The Practical Management of Depression

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The Practical Management of Depression

• Dr Frans A Korb
• Psychiatrist and Clinical Psychologist
• Private Practice
• Fourways Intercare

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Overview Depression

• The Background
• The Facts
• Some Biology
• Making the Diagnosis
• Measuring Depression
• Management Pharmaceutical
• Management Other
• The Final Word

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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
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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.
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DEPRESSIVE DISORDERS

• DSM-IV vs ICD-10
• Major Depressive Disorder
• Dysthymic Disorder
• Bipolar Disorder
• Cyclothymic Disorder

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Depression The Facts
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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

1. Zung WW, et al. J Fam Pract. 199337337-344.
2. Kessler RC, et al. J Affect Disord.
   19932985-96.
3. Solomon DA, et al. Am J Psychiatry. 2000
   157229-233.

4. U.S. Agency for Health Care Policy and
Research. Depression in Primary Care Vol. 1.
Detection and Diagnosis. Rockville, MD 1993 23.
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Prevalence Rates of Depression in Chronic Medical
Disorders
Adapted from WPA/PTD Educational Program on
Depressive Disorders. Gavard JA, et al. Diabetes
Care. 199316(8)1167-1178.
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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.
19932985-96.
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Depression Some Biology
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Neurotransmission

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

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5-HT and NA at the Synaptic Level Healthy vs.
Depressed
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Depression -- Making the Diagnosis
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What is Depression ?
Depressed mood Traurigkeit
Depression
Slowed moving Bewegungshemmung
Slowed thinking Gedankenhemmung
Weygandt Uber die Mischzustande des
manisch-depressiven Irreseins (Munchen, 1899)
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Depression. Its not only a state of mind.
The emotional and physical symptoms of depression
Emotional Symptoms Include
Always feeling sad
Loss of interest or pleasure
Worrying
Anxiety
Diminished ability to think or concentrate, indecisiveness
Excessive or inappropriate guilt
Physical Symptoms Include
Vague aches and pains
Headache
Sleep disturbances
Fatigue
Vague back pain
Significant change in appetite resulting in weight loss or gain
Reference Adapted from American Psychiatric
Association. Diagnostic and Statistical Manual of
Mental Disorders. Fourth Edition,Text Revision.
Washington, DC American Psychiatric Association.
2000345-356,489.
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Anxious
Tired Unmotivated
(Agitated)
(Retarded)
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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 (n1590).
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SPECIAL FORMS OF DEPRESSIVE DISORDERS

• Psychotic Depression
• Somatic Depression
• Atypical Depression
• Seasonal Depressive Disorder
• Rapid-cycling Bipolar Disorder
• Secondary Depressive Disorder

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OTHER FORMS OF DEPRESSIVE DISORDERS

• Dysthymia
• Postpartum Depression
• Recurrent Brief Depression
• Mixed Anxiety-Depression Syndrome
• Subthreshold Depression

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Measuring Depression
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Depression Management -- Pharmaceutical
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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.
198441971-78. 2) Wells KB, et al. JAMA.
1989262(23)3298-3302. 3) Lepine C, et al. Intl
Clin Psychopharm. 19971219-29. 4) Katon W, et
al. Medical Care. 199239(1)67-76.
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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
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Depression Treatment Goals
Recovery
Remission
Recurrence
No Depression
Relapse
X
X
Relapse
X
Response
Symptoms
Severity
Progression to disorder
Syndrome
Maintenance
Continuation
Acute
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
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Switching Strategies
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Pharmacological Strategies for Treatment-Resistant
Depression (TRD)
Optimization (monotherapy) Increase the dose or duration, or alter the timing of the primary antidepressant.
Substitution (switching) Stop first medication, start next one as monotherapy. New drug can be within or across class.
Augmentation Add a second drug (adjunct) that is not an antidepressant to the antidepressant that has not produced and adequate response.
Combination Two antidepressants used together, typically for synergistic mechanisms.
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Depression Management -- Other
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Patient Programmes
www.sadag.co.za mySupport Programme www.bouncing
back.co.za
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Depression The Final Word
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Social-Endocrine-Psychological Interactions
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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.
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Depression Is ...

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

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