1. Malaysian CPG on the Management of Major Depressive Disorder

2. Major depressive disorder: prevalence
Lifetime prevalence from community surveys: 5% to 17% (Kessler 1994, AHCPR 1993)
Six- to 12-month prevalence estimates: 2-11%, weighted mean 6% (Andrade et al. 2003; Robins and Regier 1991)

3. Burden of disease
By year 2020 major depression projected to be 2nd largest contributor to global burden of disease, after heart disease (Murray & Lopez, 1997)
By 2030, the leading cause of DALYs worldwide is projected to be unipolar depressive disorders, followed by ischaemic heart disease and road traffic accidents (WHO 2008)
Risk for suicide associated with depressive disorders elevated 12- to 20-fold compared to general population (Harris & Barraclough 1997)

4. Malaysian Burden of Disease and Injury Study 2004:
Mental disorders contributed 8.6% of total DALYs, ranking as the 4th leading cause of disease burden
Unipolar major depression accounted for 45% of total burden due to mental disorders

5. Causes of DALYs, Malaysia 2000 (Malaysian Burden of Disease & Injury Study 2004)
Males: unipolar major depression was 9th leading cause (3% of 111 diseases)
Females: unipolar major depression was 3rd leading cause (5% of 111 diseases)

6. Leading causes of YLDs in 2004 (WHO 2008)
Unipolar depressive disorder ranked first, for both males and females
Males: 8.3% of total YLDs
Females: 13.4% of total YLDs
NB: YLD = years lived with disability

7. Hidden morbidity
Patients often delay seeking professional treatment for depression (Olfson et al 1998)
Surveys in 6 Western European countries found that only 36.6% of those with active depression in the last 1 year received any professional treatment during the subsequent year (ESEMeD/MHEDEA 2000 Investigators 2004)

8. Roles of healthcare providers

9. Level
People responsible
Focus of Disease
Action
Level 1
Primary care
Assistant medical officer
Nurses
Medical Officer
Recognition
Screening
Level 2
Primary Care
Family Medicine Specialist
Mild Depressive Episode
Psychological Intervention- (counselling , problem solving and supportive psychotherapy)
± Medication
Level 3
Moderate Depressive Episode
Medication
Psychological Intervention
Referral to secondary care if indicated including for cognitive behaviour therapy (CBT)

10. Level
People responsible
Focus of Disease
Action
Level 4
Secondary Care
Outpatient psychiatric services
Moderate to Severe Episode
Medication
Psychological intervention including CBT
Level 5
In-patient setting
Risk to self/others
Severe self neglect
Psychotic symptoms
Lack of impulse control
ECT

11. Assessment & Diagnosis

12. Screening for depression
Two-question Case Finding Instrument
Evaluate for depression if “Yes” to either question
Sensitivity 96%, specificity 57%
PPV 33%, NPV 98% (at prevalence of 18%) (Whooley et al 1997)

13. At estimated local prevalence of 5.6%
PPV = 12%
NPV = 99.6%

14. ICD-10 criteria Typical symptoms of depressive episodes Depressed mood
Loss of interest & enjoyment
Reduced energy

15. ICD-10 criteria Common symptoms of depressive episodes
Reduced concentration & attention
Reduced self-esteem & self –
confidence
Ideas of guilt & unworthiness
Bleak & pessimistic views of the future
Ideas or acts of self-harm or suicide
Disturbed sleep
Diminished appetite

16. ICD-10 criteria contd.. Mild Depressive Episode
At least 2 typical symptoms + 2 common symptoms
No symptom should be present to an intense degree
Minimum duration of whole episode is at least 2 weeks
The person has some difficulty in continuing ordinary work & activities

17. ICD-10 criteria contd.. Moderate depressive episode
At least 2 typical symptoms + 3 common symptoms
Some symptoms may be present to a marked degree
Minimum duration of whole episode is at least 2 weeks
The person has considerable difficulty in continuing social, work or domestic activities

18. ICD-10 criteria contd..
Severe depressive episode without psychotic symptoms
All 3 typical symptoms + at least 4 common symptoms
Some of the symptoms are of severe intensity
Minimum duration of whole episode is at least 2 weeks ( may be <2 weeks if symptoms are very severe & of very rapid onset.
The person is very unlikely to continue with social, work or domestic activities

19. ICD-10 criteria contd..
Severe depressive episode with psychotic symptoms
A severe depressive episode
Delusions, hallucinations or depressive stupor are present

20. Referral to Psychiatric Services
Unsure of diagnosis
Attempted suicide
Active suicidal ideas/plans
Failure to respond to treatment
Advice on further treatment
Clinical deterioration
Recurrent episode within 1 year
Psychotic symptoms
Severe agitation
Self neglect

21. Common criteria for psychiatric admission include:
Risk of harm to self
Psychotic symptoms
Inability to care for self
Lack of impulse control
Danger to others

22. Psychological interventions

23. Counselling
A systematic process which gives individuals an opportunity to explore, discover and clarify ways of living more resourcefully, with a greater sense of well-being. (British Association for Counselling and Psychotherapy)
Concerned with addressing and resolving specific problems, making decisions, coping with crises, working through conflict or improving relationships with others.

24. Problem solving therapy
Time-limited, structured intervention that focuses on learning to cope with specific problem areas.
Therapist and patient work collaboratively.

