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