1. Dr. Sujit Kumar Kar
Assistant professor in Psychiatry,
K.G.Medical University, Lucknow

2. LEARNING OBJECTIVES
To be able to identify depression in outpatient settings
To distinguish between unipolar depression and bipolar mood
disorders
To be able to assess and decide treatment for depression
To understand the dosages, duration and side effects of
antidepressants
To know when to refer

4. normal human
emotions
abnormal
excessive
disproportionate
impairment

5. Depression is one of the
commonly encountered
psychiatric illness,
prevalent worldwide
It is primarily a disorder
of mood effecting all
ages, races and both
sexes

6. Depression
produces
significant
psychological
distress and
declines the
quality of life

7. Depression should not be
confused with depressive
symptoms or depressive moods
which are an integral part of
human emotions

8. • Rapidly changing life style
• Increased struggle
• Poverty , unemployment
• Substance abuse
• High expectations
• Conflicts
Individual
susceptibility
(genetic
constitution)
Medical
illnesses

9. Distribution
Life time prevalence – 10 to 20%
Mean age of onset - ~27yrs
Females : male ~ 2 :1
Higher among singles (divorced/widow/ unmarried)
and unemployed

11. Signs and symptoms
• Avoiding people/ psychomotor slowing/
agitation/ self harm behaviourBehavioural
• Lack of motivation for work/ food/ sex/
other pleasurable activitiesMotivational
• Sadness of moodAffective
• Inattentiveness, forgetfulness, slowness of
thinking, pessimistic thinking, guilt feelingCognitive
• Multiple pain symptoms ,Dyspepsia ;etcSomatic

13. As per ICD-10
The individual usually suffers from depressed mood, loss
of interest and enjoyment, and reduced energy leading to
increased fatiguability and diminished activity.
Other common symptoms are:
• Reduced concentration and attention
• Reduced self-esteem and self-confidence
• Ideas of guilt and unworthiness (even in a mild type of episode)
• Bleak and pessimistic views of the future
• Ideas or acts of self-harm or suicide
• Disturbed sleep
• Diminished appetite

14. Minimum duration required
to diagnose depression as
per international guidelines
(ICD-10/ DSM-IV) is 2 weeks

15. Variants of depressive disorders
Unipolar depression – Single episode of depression
Bipolar depression – At least one previous manic
episode
Recurrent depressive disorder – Multiple episodes of
depression
Dysthymia – Chronic low grade depression (>2yrs)
Seasonal affective disorder

16. Causes of depression

17. Psycho-social factors
• Parenting
• Stress
• Personality
• Coping skills and defense mechanisms
• Social support
• Interpersonal conflicts

18. Biological factor
• Strong genetic linkage (chromosome 22 &18)
• Multiple genes are involved
• Positive family history is a risk factor ( if one parent is
having mood disorder there is 10 -25% chance of
having mood disorder among children, if both parents
are affected the risk is double)
• Risk among twins (monozygotic -70-90%, di-zygotic –
16-35%)

19. Medical causes of depression
• Chronic medical illnesses- Tuberculosis, Cancers, Rheumatoid arthritis
• Metabolic disorders- Diabetes, hypertension, Chronic renal failure
• Endocrinological disorders- Hyper/ Hypothyroidism, Cushing’s disorder
etc
• Cardiovascular – Myocardial infarction
• Anemia and other nutritional deficiencies
• Skin disorders- Psoriasis
• Drug induced- steroid, antihypertensives, anticancer, antiretroviral drugs
etc
• Infections – AIDS, Hepatitis B
• Burn
• Neurological – Parkinsonism, Dementia, Stroke
• Post menopausal, premenstrual, postpartum period

20. Biological

21. Neurotransmitters
Neurotransmitters
involved in
depression are
• Serotonin (low)
• Nor epinephrine (low)
• Dopamine (low)

24. Brain changes in depression

25. Risk factors of depression
Age – risk increases with age
Gender – females > males
Substance abuse
Personality
Genetic ( +ve family history)
Exposure to stressful environment
Co-morbid physical disorders (eg. Diabetes, hypertension etc)
Low socioeconomic status

