depression & suicide
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DEPRESSION & SUICIDE DR.SARATH MENON.R
DEPARTMENT OF NEUROLOGY
MGM MEDICAL COLLEGE,INDORE
INTRODUCTION
Mood disorder Syndrome- set of symptoms - definite time period
For atleast 2 weeks Distress to self and others Social & vocational impairment
EPIDEMIOLOGY
Global prevalance 1.9 % (men) 3.3 % (women) In India Prevalence – 26.8 % (2011) Suicidal mortality rate- 10.5/1L (2011) Studies Chandrasekhar & Reddy etal (Hyderabad) prevalence -7.9 to 8.9 /1000 double prevalance rate in urban population
STUDIES
South India- Chennai based study prevalence of 15.6 %
Srinath etal study ( Andhra) 1.61/1000 children – unipolar depression
DETERMINANTS OF DEPRESSION
Female gender Old age Economic impoverishment Illiteracy Violence /trauma Substance abuse –alcoholism Chronic medical illness
IMPACT ON MORTALITY
Around 8,00,000 commit suicide
India has highest suicidal rate among young people
70 % increase in mortality in people age > 65
yr
THREE TYPES OF DEPRESSION
Major depression
Minor depression (dysthymia)
Bipolar depression
MAJOR DEPRESSION- DSM IV CRITERIA
2 week duration 5 or more symptoms - depressed mood most of the days - diminished interest or pleasure - significant weight loss (>5% in a month) - insomnia/hypersomnia nearly every day - psychomotor agitation/ retardation - fatigue/ loss of energy - feeling of worthlessness/guilt - recurrent thoughts of death/suicidal
ideation
MINOR DEPRESSION
Often referred as dysthymia Symptoms are same as major depression Low level doesn’t disrupt one’s life Duration of atleast 2 yrs Chances to develop into major depression if
untreated
BIPOLAR DEPRESSION
Two sides of highs & lows Symptoms of mania/hypomania in one side &
major depression on other Can fluctuate between these stages Rapid or sudden fluctuations seen at times
CLINICAL SUBTYPES OF DEPRESSION
Retarded depression Agitated depression Psychotic depression Paranoid depression Peuperial depression Seasonal depression Chronic depression
ETIOLOGY
Biological factors - serotonin - norepinephrine - dopamine Neuroendocrine regulation - thyroid axis - adrenal axis - growth hormone Sleep abnormalities - delayed sleep onset - shortened REM latency
Brain imaging - Bipolar – enlarged cerebral ventricle - SPECT /PET scan- decreased blood flow esp. frontal cortex Genetics - Psychisocial factors stress premorbid personality cognitive factors negative distortion of factors - negative self evaluation - pessimism - hopelessness
Positron Emission Tomography (PET) Scan often used to see shrinkage of the hippocampus and frontal lobe
.
(“Position Emission Tomography Scan of the Brain for Depression”)
SEROTONIN
Imbalance in Serotonin can influence mood and emotions
Problems in the brain with low levels of Serotonin: the brain being unable to receive Serotonin and/or an overall shortage of Serotonin in the brain are being linked to Depression and it’s symptoms
PATHOPHYSIOLOGY & CLINCAL PRESENTATION OF DEPRESSION
Mood disturbances - painful arousal - hypersensitivity to unpleasant event - insensitivity to unpleasant event - depressed mood - anhedonia - reduced anticipatory pleasure Psychomotor disturbances - pyschomotor retardation - agitation - pseudi dementia/stupor
Cognitive disturbances - ideas of deprivation & loss - low self esteem & self confidence - self reproach & pathological guilt - recurrent thought of death & suicide Vegetative disturbances -anorexia, weight loss or gain -insomnia/hypersomnia - sexual dysfunction Suicide Anxiety Guilt
SYMPTOMS OF DEPRESSION
Feeling sad, empty, nervous for a long time Feeling hopeless, helpless, pessimistic Problems sleeping, waking early in the morning and unable to
get back to sleep Loss of interest or enjoyment in hobbies, activities previously
enjoyed Feeling worthless, guilty, overwhelmed, inadequate Feeling tired, lazy, no energy or zest Problems concentrating, thinking clearly, remembering things Ambivalence, can’t make decisions No appetite with weight loss or overeating with weight gain Agitation, irritability, physical restlessness Loss of interest or enjoyment in sex Persistent thoughts of death or suicide Physical symptoms (such as headaches, stomach distress,
chest pain, chronic pain) that won’t go away despite treatment
TREATMENT
Psychosocial therapy
Pharmacotherapy
PSYCHOSOCIAL THERAPY
Interpersonal therapy
Cognitive therapy
Behaviour therapy
PHARMACOTHERAPY- GENERAL GUIDELINES
Usual recovery by 1 month
3-4 weeks for anti-depressants to act
Choice of antidepressents determined by side effect profile,physical status,lifestyle
Dosage raised to max.recommended level & maintained for 4 or 5 wks
DURATION & PROPHYLAXIS
Atleast 6 months or length of previous episode
Prophylactic Rx - seriousness of previous episodes - suicidal ideation - impairment of psychosocial
functions
INITIAL MEDICATION SELECTION
Depending on - chronicity - family history - prior treatment response - concurrent psychiatric /
general condition - patient preference
ACUTE TREATMENT FAILURE
Cannot tolerate side effects idiosyncratic adverse side effects inadequate clinical response wrong diagnosis
Lack of partial response ( 25% symptom reduction) in 4 – 6 wks - change treatment
Can have a 2nd trial for another 4-6 wks.
