2. Major Depressive Disorder Presenting Complaints
May present initially with one or more physical symptoms
Fatigue
Pain
Low mood, loss of interest or irritability.
Symptoms must be present for at least 2 weeks, without a break.

3. Major Depressive Disorder Diagnostic Features
LOW OR SAD MOOD.
LOSS OF INTEREST OR PLEASURE.
Associated symptoms include:
Disturbed sleep
Guilt or low self-worth
Pessimism or hopelessness about future
Fatigue or loss of energy
Poor concentration
Disturbed appetite
Suicidal thoughts or acts
Slowing of speech or movements or agitation
Loss of confidence
Sexual dysfunction
Symptoms of anxiety or physical symptoms are a frequent presentation.

4. Major Depressive Disorder Differential Diagnosis
Anxiety
Bipolar Disorder
Thyroid Dysfunction
Substance-Induced Depression
Secondary to chronic physical illnesses

5. Major Depressive Disorder: Specific Counseling to Patient and Family
Involve the relatives in patient care.
Ask about risk of suicide.
Plan short-term activities
Resist pessimism and self-criticism.
Address physical symptoms if present
After improvement, discuss signs of relapse

6. Major Depressive Disorder Considerations for medication
Consider antidepressant drugs if
Sad mood or loss of interest is pervasively prominent for at least 2 weeks
Four or more of following symptoms are present:
1.Fatigue or loss of energy 2.Disturbed sleep
3.Guilt or self-reproach 4.Poor concentration
5.Thoughts of death or suicide
6.Disturbed appetite
7.Agitation OR slowing of movement and speech

7. Major Depressive Disorder: Considerations for medication
If good response to one drug in the past, use that again.
Use caution with older or medically ill patients
Build up to effective dose
Explain how medications should be used:
Continue antidepressant at least 6 months after symptoms improve.

8. Major Depressive Disorder: Consider Consultation with Specialist
If significant depression persists despite full course of treatment with at least two groups of antidepressants
If suicide risk is severe, consider immediate consultation and hospitalization.

9. Bipolar Disorder: Presenting Complaints
May present during a period of depression or separately as mania or excitement.

10. Bipolar Disorder: Diagnostic Features
Periods of MANIA or HYPOMANIA lasting 4 – 7 days with
Increased energy and activity level
Rapid or loud speech
Reports of racing thoughts
Easily distracted
Decreased Need for Sleep
Grandiose ideas about self
Elevated mood or irritability
Loss of Inhibitions (over spending or hyper sexuality)

11. Bipolar Disorder: Diagnostic Features
Even a single Manic episode is treated as Bipolar Disorder.
Mixed states are very common
In severe cases, may have hallucinations or delusions during either period of mania or depression, but not in hypomania.

12. Bipolar Disorder: Differential Diagnosis
Alcohol or drug use can cause similar symptoms.
Schizophrenia presents with at least 6 month history of progressive deterioration, and no intervening period of normalcy.

13. Bipolar Disorder: Specific Counseling to Patient and Family
Involve relatives in patient’s care.
Ask about risk of suicide
During manic periods - Avoid confrontation, unless necessary to prevent harmful or dangerous acts.
During depressed periods - Resist pessimism and self-criticism. Do not make major financial decisions.

14. Bipolar Disorder: Medications
Drug treatment in acute phases is similar to treatment in acute psychotic disorder
Anticonvulsants, lithium, carbamazepine and sodium valporate are used as mood stabilizers
If hallucinations, delusions or disordered thinking are present, antipsychotic medication may be helpful
Anti-anxiety medication may also be used in conjunction with neuroleptics

15. Bipolar Disorder: Psychiatric Consultation
If suicide risk is present consider immediate referral and hospitalization
If agitation/hyperactivity is severe consider referral
If significant depression or mania continues, consider psychiatric consultation.

16. Sleep Problems: Diagnostic Features
Difficulty falling asleep
Restlessness or unrefreshing sleep
Early awakening
Frequent or prolonged awakenings
Primary sleep problems are relatively rare. They are usually indicative of some other physical or psychiatric condition.

17. Sleep Problems: Differential Diagnosis
Transient insomnia (several days’ duration, commonplace)
Short-term insomnia (lasting several weeks)
Chronic insomnia (lasting months or years)

18. Sleep Problems: Differential Diagnosis
If daytime anxiety is prominent, consider Generalized Anxiety Disorder.
If low or sad mood is prominent, consider Depression.
If loud snoring is present, consider sleep apnea
Consider medical conditions
heart failure
pulmonary disease
pain conditions
thyroid dysfunction

19. Sleep Problems: Essential Information for Patient and Family
Temporary sleep problems are common at times of stress or medical Illness and do not require treatment
6 hours of sleep per day may be normal and sufficient, especially for older patients.
Improving sleep habits (not sedative medication) is the best treatment.
Worry about not being able to sleep can worsen insomnia.
Alcohol may help falling asleep but can lead to restless sleep and early awakening.
Stimulants (including coffee, tea or nicotine) can cause or worsen insomnia.

20. Sleep Problems: Specific Counseling to Patient and Family
Maintain a regular sleep routine:
Practice relaxation exercises to aid in falling asleep.
Avoid caffeine and alcohol.
If unable to fall asleep after 20 minutes, get up and try again later when feeling sleepy.
Daytime exercise may help, but evening exercise may contribute to insomnia.
Avoid daytime napping.
Ensure appropriate sleeping environment

21. Sleep Problems: Medication
Treat any underlying psychiatric or medical condition.
Make needed changes in medication.
Hypnotic medication not more than 14 days (benzodiazepines)
Risk of dependence increases significantly after 14 days of use.

22. Sleep Problems: Specialist Consultation
Consider consultation:
For narcolepsy or sleep apnea
If significant insomnia continues