Guyana Primary Health Care

Depression Guidelines

What are todays Objectives??

by the end of the day, you should be able to

Understand the risk factors for depression

Screen for depression Understand the factors that play a role in the development of depression Appreciate the widespread effects of depression Differentiate the types of depression Understand the natural course of depression Understand the treatment options for depression

What is

Depression?

Depression is a medical illness that affects the way one

feels, thinks and acts.

What is

Depression?

There are many symptoms associated with depression including:

Sadness Sleep changes Weight and appetite

changes Lack of energy Feeling guilty or worthless

Emotional numbness or emptiness Difficulty concentrating Moving or speaking slower than usual Thinking life is not worth living

How is Depression different from Sadness?

Sadness
In response to stressful, life-changing events such as the death of a loved one, the loss of a relationship or employment, the natural reaction is sadness, discouragement and frustration. These emotions should gradually dissipate on their own after a few days or weeks.

Depression
When these feelings last for two weeks or longer and start to interfere with the activities of daily living such as work, family or relationships, this low mood may be clinical depression.

How Common is Depression?

Depression is common, with a lifetime risk for major depressive disorder

Men 7-12%

Women 20-25%
Depression is projected to become the leading cause of disability and the second leading contributor to the global burden of disease by the year 2020. Depression occurs in persons of all genders, ages, and backgrounds.

Depression matters because

Treatable cause of pain, suffering, disability Recurrent and chronic course Major public health concern Increased absenteeism from work Affects family members and caregivers Increased use of medical services and emergency services/ increased length of stay in hospital for coexisting medical conditions
Increased mortality rates

What Causes Depression?

Genetics Biochemistry Medical Conditions

Triggers

Depression

Gender Environment

Personality

What is the Onset

and Natural Course of Depression?
Depression can present at any age, but most commonly it first presents in the early 20s to 30s. It is an illness that is chronic, characterized by frequent episodes of recurrences during a patients lifetime. After a Major Depressive Episode 85% of patients experience a recurrence within 15 years.

What Disorders co-occur with

Depression?

anxiety disorders substance abuse/ dependence personality disorders (avoidant, obsessivecompulsive and self-defeating) migraine headaches cancer cerebral accidents myocardial infarctions

Who is at risk for

Major Depressive Disorder ?

Sex: female > male Age: onset in 25-50 age group Family History: depression, alcohol abuse, sociopathy Childhood Experiences: loss of parent before 11 years old, negative home environment (abuse, neglect) Personality: avoidant, dependent, or obsessive compulsive Recent Stressors: financial, legal, migration, illness (chronic insomnia, chronic pain, diabetes, arthritis, myocardial infarction, stroke, recent trauma) Postpartum < 6 months Lack of intimate, confiding relationship or social isolation

DETECTION AND DIAGNOSIS

How do you Detect and Diagnose Depression?

For patients at risk for major depressive disorder, you can use this 2-question screening test:

Have you felt sad, low, down depressed or hopeless? Have you lost interest or pleasure in things you usually like to do?
* The symptoms must be present most of the day, nearly every day, during the same two-week period.

If the patient answers YES to either question, you should proceed with a further assessment.

Detect and Diagnose

There are 5 criteria that determine whether a person is suffering from major depressive disorder.
1) In addition to the depressed mood or loss of interest, the person must have symptoms including three or more of the following:
Significant weight loss/gain or an increased/decreased appetite. Problem sleeping (insomnia or hypersomnia). Psychomotor agitation or retardation. Fatigue or loss of energy. Feelings of worthlessness or excessive guilt. Diminished ability to think or concentrate, indecisiveness. Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or specific plan for committing suicide

Detect and Diagnose

2) These symptoms must cause functional impairment.

3) These symptoms do not meet criteria for a mixed mood episode (an episode with symptoms of mania and depression occurring simultaneously.)

4) The symptoms are not due to the effects of a substance or general medical condition.

5) The symptoms are not better explained by bereavement.