26. Sequels of Depression
The sequels of depression can be
divided in to
Physical sequels
Psychological sequels

27. Physical sequels
Neurological – stroke
Cardiovascular – hypertension, myocardial infarction
Immune suppression
Gastrointestinal – peptic ulcer, IBD
Road traffic accidents
Sexual dysfunction, infertility
Alopecia
Weight gain (obesity)

28. Psychological sequels
Suicide
Marital disharmony
Eating disorders
Cognitive slowness
Memory disturbances (pseudo dementia)
Substance abuse

29. Co-morbidities with depression
Anxiety disorders
Substance abuse disorders
Personality disorders
Obsessive compulsive disorder
Bipolar disorder

30. Depression is treatable

31. Clinical assessment
• History taking
• Mental status examination
• General / systemic examination
Clinical severity of depression
Suicidal risk
Co-morbidity (if any)
LOOK
FOR
FORMULATION OF MANAGEMENT PLAN

32. Mental status examination
 Generalised psychomotor retardation ( or agitation in elderly),
stooped posture, slow spontaneous movements, downcast gaze
 decreased rate of speech with increased reaction time
 depressed mood and restricted affect
 delusions or hallucinations in perceptual disturbance
 Thought process- may be slow with poverty of ideas
 Memory may be impaired with increased impulsivity (assess for
suicide) with impaired judgement (too pessimist) and insight may
be impaired
 Classic triad of pessimist thoughts about self, future and others

33. MANAGING DEPRESSION
• Psychoeducation
• Relieve the symptoms of present episode
• Frequent follow ups until remission
• Restore premorbid functioning of individual
• Maintain treatment to prevent relapse (usually
if no or minimal depressive symptoms for 9 –
12 months and ability to carry out routine
activities for that time period consider tapering
and stopping the antidepressant)
Goals

34. Suicide – A serious
complication/sequel of depression
• Suicide is preventable
• Clinician need to assess the
risk of suicide

36. •Antidepressants
•Anxiolytics
•Hypnotics
•Mood stabilizer
•Antipsychotics
Drug
treatment

37. • Source - Trivedi JK, Kar SK. Depression in surgically-ill patients. Depression in medically ill patients.
EACB clinical update: Psychiatry. 1st edition. 012; pp- 93 – 109.
Severity of symptom Antidepressant preferred
Mild SSRIs, bupropion
Moderate SSRIs, Mirtazapine, bupropion
Severe Mirtazapine, duloxetine, venlafaxine, SSRIs.
Selection of Antidepressant on the Basis of Symptom Severity

38. • Source - Trivedi JK, Kar SK. Depression in surgically-ill patients. Depression in medically ill patients. EACB clinical
update: Psychiatry. 1st edition. 2012; pp- 93 - 109

39. Choice of Antidepressants according to
Drug-Drug Interactions
SSRIs – Escitalopram, Sertraline
SNRIs – Duloxetine
Others- Agomelatine, Mirtazapine

40. Choice of Antidepressants according to
Comorbid physical illness
Diabetes Mellitus- SSRIs (Escitalopram, Sertraline), ?Agomelatine
Hypertension – SSRIs
Arrhythmias – SSRIs
Myocardial Infarction – Escitalopram/ Sertraline
Thyroid dysfunction - SSRIs
Sexual dysfunction – Bupropion, Mirtazapine
Hepatic dysfunction – Escitalopram, Imipramine
Renal dysfunction - SSRIs
Tuberculosis – Escitalopram, Mirtazapine
AIDS- Escitalopram, Mirtazapine

41. Antidepressants in special population
Elderly – SSRIs, Agomelatine, Mirtazapine
Pregnancy – Escitalopram, Sertraline
Lactation – SSRIs (Sertraline, Paroxetine), Nortriptyline,
Imipramine
Pediatric population – Fluoxetine, Sertraline

42. • Source - Trivedi JK, Kar SK. Depression in surgically-ill patients. Depression in medically
ill patients. EACB clinical update: Psychiatry. 1st edition. 2012; pp- 93 - 109

43. • Source - Trivedi JK, Kar SK. Depression in surgically-ill patients. Depression in
medically ill patients. EACB clinical update: Psychiatry. 1st edition. 2012; pp- 93 – 109.

