2 Major Depressive Disorder Presenting Complaints May present initially with one or more physical symptomsFatiguePainLow 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 sleepGuilt or low self-worthPessimism or hopelessness about futureFatigue or loss of energyPoor concentrationDisturbed appetiteSuicidal thoughts or actsSlowing of speech or movements or agitationLoss of confidenceSexual dysfunctionSymptoms of anxiety or physical symptoms are a frequent presentation.
4 Major Depressive Disorder Differential Diagnosis AnxietyBipolar DisorderThyroid DysfunctionSubstance-Induced DepressionSecondary 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 activitiesResist pessimism and self-criticism.Address physical symptoms if presentAfter improvement, discuss signs of relapse
6 Major Depressive Disorder Considerations for medication Consider antidepressant drugs ifSad mood or loss of interest is pervasively prominent for at least 2 weeksFour or more of following symptoms are present:1.Fatigue or loss of energy 2.Disturbed sleep3.Guilt or self-reproach 4.Poor concentration5.Thoughts of death or suicide6.Disturbed appetite7.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 patientsBuild up to effective doseExplain 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 antidepressantsIf 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 withIncreased energy and activity levelRapid or loud speechReports of racing thoughtsEasily distractedDecreased Need for SleepGrandiose ideas about selfElevated mood or irritabilityLoss 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 commonIn 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 suicideDuring 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 disorderAnticonvulsants, lithium, carbamazepine and sodium valporate are used as mood stabilizersIf hallucinations, delusions or disordered thinking are present, antipsychotic medication may be helpfulAnti-anxiety medication may also be used in conjunction with neuroleptics
15 Bipolar Disorder: Psychiatric Consultation If suicide risk is present consider immediate referral and hospitalizationIf agitation/hyperactivity is severe consider referralIf significant depression or mania continues, consider psychiatric consultation.
16 Sleep Problems: Diagnostic Features Difficulty falling asleepRestlessness or unrefreshing sleepEarly awakeningFrequent or prolonged awakeningsPrimary 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 apneaConsider medical conditionsheart failurepulmonary diseasepain conditionsthyroid 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 treatment6 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.