Depression

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 Session outline

• Introduction to depression
• Assessment of depression
• Management of depression
• Follow-up
• Review

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 Mood – is a pervasive and sustained feeling that is
experienced internally and that influences a person’s
behavior and perception of the world.
Affect- is the external expression of mood.
Mood disorders- are group of clinical conditions characterized
by loss of that sense of control and subjective experience of
great distress.
 MANIA
ELEVATED
HYPOMANIA

NORMAL

DYSTHYMIA
DEPRESSED

DEPRESSION
SEVERE/ACUTE
 EPIDEMIOLOGY
• Lifetime prevalence:

• Major depressive episode- 5-17%

• Dysthymic disorder- average of 3-6%
• Minor Depressive disorder – 10%
• Recurrent brief depressive disorder –
16%
• Bipolar I disorder- 0-2.4 %
• Bipolar II disorder- 0.3- 4.8 %
• Cyclothymia- 0.5-6.3 %
• Hypomania- 2.6-7.8 %
EPIDEMIOLOGY

Sex- females have two-fold greater prevalence of MDD than males Why?
• Hormonal differences
• Effects of childbirth
• Differing psychosocial factors for men and women
• Manic episodes are more common in men, and depressive episodes
are more common in women. Women- mixed episode and rapid
cyclers.
EPIDEMIOLOGY
Age
Mean age of onset :
MDD = 20-50 y/o; mean age of 40 y/o
increasing incidence of MDD in <20 y/o due to increased
use of alcohol and drugs of abuse.

Marital Status- MDD occur more common in separated/ divorced

and single persons.

Socio-economic and Cultural factors- No correlation between this

factor and that with MDD. Higher incidence among upper socio-
economic groups.
 OVERVIEW OF ETIOLOGIC FACTORS

Psychological
•Stressful life events
•Behavioural factors
•Cognitive factors
•Psychodynamic
Biological
•Neurotransmitters
•Endocrine system
•Family and
MOOD DISORDERS
genetics
•Sleep dysfunction
•Woman & mood
disorders

Social
•Support system
•Woman & mood disorders
 BIOLOGICAL:
NEUROTRANSMITTERS
Low levels of serotonin
associated with depression.
􀂄Dopamine levels:
High > Mania
Low > Depression
􀂄Norepinphrine
BIOLOGICAL: ENDOCRINE
SYSTEM
Depression has been associated with
dysfunction of the endocrine system,
specifically:
Elevated levels of the stress hormone
Cortisol
Malfunctioning of the thyroid gland
PSYCHOLOGICAL: STRESSFUL
EVENTS • Stressful events strongly
linked to onset of mood
disorders.
• Context and meaning of
the event more important
than the exact nature of
event
• In Bipolar disorders
stressful events linked with
initial episodes but not
later episodes
PSYCHOLOGICAL:
Learned Helplessness:
•BEHAVIOURAL
Learned helplessness in humans linked with attributions of a
lack of control after experiences of being in an impotent
position
• Environment which lacks positive reinforcement > reduction in
activities and withdrawal
Core symptoms of depression

• Persistent depressed mood.

• Markedly diminished interest in or

pleasure from activities.

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Common presentations of depression

• Multiple persistent • Significant change in

physical symptoms with appetite or weight
no clear cause (weight gain or loss)
• Low energy • Beliefs of worthlessness
• Fatigue
• Excessive guilt
• Sleep problems (sleeping
too much or too little) • Indecisiveness
• Anxiety • Restlessness/agitation
• Hopelessness
• Suicidal thoughts and acts
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Contributing factors

HEALTH
ILLNESS

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 Identifying depression

The length of time that a person

experiences the symptoms is one of the
distinctions between depression and
general low mood.

How long do you think symptoms should

be present?

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 Identifying depression

• Depression means that there is a considerable

impairment in a person’s ability to function in daily
life.

• Some people may experience a persistent

depressed mood but they are able to continue
functioning in daily life. Therefore, their symptoms
do not amount to depression and can be managed
via the Module: Other significant mental health
complaints in mhGAP-IG Version 2.0.

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 Socioeconomic impact
• High unemployment
High prevalence rates
• Worsening living conditions
• 322 million people
worldwide
• 4.4% in the community
• 10–20% in primary care Disability and mortality
attenders • Major cause of disability
• 10% women who have given • High suicide rates
Depression:
birth
A public health
priority
Impact on families Correlations with other
• Infant growth physical health
conditions
• Family relationships
• Child rearing • Noncommunicable diseases
• Communicable diseases

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Average prevalence of depression in people
with physical diseases (70 countries)

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Process of Assessment in the Video

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 Sarah’s case

• Sarah is 23 years old and has a baby at

home.
• What else do we want to know:
o Is she breastfeeding?
o Is she pregnant?
o Is the baby developing well?

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Consider physical conditions.

