DEPRESSION & SUICIDE

DR.SARATH MENON.R

DEPARTMENT OF NEUROLOGY
MGM MEDICAL COLLEGE,INDORE

INTRODUCTION
Mood disorder
Syndrome- set of symptoms
- definite time period

For atleast 2 weeks

Distress to self and others
Social & vocational impairment

EPIDEMIOLOGY
Global prevalance
1.9 % (men) 3.3 % (women)
In India
Prevalence 26.8 % (2011)
Suicidal mortality rate- 10.5/1L (2011)
Studies
Chandrasekhar & Reddy etal (Hyderabad)
prevalence -7.9 to 8.9 /1000
double prevalance rate in urban population

STUDIES

South India- Chennai based study

prevalence of 15.6 %

Srinath etal study ( Andhra)

1.61/1000 children unipolar depression

DETERMINANTS OF DEPRESSION
Female gender
Old age
Economic impoverishment
Illiteracy
Violence /trauma
Substance abuse alcoholism
Chronic medical illness

IMPACT ON MORTALITY

Around 8,00,000 commit suicide

India has highest suicidal rate among young people

70 % increase in mortality in people age > 65 yr

THREE TYPES OF DEPRESSION

Major depression

Minor depression (dysthymia)

Bipolar depression

MAJOR DEPRESSION- DSM IV

CRITERIA
2 week duration
5 or more symptoms
- depressed mood most of the days
- diminished interest or pleasure
- significant weight loss (>5% in a month)
- insomnia/hypersomnia nearly every day
- psychomotor agitation/ retardation
- fatigue/ loss of energy
- feeling of worthlessness/guilt
- recurrent thoughts of death/suicidal ideation

MINOR DEPRESSION
Often referred as dysthymia
Symptoms are same as major depression
Low level doesnt disrupt ones life
Duration of atleast 2 yrs
Chances to develop into major depression if
untreated

BIPOLAR DEPRESSION
Two sides of highs & lows
Symptoms of mania/hypomania in one side &
major depression on other
Can fluctuate between these stages
Rapid or sudden fluctuations seen at times

CLINICAL SUBTYPES OF
DEPRESSION
Retarded depression
Agitated depression
Psychotic depression
Paranoid depression
Peuperial depression
Seasonal depression
Chronic depression

ETIOLOGY
Biological factors
- serotonin
- norepinephrine
- dopamine
Neuroendocrine regulation
- thyroid axis
- adrenal axis
- growth hormone
Sleep abnormalities
- delayed sleep onset
- shortened REM latency

Brain imaging
- Bipolar enlarged cerebral ventricle
- SPECT /PET scandecreased blood flow esp. frontal cortex
Genetics
- Psychisocial factors
stress
premorbid personality
cognitive factors
negative distortion of factors
- negative self evaluation
- pessimism
- hopelessness

Positron Emission Tomography

(PET) Scan often used to see
shrinkage of the hippocampus
and frontal lobe

(Position Emission
Tomography Scan of the
Brain for Depression)

SEROTONIN

Imbalance in Serotonin can

influence mood and emotions
Problems in the brain with low
levels of Serotonin: the brain being
unable to receive Serotonin and/or
an overall shortage of Serotonin in
the brain are being linked to
Depression and its symptoms

PATHOPHYSIOLOGY & CLINCAL

PRESENTATION OF DEPRESSION
Mood disturbances
- painful arousal
- hypersensitivity to unpleasant event
- insensitivity to unpleasant event
- depressed mood
- anhedonia
- reduced anticipatory pleasure
Psychomotor disturbances
- pyschomotor retardation
- agitation
- pseudi dementia/stupor

Cognitive disturbances
- ideas of deprivation & loss
- low self esteem & self confidence
- self reproach & pathological guilt
- recurrent thought of death & suicide
Vegetative disturbances
-anorexia, weight loss or gain
-insomnia/hypersomnia
- sexual dysfunction
Suicide
Anxiety
Guilt

SYMPTOMS OF DEPRESSION

Feeling sad, empty, nervous for a long time

Feeling hopeless, helpless, pessimistic
Problems sleeping, waking early in the morning and unable to get
back to sleep
Loss of interest or enjoyment in hobbies, activities previously enjoyed
Feeling worthless, guilty, overwhelmed, inadequate
Feeling tired, lazy, no energy or zest
Problems concentrating, thinking clearly, remembering things
Ambivalence, cant make decisions
No appetite with weight loss or overeating with weight gain
Agitation, irritability, physical restlessness
Loss of interest or enjoyment in sex
Persistent thoughts of death or suicide
Physical symptoms (such as headaches, stomach distress, chest pain,
chronic pain) that wont go away despite treatment

