1. RECOGNITION & TREATMENT OF
DEPRESSION
Prof. Fareed Aslam Minhas
MB,MCPS,Dip.Psych,MSc,MRCPsych
Head
Institute of Psychiatry
Rawalpindi Medical College
Rawalpindi.

2. EVIDENCE FOR MENTAL DISORDERS CAUSING
SUBSTANTIAL BURDEN GLOBALLY
• Estimated percent of DALY (Disability adjusted life years) for
Neuropsychiatric disorders world-wide:
1990 – 10.5%
1998 – 11.5%
2020 – 15%
•
1990 estimate of DALY lost, range from 25% in Established
Market Economies (EME) to 7% in developing countries.
•
1998 estimate range from 23.5% in high-income countries to 10.5%
in low/medium income countries.

3. GLOBAL DISTRIBUTION OF HEALTH
BURDENS, 1995:
Rank
Cause
%DALYs loss
Lower respiratory diseases
7.3
•
•
Diarrhoeal diseases
6.5
Perinatal conditions
6.1
•
Unipolar Major Depression
4.2
•
Ischaemic Heart Disease
4.0
•
HIV
3.4
•
•
Cerebrovascular disease
3.2
Motor vehicle accidents
3.0
•
Malaria
3.0
•
Tuberculosis
3.0
•
__________________________________________________________
Major depression is estimated to become the second largest contributor to
DALYs by 2020

4. Disease Burden in
Depression
• Functional disability is high 1
• Disability is greater when depression co-exists
with other psychiatric conditions such as panic
disorder or generalized anxiety disorder 2, 3
• The rate of attempted suicide is 15%; this figure
rises when comorbid psychiatric disorders are
present 4

5. Disease Profile
Depression…the most common psychiatric
disorder that primary care clinicians
encounter.
• A prevalent and a serious psychiatric disorder
• Risk of suicide is high among individuals with depression
• Symptoms of depression are made more severe by the coexistence of anxiety
• People can experience depression at any time of life

6. THE BROAD IMPACT OF MENTAL
ILLNESS
Level
Examples of Impact
Direct cost
Indirect costs Intangible cost
Patient
Service fees
Lost
employment
Quality costs
Family
Travel cost,
fees
Lost
employment
Carer burden
Service
system
Psychiatry
Criminal
Justice
Staff morale
Wider society
Tax burden
Personal safety
Fear

7. AFFECTIVE DISORDERS
ICD 10
• MANIC EPISODE
• BIPOLAR AFFECTIVE DISORDERS
• DEPRESSIVE EPISODE
• RECURRENT DEPRESSIVE DISORDERS
• PERSISTENT MOOD DISORDERS
• RECURRENT BRIEF DEPRESSION.

8. Types of Depression in
Primary Care
• Anxious Depression
• Chronic Anxious Depression
• Depression with Somatic Symptoms
• Treatment Resistant Depression
• Bipolar Depression

9. Anxious depression
• Commonest kind of depressive disorder in general medical
practice.
• Co-Morbid Depression and Generalized anxiety
• Often very severe disorder.
• Should be offered a sedating antidepressant.
• Depression without anxiety is less common in primary care
• May need an alerting antidepressant.

10. Chronic Anxious Depression
Some patients are usually well known to their doctors, have
been symptomatic for many years.
Important not to treat with many different drugs and try to
confine yourself only to those that are effective for that
individual.
These patients often have
• Intractable or insoluble life problems
• It is unreasonable to suppose that these problems will
disappear with drug treatment.

11. • Arrange to see these patients at Regular Intervals
• If left to themselves, they often arrive more frequently.
• Spend time with them discussing their personal problems,
• Perform physical examinations for any physical disorders
• If new physical symptoms arise.

12. Depression with somatic
symptoms
These can be divided into two groups
• Those whose physical symptoms are part of an undoubted
physical illness.
• Those for whom no physical cause can be found, despite
physical examination and any necessary investigations.
• Neither group consider themselves depressed.
• They will readily admit to depressive symptoms if asked
directly
• They improve considerably on anti-depressants.
•
•
•
Doctors are typically distracted by the somatic symptoms,
so that the psychiatric disorder goes undetected.
These group are best managed with Re-Attribution

13. Treatment-Resistant Depression
Refers to any patient
Does not respond to drug treatment given at the proper dosage
for an adequate time
About one third of depressed patients fall into this category.
Have to think of an antidepressant in another category; if this
is not effective, a combination of drugs may be necessary.
Alternately refer to a psychiatrist
.