SELECTION OF 2ND TREATMENT OPTIONS
Switching to alternate treatment (preferred)
augmentation of current treatment
combination therapy of SSRI & Bupropion – widely employed
ECT effective in non responsive cases & acute severe depression.
ANTIDEPRESSANTSName Usual daily dose(mg) Side effects
NE reuptake inhibitor
Desipramine 75-300 Drowsiness,insomnia,agitation, arrythmia.weight gain, anti cholinergic
Nortriptyline 40-200 - Do-
5-HT reuptake inhibitors (SSRI)
Citalopram 20-60 Insomnia, agitation, sexual dysfunction,GI distress, sedation
Escitalopram 10-20 -do-
Fluoxetine 10-40 -do-
Fluvoxamine 100-300 -do-
Paroxetine 20-50 -do-
Sertraline 50-150 -do-
Name Usual daily dose(mg) Side effects
NE& 5-HT reuptake inhibitors
Amitriptyline 75-300 Drowsiness,OSH,arrythmia,weight gain,anticholinergic
Imipramine 75-300 -do- + agitation,insomnia
Venlafaxine 150-375 Sleep changes,GI distress.discontinuation syndrome
Duloxetine 30-60 GI distress.discontinuation syndrome
Pre & post synaptic active agents
Mirtazapine 15-30 Sedation,weight gain
Name Usual daily dose (mg) Side effects
Dopamine reuptake inhibitor
Bupropion 200-400 Insomnia,agitation,GI distress
Mixed action agents
Amoxapine 100-600 Drowsiness,insomnia/agitation,arrythmia,weight gain,OSH,anticholinergic
Clomipramine 75-300 drowsiness.,weight gain
Discuss Choice of drug with patient Include : Therapeutic effects
Adverse effectsDiscontinuation effects
Start antidepressant Titrate to recognised
therapeutic dose. Assess efficacy over 4-6 weeks
Increase DoseAssess over a further
2-4 weeks
Continue for 4-6 months at full treatment
doseConsider longer–term treatment
in recurrent depression
Give an antidepressant from a different class
Titrate to therapeutic dose. Assess over 4-6 weeks
Give an antidepressant from a different class
Titrate to therapeutic dose. Assess over 4-6 weeks,
increase dose as necessary
Refer to Suggested treatments for refractory depression
No EffectPoorly
tolerated
Poorly tolerated
or no effect
No Effect Effective
No Effect
Effective
Effective
Effective
Treatment of refractory depression
OTHER REPORTED TREATMENTS (may be worth trying, but limited published support)
Treatment
Add bupropion 300 mg /dayAdd clonazepam 0.5- 1.0 mg at night Add mirtazapine 15-30 mg ONAdd modafinil 100-200 mg/dayAdd risperidone 0.5-1.0 mg /dayKetoconazole 400-800 mg /dayOestrogens (various regimes used)SSRI + TCA (e.g. citalopram 20 mg / day with amitriptyline 50 mg /day Try S-adenosyl – I – methionine 400 mg / day imSNRI = reboxetineAdd omega – 3 fatty acid (EPA 1 g daily)
DEPRESSION IN MEDICAL DISORDERS
Neurological - CVA - migraine - dementia - Parkinons d/s - epilepsy - multiple
sclerosis - Huntingtons d/s - Wilsons d/s Endocrine - adrenal- cushings,addisons - hypothroidism - hyper/hypo parathyroidism Infections/inflammatory - HIV,IMN,SLE, temporal arteritis
Drugs -analgesics- indometahcin,ibuprofen,opiates - antibiotics-
ampicillin,metronidazole,tetracyclines - steroids- corticosteroids,OCP,prednisolone - antihypertensives- b-blockers,clonidine,reserpine - anti cancer- bleomycin,vincristine Miscellaneous - cancers - uremia - vitamin deficiency - porphyria
SUICIDE –INCIDENCE & PREVALENCE
1.2 lakh/yr suicidal deaths
4 lakh/yr attempt suicide
Majority of suicide (37.8%) -< 30 yr age gp.
