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Depression-An under-recognized condition

Non- attendance

(A) The Epidemiological Catchment Area Study carried out in the USA suggests that
approximately one third of people suffering from depression do not seek help or
treatment

(B) A European survey of 80,000 people also revealed third of people with major
depression had not consulted a health-care specialist.
Men were less likely to consult a medical specialist than women.
Many believed --------They would get better by themselves
Some--------------------Too embarrassed to seek help

Other reasons why patients dont consult doctors include:
They may not recognise they have an illness

They may regard their symptoms as appropriate in their circumstances

Many people do not know depression can be treated easily

Misconceptions over treatment
Poor recognition

GPs manage about 80 per cent of all mental illness, but evidence suggests that
depression is frequently missed in general practice.

1. Half of patients severe depression -----------not recognised at the first consultation.

2. A further 10%------------- Recognised in subsequent consultations.

3. 20%--------------------------Remit during this time.

4. The remaining 20%-------- may remain unrecognised even after six months

5. Recognising difficulty -----------presentations with somatic symptoms -
70% cases - and of depression related to physical disorders

1. Other factors include an aversion on the part of both GPs and patients to
talk about psychological problems and inadequate time for
consultations
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MAJOR DEPRESSIVE DISORDER
OR
AFFECTIVE DISORDER( DEPRESSIVE EPISODE)

INCIDENCE

Male 5-12%


Female 10-25%


More in females, the ratio 2:1

Age 20-50 years


Average 40 years
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Lifetime Prevalence of Various Mood Disorders
Mood Disorder Lifetime Prevalence
Depressive disorders
Major depressive disorder (MDD) 1025% for women
512% for men

Recurrent, without full 2530% of persons with MDD
interepisode recovery,
superimposed on dysthymic disorder (double depression)
Dysthymic disorder 36%
Bipolar disorders
Bipolar I disorder 0.41.6%
Bipolar II disorder <1%
Bipolar I disorder or bipolar II 515% of persons with
disorder, with rapid cycling bipolar disorder

Cyclothymic disorder 0.41.0%
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ICD-10 Criteria for Depressive Episode

A. Five (or more) of the following symptoms have been
present during the same 2-week period and represent
a change from previous functioning;

At least one of the symptoms is either (1) depressed
mood or (2) loss of interest or pleasure.
.
(1)Depressed mood most of the day, nearly every day,

Either subjective report (e.g., feels sad or empty) or

Observation made by others (e.g., appears tearful).
Note: in children and adolescents, can be irritable mood.

(2) Markedly diminished interest or pleasure in all, or almost all,
activities most of the day, nearly every day

(as indicated either by subjective account or observation made by others)

(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

(5) Psychomotor agitation or retardation nearly every day

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(6) Fatigue or loss of energy nearly every day

(7) Feelings of worthlessness or excessive or inappropriate
guilt (which may be delusional) nearly every day

(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 suicide attempt or a specific plan for committing
suicide
B. The symptoms do not meet criteria for a mixed episode.

C. Significant distress or impairment in social,
occupational, or other important areas of functioning.

D. Not due to the direct physiological effects of a
Substance
General medical condition (e.g., hypothyroidism).

E. Not better accounted for by bereavement,
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Somatic syndrome
Some depressive symptoms are widely regarded as having special
clinical significance and are here called "somatic." (Terms such as
biological, vital, melancholic, or endogenomorphic are used for this
syndrome in other classifications.)

(1) Marked loss of interest or pleasure in activities that are normally
pleasurable;

(2) Lack of emotional reactions to events or activities that normally
produce an emotional response;

(3) Waking in the morning 2 hours or more before the usual time;

(4) Depression worse in the morning;

(5) Objective evidence of marked psychomotor retardation or agitation
(remarked on or
reported by other people);

(6) Marked loss of appetite;

(7) Weight loss (5% or more of body weight in the past month);

(8) Marked loss of libido.
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Criteria for Seasonal Pattern

With seasonal pattern

can be applied to:-

Major depressive episodes in bipolar I disorder, bipolar II disorder,
or
Major depressive disorder, recurrent)

A. There has been a regular temporal relationship between the
onset of and a particular time of the year (e.g., regular appearance
of the major depressive episode in the fall or winter)

B. Full remissions (or a change from depression to mania or
hypomania) also occur at a characteristic time of the year (e.g.,
depression disappears in the spring).

