥3 of the following nearly everyday during an MDE:

[drawn from list of sxs for a manic/hypomanic episode, minus distractibility;
this list includes elevated/expansive mood…]
 w/ seasonal pattern w/ mood-[congruent, incongruent]
w/ anxious distress psychotic features

w/ mixed features Major depressive disorder w/ peripartum onset

w/ catatonia
w/ atypical features w/ melancholic features

≥1 of the following during the most severe portion of the current episode:
• absolute anhedonia or absolute mood non-reactivity

plus ≥3 of the following:

• a distinct quality of depressed mood (e.g., worse than prior MDEs)
• worse in the AM
• early AM awakening (by at least 2h)
• marked PMA or PMR
• significant appetite or wt loss
• excessive guilt
 w/ seasonal pattern
w/ anxious distress w/ mood-[congruent, incongruent]
psychotic features

Major depressive disorder w/ peripartum onset

w/ mixed features

w/ catatonia
w/ atypical features w/ melancholic features

• mood reactivity MAO-I’s (but SSRI’s still 1st line…)

plus ≥2 of the following:

• significant appetite or wt increase
• hypersomnia
• leaden paralysis
• long-standing interpersonal rejection sensitivity leading to social/work problems
 w/ seasonal pattern
w/ mood-[congruent, incongruent]
w/ anxious distress psychotic features

Major depressive disorder

w/ mixed features w/ peripartum onset

w/ catatonia
w/ atypical features w/ melancholic features

• delusions &/or hallucinations

• examples of congruent delusions: personal inadequacy, guilt, death, nihilism,

deserved punishment
 w/ seasonal pattern w/ mood-[congruent, incongruent]
w/ anxious distress psychotic features

w/ mixed features Major depressive disorder w/ peripartum onset

w/ atypical features w/ catatonia w/ melancholic features

during most of the episode, ≥3 of the
following:

• stupor
• catalepsy (passive induction of a posture • mannerism (odd cariacture of a
held against gravity)
• waxy flexibility
normal action)
• mutism • stereotypy
• negativism • agitation (indep of external stimulus)
• posturing (spontaneous, maintenance • grimacing
against gravity) • echolalia or echopraxia
 w/ seasonal pattern w/ mood-[congruent, incongruent]
w/ anxious distress
psychotic features

Major depressive disorder

w/ mixed features w/ catatonia w/ peripartum onset

w/ atypical features w/ melancholic features

• during pregnancy or in the 4wks after delivery

 w/ seasonal pattern w/ mood-[congruent, incongruent]
w/ anxious distress psychotic features

Major depressive disorder

w/ mixed features w/ peripartum onset

w/ atypical features w/ catatonia w/ melancholic features

• relapses and remissions occur at characteristic times of the year

• at least 2 seasonal MDE’s in the last 2y (and no non-seasonal MDEs during this
period)
• seasonal episodes outnumber non-seasonal episodes (lifetime)

If a patient always gets depressed with season unemployment (or the beginning
of the school year), would we call this ‘w/ seasonal pattern?’ No.
Epidemiology

2nd biggest cause of disability

worldwide by 2020 (WHO)
(IHD still the biggest)

Associated with increased

physical illness

• 5% during lifetime have MDD

• 1 in 20 consultations
• MDD & Dysthymia > in females
• 20% develop chronic depression
• 30% of in-patients have depressive symptoms
Suicide
Final clinical pathway

1 million deaths per year, 10-12 million attempts

Males – most common in older

Female – most common in middle age

15 per 100,000 deaths males

6 per 100,000 deaths females
Almost 50% fail on first attempt

Previous attempters 23 times more likely to dies from suicide than those without
previous attempts

Internal stress
Pre-existing psychiatric morbidity
Demographics
Opportunities
Behavioural Indicators

- recent bereavement or other life-altering loss

- recent break-up of a close relationship
- major disappointment (failed exams or missed job promotion)
- change in circumstances (retire, redundant or children leaving home)
- physical illness
- mental illness
- substance misuse / addiction
- deliberate self-harm, (particularly in women)
- previous suicide attempts
- loss of close friend / relative by suicidal means
- loss of status
- feelings of hopelessness, powerlessness and worthlessness
- declining performance in work / activities (sometimes this can be reversed)
- declining interest in friends, sex, or previous activities
- neglect of personal welfare and hygiene
- alterations in sleeping habits (either direction) or eating habits
Epidemiology

Depression more common in those with:

