Depression

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					  Depression




Depression
     Risk factors for depression
1- Age: young patient are more prone to
  depression . Peak incidence from 20 – 40
2- Sex: women are twice as men to develop
  depression
3- Pregnancy: one in 10 of pregnant women
  develop post partum depression
4- Family history of depression
    Risk factors for depression
Nutritional status is often a symptom of
depression. Depressed patient often either
under or overeating. Nutritional intake in itself
not considered a risk facto
   Do women depression more easily
            diagnosed?
• Yes it is easily diagnosed more than men,
  children or adolescent,
• Because they declare their emotional state
  and report it easily during a medical visit. It is
  not because the symptoms are more sever
  among women.
      Why it is difficult to diagnose
         depression in men?
1- Men feel stigmatized of being depressed.
2- Men believe that it is not socially appropriate
  for them to report depression symptoms and
  to seek help.
3- Also males are more likely than females to
  mask a depression mood and they may more
  likely to appear as they are using drugs or
  alcohol than being depressed (outlook with
  chemical abuse).
Why identifying depression in children and adolescents is often
                  difficult in family practice?


   Is it because there is no screening tests for
             depression in such groups?

No, there are plenty of screening tests to screen
 depression in children and adolescents but
 even with those it is difficult. Why?
  Adolescents and children often report quite
  different signs. They describe internalizing
  symptoms that not necessarily specific to
  depression like feeling ,
• like a failure,
• not being able to succeed anymore, or
• always being in a bad mood.
Examples of what can be said by them:
Children say:
• I do not like anyone in my class?
• I do not want to go out with my friends
  anymore.
Parents say:
• He is gotten lazy and is not studying anymore
• She is becoming so moody I can not even talk
  to her without losing her temper with me.
     How depression is presented in
              children?
• Change in behavior and decline at school and
  extracurricular activities symptoms . But those
  are not recognized as potential signs of
  depression.

• Feeling like a failure and not being able to
  succeed anymore.
   How depression is presented in
          adolescents?

It is more likely to present with irritability,
 social withdrawal, oppositional attitude
 and substance abuse more than present
 with sadness or depressed mood. They
 are atypical symptoms and thus missed.
         Types of depression
1- Major depressive disorder
2- Dysthymic disorder
3- Manic Depression (now known as Bipolar
  Disorder)
4- Post Partum Depression
5- Seasonal Affective Disorder (SAD)
6- Anxiety Depression
 Diagnosis of Major depressive disorder (MDD)

During the same 2 week period every day five out of nine symptoms
    must be present but one and two must be present.
1- depressed mood most of the day, nearly every day, as indicated by
    either the patient or observation by others (appears tearful).
2- lose interest in all activities.
3- undesired weight change
4- sleep disturbance (less or more)
5- agitation or retardation
6- fatigue or loss of energy
7- Feeling of worthlessness or guilt
8- cognitive dysfunction
9- strong suicidal ideas , plan or attempt
The symptoms must not related to a medical condition (cancer), loss of
    a loved one, drug abuse or medication)
• A positive depression screen must be followed by
  an interview , because depression screening
  measures do not diagnose depression
• Depression screening can provide:
   - critical information about severity of symptoms
   - how they change in response to treatment or
   - lack of treatment
  but does not diagnose depressive illness.
Depressed patient are more likely to present with
physical symptoms such as:
 - insomnia,
 - hypersomnia (sleeping too much),
 - loss of appetite,
 - pain and
 - fatigue

 than to present with emotional difficulties
    Dysthymic Disorder is a chronic mood disorder that falls within the
                          depression spectrum.


• Dysthymia is a chronic long lasting form of depression
  sharing many characteristic symptoms of major depressive
  disorder. However, these symptoms tend to be less severe
  but do fluctuate in intensity. To be diagnosed an adult must
  experience 2 or more of the following symptoms "for most
  of the day more days than not for at least 2 years without
  interruption of symptoms for longer than 2 months
• Feelings of hopelessness
• Insomnia or hypersomnia
• Poor concentration or difficulty making decisions
• Low energy or fatigue
• Low self-esteem
• Poor appetite or overeating
     Manic Depression (now known as
            Bipolar Disorder)
 This kind of depression includes periods of mania and depression. Cycling between
    these two states can be rapid or only mania can be present without any depressive
    episodes. A manic episode consists of a persistent elevated or irritable mood that
    is extreme, which lasts for at least one week. At least three (four if only irritable
    mood) other features are also present:
• inflated self-esteem or self-importance
• decreased need for sleep
• more talkative than usual or compelled to keep talking
• easily distracted
• increase in goal-oriented activity (social, work, school, sexual) or excessive
    movement
• excessive involvement in potentially risky pleasurable behavior (e.g. over spending,
    careless sexual activity, unwise business investments)
• Symptoms can be severe enough to warrant hospitalization to prevent harm to self
    or others or include psychotic features (e.g. hallucinations, delusions).
4- Post Partum Depression – Major depressive episode
   that occurs after having a baby. Depressive symptoms
   usually begin within four weeks of giving birth and can
   vary in intensity and duration.

