1. Depression

2. Risk factors for depression 1- Age: young patient are more prone to depression. Peak incidence from 20 – 40 2- Sex: women are twice as men to develop depression 3- Pregnancy: one in 10 of pregnant women develop post partum depression 4- Family history of depression

3. Risk factors for depression Nutritional status is often a symptom of depression. Depressed patient often either under or overeating. Nutritional intake in itself not considered a risk facto

4. Do women depression more easily diagnosed?  Yes it is easily diagnosed more than men, children or adolescent,  Because they declare their emotional state and report it easily during a medical visit. It is not because the symptoms are more sever among women.

5. Why it is difficult to diagnose depression in men? 1- Men feel stigmatized of being depressed. 2- Men believe that it is not socially appropriate for them to report depression symptoms and to seek help. 3- Also males are more likely than females to mask a depression mood and they may more likely to appear as they are using drugs or alcohol than being depressed (outlook with chemical abuse).

6. Why identifying depression in children and adolescents is often difficult in family practice? Is it because there is no screening tests for depression in such groups? No, there are plenty of screening tests to screen depression in children and adolescents but even with those it is difficult. Why?

7. Adolescents and children often report quite different signs. They describe internalizing symptoms that not necessarily specific to depression like feeling,  like a failure,  not being able to succeed anymore, or  always being in a bad mood.

8. Examples of what can be said by them: Children say:  I do not like anyone in my class?  I do not want to go out with my friends anymore. Parents say:  He is gotten lazy and is not studying anymore  She is becoming so moody I can not even talk to her without losing her temper with me.

9. How depression is presented in children?  Change in behavior and decline at school and extracurricular activities symptoms. But those are not recognized as potential signs of depression.  Feeling like a failure and not being able to succeed anymore.

10. How depression is presented in adolescents? It is more likely to present with irritability, social withdrawal, oppositional attitude and substance abuse more than present with sadness or depressed mood. They are atypical symptoms and thus missed.

11. Types of depression 1- Major depressive disorder 2- Dysthymic disorder 3- Manic Depression (now known as Bipolar Disorder) 4- Post Partum Depression 5- Seasonal Affective Disorder (SAD) 6- Anxiety Depression

12. Diagnosis of Major depressive disorder (MDD) During the same 2 week period every day five out of nine symptoms must be present but one and two must be present. 1- depressed mood most of the day, nearly every day, as indicated by either the patient or observation by others (appears tearful). 2- lose interest in all activities. 3- undesired weight change 4- sleep disturbance (less or more) 5- agitation or retardation 6- fatigue or loss of energy 7- Feeling of worthlessness or guilt 8- cognitive dysfunction 9- strong suicidal ideas, plan or attempt The symptoms must not related to a medical condition (cancer), loss of a loved one, drug abuse or medication)

13.  A positive depression screen must be followed by an interview, because depression screening measures do not diagnose depression  Depression screening can provide: - critical information about severity of symptoms - how they change in response to treatment or - lack of treatment but does not diagnose depressive illness.

14. Depressed patient are more likely to present with physical symptoms such as: - insomnia, - hypersomnia (sleeping too much), - loss of appetite, - pain and - fatigue than to present with emotional difficulties

15. Dysthymic Disorder is a chronic mood disorder that falls within the depression spectrum.chronicmood disorderdepression spectrum  Dysthymia is a chronic long lasting form of depression sharing many characteristic symptoms of major depressive disorder. However, these symptoms tend to be less severe but do fluctuate in intensity. To be diagnosed an adult must experience 2 or more of the following symptoms "for most of the day more days than not for at least 2 years without interruption of symptoms for longer than 2 monthssymptoms  Feelings of hopelessness  Insomnia or hypersomnia Insomniahypersomnia  Poor concentration or difficulty making decisions  Low energy or fatiguefatigue  Low self-esteemself-esteem  Poor appetite or overeating

16. Manic Depression (now known as Bipolar Disorder) This kind of depression includes periods of mania and depression. Cycling between these two states can be rapid or only mania can be present without any depressive episodes. A manic episode consists of a persistent elevated or irritable mood that is extreme, which lasts for at least one week. At least three (four if only irritable mood) other features are also present:  inflated self-esteem or self-importance  decreased need for sleep  more talkative than usual or compelled to keep talking  easily distracted  increase in goal-oriented activity (social, work, school, sexual) or excessive movement  excessive involvement in potentially risky pleasurable behavior (e.g. over spending, careless sexual activity, unwise business investments)  Symptoms can be severe enough to warrant hospitalization to prevent harm to self or others or include psychotic features (e.g. hallucinations, delusions).

17. 4- Post Partum Depression4- Post Partum Depression – Major depressive episode that occurs after having a baby. Depressive symptoms usually begin within four weeks of giving birth and can vary in intensity and duration. 5- Seasonal Affective Disorder (SAD) It is MDD with a seasonal pattern – A type of depressive disorder which is characterized by episodes of major depression which reoccur at a specific time of the year (e.g. fall, winter). In the past two years, depressive periods occur at least two times without any episodes that occur at a different time.