Subtypes of Depression
and how are they diagnosed?
a) Major Depressive Disorder, characterized by Major Depressive Episodes b) Dysthymic Disorder c) Depressive Disorder, not otherwise specified

What else to study in a Depressive Episode?

Mild
5 14 PHQ-9

Catatonic
Marked psychomotor disturbance (motoric immobility, excessive motor activity, negativism, mutism)

Moderate
15 19 PHQ-9

Melancholic
Loss of interest in all activities or lack of reactivity to pleasurable stimuli

Severe
20 o higher PHQ-9

Atypical
Significant weight gain or increase in appetite & hypersomnia

- with Psychotic Features - without Psychotic Features

Postpartum
Onset of episode within 4 weeks postpartum

Adolescent Depression
Adolescence comprises the years from puberty to the mid-twenties Major depressive disorder (MDD) affects 6-8% of adolescents

Most people who develop MDD experience their first episode between the ages of 14-24
Youth onset of MDD usually develops into a chronic condition with substantial morbidity, poor economic/ vocational/ interpersonal outcomes and increased morbidity (from suicide and, in the long term, from other chronic illness: diabetes, heart disease, etc)

Adolescent Depression
Effective treatments that can be provided by first contact health providers are available Early identification and early effective treatment can decrease short-term morbidity and improve long-term outcomes (including decreased mortality)

Diagnosis of MDD in Adolescence

Mood States in young people may change rapidly and are often strongly influenced by their environment.

It is important to distinguish a depressive disorder from depressive distress.

Differentiation of Distress and Disorder

Distress
Always associated with a precipitating event

Disorder
May be associated with a precipitating event

Functional impairment is usually mild

Transient will usually ameliorate with change in environment Professional intervention not usually necessary

Functional impairment may range; mild severe

Long lasting or may be chronic, environment may modify but not ameliorate External validation (syndromal) Professional intervention is usually necessary

Differentiation of Distress and Disorder: important for outcome and intervention Distress
Can be a positive factor in life person learns new ways to deal with adversity Social supports such usual friendship and family networks help Counseling and other technical psychological interventions can help but may not be needed

Disorder
May increase adversity due to its effect on creation of negative life events (low mood can lead to relationship loss) May lead to long term negative outcomes (substance abuse, job loss, etc.)

Social supports and other psychological interventions are often helpful

Medications may be needed but must be used properly

Medications should not be used

Adolescent Depression
Risk Factors for MDD in Youth: 1. Family history of MDD 2. Family history of suicide 3. Family history of a mental illness (especially a mood disorder, anxiety disorder, substance abuse disorder) 4. Childhood onset anxiety disorder

M= mood
S= sleep I= interest G= guilt E= energy

A Memory Aid

C= concentration
A= appetite P= psychomotor agitation/ retardation S= suicide

Dysthymic Disorder
Depressed mood for most of the day, for more days than not, as indicated by either subjective account or observation by others, for at least 2 years.

Note: In children and adolescents, mood can be irritable and

duration must be at least 1 year. Presence, while depressed, or 2 or more of the following:

poor appetite or overeating insomnia or hypersomnia low energy or fatigue poor concentration or difficulty making decisions feelings of hopelessness

Dysthymic Disorder
During the 2-year period (1 year for children and adolescents) of the disturbance, the person has never been without the symptoms in the first two criteria for more than 2 months at a time.

No MDE has been present during the first two years of the disturbance, that is, the disturbance is not better accounted for by chronic MDD, or MDD in partial remission.

The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Depressive Disorders: not otherwise specified

Premenstrual Dysphoric Disorder: in most menstrual cycles during the past year, symptoms regularly occurred during the last week of the luteal phase and remitted within a few days of the onset of menses Minor Depressive Disorder: episodes of at least 2 weeks of depressive symptoms but with fewer than the 5 items required for MDD Recurrent Brief Depressive Disorder of schizophrenia: depressive episode lasting from 2 days to 2 weeks, occurring at least once a month for 12 months and not associated with the menstrual cycle An MDE superimposed on the following: delusional disorder, psychotic disorder not otherwise specified, or the active phase of schizophrenia Situations in which the clinician has concluded that a depressive disorder is present but is unable to determine whether it is primary, due to a general medical condition, or substance- induced

M= mood
S= sleep I= interest G= guilt E= energy

Back to the Memory Aid

C= concentration
A= appetite P= psychomotor agitation/ retardation S= suicide

What is mood?
Mood is the ongoing inner feeling experienced by an individual.
+ 10 +7 +3

0
-3 -7

- 10

How am I feeling inside?