• Life threatened / limited / chronic physical illness

• Unpleasant / demanding treatment

o L
• Low social support Q
• Adverse social circumstances

• Personal / family history of depression / psychological vulnerability

• Substance misuse

• Anti-hypertensive / Corticosteroid / Chemotherapy use

http://trivalleypsychotherapy.com/work-relatedstress.html
Different Reasons

Most depressions have triggering life events - Reactive depression

Especially in a first episode

Many patients present with physical symptoms - Somatisation syndrome

Some may show multiple symptoms of depression in the apparent absence

of low mood - Masked Depression

Complication of physical illness - Secondary depression

Some depression has no triggering cause - Endogenous Depression

More persistent and resistant to treatment

Major depression (DSM IV-TR)

5 or more…..
• decreased interest / pleasure *
• depressed mood *
• reduced energy
• weight gain / loss
• insomnia / hypersomnia
• feeling worthless
• guilt
• recurrent morbid thought
• psychomotor changes
• fatigue
• poor concentration
• pessimism / bleak views
• self harm ideas / actions
• suicide ideation
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

Significant change in appetite

Excessive or inappropriate guilt 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.
Classification of Depression (ICD-10)

Primary
Unipolar
· Mixed anxiety and depressive disorder (prominent anxiety)
· Depressive episode (single episode)
· Recurrent depressive disorder (recurrent episodes)
· Dysthymia - Persistent and mild ("depressive personality")
Bipolar
· Bipolar affective disorder - manic episodes ("manic depression")
· Cyclothymic - Persistent instability of mood
Other primary
· Seasonal affective disorder
· Brief recurrent depression
Depressive episode may be
Moderate or severe
With/Without somatic syndrome
With/Without psychotic symptoms
What Is Depression? - Various Criteria.

Defeat Depression Campaign

• Depressed mood or loss of pleasure for at
least 2 weeks. Plus 4 or more of:
– Worthlessness or guilt
– Impaired concentration
– Loss of energy and fatigue
– Thoughts of suicide
– Loss or increase of appetite or weight
– Insomnia or hypersomnia
– Retardation or agitation
What Is Depression? - Various Criteria.
DSM – IV
• Duration > 2 weeks Depressed mood or Marked loss of
interest or pleasure in normal activities
• Plus 4 of:
i. Significant change in weight
ii. Significant change in sleep pattern
iii. Agitation or retardation
iv. Fatigue or loss of energy
v. Guilt / worthlessness
vi. Can’t concentrate or make decisions
vii. Thoughts of death or suicide
What Is Depression? - Various Criteria.

ICD – 10 ¨ Mild.
• Patient has low mood: Two criteria from 1-3 and 2 others.
¨ Moderate.
1) How bad is it and how long has it been going on?
Two criteria from 1-3 and 3-4 others or a yes to
2) Have you lost interest in things? question 5.
3) Are you more tired than usual? ¨ Severe.
If the answer is yes to these, then: Most of the criteria in severe form especially
questions 5 & 9.
4) Have you lost confidence in yourself?
5) Do you feel guilty about things?
6) Concentration difficulties?
7) Sleeping problems?
8) Change in appetite or weight?
9) Do you feel that life is not worth living any more?
Somatization Syndrome (DSM IV)

4 or more…..
Anhedonia (inability experience pleasure)
Loss of emotional reactivity
Early waking (>2 hours early)
Psychomotor retardation or agitation
Marked loss of appetite
Weight loss >5% of body mass in one month
Loss of libido (important and often ignored)
Risk Factors

Anxiety + Sadness + Somatic discomfort

Normal psychological response to life stress

Clinical depression is a “final common pathway”

Resulting from interaction of biological, psychological, and social factors

Likelihood of this outcome depends on many factors:

• genetic and family predisposition
• clinical course of concurrent medical illness
• nature of any treatment
• functional disability
• individual coping style
• social and other support
 Depresi score: 50-69
Highest score: 80
Screening Questionnaires
 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.
Depression: Treatment Goals

Recovery
Remission Recurrence
No Depression Relapse X
X

Symptoms Relapse
X

Pro orde
Severity Response
to d
gre
Syndrome is
ssi
on
r
Acute Continuation Maintenance
6-12 weeks 4-9 months 1 or more years
Treatment Phases
Time
Reprinted with permission from Kupfer, 1991
WPA/PTD Educational Program on Depressive Disorders
Switching Strategies
Drug Treatment