18. 6- Anxiety Depression - Not an official depression type (as defined by the DSM). However, anxiety often also occurs with depression. In this case, a depressed individual may also experience anxiety symptoms (e.g. panic attacks) or an anxiety disorder. There is a type called adjustment disorder with depressed mood which is defined as a reaction to some identifiable psychosocial stressors that occur within 3 months of the onset of the depressed mood. Treatment of this case by counseling and stress management.

19. The cause of these conditions  A neurotransmitter imbalance that appears to be caused by a relative deficiency of the neurotransmitter serotonin ( the new SSRIs add confirming evidence to this hypothesis)

20. The most important question to ask a patient who presents with signs and symptoms of depression  Asking about suicide.  The following questions are useful in exploring suicidality: 1- You seem so terribly unhappy. Have you had any thoughts about hurting yourself? 2- If you have, have you thought of the means by which you would do it? Have you considered a specific plan for ending your life? Under what circumstances would you carry it out? 3- What would it take to stop you from killing yourself? 4- Do you feel that your situation is hopeless?

21. Techniques used by family physician in the outpatient clinics 1- BATHE technique B - Background - What happening that of concern to the patient or what is going in your life? A- Affect - How the patient feels about what is happening? T- Trouble - What troubles you the most? H- Handling – How the patient is handling the situation? E- Empathy – An empathic or supportive statement to conclude the sequence.

22.  It is recommended to use this test in every patient encountered by family physician.  It takes from 5 – 7 minutes  Indications for using this technique: - basic level of counseling - little time for counseling - patient has psychosocial issues

23. Contraindication for BATHE technique:  Suicidal patient  Family violence  Drug abuse  Personality disorders

24. SPEAK technique It is used by family physician as a therapeutic tool. It is five steps counseling. S – schedule each day – activate patient to prepare a written daily schedule. P – pleasant – it indicate that family physician encourage depressed patient to have at least one of the daily activities pleasant to himself

25. E – exercise – exercise has shown to be beneficial in alleviating depression symptoms. A – assertion- family physician should encourage their depressed patient to assume more control in their lives to regain their previous sense of self reliance and self confidence as expression of anger should be avoided K- kind – thinking kind thoughts about oneself

26.  Depressed patients usually focus on negative perceptions of themselves, their ongoing experiences in the future. See the empty half of a glass of water. They should be encouraged to identify positive coping abilities and strengths.  The SPEAK technique is used to motivate depressed patients and it is more effective when it is used in conjunction with the BATHE technique.

27. The BATHE technique can be used as the assessment part of the visit ( a screening test) because it helps define issues where SPEAK technique is part of the plan because it helps design a plan to activate the patient.

28. DIG technique  Its aim to assist patent in constructing solutions for their problem.  It is used to help patient create solutions to their problems.  It is not a screening or diagnostic tool but rather a therapeutic tool to create solutions for problems of the depressed patients

29. DIG technique D - Dream – the first step is to have patient dream of the miracle that would solve their problem I- Initiate – the next step is for patient to initiate a process that will make that miracle happen and to make changes in themselves that miracle would happen G- Get going – the third step is getting going and implementing activities to have the process of change occur. This test takes 15 minutes to be completed

30. Management of depression  Medication generally provide rapid response to depression in outpatient settings. However, this response does not reduce the risk of relapse, after medication is withdrawn.  Depression generally responds more slowly to behavioral therapy but it is as effective as medications.  Usually a combination of behavioral therapy and medication is good for chronic patients

31. Cognitive behavioral therapy  It is shown to reduce the subsequent risk for relapse of depression.  It is based on that maladaptive thoughts and behavior are learned from experience and that they can be modified through corrective experiences  It is a well documented and effective approach to the treatment of depression

32.  It employs a short term, good- oriented approach.  The thought of the dysfunctional thinking can be modified and,therefore, the emotions produced by the dysfunctional thinking will be changed.  Those vulnerable to depression harbor negative core beliefs and those stable beliefs trigger distorted automatic thoughts that induce depressogenic effect and behaviour ( if there is a stressor or an experience that caused a negative feeling, the approach to this stressor can be changed.

33. Who treats depression?  Most patient with depression are treated by primary care provider and most of them never see a mental health provider.  The majority of antidepressant medications are prescribed by family physicians but sometimes there is a need for consultation with a mental health provider

34. Causes of referral  Combined psychiatric disease  Personality disorder  When at least two trials of medications have failed  When patient request that help

35. Serotonin & the Serotonergic System Function  Induction & maintenance of sleep  Regulation of body temperature  Perception of sensations (hunger, mood, behaviour  Also the regulation of muscle contraction, and some cognitive functions including memory and learning.

36. Treatment  Medications for 6 months  Cognitive psychotherapy ( it reduce recurrence)  Exercise  Relaxation therapy is used for treatment of anxiety than for depression

37.  Drugs as  1- Tricyclic antidepressant as Tofranil it is presented in 10 or 25 mg.  SSRIs (serotonin reuptake inhibitor) It has a short half life example Fluoxetine Side effect: Sexual dysfunction

38.  SSRIs discontinuation syndrome: is characterized by flue like syndrome and ca be avoided by tapering SSRI over 1 to 2 weeks. (flue like symptoms as nausea, dizziness, headache, anxiety and crawling sensation under the skin. Exercise has been shown to lower level of depression. Some studies have shown it to be as effective as individual or group psychotherapy or cognitive therapy. It is also effective in anxiety.