25. Supportive therapy
Any form of treatment intended to relieve symptoms or help the patient live with them rather than attempt changes character structure.

26. Components of supportive therapy
Reassurance
Explanation
Guidance
Suggestion
Encouragement
Effecting changes in patient’s environment
Allowing catharsis

27. Cognitive Behaviour Therapy
Basic idea is that it is not events that distress us, but what we think about them
CBT helps patients become aware of their own thoughts and replace them with more realistic thoughts

28. Computerised cognitive-behaviour therapy (CCBT)
The delivering of CBT via an interactive computer interface. It may be used for mild to moderate depression.
Examples of programmes available over the internet:
Moodgym
Beating the Blues (BtB)
COPE
Overcoming depression

29. Psychodynamic psychotherapy
Patient explores feelings, and conscious and unconscious conflicts originating in the past, and gains insight.
Should be reserved for selected patients, e.g. those with complex co-morbidities, personality problems, traumatized persons and those with co-morbid anxiety disorders.

30. Interpersonal therapy
A time-limited , structured psychological intervention that focuses on interpersonal issues.
Therapist and patient work to identify the effects of problems related to:
interpersonal conflicts
role transitions
grief and loss
social skills

31. PHARMACOTHERAPY

32. Phases of pharmacotherapy
Acute Phase
A period where remission is achieved.
Continuation Phase
A period after sustained and complete remission from the acute phase. Usually a period of 6-9 months.
Maintenance Phase
A period to prevent recurrence (a new episode of depression) and to prevent the development of chronicity.

33. Acute phase pharmacotherapy

34. Mild depressive episode
May exercise the option of treating by non-pharmacological means alone, viz. problem-solving, counselling, and supportive therapy, and exercise as an adjunct.
Close follow-up appointment (within 2 weeks) so that patient’s condition can be monitored closely.

35. Consider antidepressant medication:
If depression persists or worsens
If patient had a past history of moderate to severe depression, and now presents with a mild depressive episode
When the patient is experiencing ongoing stressors that may perpetuate or worsen the depression

36. Moderate-severe depressive episode
Offer antidepressants
Drug of first choice is an SSRI
Fluoxetine
Fluvoxamine
Sertraline
Escitalopram
Paroxetine
Citalopram

37. Role of benzodiazepines

38. Failed response to initial treatment
Patients who have not responded after 4 weeks of antidepressant therapy at an adequate dose are acute phase non-responders.

39. Apparent non-response
This may be due to:
incorrect diagnosis
psychotic depression
organic conditions
co-morbid psychiatric disorder
adverse psychosocial factors
non/poor compliance

40. Apparent non-response
If these other causes of apparent non-response have been ruled out, the further strategies to follow are:
Optimisation
Switching

41. Optimisation
If there are no significant side effects, increase the dose of medication gradually until
response is achieved
or to the maximum dose that can be tolerated
or until the maximum allowable dose is achieved

42. Switching This refers to a change of antidepressant.
You may switch within the same class of antidepressant (i.e. SSRI) or to another class.
Reduce the dose of the first antidepressant gradually and slowly titrate upwards the dose of the new antidepressant.

43. Treatment-resistant depression
Depression that has failed to respond to two or more antidepressants given sequentially at an adequate dose for an adequate duration of time.
Adequate dose is at least 150 mg/day imipramine equivalent
Adequate duration refers to at least 4 weeks.

44. Continuation phase pharmacotherapy
After remission is achieved, continue antidepressants for another 6-9 months
Use the same dose as for the acute phase

45. Maintenance phase pharmacotherapy
Not all patients will need to go on to the maintenance phase pharmacotherapy
Maintenance phase treatment should be considered for the following:
3 or more episodes of depression
2 episodes with severe functional impairment

46. Maintenance phase pharmacotherapy contd...
2 episodes of depression, plus one or more of the following:
family history of bipolar disorder
history of recurrence within 1 year after discontinuation of medication
family history of recurrent major depression
early onset (< age 20) of first depressive episode

47. Maintenance phase pharmacotherapy contd...
depressive episodes were severe, sudden, or life threatening within the past 3 years
Residual symptoms
Co-morbid dysthymic disorder, substance abuse or anxiety disorders
(Bauer et al 2002, AHCPR 1993)

48. Discontinuation of medication
Drug therapy should not be terminated abruptly
The medication should be tapered down gradually over weeks and sometimes even months

49. Electroconvulsive therapy
Effective and rapid form of somatic treatment for major depressive disorder
Indications:
High degree of symptom severity and functional impairment
Psychotic symptoms
Catatonic features
Urgent response needed/life-threatening condition

50. OTHER THERAPIES

51. Exercise Therapy
Structured and supervised exercise activity minutes per session, up to 3 times per week and prescribed for weeks has been shown to be effective.
For practical purposes at least 30 minutes of daily moderate aerobic exercise is recommended.

52. Social rhythm/ lifestyle
Rhythm and regularity of activities are important for mental health
Interaction with significant others reduces isolation
Schedule activities (rest and recreation) that involve others
Proper diet and exercise are helpful
Maintain regular sleeping hours

53. Guideline implementation - priorities
Training module
Manual
PowerPoint presentations
Video vignettes
Quick reference for healthcare providers
Patient information leaflet

54. Note: these slides are a distillation of the information contained in the CPG, with some additional material on burden of disease.