77 % suicide - < 44 yr age- huge burden
STUDIES
Venkoba Rao etal- Madurai - incidence- 43/1,00,0000 - fatality- 1/12 attempts
Hegde et al (Karnataka) - incidence rate- 10.2/1,00,000 - Male preponderance- 67%
Shukla et al (Jhansi) - 29/1,00,000 - 34/1lakh (women) & 24 /1 lakh (men)
OTHER STUDIES
Banerjee etal (kolkata) - incidence – 43/1,00,000 - women – 79.3 % - 75 % -< 25 yr age
SUICIDE & PSYCHIATRIC DISORDERS
Psychological autopsy studies done in various countries over almost 50 years report the same outcomes:
90% of people who die by suicide are suffering from one or more psychiatric disorders:
Major Depressive Disorder Bipolar Disorder, Depressive phase Alcohol or Substance Abuse Schizophrenia Personality Disorders such as Borderline
RISK FACTORS FOR SUICIDE
Psychiatric disorders
Past suicide attempts
Symptom risk factors
Sociodemographic risk factors
Environmental risk factors
RISK FACTORS
Psychiatric Disorders
Most common psychiatric risk factors resulting in suicide:
Depression* Major Depression Bipolar Depression
Alcohol abuse and dependence Drug abuse and dependence Schizophrenia
*Especially when combined with alcohol and drug abuse
RISK FACTORS Other psychiatric risk factors with potential to result
in suicide (account for significantly fewer suicides than Depression):
Post Traumatic Stress Disorder (PTSD) Eating disorders Borderline personality disorder Antisocial personality disorder
RISK FACTORS Major physical illness, especially recent
Chronic physical pain
History of childhood trauma or abuse
Family history of death by suicide
Substance abuse
RISK FACTORS
Sociodemographic Risk Factors
Over age 65WhiteSeparated, widowed or divorced Living aloneBeing unemployed or retiredOccupation: health-related occupations higher ( doctors, nurses, social workers)
METHODS OF SUICIDE
Hanging ( 31.7 %) Poisoning –pesticide, drug overdose etc
(34.8%) Firearms – (8 %) Drowning Wrist cutting Hypothermia Electrocution Jumping from height Vehicular impact-rail,traffic collision Immolation
Observable signs of serious depression Unrelenting low mood Pessimism Hopelessness Desperation Anxiety, psychic pain, inner tension Withdrawal Sleep problems
Increased alcohol and/or other drug use Recent impulsiveness and taking unnecessary risks Threatening suicide or expressing strong wish to die Making a plan
Giving away prized possessions Purchasing a firearm Obtaining other means of killing oneself
Unexpected rage or anger
WARNING SIGNS
PROPOSED DSM-V SUICIDE ASSESSMENT DIMENSION
Level of concern aboutpotential suicidal behavior:
(sum of items coded as present)
1. 0: Lowest concern
2. 1-2: Some concern
3. 3-4: Increased concern
4. 5-7: High concern
Suicide risk factor groups:
1. Any history of a suicide attempt2. Long-standing tendency to lose temper or become aggressive with little provocation3. Living alone, chronic severe pain, or recent (within 3 months) significant loss4. Recent psychiatric admission/discharge or first diagnosis of MDD, bipolar disorder or schizophrenia5. Recent increase in alcohol abuse or worsening of depressive symptoms6. Current (within last week) preoccupation with, or plans for, suicide7. Current psychomotor agitation, marked anxiety or prominent feelings of hopelessness
PREVENTING SUICIDEPrevention within our community
Education
Screening
Treatment
Means Restriction
CONCLUSION
Depression - common disorder By 2025, major cause of morbidity &
mortality India has highest number of suicides among
young people Treatable but under diagnosed Newer drugs with less side effects available.
REFERENCES
Kaplan & Saddock’s Synopsis of Psychiatry-10th edition
Text book of depressive disorders by Maj & Sartorius -2nd edition
Indian journal of psychiatry
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