C. In the last 2 years, two major depressive episodes have
occurred that demonstrate the temporal seasonal relationships
defined in criteria A and B, and no non seasonal major depressive
episodes have occurred during that same period.

D. Seasonal major depressive episodes (as described above)
substantially outnumber any non seasonal major depressive
episodes that may have occurred over the individual's lifetime.
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Recurrent depressive disorder, current episode mild

Without somatic syndrome
With somatic syndrome

Recurrent depressive disorder, current episode
moderate

Without somatic syndrome
With somatic syndrome

Recurrent depressive disorder, current episode
without psychotic symptoms

Recurrent depressive disorder, current episode severe
with psychotic symptoms

With mood-congruent psychotic symptoms
With mood-incongruent psychotic symptoms

Recurrent depressive disorder, currently in remission

Other recurrent depressive disorders

Recurrent depressive disorder, unspecified

Persistent mood [affective] disorders

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Diagnostic Criteria for Dysthymic Disorder


A Depressed mood for most of the day, for more days than
not, for at least 2 years.

B. Presence, while depressed, of two (or more) of the
following:

(1) Poor appetite or overeating

(2) Insomnia or hypersomnia

(3) Low energy or fatigue

(4) Low self-esteem

(5) Poor concentration or difficulty making decisions

(6) Feelings of hopelessness

C. Never without symptoms for more than two months during
the last 2-year period

D. No major depressive episode has been present during the
first 2 years of the disturbance (1 year for children and
adolescent

Early onset------------Before 21 years of age

Late onset-------------21 years or older
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ICD-10 Diagnostic Criteria for
Adjustment Disorders
A. Onset of symptoms must occur within 1 month of
exposure to an identifiable psychosocial stressor, not
of an unusual or catastrophic type.
. Symptoms may be variable in both form and
severity.
The predominant feature of the symptoms may be
further specified as:-

Brief depressive reaction
A transient mild depressive state of a duration not
exceeding 1 month.

Prolonged depressive reaction
A mild depressive state occurring in response to a
prolonged exposure to a stressful situation but of a
duration not exceeding 2 years.

Mixed anxiety and depressive reaction
Both anxiety and depressive symptoms are
prominent, but at levels no greater than those
specified for mixed anxiety and depressive disorder
or other mixed anxiety disorders.
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Bipolar affective disorder
Episodes are demarcated by a switch to an episode of opposite or mixed
polarity

Bipolar affective disorder, current episode hypomanic
A. The current episode meets the criteria for hypomania.
B. There has been at least one other affective episode in the past, meeting the
criteria for hypomanic or manic episode, depressive episode, or mixed
affective episode.

Bipolar affective disorder, current episode manic without psychotic
symptoms
The current episode meets the criteria for mania without psychotic symptoms.
.
Bipolar affective disorder, current episode manic with psychotic symptoms

The current episode meets the criteria for mania without psychotic symptoms.
. With mood-congruent psychotic symptoms
With mood-incongruent psychotic symptoms
Bipolar affective disorder, current episode moderate or mild depression
A. The current episode meets the criteria for a depressive episode of either mild
or moderate severity.
1. Without somatic syndrome
2. With somatic syndrome

Bipolar affective disorder, current episode severe depression without
psychotic symptoms

Bipolar affective disorder, current episode severe depression with psychotic
symptoms
1. With mood-incongruent psychotic symptoms
2. With mood-congruent psychotic symptoms

Bipolar affective disorder, current episode mixed

. Both manic and depressive symptoms must be prominent most of the time
during a period of at least 2 weeks.

