Professional Documents
Culture Documents
and Suicide
Dr. E Cheung
Associate Consultant
Psychogeriatric Team
Castle Peak Hospital
Prevalence of
depressive
symptoms
Prevalence of
major
depressive
disorder
Community
15%
1-3%
Primary care
20%
10-12%
Acute hospital
20-25%
10-15%
30-40%
16%
In Hong Kong
1034 elderly aged 70 and above living in
Shatin (Chiu et al, 1998):
Major depression 1.54%
Dysthymia 3.66%
Adjustment disorder with depressed
mood 1.54%
2020
Lower respiratory
diseases
Diarrhoeal diseases
Unipolar depression
Perinatal conditions
Unipolar major
depression
CVA
COAD
FU (months)
Mortality
(%)
Murphy,
1983
124
12
14
Rabins,
1986
100
12
Murphy,
1988
120
48
34
Baldwin,
1986
100
48
26
Aetiology (1)
Social: reduced social networks, loneliness,
bereavement, poverty, physical ill health
Psychological: low self-esteem, lack of
capacity for intimacy, physical ill health
Biological: neuronal loss/neurotransmitter
loss, genetic risk, physical ill health
Aetiology (2)
Disease:
Direct: CVA, Parkinson's disease,
thyroid disease, Cushing's disease,
Hungtington's disease
Indirect: pain, disability, chronicity, poor
diet, decreased activity
Aetiology (3)
Drugs:
Digoxin, L-dopa, steroid
Beta-blockers, methyldopa
Chronic benzodiazepine use
Phenobarbitone
Neuroleptics in chronic use
Diagnosis
A syndromal diagnosis
Based on eliciting a specific cluster of
symptoms through careful history taking
and mental state examination, supplemented
by relevant physical examination
No confirmatory laboratory tests
ICD-10 or DSM-IV
International Classification of
Disease (ICD-10)
Diagnostic difficulties
Primary care physicians could identify no
more than 50% of patients with a
diagnosable depressive syndrome (Mulsant
& Ganguli, 1999)
Presentation of depression in the elderly
may be modified by factors associated with
old age
Assessment
History
Mental state examination
Use of standardised instruments, e.g.
Geriatric depression scale (GDS)
Cognitive assessment
Physical examination
Investigation
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
? ()
()
________
Principles of management
1.
2.
3.
4.
5.
Treatment
Physical treatment
Pharmacological treatment
Electroconvulsive therapy
Psychosocial treatment
Pharmacological treatment
Recovery
Remission
Mood
Response
Relapse
Acute
Continuation
treatment treatment
Time
Recurrence
Maintenance
treatment
Principles of antidepressant
treatment
1.
2.
3.
4.
5.
Ascertain diagnosis
The ultimate aim of treatment is remission
Treatment has to be adequate in dosage,
duration and compliance has to be ensured
If there is no response after an adequate trial,
switch to another class of antidepressant
If there is partial response, further increase
dosage and/or persist for a longer duration or
augmentation
Principles of antidepressant
treatment
6.
7.
8.
Comorbidity
Chronic medical conditions
Chronic affective symptoms
Older age of onset of first episode
Severe functional impairment during depression
Psychotic depression
Previous suicide attempt
Family history of suicide and bipolar disorder
Shown here is an icon of a tricyclic antidepressant (TCA). These drugs are actually five drugs
in one: (1) a serotonin reuptake inhibitor (SRI); (2) a noradrenaline reuptake inhibitor (NRI);
(3) an anticholinergic/antimuscarinic drug (M1); (4) an alpha adrenergic antagonist (alpha); and
(5) an antihistamine (H1).
Stephen M. Stahl: Es
Stephen M. Stahl, Es
The noradrenergic portion of the TCA is inserted into the noradrenaline reuptake
pump , blocking and causing an antidepressant effect
Stephen M. Stahl, Es
Side effects of the tricyclic antidepressants- part 1. In this diagram, the icon of the
TCA is shown with its H1 (antihistamine) portion inserted into histamine receptors,
causing the side effects of weight gain and drowsiness.
Stephen M. Stahl, Es
Side effects of the tricyclic antidepressants - part 2. In this diagram, the icon of
the TCA is shown with its M1 (anticholinergic/antimuscarinic) portion inserted
into acetylcholine receptors, causing the side effects of constipation, blurred
vision, dry mouth and drowsiness.
Stephen M. stahl, Es
Side effects of the tricyclic antidepressants - part 3. In this diagram, the icon
of the TCA is shown with its alpha (alpha adrenergic antagonist) portion
inserted into alpha adrenergic receptors, causing the side effects of dizziness,
decreased blood pressure and drowsiness.
