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The Practical Management of Depression

The Practical Management of Depression. Dr Frans A Korb Psychiatrist and Clinical Psychologist Private Practice Fourways Intercare. Overview : Depression. The Background The Facts Some Biology Making the Diagnosis Measuring Depression Management – Pharmaceutical Management – Other

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The Practical Management of Depression

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  1. The Practical Management of Depression Dr Frans A Korb Psychiatrist and Clinical Psychologist Private Practice Fourways Intercare

  2. Overview : Depression • The Background • The Facts • Some Biology • Making the Diagnosis • Measuring Depression • Management – Pharmaceutical • Management – Other • The Final Word

  3. Definition : Depression ‘Mood is a sustained emotional tone perceived along a normal continuum of sad to happy. Mood disorders are characterized by abnormal feelings of depression or euphoria with associated psychotic features in some severe cases. Mood disorders are divided into bipolar and depressive disorders’ Kaplan & Sadock

  4. Depression: Impact on Society A Major Cause of Disability Worldwide Rank 1990 2020 (Estimated) 1 Lower respiratory infections Ischemic heart disease 2 Perinatal conditions Unipolar major depression 3 HIV/AIDS Road traffic accidents 4 Unipolar major depression Cerebrovascular disease 5 Diarrheal diseases Chronic obstructive pulmonary disease Murray CJL, Lopez AD, eds. The Global Burden of Disease. Boston: Harvard University Press; 1996.

  5. DEPRESSIVE DISORDERS • DSM-IV vs ICD-10 • Major Depressive Disorder • Dysthymic Disorder • Bipolar Disorder • Cyclothymic Disorder

  6. Depression – The Facts

  7. The Epidemiology of Depression • Approximately 20% of primary care patients present with depressive symptoms.1 • Depression is almost twice as prevalent in females as in males.2 • Nearly two-thirds of MDD patients have multiple episodes. The risk of recurrence progressively increases with each successive episode and decreases as the duration of recovery increases.3 • Prevalence rates for MDD are unrelated to race, (religion),education, income, or civil status.4 • Zung WW, et al. J Fam Pract. 1993;37:337-344. • Kessler RC, et al. J Affect Disord. 1993;29:85-96. • Solomon DA, et al. Am J Psychiatry. 2000; 157:229-233. 4. U.S. Agency for Health Care Policy and Research. Depression in Primary Care: Vol. 1. Detection and Diagnosis. Rockville, MD: 1993: 23.

  8. Prevalence Rates of Depression in Chronic Medical Disorders Adapted from: WPA/PTD Educational Program on Depressive Disorders. Gavard JA, et al. Diabetes Care. 1993;16(8):1167-1178.

  9. Gender Demographics1 MDE Hazard Rates by Age and Sex 0.0140 Female 0.0120 Male 0.0100 Hazard Rates 0.0080 0.0060 0.0040 0.0020 0.0000 5-9 10-14 15-19 20-24 0-4 25-29 30-34 35-39 40-44 45-49 50-54 Age Category 1. Kessler RC, et al. J Affective Disord. 1993;29:85-96.

  10. Depression – Some Biology

  11. Neurotransmission is the process of sending signals from one component of the nervous system to another Neurotransmission

  12. Healthy Depressed 5-HT Reuptake Transporter 5-HT NAReuptake Transporter NA Theoretical Representation 5-HT and NA at the Synaptic Level: Healthy vs. Depressed

  13. Depression -- Making the Diagnosis

  14. What is Depression ? Depressed mood Traurigkeit Depression Slowed moving Bewegungshemmung Slowed thinking Gedankenhemmung Weygandt “Uber die Mischzustande des manisch-depressiven Irreseins” (Munchen, 1899)

  15. Depression. It’s not only a state of mind. The emotional and physical symptoms of depression 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.

  16. Anxious Tired Unmotivated (Agitated) (Retarded) 34% 31% 35% 35% have low mood, fatigue, low energy, and lack of motivation. 34% have mild symptoms of fatigue, low energy, and excessive worry, and are easily overwhelmed 31% have primary anxiety complaints Adelphi Neurosis Market Research Study. 1997. A. Gupta 2000 (n=1590).

  17. SPECIAL FORMS OF DEPRESSIVE DISORDERS • Psychotic Depression • Somatic Depression • Atypical Depression • Seasonal Depressive Disorder • Rapid-cycling Bipolar Disorder • Secondary Depressive Disorder

  18. OTHER FORMS OF DEPRESSIVE DISORDERS • Dysthymia • Postpartum Depression • Recurrent Brief Depression • Mixed Anxiety-Depression Syndrome • Subthreshold Depression

  19. Measuring Depression

  20. Depression Management -- Pharmaceutical

  21. 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.

  22. 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

  23. Depression: Treatment Goals Recovery Remission Recurrence No Depression Relapse X X Relapse X Response Symptoms Severity Progression to disorder Syndrome Acute Continuation Maintenance 6-12 weeks 1 or more years Treatment Phases 4-9 months Time Reprinted with permission from Kupfer, 1991WPA/PTD Educational Program on Depressive Disorders

  24. Switching Strategies

  25. Pharmacological Strategies for Treatment-Resistant Depression (TRD)

  26. Depression Management -- Other

  27. Patient Programmes www.sadag.co.za mySupport Programme www.bouncingback.co.za

  28. Depression – The Final Word

  29. Social-Endocrine-Psychological Interactions

  30. Depression: Treatment Goals Treatment Reduce/Remove Signs, Symptoms Minimise Relapse/ Recurrence Risk Restore Role/ Function AHCPR Guidelines: Depression in Primary Care, Vol 2. US Dept. of Health and Human Services; 1993.

  31. Depression Is ... • Prevalent worldwide • Common in primary care setting • Often unrecognized, inadequately treated • Associated with high morbidity, mortality, cost • PCP can provide effective treatment

  32. fakorb@telkomsa.net

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