Bipolar affective disorder, currently in remission

The current state does not meet the criteria for depressive or manic episode of any severity or
for any other mood [affective] disorder (possibly because of treatment to reduce the risk of
future episodes).
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M
A
N
I
A
D
E
P
R
E
S
S
I
O
N
Normal State
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BIPOLAR AFFECTIVE DISORDERS
M
A
N
I
A
D
E
P
R
E
S
S
I
O
N
NORMALSTATE
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ICD-10 Diagnostic Criteria for Mood [Affective] Disorders

Manic episode

.Mania without psychotic symptoms
A. Mood must be predominantly elevated, expansive, or irritable,

Change must be prominent and sustained for at least 1 week (unless it is
severe enough to require hospital admission).

B. At least three of the following signs must be present (four if the mood is
merely irritable), leading to severeinterference with personal
functioning in daily living:
(1) increased activity or physical restlessness;

(2) increased talkativeness ("pressure of speech");

(3) flight of ideas or the subjective experience of thoughts racing;

(4) loss of normal social inhibitions, resulting in behavior that is inappropriate
to the circumstances;

(5) decreased need for sleep;

(6) inflated self-esteem or grandiosity;

(7) distractibility or constant changes in activity or plans;
(8) behavior that is foolhardy or reckless
e.g., spending sprees, foolish enterprises, reckless driving;
(9) Marked sexual energy or sexual indiscretions.

C. There are no hallucinations or delusions, although perceptual
disorders may occur

D.The episode is not attributable to psychoactive substance use or to any
organic mental disorder.
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Mania with psychotic symptoms
.

Delusions or hallucinations are present,

The commonest examples are those with grandiose, self-
referential, erotic, or persecutory content.
.
Congruent with the mood:

With mood-congruent psychotic symptoms

Example: - Grandiose delusions or voices telling the
individual that he or she has superhuman powers)

With mood-incongruent psychotic symptoms

Example: -voices speaking to the individual about affectively
neutral topics, or delusions of reference or persecution)
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Hypomania

A. The mood is elevated or irritable to a degree that is
definitely abnormal for
The individual concerned and
Sustained for at least 4 consecutive days.

B. At least three of the following signs must be present,
leading to
some interference with personal functioning in daily
living:

(1) Increased activity or physical restlessness;

(2) Increased talkativeness;

(3) Distractibility or difficulty in concentration;

(4) Decreased need for sleep;

(5) Increased sexual energy;

(6) Mild overspending, or other types of reckless or
irresponsible behavior;

(7) Increased sociability or overfamiliarity.

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Table 14.6-7. DSM-IV Criteria for Manic Episode
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood,
lasting at least 1 week (or any duration if hospitalization is necessary).
B. During the period of mood disturbance, three (or more) of the following symptoms have
persisted
(1) inflated self-esteem or grandiosity
(2) decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
(3) more talkative than usual or pressure to keep talking
(4) flight of ideas or subjective experience that thoughts are racing
(5) distractibility (i.e., attention too easily drawn to unimportant or irrelevant external
stimuli)
(6) increase in goal-directed activity (either socially, at work or school, or sexually) or
psychomotor agitation
(7) excessive involvement in pleasurable activities that have a high potential for painful
consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish
business investments)
C. The symptoms do not meet criteria for a mixed episode.
D. The mood disturbance is sufficiently severe to cause marked impairment in
occupational functioning or in usual social activities or relationships with others, or to
necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug
of abuse, a medication, or other treatment) or a general medical condition (e.g.,
hyperthyroidism).
Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment
(e.g., medication, electroconvulsive therapy, light therapy) should not count toward a
diagnosis of bipolar I disorder.

