Malaysian CPG on the Management of Major Depressive Disorder

Major depressive disorder: prevalence Lifetime prevalence from community

surveys: 5% to 17% (Kessler 1994, AHCPR 1993)

Six- to 12-month prevalence estimates: 2-11%, weighted mean 6% (Andrade et al. 2003; Robins and Regier 1991)

Burden of disease By year 2020 major depression projected to

be 2nd largest contributor to global burden of disease, after heart disease (Murray & Lopez, 1997)

By 2030, the leading cause of DALYs worldwide is projected to be unipolar depressive disorders, followed by ischaemic heart disease and road traffic accidents (WHO 2008)

Risk for suicide associated with depressive disorders elevated 12- to 20-fold compared to general population (Harris & Barraclough 1997)

Malaysian Burden of Disease and Injury Study 2004:– Mental disorders contributed 8.6% of total

DALYs, ranking as the 4th leading cause of disease burden

– Unipolar major depression accounted for 45% of total burden due to mental disorders

Causes of DALYs, Malaysia 2000 (Malaysian Burden of Disease & Injury Study 2004)

Males: unipolar major depression was 9th leading cause (3% of 111 diseases)

Females: unipolar major depression was 3rd leading cause (5% of 111 diseases)

Leading causes of YLDs in 2004 (WHO 2008)

Unipolar depressive disorder ranked first, for both males and females– Males: 8.3% of total YLDs– Females: 13.4% of total YLDs

NB: YLD = years lived with disability

Hidden morbidity

Patients often delay seeking professional treatment for depression (Olfson et al 1998)

Surveys in 6 Western European countries found that only 36.6% of those with active depression in the last 1 year received any professional treatment during the subsequent year (ESEMeD/MHEDEA 2000 Investigators 2004)

Roles of healthcare providers

Level People responsible

Focus of Disease Action

Level 1

Primary careAssistant medical officerNursesMedical Officer

 Recognition

 Screening

Level 2

Primary CareFamily Medicine SpecialistMedical Officer

 Mild Depressive Episode

 Psychological Intervention- (counselling , problem solving and supportive psychotherapy)± Medication

Level 3

Primary Care Family Medicine Specialist 

 Moderate Depressive Episode

MedicationPsychological Intervention Referral to secondary care if indicated including for cognitive behaviour therapy (CBT) 

Level 4

Secondary CareOutpatient psychiatric services

 Moderate to Severe Episode

 MedicationPsychological intervention including CBT

Level 5

Secondary CareIn-patient setting

Risk to self/othersSevere self neglectPsychotic symptomsLack of impulse control 

MedicationPsychological intervention including CBTECT

Level People responsible

Focus of Disease Action

Assessment & Diagnosis

Screening for depression

Two-question Case Finding Instrument

Evaluate for depression if “Yes” to either question

Sensitivity 96%, specificity 57%PPV 33%, NPV 98% (at prevalence of 18%) (Whooley et al

1997)

At estimated local prevalence of 5.6%

PPV = 12% NPV = 99.6%

ICD-10 criteria

Typical symptoms of depressive episodes

Depressed mood Loss of interest & enjoyment Reduced energy

ICD-10 criteria

Common symptoms of depressive episodes

Reduced concentration & attention Reduced self-esteem & self – confidence Ideas of guilt & unworthiness Bleak & pessimistic views of the future Ideas or acts of self-harm or suicide Disturbed sleep Diminished appetite

ICD-10 criteria contd.. Mild Depressive Episode

At least 2 typical symptoms + 2 common symptoms

No symptom should be present to an intense degree

Minimum duration of whole episode is at least 2 weeks

The person has some difficulty in continuing ordinary work & activities

ICD-10 criteria contd.. Moderate depressive episode

At least 2 typical symptoms + 3 common symptoms

Some symptoms may be present to a marked degree

Minimum duration of whole episode is at least 2 weeks

The person has considerable difficulty in continuing social, work or domestic activities

ICD-10 criteria contd.. Severe depressive episode without psychotic symptoms

All 3 typical symptoms + at least 4 common symptoms

Some of the symptoms are of severe intensity Minimum duration of whole episode is at least 2

weeks ( may be <2 weeks if symptoms are very severe & of very rapid onset.

The person is very unlikely to continue with social, work or domestic activities

ICD-10 criteria contd.. Severe depressive episode with psychotic symptoms

A severe depressive episode Delusions, hallucinations or depressive

stupor are present

Referral to Psychiatric Services

Unsure of diagnosis Attempted suicide Active suicidal ideas/plans Failure to respond to treatment Advice on further treatment Clinical deterioration Recurrent episode within 1 year Psychotic symptoms Severe agitation Self neglect

Common criteria for psychiatric admission include:

Risk of harm to selfPsychotic symptoms Inability to care for selfLack of impulse controlDanger to others

Psychological interventions

Counselling A systematic process which gives individuals

an opportunity to explore, discover and clarify ways of living more resourcefully, with a greater sense of well-being. (British Association for Counselling and Psychotherapy)

Concerned with addressing and resolving specific problems, making decisions, coping with crises, working through conflict or improving relationships with others.

Problem solving therapy

• Time-limited, structured intervention that focuses on learning to cope with specific problem areas.

• Therapist and patient work collaboratively.