How to ask the questions for mood

How is your mood? Have you been feeling sad, blue, down or depressed?

IF YES:
For how long have you been feeling this way? Do you feel that way nearly every day?

How bad is the feeling?

How to ask the questions for anhedonia

Have you lost interest in or do you get less pleasure

from the things you used to enjoy?

IF YES:
What do you normally enjoy doing? (Television? Reading? Sports? Shopping? Socializing? Eating? Hobbies? Sex?) What do you still enjoy?

What have you lost interest in?

For how long have you not enjoyed these things like you used to? It is like that nearly every day?

How to ask the questions for

appetite

Has there been any change in your appetite?

IF INCREASED OR DECREASED:
How much more/less have you been eating? Is it like that nearly every day? For how long has your appetite been increased/ decreased?

Have you gained/lost any weight?

IF YES:
How much more/less? Since when?

How to ask the questions for

How have you been sleeping?

sleep

How many hours per night have you been sleeping?

How does this compare to normal?

IF INCREASED OR DECREASED:
Is it a problem nearly every day? For how long have you had sleep problems?

* Do you have problems falling asleep, staying, or waking up too early in the morning?

How to ask the questions for psychomotor agitation/ retardation

Agitation: Have you been more fidgety and having problems sitting still?
IF YES:
Do you pace back and forth? Have others noticed your restlessness?

Retardation: Have you felt slowed down, like you were moving in slow motion or stuck in mud? IF YES:
Have others noticed this?

How to ask the questions for

How has your energy level been?

engery

Have you been feeling tired or worn out?

IF YES How long have you been feeling this way? Do you feel like this nearly every day?

How to ask the questions for

How have you been feeling about yourself? Whats your self-esteem been like?
IF LOW: What type of thoughts do you have about yourself? Do you feel like you are worthless or a failure? IF YES: Tell me about it. Have you been blaming yourself for things?

guilt

IF YES: Like what?

How to ask the questions for

Do you feel guilty?
IF YES:

guilt

About what? How hard is it to get your mind off of this? Do you think about things from the past and feel guilty about them?

IF YES: Like what?

*How often do you think of these things? Is it on your mind every day?*

How to ask the questions for

concentration

Have you been having problems thinking or concentrating? IF YES: What does this interfere with? Are you able to read? Watch TV? Follow a conversation? (how often, nearly every day?) Is it harder to made decisions than before?

IF YES: What kind of decisions are harder to make? What about every day decisions? (how often, nearly every day?

How to ask the questions for

suicide

Sometimes when a person feels down or depressed they might think about dying. Have you been having any thoughts like that? IF YES: Tell me about it. Have you thought about taking your life? IF YES:

Did you think of a way to do it? How close have you come to doing it?

IF NO: Do you wish you were dead? When you go to sleep, do you often wish you would not wake up?

How do you Assess Suicide Risk?

Every depressed patient should be assessed for suicide.

Questions should include: Do you ever feel hopeless, or feel as though life is not worth living? Have you ever thought of committing suicide? Have you ever attempted suicide before?

If the patient is considering suicide, the questioning must continue:

How much have you thought about suicide? Have you thought of a method in which you will commit suicide? Do you have access to materials required for suicide? Have you said your goodbyes, written a note or given things away? What specific conditions would precipitate suicide? What is stopping you from following through with suicide?