Stephen M. Stahl, Es
Stephen M. Stahl, Es
Stephen M. Stahl, Es
Serotonergic-Noradrenergic
Reuptake Inhibitor (SNRI)
Venlafaxine (Efexor/Efexor XR)
Side effects similar to SSRI
May cause hypertension at high doses
Serotonergic-noradrenergic Reuptake
Inhibitors (SNRI)
Shown here is the icon of a dual reuptake
inhibitor which combines the actions of both a
serotonin reuptake inhibitor (SRI) and a
noradrenaline reuptake inhibitor (NRI). In this
case, 3 out of the 5 pharmacological properties
of the TCAs (tricyclic antidepressants) were
removed. Both the SRI portion and the NRI
portion of the TCA remain; however the alpha,
antihistamine and anticholinergic portions are
removed. These serotonin/noradrenaline
reuptake inhibitors are called SNRIs or dual
inhibitors. A small amount of dopamine
reuptake inhibition (DRI) is also present in
some of these agents, especially at high doses.
e.g. Venlafaxine
Stephen M. Stahl, Es
Reversible inhibitors of
monoamine oxidase A (RIMA)
Moclobemide (Aurorix)
Nausea
Headache
Insomnia
Restlessness
Agitation
Other antidepressants
SARI nefazodone (Serzone)
Sedation, lack of 5HT2 stimulation S/E
NaSSA mirtazapine (Remeron)
Sedation, dry mouth, increased appetite,
weight gain
NDRI bupropion (Wellbutrin)
Headache, dry mouth, agitation, nausea,
insomnia
Stephen M. Stahl, Es
e.g. Mirtazapine
Stephen M. Stahl, Es
Other antidepressants
Mianserin (Tolvon):
Sedation, aplastic anaemia,
agranulocytosis
Trazodone:
Sedation, orthostatic hypotension,
priapism
Member
commonly used
in the elderly
Starting dose
Therapeuti
c dose
SSRI
Sertraline
50 mg OM
50 mg BD
Nausea, headache,
weight loss
Citalopram
10 -20 mg OM
TCA
Nortriptyline
10 -25 mg
nocte
40 mg
OM
75 - 100
mg nocte
SNRI
Venlafaxine XR
75 mg daily
150 - 225
mg daily
Hypertension
NaSSA
Mirtazapine
15 mg nocte
30 - 45
mg nocte
Weight gain,
sedation, dizziness
RIMA
Moclobemide
150 mg BD
300 mg
BD
Agitation, insomnia
and headache
Others:
Antipsychotics
Lithium augmentation
Tri-iodothyronine (T3) augmentation
Antidepressant combination
Anticonvulsant augmentation
Buspirone augmentation
Pindolol augmentation
Psychosocial interventions
Psychoeducation
Nature and pathogenesis of depression
Use of a Stress-diathesis model
Proposed treatment, expected side effects,
delay in onset of therapeutic response
Expected duration of continuation and
maintenance treatment
Evidence-based psychosocial
treatments
Interpersonal therapy
Cognitive behavioural therapy
For moderate to severe depression, the
combination of pharmacotherapy and
psychological treatment has been found to
be superior to either treatment given alone
(Reynolds et al, 1999)
Elderly suicide
Country
Number of
suicides
Rate per
100 000
Ranking by
suicide rate
China
195 000
16.1
24
India
87 000
9.7
45
Russia
52 500
41.5
USA
31 000
11.9
38
Japan
20 000
16.8
23
Germany
12 500
15.8
25
Country
Lithuania
Ranking by
number of
suicides
1600
41.9
22
600
40.1
25
Russia
52 500
37.6
Latvia
850
33.9
23
Hungary
3000
32.9
16
Sri Lanka
5400
31.0
Estonia
Risk factors
Psychiatric disorder
Social milieu
Personality
Genetics
Family Hx
Completer- 30/100,000
Attempter 100/100,000
Normal
Slightly
depressed
Life
Not
Worth
Living
Suicidal
Intentions
Attempters
Completers
TIME-LINE
2.
3.
4.
6.
7.
8.
9.
Aims of ESPP
1.
2.
Early detection
1.
Early detection
2.
Service boundary
1.
2.
3.
Age 65 or above
Residing in the relevant catchment areas
Inclusion criteria
a.
Suicidal ideation/thoughts/talk/plan
b.
Previous attempt of suicide
c.
Suspected moderate to severe depression
(either by medical assessment or by screening
using the GDS)
Workflow of ESPP
NGO/hotlines
(Screening)
GP/DH/GOPD
TMH/POH
A&E, in-patient
Mood problem
Suicidal idea
Early
Intervention
(CPN)
Home visits/telecheck
Consultation
FTC
Suicide
attempt
Multidisciplinary
team
In-patient service
The End