1. D EPRESSION

2. E PIDEMIOLOGY AND BURDEN Depression is a highly prevalent condition About one in a seven will experience depression during their lifetime Many people with depression will have a recurrent or chronic course Depression is the fourth leading cause of disability worldwide Depression results in work absence and loss of productivity leading to significant economic loss

3. A ETIOLOGY OF DEPRESSION Biological (genetics), psychological (life events), and social factors (lack of social support) are involved in the etiology and pathophysiology of depression Stressful life events and stress reactivity can modify genetic and biological processes

4. F ACTORS PREDICTING PROLONGED COURSE OF DEPRESSIVE EPISODE Severe depression Alcohol and drug abuse Comorbid illness Psychotic features Poor social support Early age of onset Long duration Low levels of functioning prior to depression

5. C LINICAL FEATURES OF DEPRESSION Depressive symptomPresentation S leep Insomnia or hypersomnia I nterest/pleasure Decreased (anhedonia) G uilt Increased; Irrational thoughts E nergy Decreased (fatigue) C oncentration Decreased (indecisive) A ppetite Decreased or increased P sychomotor activity Agitation or retardation S uicide Thoughts, plans, attempts

6. T YPES OF DEPRESSION Types of depression Major depressive disorder Dysthymia Depressive disorder, not otherwise specified Minor depressive disorder Premenstrual dysphoric disorder Severity of depression Mild Moderate Severe

7. M AJOR DEPRESSIVE DISORDER Five or more of the following for at least 2 weeks: 1. Depressed mood 2. Loss of interest in pleasure 3. Significant weight loss 4. Insomnia or hypersomnia 5. Psychomotor agitation or retardation 6. Fatigue 7. Excessive guilt or feelings of worthlessness 8. Diminished ability to think or concentrate 9. Recurrent thoughts of death

8. D YSTHYMIA A. Depressed mood for at least 2 years B. Two or more of the following: 1. Poor appetite or overeating 2. Insomnia or hypresomnia 3. Low energy or fatigue 4. Low self esteem 5. Indecisive or poor concentration 6. Feelings of hopelessness

9. M INOR DEPRESSIVE DISORDER Episodes of at least 2 weeks of depression Fewer than five items required for major depressive disorder

10. R ISK FACTORS FOR SUICIDE E PISODE RELATED Current suicidal plans Prior attempts Severe depression Hopelessness and guilt Bipolarity Mixed state (with agitation) Psychotic features Substance abuse Serious medical condition Anxiety

11. R ISK FACTORS FOR SUICIDE D EMOGRAPHICS Male Adolescent or elderly Early onset of mood disorder Family history of suicide Adverse childhood experiences Adverse life circumstances Recent stressor Lack of social support

12. D IFFERENTIAL DIAGNOSIS Substance induced mood disorder Bereavement Mood disorder due to a general medical condition

13. C OMMON DRUGS OF ABUSE CAUSING DEPRESSION Alcohol Amphetamines Anti-anxiety drugs Cocaine Hallucinogens Hypnotics Inhalants Opioids Sedatives

14. D EPRESSION DUE TO GENERAL MEDICAL CONDITIONS Diabetes Cardiovascular disease Neurological – CNS infections – Epilepsy – Sleep apnoea Systemic disorders – Viral and bacterial infections Endocrine disorders – Thyroid disorders Vitamin deficiencies (B12/Folate; Vitamin C; Niacin; Thiamine) Others – AIDS – Cardiopulmonary disease

15. M ANAGEMENT OF DEPRESSION Phase 1: Acute phase - to achieve full remission of depressive symptoms Phase 2: Maintenance phase - to prevent relapse and recurrence

16. A CUTE PHASE MANAGEMENT OF DEPRESSION 8-12 weeks of treatment Goal: remission of symptoms Establish therapeutic alliance Educate patients and relatives Aid self management Choose treatment(s) Manage side effects Monitor and follow-up

17. M AINTENANCE PHASE MANAGEMENT OF DEPRESSION 6-24 months or longer of treatment Goal: prevention of relapse and recurrence Educate patients and relatives Aid self management Manage side effects Rehabilitate work and social function Monitor for recurrence

18. P HARMACOTHERAPY RECOMMENDATIONS Minimum six months treatment after full remission of symptoms At least 2 years (for some lifetime) Severe episodes Chronic episodes Comorbidity Difficult-to-treat episodes Frequent episodes

19. P ATIENT /F AMILY E DUCATION Explain depression in terms of biochemical basis: “Depression is an illness, not a weakness” Early diagnosis and treatment is important for recovery Reducing and stopping medications without medical advice is wrong Monitor weight; advise exercise and food plans

20. P ATIENT EDUCATION MESSAGES T REATMENT Antidepressants are not addictive Medications daily, as prescribed It may take 2-3 weeks before any relief is seen Mild side effects are common, they get better over time Medications should not be stopped without medical advice

21. S ELECTING AN ANTIDEPRESSANT The first line medications are selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) They are preferred over tricyclic antidepressants (TCAs)

22. S ELECTING AN ANTIDEPRESSANT Efficacy Side effect profile Concurrent medication Comorbidity Subtype of depression Simplicity of use Cost

23. SSRI S Mechanism of action Common side effects DrugDaily dose Selective inhibition of serotonin reuptake GI distress, nausea, vomiting, diarrhoea Headache, agitation, sleep disturbance, drowsiness, dry mouth, sexual side effects Escitalopra m 5-20 mg Fluoxetine20-80 mg Sertraline50-200 mg Paroxetine20-60 mg Fluvoxamin e 100-300 mg

24. TCA S Mechanism of action Common side effects DrugDaily dose Inhibition of serotonin and norepinephrin e reuptake Dry mouth, blurred vision, constipation, urinary retention, confusion drowsiness, sedation, weight gain, nausea, tremor, headache, seizures, sexual dysfunction Imipramine75-300 mg Amitryptaline75-300 mg Cloimipramin e 75-300 mg Dothiepin75-300 mg Nortrptaline75-150 mg

25. O THER EVIDENCE BASED THERAPIES FOR DEPRESSION Electro Convulsive therapy (ECT) Exercise, wake therapy and light therapy Psychotherapy Cognitive Behaviour therapy Family therapy Interpersonal psychotherapy

26. C ONCLUSION Depression a disabling illness Can be recurrent and chronic There are cognitive, emotional and physical symptoms of depression Suicide in a important risk of depression Depression can be treated effectively with evidence based therapies such as antidepressants, ECT and psychotherapy