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MDD
Ref: Malaysian CPG on Management Of Major Depressive
Disorder, May 2007
+ DSM 5
By: dr ismah, PSY dept, HQE
1
Contents
 Introduction
 Epidemiology
 Screening
 Diagnosis
 Management
2
Introduction
 Major depressive disorder (MDD) is a significant mental
health problem that disrupts a person's mood and
ad...
Epidemiology
4
Lifetime prevalence levels
from community-based
surveys range from 4.9% to
17.1%
It is estimated that about...
Screening
‘’During the pass month, have you often been
bothered by feeling down, depress or hopeless?’’
‘’During the pass ...
Diagnosis (DSM 5)
A. Five (or more) of the following symptoms have been present during
the same 2-week period and represen...
 3. Significant weight loss when not dieting or weight gain (e.g., a change of more
than 5% of body weight in a month), o...
B. The symptoms cause clinically significant distress or impairment in social,
occupational, or other important areas of f...
 Note: Criteria A-C represent a major depressive episode.
 Note: Responses to a significant loss (e.g., bereavement, fin...
Severity is based on the number of criterion symptoms, the severity
of those symptoms, and the degree of functional disabi...
 In partial remission:
Symptoms of the immediately previous major depressive
episode are present, but full criteria are n...
Management12
Criteria for referral to psy service Criteria for admission
• Unsure of diagnosis
• Attempted suicide
• Activ...
13
14
15
SSRIs
SNRIs
RIMA NaSSA
TCA
SSRE
Phases of treatment
 Acute: patients are given antidepressants until they achieve
remission
 Continuation: duration of c...
17
18
Cont…
19
Failed response to initial treatment20
Treatment resistant depression (TRD)
 Failed to respond to two or more antidepressant
treatments at an adequate dose for ...
22
TRD
Switching (grade A) Same class/another
Augmentation
Atypical
antipsychotics
Lithium
Anticonvulsant
- Lamotrigene
- ...
ECT
Indications for ECT in patients with MDD include:-
 A high degree of symptom severity and functional impairment
 Psy...
 ECT causes short term cognitive impairment but there is no
evidence to show that it causes structural brain damage
 ECT...
Psychological interventions
 CBT
 Supportive therapy
 Problem solving therapy
 Counselling
 For moderate and severe d...
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Management of MDD (based on Malaysia CPG, may 2007)

  1. 1. MDD Ref: Malaysian CPG on Management Of Major Depressive Disorder, May 2007 + DSM 5 By: dr ismah, PSY dept, HQE 1
  2. 2. Contents  Introduction  Epidemiology  Screening  Diagnosis  Management 2
  3. 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 3
  4. 4. Epidemiology 4 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. 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% 5
  6. 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). 6
  7. 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. 7
  8. 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 8
  9. 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 9
  10. 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. 10
  11. 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. 11
  12. 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. 13
  14. 14. 14
  15. 15. 15 SSRIs SNRIs RIMA NaSSA TCA SSRE
  16. 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) 16
  17. 17. 17
  18. 18. 18 Cont…
  19. 19. 19
  20. 20. Failed response to initial treatment20
  21. 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 21
  22. 22. 22 TRD Switching (grade A) Same class/another Augmentation Atypical antipsychotics Lithium Anticonvulsant - Lamotrigene - Valproate - Carbamazepine - Benzodiazepines Combination therapy (grade B)
  23. 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 23
  24. 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) 24
  25. 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 25
  26. 26. Thank you26
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    Jan. 11, 2017
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    Mar. 12, 2016
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    Oct. 20, 2015

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