Management of depression in primary health care

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Management of depression in primary health care

• Dr. Tarik S. Khammas
• Consultant Psychiatrist
• New Psychiatry Hospital
• Abu Dhabi

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INTRODUCTION

• It is estimated that depressive disorders will
  affect one of five patients in general practice.
• These patients may be unaware of their mental
  state its influence, seeking treatment for a
  somatic disorder.
• In depressed patients, the associated somatic
  complaints may be also be gender related.
• Information regarding these symptoms may be
  difficult to obtain, often only becoming apparent
  with gentle questioning. If further information
  is needed, relative a friend are often a
  valuable source.

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Affective Disorders

• The word affect is a synonym for mood.
• Affective disorders are so named because their
  main feature is an abnormality of mood, namely
  depression or elation.
• ICD-10 classification (Manic episode, Depressive
  episode- mild, moderate severe, Bipolar
  affective disorder, Persistent mood states-
  cyclothymic dysthymia ).
• DSM-IV classification ( Manic episode, Major
  depressive episode, Bipolar disorders,
  Cyclothymia dysthymia ).
• Both depression elation can be secondary to
  other psychiatric syndromes also accompany
  physical illness.

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Depressive disorder

• The central features of depression are low mood,
  pessimistic thinking, lack of enjoyment, reduced
  energy, slowness, poor concentration low
  self-esteem.
• Depressive disorder is frequent in general
  hospital practice but is often undetected,
  especially when there are physical symptoms.
• Unrecognized depressive disorder is a common
  cause of distress slow recovery from physical
  illness.
• All doctors should be able to recognize the
  condition, treat the less severe cases, identify
  those requiring specialist care.
• They are classified as single or recurrent
  episodes less severe form (dysthymia).

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General clinical features

• Sadness is a normal emotion commonly experienced
  by healthy people in response to misfortunes,
  especially losses(grief). It is often accompanied
  by anxiety, lack of energy poor sleep.
• More severe unhappiness associated with low mood,
  depressive thinking biological symptoms.
• Depressive symptoms also occur in many other
  psychiatric disorders such as schizophrenia
  dementia.
• Many anxiety depression seen in primary health
  care are due to depressive disorder.
• Sometimes the symptoms of depressive disorders is
  denied patient smiles a condition described as
  masked depression.

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Mild depressive disorder

• Complains of low mood, lack of energy enjoyment
  and poor sleep.
• Other symptoms include anxiety, phobia
  obsessional symptoms.
• Sleep disturbance is often difficult to fall
  asleep, restless with period of waking during
  the night followed sound sleep before waking.
• Mood may vary during the day worse in the
  evening than in the morning in contrast to more
  severe cases.
• Biological features are uncommon.

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Moderately severe depressive disorder

• Appearance-sad appearance psychomotor
  retardation
• Low mood-misery, worse in the morning
  irritability and agitation.
• Lack of interest enjoyment-reduced energy, poor
  concentration memory.
• Depressive thinking-pessimistic guilty
  thoughts, self-blame, suicidal ideas
  hypochondriacal ideas.
• Biological symptoms-early wakening, weight loss
  reduced appetite reduced sexual drive.
• Other symptoms-obsessional symptoms,
  depersonalization etc.

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Severe depressive disorder

• All the features described under moderate
  depressive disorder occur with greater intensity.
• There may be additional symptoms namely
  delusions hallucinations (
  psychotic depression ).
• Delusion namely worthlessness, guilt,
  ill-health, poverty,hypochodriacal delusions,
  delusion of impoverishment, nihilistic delusions
  delusion of persecution.
• Perceptual disturbances fall short of
  hallucinations but few experience true
  hallucinations usually auditory.
• Suicidal ideas rarely homicidal ideas
  particularly important when related to young
  children.

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Variants of depression

• Agitated depression is applied to depressive
  disorders in which agitation is severe, common in
  middle-aged elderly.
• Retarded depression is applied to depressive
  disorders in which psychomotor retardation is
  prominent, may lead to depressive stupor.
• Depressive stupor is a rare variant of severe
  depression, the patient is motionless, mute
  refusing tp eat drink.
• Atypical depression a minority of patients have
  severe anxiety, severe fatigue, increased sleep
  increased appetite.
• Seasonal affective disorder (SAD) some people
  develop depression at the same time of the year.

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Who develops depression?

• Certain events in life are known to precipitate
  depression reaction to loss of a parent in early
  childhood, a limb or another part of the body (
  mastectomy), miscarriage,or loss of self-esteem,
  divorce or separation.
• Women more prone to depression premenstrually,
  after childbirth at menopause.
• A prepubertal child may develop depression as a
  reaction to organic or environmental ( familial
  or scholastic ) conditions.
• The confusing social, emotional physical
  changes experienced in adolescence may cause
  depression.
• Depression is common in the elderly especially
  when there is loneliness, isolation or
  bereavement.

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What somatic symptoms are suggestive of
depression ?

• The more insightful articulate patient may help
  in the diagnosis of depression.
• In depressed patient many physical discomforts
  are often of a psychosomatic in nature.
• Complaints of gastrointestinal disturbance,
  headache, muscular pains, backache, menstrual
  disturbances, thoracic pain, etc. are common.
• Physical examination laboratory procedures need
  to be conducted to exclude possible organic
  causes. These may include anaemia,
  hypothyroidism, neoplasm, chronic fatigue
  syndrome, cardiac diseases, peptic ulcer, bowel
  disease as well as other somatic diseases.

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Management

• A full psychiatric physical examination should
  be completed any underlying organic cause
  identified treated.
• If no organic cause exists, the best approach to
  treatment will often be individualized global
  in nature integrating pharmacotherapy,
  psychotherapy prophylactic measures.
• Medication may be particularly necessary when the
  depression is associated with genuine somatic
  condition

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Psychopharmacology

• Anxiolytics such as benzodiazepines are effective
  in treating anxiety.
• Antidepressants of choice would be an agent which
  has been demonstrated to be safe effective
  without sedation other adverse effects
  including anticholinergic, potentiation with
  alcohol, drug interaction toxicity in case of
  suicide attempt.
• In general practice, tricyclic antidepressants
  are widely prescribed ( Imipramine
  amitryptyline).
• New agents have been developed which act more
  rapidly, are less toxic nonsedating
  (Prozac,seroxat, zoloft, faverin, effexsor
  cipram ).