Risks for suicide

Male Advanced age, in Guyana however 25-30 is a high risk age group Single or living alone Prior suicide attempt Family history of substance abuse Hopelessness Psychosis Medical Illness Substance Abuse

Patients should be monitored closely and treated if:

Suicidal thoughts are persistent The patient has a prior history of a suicide attempt or a current plan, or if the patient has several risk factors for suicide

Clinical cases

Lets meet some patients

Kwesia, a 43 year old woman, presents to you complaining of the inability to concentrate Priya, a 25 year old woman, gave birth to her first child 3 weeks ago and she presents to you for a health check up Raj, a middle aged man, presents to outpatients complaining of feeling tired most of the time

Case # 1
Kwesia, a 43 year old woman, presents to you complaining of not being able to concentrate as well as she used to.
On further questioning you learn that her husband died suddenly 3 months previously and she is now solely responsible for the care of his 4 children. She is still very upset about his husbands death and her mood is low most every day. She has very little energy necessary to care for her children and go to work each day. She is tired most of the day even though she is sleeping 8 hrs each night- a lot more than he is used to. She no longer has an appetite and says that sometimes she wishes to die alongside his husband.

Case # 1
Does Kwesia qualify as a major depressive episode? Or is she just grieving the death of her husband?

What is the diagnosis?

Case # 2
Priya, a 25 year old woman had a healthy pregnancy and a
normal delivery. She and her husband were happy to welcome a healthy baby girl into their family. Directly following the birth Priya was excited about her new role as a mother but, within two weeks, she became more and more sad and withdrawn. She felt as though she would never be a good mother. She would never catch up on her sleep and she felt hopeless about the future. What further questions would you like to ask her?

Case # 2
Mood? low most every day Sleep? unable to sleep between feedings Interest in normally pleasurable activities? doesnt want to leave the house Guilt? feels extremely guilty about being a bad mother Energy level? she has very little energy Concentration? (decreased) Appetite? she has no interest in food Psychomotor retardation/ agitation? she feels as though she is always moving in slow motion Suicide Ideation? sometimes she goes to bed wishing she wouldnt wake up in the morning

What is the Diagnosis?

Case # 3
Raj is a 55 year old man who has been active and employed as a laborer all his life. He is married with 2 grown children. For the last 2-3 years he has had increasing troubles at work. He has become more and more irritable and difficult to work with ultimately leading to the loss of his job.

He presents to you in outpatients complaining of sleep problems.

What other questions would you like to ask?

Case # 3
For the past 2 years. Sleep .. He has been unable to sleep more than one hour at a time and never feels rested. Energy .. He has had no energy and wants to spend his days in bed. Appetite .. He no longer has much of an appetite.

Mood .. His wife reports she hasnt seen him smile in over a year
and that his mood is chronically low.

What is the Diagnosis?

TREATMENT

Goal of Treatment
Restoring brain neurochemical balance. Improving sleep. Raising the energy level. Returning to normal appetite. Restore mood, interest and concentration to functional levels.

How do you acutely treat depression?

Mild to Moderate MDD
#1 Psychotherapy
Cognitive-behavioural therapy (CBT) Interpersonal therapy (ITP) Problem-solving therapy (PST)

#2 Anti-depressants
SSRI TCA

How do you acutely treat depression?

Moderate to Severe MDD
#1 Anti-depressants
SSRI TCA

#2 Psychotherapy
Cognitive-behavioural therapy (CBT) Interpersonal therapy (ITP) Problem-solving therapy (PST).

In Depressive illness self-management and supportive interventions are very helpful.

It is always helpful to include the patient in the treatment of their illness and have them be aware of their symptoms and signs of a relapse.
It is also helpful to utilize any community resources that exist.

Supportive interventions include:

Arrange regular follow-up visits Use the power of the prescription pad to prescribe one brief walk per day, one nutritious meal per day, and one pleasurable activity per day Encourage the patient to keep a simple daily mood chart Encourage and promote patient self-management

Treatment Flowsheet for SSRI Fluoxetine/Citalopram

Diagnosis of moderate to severe Major Depressive Disorder

Establish baseline PHQ-9 and baseline sleep and sexual function status

Start Fluoxetine or Citalopram 10mg by mouth once a day, each morning for 5 days, if well tolerated increase to 20mg.

