Case: A 46-years-old gentleman presented in the outpatients clinic with a 6 months history of generalised un wellbeing, weakness and lethargy, loss of weight, poor appetite, insomnia and extreme tiredness. He lost his wife 2 years back and did not have any children and also suffered from diabetes mellitus. He has consulted many physicians and underwent a battery of tests without any conclusive diagnosis. His diabetic status was well under control with oral hypoglycaemic drugs. Routine biochemical parameters (LFT, TFT, auto immune screening, cortisol, electrolytes, CRP) haematological parameters (Hb, TC, DC, platelet ESR), virological screening (Hepatitis B, Hepatitis C, HIV) were all satisfactory. X-ray and ECG were normal. CT brain was normal.
Diagnosis : Depressive illness
Discussion :
Depression is a major problem in primary care. At least 30% of patients attending clinic, has major depression. However, majority of them are unrecognised or inappropriately treated leading to loss of Productivity, functional decline and increased mortality.
Diagonising depression can be difficult as patients rarely present with symptoms that fit neatly into diagnostic taxonomies.
Patients in medical settings usually present with physical social and psychological problems along with somatic symptoms and the consulting doctor has to find out depressive illness from the above mentioned presenting problems.
Consulting styles also influence whether depression is recognised. It has been found that doctors who ask open question initially (like enquiring about sleep pattern, mood etc.), give more time, are more empathic, make more eye contact and interrupt less are more likely to detect depression.
When to consider depression in the differential diagnosis :
The patients usually complain of :
depressed mood, diminished interest or pleasure in all activities, unintentional weight loss or weight gain, insomnia or hypersomnia nearly every day, early morning waking or interrupted sleep, feeling of guilt, worthlessness, loss of energy, lack of concentration and in severe cases thoughts of death and suicide.
In addition, there are certain co-morbid medical condition, where depression is common and clinician should positively look for evidence of depression if suggestive symptoms are present in such cases - these conditions are :
n cancer
n Parkinson disease
n cerebrovascular accidents
n old MI, chronic pain
n diabetes mellitus
n old age
Depression is a major problem in primary care. At least 30% of patients attending clinic, has major depression. However, majority of them are unrecognised or inappropriately treated leading to loss of Productivity, functional decline and increased mortality.
Diagonising depression can be difficult as patients rarely present with symptoms that fit neatly into diagnostic taxonomies.
Patients in medical settings usually present with physical social and psychological problems along with somatic symptoms and the consulting doctor has to find out depressive illness from the above mentioned presenting problems.
Consulting styles also influence whether depression is recognised. It has been found that doctors who ask open question initially (like enquiring about sleep pattern, mood etc.), give more time, are more empathic, make more eye contact and interrupt less are more likely to detect depression.
When to consider depression in the differential diagnosis :
The patients usually complain of :
depressed mood, diminished interest or pleasure in all activities, unintentional weight loss or weight gain, insomnia or hypersomnia nearly every day, early morning waking or interrupted sleep, feeling of guilt, worthlessness, loss of energy, lack of concentration and in severe cases thoughts of death and suicide.
In addition, there are certain co-morbid medical condition, where depression is common and clinician should positively look for evidence of depression if suggestive symptoms are present in such cases - these conditions are :
n cancer
n Parkinson disease
n cerebrovascular accidents
n old MI, chronic pain
n diabetes mellitus
n old age
Anxiety disorder like phobia, panic disorder, obsessive compulsive state, generalised severe anxiety are quite common presentation in general practice. These patients are also more vulnerable to depression and the clinician should be aware of this. Somatization is also an integral part of the presentation in depression. As the psychiatric definition of depression does not take into account somatic presentation, an astute clinician should be aware of this fact and try to find out whether depression is underlying cause for the somatization.
Treatment :
Majority of the depressive illness can be treated at primary care level (if the clinician is willing). However some alarm signs should prompt the physicians for a prompt psychiatric referral.
Majority of the depressive illness can be treated at primary care level (if the clinician is willing). However some alarm signs should prompt the physicians for a prompt psychiatric referral.
Drug Therapy :
If used appropriately, drugs are successful in more than 70% of cases. However, selection of medication is important.
It was recognised in the 50's that the depression was mediated mainly the deficiency of monoamine neurotransmitter like serotonin, nor-adrenaline and dopamine."
