The Practical Management of Depression

Dr Frans A KorbPsychiatrist and Clinical Psychologist

Private PracticeFourways Intercare

• The Background

• The Facts

• Some Biology

• Making the Diagnosis

• Measuring Depression

• Management – Pharmaceutical

• Management – Other

• The Final Word

Overview : Depression

Definition : Depression

‘Mood is a sustained emotional tone perceived alonga normal continuum of sad to happy. Mood disordersare characterized by abnormal feelings of depression

or euphoria with associated psychotic features in somesevere cases. Mood disorders are divided into bipolar

and depressive disorders’

Kaplan & Sadock

Depression: Impact on Society

Murray CJL, Lopez AD, eds. The Global Burden of Disease. Boston: Harvard University Press; 1996.

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

A Major Cause of Disability Worldwide

DEPRESSIVE DISORDERS

• DSM-IV vs ICD-10

• Major Depressive Disorder

• Dysthymic Disorder

• Bipolar Disorder

• Cyclothymic Disorder

Depression – The Facts

1. Zung WW, et al. J Fam Pract. 1993;37:337-344.2. Kessler RC, et al. J Affect Disord. 1993;29:85-96.3. Solomon DA, et al. Am J Psychiatry. 2000; 157:229-233.

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

4. U.S. Agency for Health Care Policy and Research. Depression in Primary Care: Vol. 1. Detection and Diagnosis. Rockville, MD: 1993: 23.

39.0%

45.0%

47.0%

42.0%

33.0%

36.0%

33.0%

9.4%

5.8%

0% 10% 20% 30% 40% 50%

Parkinson's Disease

MI

Stroke

Cancer Inpatients

Cancer Outpatients

Older Inpatients

Hospitalized

Chronically Ill

General Population

Adapted from: WPA/PTD Educational Program on Depressive Disorders. Gavard JA, et al. Diabetes Care. 1993;16(8):1167-1178.

Prevalence Rates of Depression in Chronic Medical Disorders

Gender Demographics1

0.0000

0.0020

0.0040

0.0060

0.0080

0.0100

0.0120

0.0140

0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54

FemaleMale

Age Category

Hazard

Rate

s

1. Kessler RC, et al. J Affective Disord. 1993;29:85-96.

MDE Hazard Rates by Age and Sex

Depression – Some Biology

Neurotransmission

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

5-HT and NA at the Synaptic Level: Healthy vs. Depressed

DepressedHealthy

NA

5-HT5-HT Reuptake Transporter

NAReuptake Transporter

Theoretical Representation

Depression -- Making the Diagnosis

Depressed moodTraurigkeit

Slowed thinkingGedankenhemmung

Slowed movingBewegungshemmung

DepressionDepression

Weygandt “Uber die Mischzustande des manisch-depressiven Irreseins” (Munchen, 1899)

What is Depression ?

Depression. It’s not only a state of mind.

Reference: Adapted fromAmerican Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition,Text Revision. Washington, DC; American Psychiatric Association. 2000:345-356,489.

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

TiredUnmotivated

Anxious

35%

34%

31%

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 (n=1590).

(Retarded)

(Agitated)

SPECIAL FORMS OF DEPRESSIVE DISORDERS

• Psychotic Depression

• Somatic Depression

• Atypical Depression

• Seasonal Depressive Disorder

• Rapid-cycling Bipolar Disorder

• Secondary Depressive Disorder

OTHER FORMS OF DEPRESSIVE DISORDERS

• Dysthymia

• Postpartum Depression

• Recurrent Brief Depression

• Mixed Anxiety-Depression Syndrome

• Subthreshold Depression

Measuring Depression

Depression Management -- Pharmaceutical

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. 1984;41:971-78.2) Wells KB, et al. JAMA. 1989;262(23):3298-3302.3) Lepine C, et al. Intl Clin Psychopharm. 1997;12:19-29.4) Katon W, et al. Medical Care. 1992;39(1):67-76.

AHCPR, 1993

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

Depression: Treatment Goals

Reprinted with permission from Kupfer, 1991WPA/PTD Educational Program on Depressive Disorders

SeveritySeverity

TimeTime

X

ResponseResponse

RelapseRelapseRecurrenceRecurrence

MaintenanceMaintenanceContinuationContinuationAcuteAcute

Treatment PhasesTreatment Phases

SymptomsSymptoms

RemissionRemission

SyndromeSyndrome

RelapseRelapse

Progression

Progression

to disorder

to disorder

No DepressionNo Depression

RecoveryRecovery

X

X

6-12 weeks 4-9 months 1 or more years

Switching Strategies

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.

Depression Management -- Other

Patient Programmes

www.sadag.co.za

mySupport Programme

www.bouncingback.co.za

Depression – The Final Word

Social-Endocrine-Psychological Interactions

Depression: Treatment Goals

TreatmentTreatment

Reduce/RemoveReduce/RemoveSigns, SymptomsSigns, Symptoms

Minimise Relapse/Minimise Relapse/Recurrence RiskRecurrence RiskRestoreRestore

Role/Role/FunctionFunction

AHCPR Guidelines: Depression in Primary Care, Vol 2. US Dept. of Health and Human Services; 1993.

Depression Is ...

• Prevalent worldwide

• Common in primary care setting

• Often unrecognized, inadequately treated

• Associated with high morbidity,

mortality, cost

• PCP can provide effective treatment

fakorb@telkomsa.net