Tricyclic Antidepressants (TCAs)

since the 1950s effective and cheap
limit compliance variable degrees of sedation
fatal in overdose (except Lofepramine)
dose-related anticholinergic side effects, postural hypotension

Monoamine Oxidise Inhibitors (MAOI’s)

rare fatalities tyramine-free diet

Selective Serotonin Re-uptake Inhibitors (SSRI’s)

fluoxetine lack sedation - no anticholinergic effects
improved compliance less immediate benefit for disturbed sleep
safe in overdose single or narrow range of doses works
Drug Treatment

Selective Serotonin Re-uptake Inhibitors (SSRI’s) - Newer

Sertraline lack sedation - no anticholinergic effects
improved compliance favourable on glucose metabolism
Platelet SSRI Decreased and favourable of CHD patients
Remission Prolonged remission with Sertraline
safe in overdose single or narrow range of doses works
Dual Norepinephrine and Serotonin Re-uptake Inhibitors (SSRI’s) – Newer
Similar in action and benefits as SSRIs but also inhibit the noradrenaline pathways
Problem in hypertensive patients
Cognitive Behavioural Therapy - CBT
Electroconvulsive Threrapy - ECT
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
Antidepressant: TCA (Imipramine)

• block the amines (NE and 5-HT)  a

nondepressed person experiences
MoA sleeping. In the depressed patient, an
elevation of mood occurs 2-3 weeks
after administration begins
• Treatment of severe endogenous
depression (characterized by
regression and inactivity).
Therapeutic • Treatment of enuresis.
uses • Treatment of obsessive-compulsive
neurosis accompanied by depression,
and phobic-anxiety syndromes,
chronic pain and neuralgia
• blurred vision, dry mouth,
ADR
constipation, urinary retention
Antidepressant: SSRI (Fluoxetine)
Mechanism of
Therapeutic uses: Adverse effects:
action:
• a selective inhibitor • used for treatment • cause anorexia.
of serotonin uptake of mild to moderate • precipitate mania
in the CNS. endogenous or hypomania.
• has little effect on depression. • result in nausea,
central • be useful in nervousness,
norepinephrine and treating obsessive- headache, and
dopamine function. compulsive insomnia.
• has less adverse disorder, obesity • cause 5-HT
effects because of syndromes
minimal binding to (hyperpyrexia,
cholinergic, convulsions, and
histaminic, and α- coma) when
adrenergic combinated with
receptors and MAO inhibitor.
Antidepressant: SNRIs (Venlafaxine & Duloxetine)

SNRIs treat cases of depression which are resistant to SSRIs.

Treat depression accompanied neuropathic pain.

No activity at adrenergic, muscarinic, or histamine receptors fewer

adverse effects than TCA.

Duloxetine is contraindicated in hepatic insufficiency & end-stage renal

disease.
Antidepressant: Atypical Antidepressants

• They are weak

trazodone:
Bupropion:

Nefazodone &
• It inhibits • It blocks

Mirtazapine:
noradrenaline presynaptic serotonin re-
and dopamine alpha2- uptake
reuptake. receptors  inhibitors.
• It decreases increases NA & • They block
craving for serotonin. postsynaptic
nicotine in • It also blocks 5-HT2
tobacco 5HT2 receptors receptors.
abusers. • It may cause • Both agents
• S/E: dry mouth, sedation & block H1-
sweating, weight gain receptor
tremor, and sedation
seizures at high
doses
Tabel Perbandingan Durasi & Dosis SGA pada kasus MDD
Algorithm for treatment of uncomplicated major depression
Pharmacological Strategies for
Treatment-Resistant Depression (TRD)
Optimization Increase the dose or duration, or alter the timing
(monotherapy) of the primary antidepressant.