14. Bipolar depression
• These are relatively rare is general practice.
• They have experienced episodes of mania or hypomania at
some time in their past.
• They merit a psychiatric opinion,
• As antidepressants will sometimes precipitate an episode of
hypomania.

15. USEFUL TERMS
• DEPRESSED MOOD
• DEPRESSIVE SYNDROME
• DEPRESSIVE ILLNESS

16. CORE SYMPTOMS OF MAJOR
DEPRESSION
•
•
•
•
•
•
•
•
•
Depressed mood.
Diminished interest or pleasure in activities.
Significant change in appetite and/or weight.
Insomnia or hypersomnia.
Psychomotor agitation or retardation.
Fatigue or loss of energy.
Lack of concentration or indecision.
Thoughts of death or suicide.
Anxiety, Pain and GI Symptoms.

17. SOMATIZATION
• Because it hurts.
• Indicates serious physical illness.
• Differential reinforcement by doctors.
• Differential reinforcement by relatives.
• Social stigma attached to emotional illness.
• Does not need to blame himself.

18. SOMATIC PRESENTATION IN MEDICAL
SETTINGS.
•
In primary care 1 in 5 new consultations are for somatic symptoms
for which no specific cause is found. ( Goldberg & Bridges 1998)
•
In hospital settings, medically unexplained somatic complaints are
among the most common reasons for referral from primary care.
•
Specific symptoms tend to cluster in medical specialties according
to the organ system.
•
The somatic symptoms of 1/3 of all patients seen in these clinics
remain medically unexplained at the time of discharge. (Hamilton et
al. 1996)

19. Depression with Anxiety
• 60 to 90% of depressed patients
have anxiety symptoms
• Coexistent anxiety and depression
results in
• more severe symptomology
• reduced treatment response
• worse prognosis

20. Profile of the Anxious Depressed
Patient
• More impaired functioning compared with
primary depression
• Increased agitation, hypochondriasis,
depersonalization, chronic depression
• Reduced response to drug therapy and
psychosocial intervention
• More severe and chronic illness
Stavrakaki C, The relationship of anxiety and depression: a review of the literature. British journal of
Psychiatry 1986: 149: 7-16

21. PATHWAYS TO CARE
Goldberg & Huxley
Level
1.
Morbidity in Random Community Samples
___________________________________________________________
Level
2.
Total Psychiatric Morbidity in Primary Care.
___________________________________________________________
Level
3.
Conspicuous Psychiatric Morbidity
___________________________________________________________
Level
4.
Total Psychiatric Patients
___________________________________________________________
Level
5.
Psychiatric in-Patients

22. STRESS & PSYCHIATRIC DISORDERS IN RURAL PUNJAB.
British Journal Of Psychiatry(1997),170,473-478
• 66% of women, 25% of men suffered from Depressive and
Anxiety disorders.
• Levels of emotional distress increased with age in both
genders.
• Women living in unitary households reported more distress
than those living in extended or joint families.
• With younger men and women, lower levels of education were
associated with greater risk of Psychiatric disorders.
• Social disadvantage was associated with more emotional
distress.

23. STRESS & PSYCHIATRIC DISORDERS IN URBAN
RAWALPINDI
British Journal of Psychiatry (2000)-177,557-562
• 25% of women, 10 % of men suffered from Depressive and
anxiety disorders.
• Levels of emotional distress increased with age.
• Women living in joint households reported more distress
than those living in unitary families.
• Higher levels of education were associated with lower risk
of common mental disorders.
• Emotional distress was negatively correlated with socio
economic variables among women.

24. PRIMARY CARE SETTING.
Gujar Khan
• 20-40% suffered from Depression and anxiety.
• More in females.
• Primary care physicians diagnosed depression in
58% of cases.
• 87% of patients presented with aches and pains .