44. Antidepressants to be avoided
Prostatic enlargement – TCAs, antidepressants with anticholinergic property
Arrhythmias – TCAs
Dyslipidemia – Mirtazapine
Obesity – Mirtazapine
Sexual dysfunction – SSRIs
Dryness of mouth – TCAs, Trazodone
AMI – TCAs, Trazodone
On Antiplatelet agents – SSRIs (Sertraline, Paroxetine, Fluoxetine, Fluvoxamine)
Hepatic dysfunction – Agomelatine, Sedating TCAs, MAOIs
Renal dysfunction - Mirtazapine, Dotheipin (Dose adjustment required)

45. Duration of therapy
• Adequate dose for adequate period of time
with compliance ensured
• Wait for 2-3 weeks time to see response
• 1st episode depression
– At least 6-9 months following complete remission
• Recurrent depression
– At least for 2-5years following complete remission
(probably lifelong for multiple episodes)

46. Electroconvulsive therapy
•Safe
•Recommended for suicidal/
severely depressed patients
•Quick response

47. Psychological treatments
•Counseling
•Psychotherapy (cognitive behaviour
therapy)
•Relaxation techniques ( YOGA/
MEDITATION, Breathing exercise,
Jacobson’s progressive muscle
relaxation)
•Biofeedback
•Exercise

49. When to refer
Patient has severe depression with psychotic features
Suicidal ideations
Failure of 2 or more antidepressants
Psychological intervention needed ( lack of resources)
Bipolar affective disorder
Multiple comorbid conditions
Special population if not manageable

50. Need to
differentiate
Bipolar Affective
Disorder

51. bipolar
affective
disorder
(BAD)
BAD
present
episode
hypomanic
BAD
current
episode
manic
BAD current
episode
depression
manic
episode

52. Pearls to remember
Depression is the commonest psychiatric morbidity in General Practice and should
not be overlooked
A depressed patient usually presents with physical symptoms that should be
explored
Comorbid psychiatric and general medical conditions are common and should be
treated
It is also important to ask about prior manic or hypomanic episode to avoid
misinterpreting bipolar disorder for unipolar depression.
Physicians should not be reluctant to ask about suicide as proactive questioning
may be life saving
Not just short term treatment but maintenance treatment, relapse prevention and
psycho social rehabilitation should be the goal

55. Changing life style,
stress, mismatch
between expectation
and achievement are the
major modifiable factors
Identifying an individuals
risk factors and
appropriate modification
can prevent depression

56. • Say no to
– Substances ( alcohol, opium, cannabis, nicotine
etc)
• Modify - stressful living
• Find happiness in small day-to-day activities
• Keep expectations within reach
• Healthy eating
• Regular exercise / meditation
• Maintaining regular daily routine
• Timely recognition and intervention if
depression develops

57. •A little effort
made everyday
can bring a great
change in life
•Prevent
depression –
add smiles to life

60. ZINDAGI KABHI PALOON ME GUZAR JATI HAI
AUR KABHI
ZINDAGI BHAR EK PAL BHI NAHIN GUZARTA

61. SYMPTOMS OF DEPRESSION
Persistent sad, anxious or “empty” mood
Negative notions
Feelings of helplessness, hopelessness, worthlessness, guilt feelings
Decreased energy, fatigue, being “slowed down”
Sleeplessness, early morning awakening or oversleeping
Loss of interest or pleasure in hobbies and activities that were once
enjoyed (including sex)
Difficulty in making decisions
Persistent physical symptoms that do not respond to treatment
(chronic aches/ pains, increased acidity, frequent motions)
Inattentiveness, forgetfulness, distractibility, inability to
concentrate
Loss of appetite, weight loss / overeating and weight gain
Suicidal tendencies/ thoughts, suicidal attempts
Extreme irritability

62. Co-morbidities with depression