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DEPRESSION

EPIDEMIOLOGY
- Women> Men
- Urban > Rural
- Prevalence higher in adverse socio-economic factors

DSM IV CRITERIA OF MDD
1. Depressed mood
2. Loss of Interest/ Pleasure
3. Weight loss/gain, appetite
4. Sleep
5. Agitation
6. Energy
7. Guilt/ worthlessness
8. Concentrate
9. Suicidal

MINOR DEPRESSIVE DISORDER
- Mixture of anxiety and depression

MODERATE DEPRESSIVE DISORDER
- Appearance; slow motor and mental activity
- Mood;
o miserable,
o low mood,
o lack enjoyment,
o reduced energy,
o poor concentration, poor memory
- Depressive thinking;
o pessimistic thinking and functional
impairment more profound,
o thought (concerned with past present and
future), self blame, unhappy side and
foresee failure.
- Biological symptoms;
o sleep disturbances,
early morning waking
delay falling asleep, waking at
night
excessive sleep, unrefreshed
waking
variation appetite, weight
loss libido

SEVERE DEPRESSIVE DISORDER
- Additional symptoms, psychotic delusion and
hallucination (auditory)
o Delusion of guilt
o Hyponchodriacal delusion
o Delusion of impoverishment
o Nihilistic delusions
o Prosecutary delusions
VARIANT OF MODERATE AND SEVERE DEPRESSIVE
DISORDER
- Agitated depression; common in older patient
- Retarded depression
- Depressive stupor; patient can recall time of
stupor on recovery period
- Atypical depression; reversed biological symptoms

DIFFERENTIAL DIAGNOSIS
1. Normal sadness
2. Grief
a. Severe pessimism, suicidal thought,
profound guilt, and psychotic symptoms
rare
3. Bipolar disorder
a. Enquire about history of elevated mood
4. Anxiety disorder
5. Functional physical symptoms
a. Concern about non-specific and medically
unexplained physical symptoms
6. Schizophrenia
a. Assess whether the delusions are
consistent with the depressive symptoms
or delusion come first and not congruent
with mood schizophrenia
7. Dementia
a. Differentiate using memory test, memory
usually not improved with the recovery of
nomal mood dementia
8. Substance abuce
a. Alcohol or non-prescribed drug to relieve
stress

AETIOLOGY
- Genetic causes
o Parents, siblings and children of severly
depressed patient lifetime risk 10-15%
than general population 1-2%
o Concordance of bipolar disorder 70%
among monozygotic twin than dizygotic
twin 23%
o Adopted children; child born to depressive
parents
- Personality
o No association
- Predisposing environmental factors
o E.g difficulty in marriage/ at work, care of
several young children, unsupportive
marriage
- Precipitating environmental factors
- Physical condition as predisposing or precipitating
factors
- Mediating process
o Abnormality process the emotion
o Tendency to remember unhappy events
more easily
o Unrealistic belief
o Cognitive distortion in drawing general
conclusion from single event

MANAGEMENT

ASSESMENT
Diagnosis
- Drugs induce depression
o Antihypertensive; beta blocker, calcium
channel blocker
o Gastrointestinal drugs; cimetidine,
ranitidine
o Interferon
o NSAIDs
o Corticosteroids; dexamethasone
o COCP
o Roaccutane
o L-DOPA
- Determine any episode of mania bipolar
disorder
Severity
- Assess risk suicide
- Functional impairment work, family, social
- Duration and course of condition

Etiological factors
- Enquiries on
o Work
o Finances
o Family life
o Social activities
o General living condition
o Physical health

Social Consequences
- Work
o Endanger people at work
- Family
o On young children neglect
o Depressive delusion lead to action
Kill children, partner
- Leisure interest

Social resources
- Family support
- Work social resources, provide distraction/
source of stress
- Housing

BIOLOGICAL
Pharmacological
1. Selective serotonin reuptake inhibitor (SSRIs)
Fluoxetine, paroxetine, sertraline, citalopram
escitalopram
SE; nausea, agitation, insomnia and sexual
dysfunction
Safe in overdose

2. Selective Serotonin and noradrenaline reuptake
inhibitor (SNRIs)
Venlafaxine, duloxetine
SE; insomnia, tremors, tachycardia, sweating

3. Tricyclic antidepressant
Imiperamine, amitrypline
SE; anticholinergic effect dry mouth,
constipation, difficulty micturition, worsen
glaucoma, confusion; alpha adrenergic effect
drowsiness, postural hypotension, sexual
dysfunction, CVS tachycardia, hypotension;
weight gain, seizure

4. Monoamine oxidase inhibitors (MAOIs)
Phenelzine, tranylcypromine, moclobemide
SE; dangerous increase BP

Electroconvulsive therapy
1. Depressive disorder has not responded to
adequate antidepressant drug treatment
2. Rapid response is necessary because of high
suicidal risk or severe psychomotor retardation

PSYCHOTHERAPY
- Supportive and problem solving treatment
- Dynamic psychotherapy
Not to dwell with past event in early stage of
treatment to prevent patients guilty introspection
- Cognitive therapy
Help prevent relapse and useful helping the
residual symptoms that remain after treatment
- Interpersonal psychotherapy
- Focusing on improving patients interpersonal
functioning and identifying problem.

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