mdd/psy/cpg

1. MDD
Ref: Malaysian CPG on Management Of Major Depressive
Disorder, May 2007
+ DSM 5
By: dr ismah, PSY dept, HQE
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2. Contents
 Introduction
 Epidemiology
 Screening
 Diagnosis
 Management
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3. Introduction
 Major depressive disorder (MDD) is a significant mental
health problem that disrupts a person's mood and
adversely affects his psychosocial and occupational
functioning
 A majority of patients improve significantly with
antidepressants treatment
 However, MDD often has a recurrent course, with
multiple episodes of relapse
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4. Epidemiology
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Lifetime prevalence levels
from community-based
surveys range from 4.9% to
17.1%
It is estimated that about 30-
50% of cases of depression in
primary care and medical
settings are not detected
By the year 2020 major
depression is projected to be
the second largest contributor
to the global burden of
disease, after heart disease
In Malaysia, a cross sectional
study done among adult
primary care attendees
reported the prevalence of
MDD as 5.6%
The most serious
consequence of
MDD is suicide

5. Screening
‘’During the pass month, have you often been
bothered by feeling down, depress or hopeless?’’
‘’During the pass month, have you often been
bothered by having little interest or pleasure in
doing things?’’
 Sensitivity is 96% and specificity 57%
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6. Diagnosis (DSM 5)
A. Five (or more) of the following symptoms have been present during
the same 2-week period and represent a change from previous
functioning:
At least one of the symptoms is either (1) depressed mood or (2) loss of
interest or pleasure.
Note: Do not include symptoms that are clearly attributable to another
medical condition
 1. Depressed mood most of the day, nearly every day, as indicated
by either subjective report (e.g., feels sad, empty, hopeless) or
observation made by others (e.g. appears tearful). (Note: In
children and adolescents, can be irritable mood.)
 2. Markedly diminished interest or pleasure in all, or almost all,
activities most of the day, nearly every day (as indicated by either
subjective account or observation).
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7.  3. Significant weight loss when not dieting or weight gain (e.g., a change of more
than 5% of body weight in a month), or decrease or increase in appetite nearly every
day. (Note: In children, consider failure to make expected weight gain.)
 4. Insomnia or hypersomnia nearly every day.
 5. Psychomotor agitation or retardation nearly every day (observable by others, not
merely subjective feelings of restlessness or being slowed down).
 6. Fatigue or loss of energy nearly every day.
 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be
delusional) nearly every day (not merely self-reproach or guilt about being sick).
 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day
(either by subjective account or as observed by others).
 9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation
without a specific plan, or a suicide attempt or a specific plan for committing suicide.
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8. B. The symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning
C. The episode is not attributable to the physiological effects of a substance or
to another medical condition
D. The occurrence of the major depressive episode is not better explained by
schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional
disorder, or other specified and unspecified schizophrenia spectrum and other
psychotic disorders
E. There has never been a manic episode or a hypomanic episode
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9.  Note: Criteria A-C represent a major depressive episode.
 Note: Responses to a significant loss (e.g., bereavement, financial ruin,
losses from a natural disaster, a serious medical illness or disability) may
include the feelings of intense sadness, rumination about the loss, insomnia,
poor appetite, and weight loss noted in Criterion A, which may resemble a
depressive episode. Although such symptoms may be understandable or
considered appropriate to the loss, the presence of a major depressive
episode in addition to the normal response to a significant loss should also
be carefully considered. This decision inevitably requires the exercise of
clinical judgment based on the individual’s history and the cultural norms
for the expression of distress in the context of loss.
 Note: This exclusion does not apply if all of the manic-like or hypomanic-like
episodes are substance-induced or are attributable to the physiological
effects of another medical condition
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10. Severity is based on the number of criterion symptoms, the severity
of those symptoms, and the degree of functional disability.
 Mild: Few, if any, symptoms in excess of those required to make the
diagnosis are present, the intensity of the symptoms is distressing but
manageable, and the symptoms result in minor impairment in social
or occupational functioning.
 Moderate: The number of symptoms, intensity of symptoms, and/or
functional impairment are between those specified for “mild” and
“severe.”
 Severe: The number of symptoms is substantially in excess of that
required to make the diagnosis, the intensity of the symptoms is
seriously distressing and unmanageable, and the symptoms
markedly interfere with social and occupational functioning.
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11.  In partial remission:
Symptoms of the immediately previous major depressive
episode are present, but full criteria are not met, or there is
a period lasting less than 2 months without any significant
symptoms of a major depressive episode following the end
of such an episode.
 In full remission:
During the past 2 months, no significant signs or symptoms
of the disturbance were present.
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12. Management12
Criteria for referral to psy service Criteria for admission
• Unsure of diagnosis
• Attempted suicide
• Active suicidal ideas/plan
• Failure to respond to treatment
• Advice on further treatment
• Clinical deterioration
• Recurrent episode in 1 yr
• Psychotic symptoms
• Severe agitation
• Self neglect
• Risk of harm to self
• Psychotic symptoms
• Inability to care for self
• Lack of impulse control
• Danger to others
• Any other reason that health
care providers deem
significant

13. 13

14. 14

15. 15
SSRIs
SNRIs
RIMA NaSSA
TCA
SSRE

16. Phases of treatment
 Acute: patients are given antidepressants until they achieve
remission
 Continuation: duration of continuation phase treatment is generally
6 to 9 months from the acute phase (grade A)
 Maintenance: is a period to prevent recurrence. At least for 2 yrs,
can up to 5 yrs or more (grade C)
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17. 17

18. 18
Cont…

19. 19

20. Failed response to initial treatment20

21. Treatment resistant depression (TRD)
 Failed to respond to two or more antidepressant
treatments at an adequate dose for an adequate
duration, given sequentially
 Adequate duration refers to at least 4 weeks
 Adequate dose to at least 150mg/day of imipramine
equivalent
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22. 22
TRD
Switching (grade A) Same class/another
Augmentation
Atypical
antipsychotics
Lithium
Anticonvulsant
- Lamotrigene
- Valproate
- Carbamazepine
- Benzodiazepines
Combination
therapy
(grade B)

23. ECT
Indications for ECT in patients with MDD include:-
 A high degree of symptom severity and functional impairment
 Psychotic symptoms
 Catatonic features
 Urgent need for response or a life-threatening condition such as
refusal to eat or highly suicidal due to the depressive illness
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24.  ECT causes short term cognitive impairment but there is no
evidence to show that it causes structural brain damage
 ECT may be considered:
• For the acute treatment of moderate or severe depression for short
term therapeutic benefits (grade A)
• To achieve rapid improvement of severe symptoms in major
depression with or without psychotic features (grade A)
• In treatment resistant depression (grade B)
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25. Psychological interventions
 CBT
 Supportive therapy
 Problem solving therapy
 Counselling
 For moderate and severe depressive disorder, the duration of
psychological interventions should be in the range of 16 to 20 sessions over
6 to 9 months
 Other:- exercise therapy
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26. Thank you26