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BIO-PSYCHO-SOCIAL VIEW
BIOLOGICAL
SOCIAL PSYCHOLOGICAL
Age
Sex
Neurotransmitters
Hormones
Genetic
Brain structure
Family Stability
Social Support
Sex
Nurture
Place of living
Minority class
Social & religious values

Stress
Nurture
Cognitions
Personality
Painful childhood
Psychoanalysis
AETIOLOGY OF DEPRESSION
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. Medical Conditions Physiologically Associated With Affective Disorders

Endocrine Disorders
Hypothyroidism
Hyperthyroidism
Parathyroid disorders
Cushing's syndrome
Neurologic Disorders
Cerebrovascular accidents
Central nervous system (CNS) lesions
Neurosyphilis
Multiple sclerosis
Neurosarcoidosis
CNS vasculitis
HI V-associated CNS pathology
Other Disorders
Vitamin deficiencies (e.g, folate and vitamin B12)
Anemia
Hypoxia
End-stage renal disease
Systemic lupus erythematosus and other connective tissue
diseases
Occult malignancy (eg, pancreatic cancer)
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Differentiating Characteristics of Bipolar and Unipolar Depressions

Bipolar Unipolar


History of mania or hypomania Yes No
(definitional)

Temperament/personality Cyclothymic/extroverted Dysthymic/introverted

Sex ratio Equal More women than men

Age of onset Teens, 20s, and 30s 30s, 40s, 50s

Postpartum episodes More common Less common

Onset of episode Often abrupt More insidious

Number of episodes Numerous Fewer


Duration of episode 3 to 6 months 3 to 12 months

Psychomotor activity Retardation > agitation Agitation > retardation

Sleep Hypersomnia > insomnia Insomnia > hypersomnia

Family history

Bipolar disorder Yes

Unipolar disorder Yes Yes

Alcoholism Yes

Pharmacological response

Cyclic antidepressants Induce hypomania-mania

Lithium carbonate Acute antidepressant effects Ineffective
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Basic principles of prescribing in depression

Discuss with the patient: -
1) Choice of drug and
2) utility/availability of other, non-pharmacological
treatments

Discuss with the patient likely outcomes. e.g.

Gradual relief from depressive symptoms over several
weeks

Prescribe a dose of antidepressant (after titration, if
necessary) that is likely effective

Continue treatment for at least 46 months after
resolution of symptoms

Withdraw antidepressants gradually;

Always inform patients of the risk and nature of
discontinuation symptoms

Treatment of affective illness
Depression
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Episode: A period lasting longer than 2 weeks (as defined
by the DSM-IV-R) during which the patient is consistently
within the fully symptomatic range of a sufficient number of
symptoms to meet syndromal criteria for the disorder.

Partial remission: A period during which an improvement of
sufficient magnitude is observed that the individual is no
longer fully symptomatic

Response: The point at which a partial remission begins. A
response, unlike a partial remission, does require treatment
and thus implies that the cause of the change in the patient's
condition is known, which may not be a valid assumption.

Full remission: A relatively brief period during which an
improvement of sufficient magnitude is observed that the
individual is asymptomatic

Recovery: A remission that lasts for a specified period of
time. Relapse: A return of symptoms satisfying the full
syndrome criteria for an episode that occurs during the period
of partial or full remission, but before recovery as defined
above. A relapse signals a need for treatment intervention or
modification of ongoing treatment.

Recurrence: The appearance of a new episode of major
depressive disorder occurring during a recovery.
Definitions of terms related to the course of depression
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Panic Disorder
50%-65%
Social Anxiety
Disorder 70%
OCD
67%
PTSD
48%
GAD
8%-39%
COMORBID MOOD & ANXIETY DISORDERS
DEPRESSION
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STRATEGIES FOR TREATMENT

When initiating acute-phase treatment, practitioners decide where the
patient should be treated (e.g., outpatient, day hospital, or
inpatient). Treatment location is dictated by factors such as

(1) the imminent risk of suicide,

(2) the capacity of the patient to recognize and follow instructions or
recommendations (adherence, psychosis),

(3) the level of psychosocial resources,

(4) the level of psychosocial stressors, and

(5) the level of functional impairment.

Next, one chooses among the four common acute-phase
treatments

(A) Medication
.
(B) The combination of medication and psychotherapy.

(C) Electroconvulsive therapy [ECT]).