25. THE PREVALENCE, CLASSIFICATION AND TREATMENT
OF MENTAL DISORDERS AMONG ATTENDERS OF
NATIVE HEALERS IN RURAL PAKISTAN.
Soc Psychiatry Psychiat Epidemiol(2000) 35: 480-485
• 61% of the attenders had psychiatric disorders.
• 29% female and 15 % males suffered from major depressive
episode.
• 15% suffered from generalized anxiety disorder
• 8% suffered from dissociative disorders.
• 9% suffered from epilepsy.

26. PERCENTAGE OF MAJOR DIAGNOSTIC
CATEGORIES DURING FOUR YEARS IN IOP
Journal of CPSP (2001)
Fig.3 Percentage of major diagnostic categories.
overall%
Males
Females
40.00%
35.00%
30.00%
25.00%
20.00%
15.00%
10.00%
5.00%
0.00%
Scizophr Depressi
Bipolar
Mania
Drug
Personal
Depende
ity
OCD
Conversi
enia
on
on
overall%
8.40%
37%
11.40%
4.80%
10.60%
1.50%
1.43%
4.80%
Males
5.70%
18%
4.15%
2.90%
10.60%
0.92%
0.95%
0.60%
Females
2.70%
19%
7.20%
1.90%
0%
0.66%
1.90%
4.20%

27. Postnatal depression in developing
countries
Goa, India
Prevalence 23%
Patel et al., 2002. American Journal of Psychiatry; 159: 43-47
Dubai, United Arab Emirites
Prevalence 15.8%
Ghubash & Abou-Saleh, 1997. British Journal of Psychiatry;
171: 65-68
Khayelitsha, South Africa
Prevalence 34.7%
Cooper et al., 1999. British Journal of Psychiatry; 175: 554-58

28. Antenatal and Postnatal depression in a
rural community
Rawalpindi, Pakistan
Rahman, et al 2003. Psychol Med 33:1161-67
• Rural, community-based sample of 670 women
• Single phase, SCAN
• Prevalence 25% in antenatal period; 28% in
postnatal period
• Depressed mothers significantly more disabled
• Risk factors include husband’s unemployment,
relationship difficulties, 2 or more young children
• Protective factors include family support in child
care, presence of infant’s grandmother, able to
complete ‘chilla’ period, financial autonomy

29. Can maternal depression
increase infant risk of illness
and growth impairment in
developing countries?
Rahman et al. 2002. Child: Care, Health &
Development
28: 51-56

30. Conclusion
Maternal depression is a major
determinant of
infant growth and well-being

31. MEAN DURATION OF STAY IN DAYS FOR
MAJOR DIAGNOSTIC CATEGORIES.
7.6
15.93
Depression
Schizophrenia
18.94
Hypomania
18.3
19.3
Bipolar
Drug Dependence

32. Measuring Improvement
• Improvement can be measured in terms of
– symptoms,
– comorbid disorders,
– functional disability,
– and overall quality of life.
• Several clinician-rated scales exist for
depression to measure severity of symptoms,
and response to therapeutic intervention.
– Hamilton rating scale for depression (HAM-D) - symptoms

33. Looking Up:
Improving the
Management of
Depression

34. Depression Is Underdiagnosed and Undertreated
Medical Outcomes Study
100
80
60
% of
Depressed Patients
40
22.7
13.7
20
0
Receiving
Antidepressant
Wells KB et al. Am J Psychiatry. 1994;151:694-700.
Receiving Adequate
Dose

35. Depression Is a Chronic Illness
100%
50%
80%
90%
50%
Probability of
Recurrent Episodes
0%
After 1 Episode
After 3
Episodes
Kupfer DJ. J Clin Psychiatry. 1991;52:(suppl 5):28-34.
After 2
Episodes

36. Defining outcomes and phases
of treatment
Remission
Relapse
Euthymia
Syndrome
Continuation
(4-9 months)
Maintenance
(>1 year)
Relapse
on
ssi
gr e
er
Pro
ord
dis
to
Symptoms
Recurrence
Treatment phases
Response
Acute
(6-12 weeks)
TIME
Adapted from Kupfer. J Clin Psychiatry 1991; 52 (Suppl 5): 28-34.