Substitution Stop first medication, start next one as

(switching) 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.
Perbandingan Efektifitas
METODE
Switching to Other SGAs
Switching From an SGA to a Different
SGA
Versus Switching to Cognitive Therapy
Augmenting With Another SGA
Augmenting With Another SGA Versus
Augmenting With Cognitive Therapy
HASIL
no difference in response when switching from 1 SGA to another (bupropion vs.
sertraline or venlafaxine and sertraline vs. venlafaxine)
No difference in response or remission when switching from 1 SGA to another
(sertraline, bupropion, or venlafaxine)compared with switching to cognitive therapy
No difference in response or remission for augmentation of citalopram treatment
with bupropion compared with augmentation with buspirone. However, augmenting
with bupropion decreases depression severity more than augmentation with
buspirone
No difference in response, remission, or depression severity for augmentation of
citalopram treatment with another SGA (bupropion or buspirone) versus
augmentation with cognitive therapy.
Perbandingan Terapi
TERAPI
SGA Versus CBT
SGA Versus Interpersonal Therapy
SGA Versus Psychodynamic Therapies
SGA Versus Acupuncture
SGA Versus St. John's Wort
SGA Versus Exercise
HASIL
Monoterapi Kombinasi
no difference in response when comparing more improvement on 3 of 5 work functioning
SGAs measures than those who received SGA
monotherapy
no difference in response when showed increased remission for SGA
comparing SGAs monotherapy
compared with SGA combined with
interpersonal
therapy (with nefazodone)
no difference in response when no difference in functional capacity for SGA
comparing SGAs monotherapy compared with SGA plus
psychodynamic combination therapy
no difference in response when improved treatment response compared with
comparing SGAs monotherapy with SGAs
no difference in response when comparing
SGAs
no difference in response when no difference in remission for treatment with
comparing SGAs sertraline compared with combination therapy
of sertraline and exercise
Comparative Tolerability
Treatment
Much depressive illness of all types is successfully treated in primary care
Four main reasons for referral to specialist psychiatric services:
1) Condition is severe
2) Failing to respond to treatment (e.g. Psychomotor retardation)
3) Complicated by other factors (e.g. Personality disorder)
4) Presents particular risks (e.g. Agitation and psychotic behaviour)

• Principal decision is whether to treat with drugs or a talking therapy

• Most patients in primary care settings would prefer a talking therapy
• Effectiveness is limited to particular forms of psychotherapy
• Mild-Mod. Depression: CBT and antidepressants are equally effective
• Severe Depression: antidepressant drugs are more effective
Management
The main aims of treatment:
• improve mood and quality of life
• reduce the risk of medical complications
• improve compliance with and outcome of physical treatment
• facilitate the "appropriate" use of healthcare resources

Primary care staff should be familiar with properties and use of:
1) common antidepressant drugs & brief psychological treatments
2) assessment of suicidal thinking and risk

Patients with more enduring or severe symptoms will usually require specific
treatment - usually drug therapy

For patients with suicidal ideation / whose depression has not responded to initial
management, specialist referral is the next step
Keys Steps in Rx of Depression

• High level of clinical suspicion

• Early Diagnosis
• Effective treatment of acute attack
• Achieving remission
• Remission maintenance with continued
Rx
• Prevent relapse
• Follow up of recurrence
Assessment

• Severity
• Duration
• Social network
• Views of self, world
and future
• Suicidal thoughts
• Past history
• Factors affecting
symptoms
• Biological features
Assessment Skills

• Directive not closed questions

• Picking up on verbal clues “clarification”
• Picking up on non-verbal clues and using them
• Empathy
• Summarising
Treatment Contract

• Key skills
– Re-frame symptoms as
depression
– Link to life events
– Negotiate anti-depressants
if necessary
– Problem list and priorities
– Set realistic time scale
– Agree regular review
Explanations

• Depressive illness is
clinically different from the
blues and involves chemical
changes in the brain.
• Depressive illness has
characteristic symptoms and
explain them.
Explanations

• Depression benefits from both

drug and non-drug
approaches.
– “Pills for symptoms.”
– “Talking for problems.”
Explanations

• Anti-depressants are not

addictive or habit forming.
• Anti-depressants take 2-3
weeks to begin to work and
need to be taken for 4-6
months after the full benefit
is obtained to prevent
relapse.
Explanations

• Side effects occur and are

expected – explain.
• Drugs enable talking therapy
to work better.
• Regular review is important
and needs to continue for at
least 6 months.
Explanations

• Talking therapy can help solve problems that are soluble, cope with the insoluble
and examine other problems that seem unrealistic to the patient or therapist.
• Prevention of further trouble will be considered when the treatment is coming to
an end.
Summary

• Detection can be hard – symptom overlap and patient unaware

• Depression a natural occurrence in population

• Whole range of depressive conditions with varying severity

• Depression can be present in acute or chronic states

• Depression can have physiological, biological or social causes

• Depression may have a mixture of causes

• Depression co-exists with many other symptoms

• Depression is a natural reaction to disease diagnosis and presence

• Depression and symptomotology are highly related

“The good physician
treats the disease,
but the great physician
treats the person.”

William Osler
Thank You