The major pharmacological manoeuvre involves increasing the level of these monoamines in the brain by either inhibiting the enzyme monoamine-oxidase, blockage of auto receptors that generate negative feed back on the release of neurotransmitters and blockage of the reuptake of the transmitter back into the nerve cell.
If used appropriately, drugs are successful in more than 70% of cases. However, selection of medication is important.
It was recognised in the 50's that the depression was mediated mainly the deficiency of monoamine neurotransmitter like serotonin, nor-adrenaline and dopamine."
The major pharmacological manoeuvre involves increasing the level of these monoamines in the brain by either inhibiting the enzyme monoamine-oxidase, blockage of auto receptors that generate negative feed back on the release of neurotransmitters and blockage of the reuptake of the transmitter back into the nerve cell.
Monoamine oxidase inhibitors :
The initial drugs were mono-amineoxidase inhibitors. However because of their side effect profile and drug interactions they are not used at least at the primary care level.
The initial drugs were mono-amineoxidase inhibitors. However because of their side effect profile and drug interactions they are not used at least at the primary care level.
Nonselective serotonin and noradrenaline reuptake inhibitors:
The second group of drugs to come were tricyclic anti depressant (non selective serotonin and noradrenaline uptake inhibitors) which are being still used very commonly in the clinical practice. The problem with them is the non-selective nature of their recepter blockage and the resultant side effect profile. Commonly used drugs are :
1. Amitriptyline- Special indication if there is associated insomnia, chronic pain, migraine, post herpetic neuralgia.
2. Imipramine - Enuresisis, insomnia, panic disorder, post traumatic stress disorder, obsessive compulsive state.
These drugs have adverse effect on cardiac function and should be avoided in patients with cardiac problems. They have prominent anticholinergic side effects.
The second group of drugs to come were tricyclic anti depressant (non selective serotonin and noradrenaline uptake inhibitors) which are being still used very commonly in the clinical practice. The problem with them is the non-selective nature of their recepter blockage and the resultant side effect profile. Commonly used drugs are :
1. Amitriptyline- Special indication if there is associated insomnia, chronic pain, migraine, post herpetic neuralgia.
2. Imipramine - Enuresisis, insomnia, panic disorder, post traumatic stress disorder, obsessive compulsive state.
These drugs have adverse effect on cardiac function and should be avoided in patients with cardiac problems. They have prominent anticholinergic side effects.
Selective serotonin and noradrenalin uptake inhibitors:
Venlafaxine :
This is a comparatively new class of drug - devoid of cardiac side effects and has quick onset of action. This is also emerging as an effective treatment for anxiety disorder (so commonly associated with depression).
Venlafaxine :
This is a comparatively new class of drug - devoid of cardiac side effects and has quick onset of action. This is also emerging as an effective treatment for anxiety disorder (so commonly associated with depression).
Special indications :
Anxiety, neuropathic pain, obsessive compulsive disorder. It can cause sedation and anticholinergic side effects are less common.
Anxiety, neuropathic pain, obsessive compulsive disorder. It can cause sedation and anticholinergic side effects are less common.
Selective serotonin re-uptake inhibitors : (SSRI)
1. Citalopram - particularly helpful in post CVA depression, diabetic neuropathy panic disorder, obsessive compulsive disorders.
2. Escitalopram - It is a new drug (isomer of citalopram) and has a very quick onset of action (compared to citalopram).
3. Fluoxetine
4. Paroxetine
5. Sertraline
They usually do not cause sedation. These group of drugs can both cause weight loss and weight gain. These are cardiac friendly drugs and can be safely prescribed in cardiac patients.
Serotonin antagonists:
Mirtazapine
This is particularly helpful in anxiety and insomnia. It can also cause weight gain. It has got sedative potential.
1. Citalopram - particularly helpful in post CVA depression, diabetic neuropathy panic disorder, obsessive compulsive disorders.
2. Escitalopram - It is a new drug (isomer of citalopram) and has a very quick onset of action (compared to citalopram).
3. Fluoxetine
4. Paroxetine
5. Sertraline
They usually do not cause sedation. These group of drugs can both cause weight loss and weight gain. These are cardiac friendly drugs and can be safely prescribed in cardiac patients.
Serotonin antagonists:
Mirtazapine
This is particularly helpful in anxiety and insomnia. It can also cause weight gain. It has got sedative potential.