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 Physical conditions that
resemble depression
Condition Symptoms
• Anaemia • Tiredness, loss of energy, problems
sleeping, physical aches and pains,
problems concentrating.
• Malnutrition • Tiredness, loss of energy, loss of
appetite, lack of interest in food and
drinks, poor concentration, low mood,
feeling weak.
• Tiredness, muscle aches and feeling
• Hypothyroidism weak, changes in appetite (weight gain),
low mood, problems with memory and
concentration (slowed thinking), loss of
libido, loss of energy.

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 Grief

• Low mood, anxiety, fear, • Social withdrawal, loss

guilt, self-blame, of interest, restlessness,
irritability, loneliness, agitation.
crying. • Loss of appetite,
• Negative thinking, problems sleeping, loss
rumination, low self- of appetite/appetite
esteem, hopelessness, gain, physical aches and
pessimism about the pains, tiredness, loss of
future. energy.

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Assess for imminent risk of suicide

• Talking about self-harm/suicide is

ESSENTIAL.
• Talking about self-harm/suicide DOES NOT
increase the risk that the person will
commit self-harm/suicide.
• If there is a risk of self-harm/suicide then
GO IMMEDIATELY TO MODULE: SELF-
HARM/SUCIDE IN THE mhGAP-IG AND
FOLLOW THE STEPS TO MANAGE SELF-
HARM/SUICIDE.

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 Promoting daily activities

Reducing stress and Brief psychological

strengthening social treatment for depression
support
Pharmacology

Psychoeducation

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 When to refer
Consider a referral to a mental Consider a referral to a
health specialist (where hospital:
available): • If a person is non-
• If a person with depression responsive to treatment.
shows any signs of psychotic • If a person shows serious
symptoms (e.g. side-effects of any
hallucinations and pharmacological
delusions). interventions.
• If the person presents with • If a person needs further
bipolar disorder. treatment for any comorbid
• If the person is pregnant or physical condition.
a breastfeeding woman. • There is a risk of self-
• In the cases of people with harm/suicide.
self-harm/suicide.
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 Link with other sectors

• Linking people with other sectors ensures:

• That the person receives a comprehensive
package of care.
• It fulfils parts of the psychosocial
interventions, e.g. in order to promote
functioning in daily activities and community
life. If the person has identified that they
would like to return to their studies and/or
start a livelihood activity, it is important to link
them to livelihood organizations.

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 Brief psychological treatments

• As first-line therapy, health-care providers may

select psychological treatments and/or
antidepressant medication.
• When deciding, they should keep in mind the:
o Possible adverse effects of antidepressant
medication.
o The ability to deliver either intervention (in terms
of expertise, and/or treatment availability).
o Individual preferences of the person.
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 Activity 5: Video demonstration:
Managing depression

You will now see a video which shows the health-care

provider managing Sarah’s depression. Whilst
watching the video think about:
1. How did the health-care provider explain the
treatment options available?
2. Did the health-care provider explain the risks and
benefits of different treatment interventions?

[Link]
t=PLU4ieskOli8GicaEnDweSQ6-yaGxhes5v&index=2
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 Pharmacological interventions:
When NOT to prescribe

• Do not prescribe an • Do not prescribe an

antidepressant if there is no antidepressant if the person
is pregnant/breastfeeding.
depression. For example: As first-line treatment, offer
o When the symptoms do not psychosocial intervention
last two weeks and/or do first.
not involve impaired • Do not prescribe if the child
is younger than 12.
functioning).
• Do not prescribe to
o If the symptoms are part of adolescents aged 12–18 as
a normal grief reaction. first-line treatment. Offer
psychosocial interventions
o If the symptoms are due to first.
a physical cause.
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Possible presentations at
follow-up
At follow up you may see people:
 IMPROVING (actively engaging with management
interventions and their symptoms are improving);
 REMAINING THE SAME (actively engaged in management
interventions but their symptoms are remining the same); or
 DETERIORATING (the symptoms are deteriorating and the
person is feeling worse).

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Monitoring people on antidepressants

It is expected that people will have a positive response, but

there are some results that will require action – if the person
shows:
• SYMPTOMS OF MANIA
• INADEQUATE RESPONSE
• NO RESPONSE.

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What do you do when symptoms worsen
or do not improve after four to six weeks
(inadequate response)?

Take three important steps before increasing the dose:

ENSURE
1. That the assessment is correct.
2. That the person is taking the medication as
prescribed.
3. That the dose is adequate.

If there is no improvement after four to six weeks at

maximum dose, consult a specialist.
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When and how to stop an antidepressant

If after 9–12 months of therapy the person reports no

or minimal symptoms:
 Discuss the plan with the person before reducing
the dose.
 Describe early symptoms of relapse.

 Plan routine and emergency follow-up.

 Reduce dose gradually over at least four weeks.

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