Supportive therapy

Any form of treatment intended to relieve symptoms or help the patient live with them rather than attempt changes character structure.

Components of supportive therapy

Reassurance Explanation Guidance Suggestion Encouragement Effecting changes in patient’s environment Allowing catharsis

Cognitive Behaviour Therapy

Basic idea is that it is not events that distress us, but what we think about them

CBT helps patients become aware of their own thoughts and replace them with more realistic thoughts

Computerised cognitive-behaviour therapy (CCBT)

• The delivering of CBT via an interactive computer interface. It may be used for mild to moderate depression.

• Examples of programmes available over the internet:– Moodgym– Beating the Blues (BtB)– COPE – Overcoming depression

Psychodynamic psychotherapy Patient explores feelings, and

conscious and unconscious conflicts originating in the past, and gains insight.

Should be reserved for selected patients, e.g. those with complex co-morbidities, personality problems, traumatized persons and those with co-morbid anxiety disorders.

Interpersonal therapy

A time-limited , structured psychological intervention that focuses on interpersonal issues.

Therapist and patient work to identify the effects of problems related to:– interpersonal conflicts– role transitions– grief and loss– social skills

PHARMACOTHERAPY

Phases of pharmacotherapy Acute Phase

A period where remission is achieved. Continuation Phase

A period after sustained and complete remission from the acute phase. Usually a period of 6-9 months.

Maintenance PhaseA period to prevent recurrence (a new episode of depression) and to prevent the development of chronicity.

Acute phase pharmacotherapy

Mild depressive episode

May exercise the option of treating by non-pharmacological means alone, viz. problem-solving, counselling, and supportive therapy, and exercise as an adjunct.

Close follow-up appointment (within 2 weeks) so that patient’s condition can be monitored closely.

Consider antidepressant medication:

If depression persists or worsens If patient had a past history of moderate

to severe depression, and now presents with a mild depressive episode

When the patient is experiencing ongoing stressors that may perpetuate or worsen the depression

Moderate-severe depressive episode Offer antidepressants Drug of first choice is an SSRI

– Fluoxetine – Fluvoxamine– Sertraline– Escitalopram – Paroxetine– Citalopram

Role of benzodiazepines

Failed response to initial treatment Patients who have not responded after

4 weeks of antidepressant therapy at an adequate dose are acute phase non-responders.

Apparent non-response

This may be due to:– incorrect diagnosis– psychotic depression– organic conditions– co-morbid psychiatric disorder– adverse psychosocial factors– non/poor compliance

Apparent non-response

If these other causes of apparent non-response have been ruled out, the further strategies to follow are:– Optimisation– Switching

Optimisation

If there are no significant side effects, increase the dose of medication gradually until– response is achieved– or to the maximum dose that can be

tolerated– or until the maximum allowable dose is

achieved

Switching This refers to a change of antidepressant. You may switch within the same class of

antidepressant (i.e. SSRI) or to another class.

Reduce the dose of the first antidepressant gradually and slowly titrate upwards the dose of the new antidepressant.

Treatment-resistant depression Depression that has failed to respond to

two or more antidepressants given sequentially at an adequate dose for an adequate duration of time.

Adequate dose is at least 150 mg/day imipramine equivalent

Adequate duration refers to at least 4 weeks.

Continuation phase pharmacotherapy After remission is achieved, continue

antidepressants for another 6-9 months Use the same dose as for the acute

phase

Maintenance phase pharmacotherapy Not all patients will need to go on to the

maintenance phase pharmacotherapy Maintenance phase treatment should be

considered for the following:– 3 or more episodes of depression– 2 episodes with severe functional

impairment

Maintenance phase pharmacotherapy contd...

– 2 episodes of depression, plus one or more of the following:

–family history of bipolar disorder–history of recurrence within 1 year

after discontinuation of medication–family history of recurrent major

depression–early onset (< age 20) of first

depressive episode

Maintenance phase pharmacotherapy contd...

–depressive episodes were severe, sudden, or life threatening within the past 3 years

– Residual symptoms– Co-morbid dysthymic disorder, substance

abuse or anxiety disorders

(Bauer et al 2002, AHCPR 1993)

Discontinuation of medication

Drug therapy should not be terminated abruptly

The medication should be tapered down gradually over weeks and sometimes even months

Electroconvulsive therapy

Effective and rapid form of somatic treatment for major depressive disorder

Indications:– High degree of symptom severity and functional

impairment– Psychotic symptoms– Catatonic features– Urgent response needed/life-threatening condition

OTHER THERAPIES

Exercise Therapy

Structured and supervised exercise activity 40-60 minutes per session, up to 3 times per week and prescribed for 10-12 weeks has been shown to be effective.

For practical purposes at least 30 minutes of daily moderate aerobic exercise is recommended.

Social rhythm/ lifestyle

Rhythm and regularity of activities are important for mental health

Interaction with significant others reduces isolation

Schedule activities (rest and recreation) that involve others

Proper diet and exercise are helpful Maintain regular sleeping hours

Guideline implementation - priorities Training module

– Manual– PowerPoint presentations– Video vignettes

Quick reference for healthcare providers

Patient information leaflet

Note: these slides are a distillation of the information contained in the CPG, with some additional material on burden of disease.