Noradrenaline and dopamine reuptake inhibitors :
Bupropion - Particularly helpful in smoking cessation and post traumatic stress disorder.
Serotonin antagonist and re-uptake inhibitors :
Nefazadone - } Panic disorder
} post traumatic stress disorder
Trazodone -. } Insomnia
Bupropion - Particularly helpful in smoking cessation and post traumatic stress disorder.
Serotonin antagonist and re-uptake inhibitors :
Nefazadone - } Panic disorder
} post traumatic stress disorder
Trazodone -. } Insomnia
Few points to remember
n Anti depressants will be effective in approximately 70% of case.
n It may take 4-6 weeks before it may be fully effective.
n If within 6 weeks therapy there is no appreciable change, one drug can be substituted for another.
(Failure of one drug does not necessarily mean that the ot her drug of the same group may not be effective).
n Wash out period is not necessary while changing from SSRI to another drug like venlafaxine or mirtazapine. (However abrupt withdrawal of SSRI may cause symptoms).
n SSRI should not be coprescribed with sibutramine (appetite suppressants).
n All anti-depressants should be used with caution in hepatic disorders.
n If no appreciable changes is noted with the 2nd drug - psychiatric opinion will be needed. In anxiety disorders, although benzodiazepines are the most effective. drugs, they should only be used for a very brief period because of dependance potential. One of the antidepressants with prominent anti anxiety effect should therefore be chosen for long term treatment of primary anxiety disorders.
n Anti depressants will be effective in approximately 70% of case.
n It may take 4-6 weeks before it may be fully effective.
n If within 6 weeks therapy there is no appreciable change, one drug can be substituted for another.
(Failure of one drug does not necessarily mean that the ot her drug of the same group may not be effective).
n Wash out period is not necessary while changing from SSRI to another drug like venlafaxine or mirtazapine. (However abrupt withdrawal of SSRI may cause symptoms).
n SSRI should not be coprescribed with sibutramine (appetite suppressants).
n All anti-depressants should be used with caution in hepatic disorders.
n If no appreciable changes is noted with the 2nd drug - psychiatric opinion will be needed. In anxiety disorders, although benzodiazepines are the most effective. drugs, they should only be used for a very brief period because of dependance potential. One of the antidepressants with prominent anti anxiety effect should therefore be chosen for long term treatment of primary anxiety disorders.
When to refer to a Psychiatrist :
If the patient needs specific therapy like prolonged counselling, conditioned behaviour therapy, opinion of a psychiatrist should be taken -
1. If the patient is not responding to the use of two successive anti depressant over a period of 2-3 months.
2. If the patients have evidence of psychosis like hearing voice or visual hallucination, have manic symptoms or judged to have high risk for suicide.
If the patient needs specific therapy like prolonged counselling, conditioned behaviour therapy, opinion of a psychiatrist should be taken -
1. If the patient is not responding to the use of two successive anti depressant over a period of 2-3 months.
2. If the patients have evidence of psychosis like hearing voice or visual hallucination, have manic symptoms or judged to have high risk for suicide.
Once the treatment has been successfully instituted, it should be carried out for atleast 6 months. If the patient has a high risk of relapse (i.e., past history of recurrent depression), the treatment should be continued for at least 2 years.
Key Points:
n Depression is a common presentation in clinical practice.
n A positive approach and leading question from the clinician will help in diagonising depression.
n Most of the illnesses may be treated at primary care level.
n Choosing the right drug will depend on the clinical circumstances and the presence of other associated conditions like anxiety disorders, presence of cardiac problem and sleep disturbance.
n In high risk patients, the patients should be referred to psychiatrists. n
n Depression is a common presentation in clinical practice.
n A positive approach and leading question from the clinician will help in diagonising depression.
n Most of the illnesses may be treated at primary care level.
n Choosing the right drug will depend on the clinical circumstances and the presence of other associated conditions like anxiety disorders, presence of cardiac problem and sleep disturbance.
n In high risk patients, the patients should be referred to psychiatrists. n
Source: “Experience with Evidence in Clinical Practice,” Dr. Subrata Maitra, Soma Book Agency.
Courtesy: Advocate Monzurur Rahman Ruskin.
Courtesy: Advocate Monzurur Rahman Ruskin.