TREATMENT

Psychosocial therapy

Pharmacotherapy

PSYCHOSOCIAL THERAPY

Interpersonal therapy

Cognitive therapy

Behaviour therapy

PHARMACOTHERAPYGENERAL GUIDELINES

Usual recovery by 1 month

3-4 weeks for anti-depressants to act

Choice of antidepressents determined by side

effect profile,physical status,lifestyle
Dosage raised to max.recommended level &
maintained for 4 or 5 wks

DURATION & PROPHYLAXIS

Atleast 6 months or length of previous episode
Prophylactic Rx
- seriousness of previous episodes
- suicidal ideation
- impairment of psychosocial functions

INITIAL MEDICATION SELECTION

Depending on
- chronicity
- family history
- prior treatment response
- concurrent psychiatric / general
condition
- patient preference

ACUTE TREATMENT FAILURE

Cannot tolerate side effects
idiosyncratic adverse side effects
inadequate clinical response
wrong diagnosis

Lack of partial response ( 25% symptom

reduction) in 4 6 wks - change treatment
Can have a 2nd trial for another 4-6 wks.

SELECTION OF 2ND TREATMENT

OPTIONS

Switching to alternate treatment (preferred)

augmentation of current treatment

combination therapy of SSRI & Bupropion

widely employed
ECT effective in non responsive cases & acute
severe depression.

ANTIDEPRESSANTS
Name

Usual daily dose(mg)

Side effects

Desipramine

75-300

Drowsiness,insomnia,agita
tion, arrythmia.weight
gain, anti cholinergic

Nortriptyline

40-200

- Do-

Citalopram

20-60

Insomnia, agitation,
sexual dysfunction,GI
distress, sedation

Escitalopram

10-20

-do-

Fluoxetine

10-40

-do-

Fluvoxamine

100-300

-do-

Paroxetine

20-50

-do-

NE reuptake inhibitor

5-HT reuptake inhibitors

(SSRI)

Name

Usual daily dose(mg)

Side effects

Amitriptyline

75-300

Drowsiness,OSH,arrythmi
a,weight
gain,anticholinergic

Imipramine

75-300

-do- + agitation,insomnia

Venlafaxine

150-375

Sleep changes,GI
distress.discontinuation
syndrome

Duloxetine

30-60

GI distress.discontinuation
syndrome

15-30

Sedation,weight gain

NE& 5-HT reuptake

inhibitors

Pre & post synaptic active

agents
Mirtazapine

Name

Usual daily dose (mg)

Side effects

200-400

Insomnia,agitation,GI
distress

Amoxapine

100-600

Drowsiness,insomnia/agita
tion,arrythmia,weight
gain,OSH,anticholinergic

Clomipramine

75-300

drowsiness.,weight gain

Dopamine reuptake
inhibitor
Bupropion

Mixed action agents

Discuss Choice of drug with

patient Include :
Therapeutic effects
Adverse effects
Discontinuation effects
Start antidepressant
Titrate to recognised
therapeutic dose.
Assess efficacy
over 4-6 weeks

No Effect

Poorly tolerated

Effective

Increase Dose
Assess over a further
2-4 weeks
No Effect

Continue for 4-6

months at full treatment
Effective
dose
Consider longerterm treatment
in recurrent depression

Give an antidepressant
from a different class
Titrate to therapeutic dose.
Assess over 4-6 weeks,
increase dose as necessary

Effective

Effective

Poorly
tolerated
or
no effect
No
Effect

Refer to Suggested treatments

for refractory depression

Give an antidepressant
from a different class
Titrate to therapeutic dose.
Assess over 4-6 weeks

Treatment of refractory
depression
OTHER REPORTED TREATMENTS
(may be worth trying, but limited published support)
Treatment
Add bupropion
300 mg /day
Add clonazepam
0.5- 1.0 mg at night
Add mirtazapine
15-30 mg ON
Add modafinil
100-200 mg/day
Add risperidone
0.5-1.0 mg /day
Ketoconazole
400-800 mg /day
Oestrogens (various regimes used)
SSRI + TCA (e.g. citalopram 20 mg / day with amitriptyline 50 mg /day
Try S-adenosyl I methionine 400 mg / day im
SNRI = reboxetine
Add omega 3 fatty acid (EPA 1 g daily)

DEPRESSION IN MEDICAL DISORDERS

Neurological
- CVA

- migraine

- dementia

- Parkinons d/s

- epilepsy

- multiple sclerosis

- Huntingtons d/s

- Wilsons d/s

Endocrine
- adrenal- cushings,addisons
- hypothroidism
- hyper/hypo parathyroidism

Infections/inflammatory
- HIV,IMN,SLE, temporal arteritis

Drugs
-analgesics- indometahcin,ibuprofen,opiates
- antibiotics- ampicillin,metronidazole,tetracyclines
- steroids- corticosteroids,OCP,prednisolone
- antihypertensives- b-blockers,clonidine,reserpine
- anti cancer- bleomycin,vincristine
Miscellaneous
- cancers
- uremia
- vitamin deficiency
- porphyria

SUICIDE INCIDENCE &

PREVALENCE

1.2 lakh/yr suicidal deaths

4 lakh/yr attempt suicide

Majority of suicide (37.8%) -< 30 yr age gp.