Monitor patient weekly for signs of side effects

Children and Adolescents

Adults

Patients should continue on anti-depressant medications for at least 6 months AFTER full remission of symptoms.

Treatment Flowsheet for TCAs Amitriptyline/Imipramine/Clomipramine

Diagnosis of moderate to severe Major Depressive Disorder

Establish baseline PHQ-9 and baseline sleep and sexual function status

Start TCA 25mg by mouth once a day, at bedtime

Monitor patient weekly for signs of side effects

Children and Adolescents

Adults

Patients should continue on anti-depressant medications for at least 6 months AFTER full remission of symptoms.

Important Message about Anti-Depressant Medications

Be sure to relay these messages to patients about anti-depressants to promote compliance:

Antidepressants are not addictive. Take your antidepressants daily. It may take 2 to 4 weeks to start noticing improvement. Do not stop antidepressants without talking to your physician, even if you are feeling better. Mild side effects are common, but are usually temporary. Contact your physician with any questions.

How do you monitor the treatment of depression?

Since depression is a chronic and recurrent illness it is important to closely monitor the patients symptoms and be aware of potential relapses. The PHQ-9 is a good tool to monitor the response to treatment. It is important to initially meet with patients at least once every week or two weeks until there is a clear improvement. At this point it is appropriate to meet with patients each month.

GPAC: Guidelines and Protocols Advisory Committee. Depression (MDD)Diagnosis and Management. British Columbia Medical Association, 2004

How do you monitor the treatment of depression?

The normal trajectory of response to anti-depressant medications is: Initial mild symptom improvement within 2-4 weeks (>20% improvement in PHQ9) Good clinical response within 4-8 weeks (>50% improvement in PHQ-9) Remission of symptoms by 8-12 weeks (PHQ-9 < 5) The normal trajectory of response to psychotherapy is: Clinical improvement within 6-8 weeks (>50% improvement in PHQ-9) Remission of symptoms by 12-16 weeks (PHQ-9 < 5)

GPAC: Guidelines and Protocols Advisory Committee. Depression (MDD)Diagnosis and Management. British Columbia Medical Association, 2004

How do you manage poor outcome?

Improvement in the depression scores should see in 3-4 weeks. If there is no improvement, the medications should be increased every 2-4 weeks until the maximum dose is reached. If there is still no improvement seen consider the following options: Re-evaluate diagnostic issues (example: mania/hypomania, medical or psychiatric co-morbidity, alcohol and substance abuse, personality traits/ disorders) Re-assess treatment issues (example: compliance with medications, sideeffects) Add psychotherapy Switch to another antidepressant in the same class (if on SSRI) or in a new class Refer to a specialist or second level. Severe depressive symptoms (active suicidality, psychosis); diagnostic uncertainty, significant psychiatric/ medical co-morbidity; and unsatisfactory response to adequate trials of two or more antidepressants.

References
American Psychiatric Association. Lets Talk Facts About Depression, 2005. American Psychiatric Association. Practice Guidelines for the Treatment of Patients with Major Depressive Disorder, 2002. British Columbia Partners for Mental Health and Addictions Information, compiled by Eric Macnaughton. Depression Toolkit: Information and Resources for Effective SelfManagement of Depression, 2006. Canadian Psychiatric Association and the Canadian Network for Mood and Anxiety Treatments (CANMAT). Clinical Guidelines for the Treatment of Depressive Disorders. Canadian Journal of Psychiatry 2001; 46. GPAC: Guidelines and Protocols Advisory Committee. Depression (MDD)- Diagnosis and Management. British Columbia Medical Association, 2004. Identification, Diagnosis and Treatment of Adolescent Depression (Major Depressive Disorder)A Package for First Contact Health Providers. Stan Kutcher & Sonia Chehil, 2008. Zimmerman, Mark. Interview guide for evaluating DSM-IV Psychiatric Disorders and the Mental Status Examination, 1994.