37. STEPS: Factors to Consider in Antidepressant
Selection
• Safety
– Drug-drug interaction potential
• Tolerability
– Acute and long term
• Efficacy
– Onset of action
– Treatment and prophylaxis
– Activity in subpopulations
• Payment (cost-effectiveness)
• Simplicity
– Dosing
– Need for monitoring

38. ANTIDEPRESSANTS GROUPS AND NAMES
TCAs × Tricyclic Antidepressants.
SSRI × Selective Serotonin Reuptake Inhibitor
RIMA × Reversible Inhibitor of Mono Amino Oxidase
SNRI × Serotonin and Noradrenalin Reuptake Inhibitor
NaSSA × Noradrenergic and Specific Serotonergic
Antidepressant
• DSA × Daul Serotonergic Antidepressant
• NARI × NorAdrenalin Reuptake Inhibitor
• (SNRI) × Selective Noradrenalin Reuptake Inhibitor
•
•
•
•
•

39. ANTIDEPRESSANTS GROUPS AND
PHARMACOLOGY (1)
• TCAs × Amitriptyline, Doxepine, Trimipramine, Clomipramine
and other.
• SSRI × Fluvoxamine, Fluoxetine, Paroxetine, Sertraline,
Citalopram
• RIMA × Moclobemide
– Reversible inhibitor, selective inhibition of MAO type A
• SNRI × Venlafaxine
– Reuptake inhibition NA/5-HT, no affinity to other systems (?)

40. ANTIDEPRESSANTS GROUPS AND
PHARMACOLOGY (2)
• NaSSA × Mirtazapine
↑2 antagonist, 5-HT2 and 5-HT3 antagonist. H1 antagonist.
• DSA × Nefazodone
– 5-HT2 antagonist and 5-HT reuptake inhibitor
• NARI (SNRI) × Reboxetine
– Selective NA reuptake inhibitor

41. Side Effects of Concern With
Antidepressant Therapy
CNS
• Activation
– Insomnia
– Anxiety
– Nervousness
– Agitation
– Tremor
– Seizures
• Sedation
– Somnolence
– Fatigue
GI
• Nausea
• Constipation
• Diarrhea
• Dyspepsia
• Weight gain
• Anorexia
Sexual function
• Decreased libido
• Impotence
• Ejaculation disorder
• Anorgasmia
Cardiovascular
• Hypertension
• Orthostatic hypotension
• Arrhythmias
Other
• Dry mouth
• Increased sweating
• Asthenia

42. OTHER THERAPIES FOR
DEPRESSION
• Psychotherapy
• Electroconvulsive therapy

43. WHEN TO INVOLVE A
SPECIALIST
• Persistent suicidal ideation or plan of action
• Development of psychotic or manic symptoms
• Poor or partial response to antidepressant
• Refusal of pharmacotherapy
• Complicating illness or concurrent medication

44. PATIENT FOLLOW-UP
• Regular monitoring of mental state
• Inform patients that improvement may not be
apparent for 2 weeks on antidepressants
• Clear instructions regarding medication and
importance of compliance

45. ANSWERS TO FREQUENTLY
ASKED QUESTIONS
• Sleep disturbances may resolve relatively quickly
with some agents
• Somatic complaints may resolve in a few weeks
• Other symptoms may take several weeks to
resolve
• Compliance is essential

46. PSYCHOTHERAPY MAY BE
INDICATED
• As an adjunct to drug therapy but is not a
substitute for it
• In patients with milder depression who do not
need or do not want drugs

47. LIFE-STYLE CHANGES
• Suggestions for life-style changes are not useful
while patients are significantly depressed
• Patients should avoid alcohol and substances with
potential for abuse while being treated

48. FOLLOW-UP THERAPY
• Continue antidepressants for several months or
longer
• See patients frequently to assess mood and side
effects
• When discontinuation is indicated, antidepressant
dosages should be tapered

49. SUMMARY
• Affective disorders are as common in Pakistan as
elsewhere in the world.
• Present with predominant Somatic symptoms.
• Not picked up by health professionals.
• Unnecessary investigations.

50. SUMMARY 2
• Even if recognized, treated with only Anti
depressants.
• Teaching of Psychiatry at under & postgraduate
levels.
• Integration into Primary Health Care System.
• Integration has positive effect on the utilisation
of general health services.