77 % suicide - < 44 yr age- huge burden

STUDIES

Venkoba Rao etal- Madurai

- incidence- 43/1,00,0000
- fatality- 1/12 attempts
Hegde et al (Karnataka)
- incidence rate- 10.2/1,00,000
- Male preponderance- 67%
Shukla et al (Jhansi)
- 29/1,00,000
- 34/1lakh (women) & 24 /1 lakh (men)

OTHER STUDIES

Banerjee etal (kolkata)

- incidence 43/1,00,000
- women 79.3 %
- 75 % -< 25 yr age

SUICIDE & PSYCHIATRIC

DISORDERS

Psychological autopsy studies done in various countries over

almost 50 years report the same outcomes:

90% of people who die by suicide are suffering from one

or more psychiatric disorders:
Major Depressive Disorder
Bipolar Disorder, Depressive phase
Alcohol or Substance Abuse
Schizophrenia
Personality Disorders such as Borderline

RISK FACTORS FOR SUICIDE

Psychiatric disorders

Past suicide attempts

Symptom risk factors

Sociodemographic risk factors

Environmental risk factors

RISK FACTORS
Psychiatric Disorders

Most common psychiatric risk factors resulting in suicide:

Depression*
Major Depression
Bipolar Depression

Alcohol abuse and dependence

Drug abuse and dependence
Schizophrenia

*Especially when combined with alcohol and drug abuse

RISK FACTORS

Other psychiatric risk factors with potential to result in

suicide (account for significantly fewer suicides than
Depression):

Post Traumatic Stress Disorder (PTSD)

Eating disorders
Borderline personality disorder
Antisocial personality disorder

RISK FACTORS

Major physical illness, especially recent

Chronic physical pain

History of childhood trauma or abuse

Family history of death by suicide

Substance abuse

RISK FACTORS
Sociodemographic Risk Factors

Over age 65
White
Separated, widowed or divorced
Living alone
Being unemployed or retired
Occupation: health-related occupations higher
( doctors, nurses, social workers)

METHODS OF SUICIDE
Hanging ( 31.7 %)
Poisoning pesticide, drug overdose etc (34.8%)
Firearms (8 %)
Drowning
Wrist cutting
Hypothermia
Electrocution
Jumping from height
Vehicular impact-rail,traffic collision
Immolation

WARNING SIGNS

Observable signs of serious depression

Unrelenting low mood
Pessimism
Hopelessness
Desperation
Anxiety, psychic pain, inner tension
Withdrawal
Sleep problems
Increased alcohol and/or other drug use
Recent impulsiveness and taking unnecessary risks
Threatening suicide or expressing strong wish to die
Making a plan
Giving away prized possessions
Purchasing a firearm
Obtaining other means of killing oneself
Unexpected rage or anger

PROPOSED DSM-V SUICIDE ASSESSMENT DIMENSION

Level of concern about

potential suicidal behavior:
(sum of items coded as
present)
1. 0: Lowest concern
2. 1-2: Some concern
3. 3-4: Increased concern
4. 5-7: High concern

Suicide risk factor groups:

1. Any history of a suicide attempt
2. Long-standing tendency to lose temper or
become aggressive with little provocation
3. Living alone, chronic severe pain, or recent
(within 3 months) significant loss
4. Recent psychiatric admission/discharge or
first diagnosis of MDD, bipolar disorder or
schizophrenia
5. Recent increase in alcohol abuse or
worsening of depressive symptoms
6. Current (within last week) preoccupation
with, or plans for, suicide
7. Current psychomotor agitation, marked
anxiety or prominent feelings of
hopelessness

PREVENTING SUICIDE
Prevention within our community

Education

Screening

Treatment

Means Restriction

CONCLUSION
Depression - common disorder
By 2025, major cause of morbidity & mortality
India has highest number of suicides among
young people
Treatable but under diagnosed
Newer drugs with less side effects available.

REFERENCES
Kaplan & Saddocks Synopsis of Psychiatry-10th
edition
Text book of depressive disorders by Maj &
Sartorius -2nd edition
Indian journal of psychiatry