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
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
• 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
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
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:
• I do not like anyone in my class?
• I do not want to go out with my friends
• 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
• Change in behavior and decline at school and
extracurricular activities symptoms . But those
are not recognized as potential signs of
• Feeling like a failure and not being able to
How depression is presented in
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
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:
- hypersomnia (sleeping too much),
- loss of appetite,
- pain and
than to present with emotional difficulties
Dysthymic Disorder is a chronic mood disorder that falls within the
• 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
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
• 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
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
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
• Asking about suicide.
• The following questions are useful in exploring
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
A- Affect - How the patient feels about what is
T- Trouble - What troubles you the most?
H- Handling – How the patient is handling the
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
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
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
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
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.
• Its aim to assist patent in constructing
solutions for their problem.
• It is used to help patient create solutions to
• It is not a screening or diagnostic tool but
rather a therapeutic tool to create solutions
for problems of the depressed patients
D - Dream – the first step is to have patient
dream of the miracle that would solve their
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
G- Get going – the third step is getting going and
implementing activities to have the process of change
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
• 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
• 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
• When patient request that help
Serotonin & the Serotonergic System
– Induction & maintenance of sleep
– Regulation of body temperature
– Perception of sensations (hunger, mood,
– Also the regulation of muscle contraction, and
some cognitive functions including memory and
• Medications for 6 months
• Cognitive psychotherapy ( it reduce
• 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
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.