(D) For some, light therapy alone or in combination with medications
may also be an option.
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Treatment Plan

A treatment plan for depression consists of three
distinct phases

Phase 1: - Acute treatment, relieves the immediate
symptoms of depression.

Phase 2, Continuation treatment, preserves the gains
achieved initially and protects the patient
from sliding back into depression.

Phase 3, Maintenance treatment, guards against
future episodes.
Treatment Phases and Goals

Phase Length Treatment goal

Acute 612 weeks Achieve remission

Continuation 1624 weeks Prevent relapse

Maintenance Varies Protect against recurrence

Remission = Return to level of symptoms and functioning that
existed before illness.
Relapse = Re-emergence of significant depressive symptoms.
Recurrence = Another major depressive episode.

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Relation of Diagnosis to Treatment Selection

Diagnosis Treatment Recommendations

Major depressive Episode Medication or time-limited
(mild-to-moderate severity) psychotherapies*
No maintenance-phase treatment
Major depressive disorder, recurrent Consider maintenance-phase treatment

Major depressive disorder Antipsychotic plus antidepressant
with psychotic features medications

Electroconvulsive therapy
Major depressive disorder with melancholic Medications essential
or severe features
Depression with atypical features Nontricylic drugs preferred
Monoamine oxidase inhibitors

Depression with seasonal pattern Light therapy or medications

Dysthymic disorder Medications; time-limited, depression-
targeted psychotherapies; or their
combination
Consider maintenance-phase therapy

Complex or chronic depressions Medication plus psychotherapy
Interpersonal psychotherapy,
cognitive therapy, or behavior therapy.
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Tricyclics and tetracyclics
Starting Dose
mg/day

Usual Dose
Mg/day
Tertiary amine tricyclics



Amitriptyline
25-50

100-300
Clomipramine
25

100-250
Doxepin
25-50

100-300
Imipramine
25-50

100-300
Trimipramine
25-50

100-300
Secondary amine tricyclics



Desipramine
25-50

100-300
Nortriptyline
25

50-200
Protriptyline
10

15-60
Tetracyclics



Amoxapine
50

100-400
Maprotiline
50

100-225
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SSRIs
b


Citalopram 20 20-60 c
Fluoxetine 20 20-60 c
Fluvoxamine 50 50-300 c
Paroxetine 20 20-60 c
Sertraline 50 50-200 c
Dopamine-nor epinephrine reuptake inhibitors
Bupropion
b
150 300
Bupropion, sustained release 150 300
Serotonin-norepinephrine reuptake inhibitors

Venlafaxine
b
37.5 75-225
Venlafaxine, extended release 37.5 75-225
Serotonin modulators
Nefazodone 50 150-300
Trazodone 50 75-300
Nor epinephrine-serotonin modulator

Mirtazapine 15 15-45
MAOIs

Irreversible, nonselective
Phenelzine 15 15-90
Tranylcypromine 10 30-60
Reversible MAOI-A
Moclobemide 150 300-600
Selective noradrenaline reuptake inhibitor

Reboxetine 4 6-8
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MAOI Drug Incompatibilities



Generally Contraindicated Hazardous Potentiation


Stimulants Weight-reducing or antiappetite drugs; amphetamine, cocaine


Decongestants Sinus, hay fever, and cold tablets; nasal sprays or drops;
asthma tablets or inhalants, cough preparations (or any
products containing ephedrine, phenylephedrine, or
phenylpropanolamine

Antihypertensives Methyldopa, guanethidine, reserpine

Tricyclics Migraine, desipramine, clomipramine

MAOIs Tranylcypromine, after other MAOIs

Sympathomimetics Dopamine, Metaraminol

Amine precursors L-dopa, L-tryptophan

Narcotics Meperidine (Demerol)


Some Potentiation Possible


Opioids Morphine, codeine

Sedatives Alcohol, barbiturates, benzodiazepines

Local anesthetics containing vasoconstrictors

Sympathomimetics Ephedrine, norepinephrine, isoproterenol

General anesthetics
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