5- Seasonal Affective Disorder (SAD) It is MDD with a
   seasonal pattern – A type of depressive disorder which
   is characterized by episodes of major depression which
   reoccur at a specific time of the year (e.g. fall, winter).
   In the past two years, depressive periods occur at least
   two times without any episodes that occur at a
   different time.
6- Anxiety Depression - Not an official depression
  type (as defined by the DSM). However, anxiety
  often also occurs with depression. In this case, a
  depressed individual may also experience anxiety
  symptoms (e.g. panic attacks) or an anxiety
  disorder.
There is a type called adjustment disorder with
  depressed mood which is defined as a reaction to
  some identifiable psychosocial stressors that
  occur within 3 months of the onset of the
  depressed mood. Treatment of this case by
  counseling and stress management.
   The cause of these conditions
• A neurotransmitter imbalance that appears to
  be caused by a relative deficiency of the
  neurotransmitter serotonin ( the new SSRIs
  add confirming evidence to this hypothesis)
  The most important question to ask a patient
   who presents with signs and symptoms of
                 depression
• Asking about suicide.
• The following questions are useful in exploring
   suicidality:
1- You seem so terribly unhappy. Have you had any
   thoughts about hurting yourself?
2- If you have, have you thought of the means by which
   you would do it? Have you considered a specific plan
   for ending your life? Under what circumstances would
   you carry it out?
3- What would it take to stop you from killing yourself?
4- Do you feel that your situation is hopeless?
  Techniques used by family physician in the outpatient clinics
                     1- BATHE technique

B - Background - What happening that of
     concern to the patient or what is going in
     your life?
A- Affect - How the patient feels about what is
     happening?
T- Trouble - What troubles you the most?
H- Handling – How the patient is handling the
    situation?
E- Empathy – An empathic or supportive statement
    to conclude the sequence.
• It is recommended to use this test in every
  patient encountered by family physician.
• It takes from 5 – 7 minutes
• Indications for using this technique:
    - basic level of counseling
    - little time for counseling
    - patient has psychosocial issues
Contraindication for BATHE technique:
•    Suicidal patient
•   Family violence
•   Drug abuse
•   Personality disorders
              SPEAK technique

  It is used by family physician as a therapeutic
   tool. It is five steps counseling.
S – schedule each day – activate patient to
    prepare a written daily schedule.
P – pleasant – it indicate that family physician
    encourage depressed patient to have at
    least one of the daily activities pleasant to
    himself
E – exercise – exercise has shown to be beneficial in
    alleviating depression symptoms.
A – assertion- family physician should
    encourage their depressed patient to
    assume more control in their lives to regain
    their previous sense of self reliance and self
    confidence as expression of anger should be
    avoided
K- kind – thinking kind thoughts about oneself
• Depressed patients usually focus on negative
  perceptions of themselves , their ongoing
  experiences in the future. See the empty half of a
  glass of water. They should be encouraged to
  identify positive coping abilities and strengths.
• The SPEAK technique is used to motivate
  depressed patients and it is more effective when
  it is used in conjunction with the BATHE
  technique.
The BATHE technique can be used as the
assessment part of the visit ( a screening
test) because it helps define issues
where SPEAK technique is part of the
plan because it helps design a plan to
activate the patient.
               DIG technique
• Its aim to assist patent in constructing
  solutions for their problem.
• It is used to help patient create solutions to
  their problems.
• It is not a screening or diagnostic tool but
  rather a therapeutic tool to create solutions
  for problems of the depressed patients
                 DIG technique
D - Dream – the first step is to have patient
     dream of the miracle that would solve their
     problem
I- Initiate – the next step is for patient to initiate a
   process that will make that miracle happen and to
   make changes in themselves that miracle would
   happen
G- Get going – the third step is getting going and
   implementing activities to have the process of change
   occur.
       This test takes 15 minutes to be completed
     Management of depression
• Medication generally provide rapid response
  to depression in outpatient settings. However,
  this response does not reduce the risk of
  relapse, after medication is withdrawn.
• Depression generally responds more slowly to
  behavioral therapy but it is as effective as
  medications.
• Usually a combination of behavioral therapy
  and medication is good for chronic patients
    Cognitive behavioral therapy
• It is shown to reduce the subsequent risk for
  relapse of depression.
• It is based on that maladaptive thoughts and
  behavior are learned from experience and
  that they can be modified through corrective
  experiences
• It is a well documented and effective approach
  to the treatment of depression
• It employs a short term, good- oriented approach.
• The thought of the dysfunctional thinking can be
  modified and ,therefore, the emotions produced by the
  dysfunctional thinking will be changed.
• Those vulnerable to depression harbor negative core
  beliefs and those stable beliefs trigger distorted
  automatic thoughts that induce depressogenic effect
  and behaviour ( if there is a stressor or an experience
  that caused a negative feeling, the approach to this
  stressor can be changed.
       Who treats depression?
• Most patient with depression are treated by
  primary care provider and most of them never
  see a mental health provider.
• The majority of antidepressant medications
  are prescribed by family physicians but
  sometimes there is a need for consultation
  with a mental health provider
            Causes of referral
• Combined psychiatric disease
• Personality disorder
• When at least two trials of medications have
  failed
• When patient request that help
 Serotonin & the Serotonergic System

Function
  – Induction & maintenance of sleep
  – Regulation of body temperature
  – Perception of sensations (hunger, mood,
    behaviour
  – Also the regulation of muscle contraction, and
    some cognitive functions including memory and
    learning.
                 Treatment
• Medications for 6 months
• Cognitive psychotherapy ( it reduce
  recurrence)
• Exercise
• Relaxation therapy is used for treatment of
  anxiety than for depression
• Drugs as
• 1- Tricyclic antidepressant as Tofranil it is
   presented in 10 or 25 mg .
• SSRIs (serotonin reuptake inhibitor)
 It has a short half life example Fluoxetine
Side effect: Sexual dysfunction
• SSRIs discontinuation syndrome: is characterized
  by flue like syndrome and ca be avoided by
  tapering SSRI over 1 to 2 weeks.
  (flue like symptoms as nausea, dizziness,
  headache, anxiety and crawling sensation under
  the skin.
  Exercise has been shown to lower level of
  depression. Some studies have shown it to be as
  effective as individual or group psychotherapy or
  cognitive therapy. It is also effective in anxiety.