Clinical Practice Guidelines for the management of Depression

Abstract

Participants of expert group on CPG for Depression Gautam Saha, I.D Gupta, Navendu Gaur, Tushar Jagawat, Anita Gautam, T. S Sathyanarayana Rao INTRODUCTION Depression is a common disorder, which often leads to poor quality of life and impaired role functioning. It is known to be a major contributor to the global burden of diseases and according to World Health Organization (WHO), depression is the fourth leading cause of disability worldwide and it is projected that by 2020, it will be the second most common leading cause of disability. Depression is also associated with high rates of suicidal behaviour and mortality. When depression occurs in the context of medical morbidity, it is associated with increased health care cost, longer duration of hospitalization, poor cooperation in treatment, poor treatment compliance and high rates of morbidity. Depression is also known to be associated with difficulties in role transitions (e.g., low education, high teen child-bearing, marital disruption, unstable employment) and poor role functioning (e.g., low marital quality, low work performance, low earnings). It is also reported to be a risk factor for the onset and persistence of a wide range of secondary disorders. Available data also suggests that between one-third and one-half of patients also experience recurrence of depressive episodes. ASSESSMENT AND EVALUATION (table-1)Table 1: Components of assessment and evaluationManagement of depression involves comprehensive assessment and proper establishment of diagnosis. The assessment must be based on detailed history, physical examination and mental state examinations. History must be obtained from all sources, especially the family. The diagnosis must be recorded as per the current diagnostic criteria. Depression often presents with a combination of symptoms of depressed mood, loss of interest or pleasure, decreased energy and fatigue, reduced concentration and attention, reduced self-esteem and self-confidence, ideas of guilt and unworthiness, bleak and pessimistic views of the future, ideas or acts of self-harm or suicide, disturbed sleep and diminished appetite. Depending on the severity of depression some of these symptoms may be more marked and develop characteristic features that are widely regarded as having special clinical significance. These symptoms are known as somatic symptoms of depression and include symptoms of loss of interest or pleasure in activities that are normally enjoyable, lack of emotional reactivity to normally pleasurable surroundings and events, waking up in the morning 2 hours or more before the usual time, depression worse in the morning, objective evidence of definite psychomotor retardation or agitation (remarked on or reported by other people), marked loss of appetite, weight loss (often defined as 5% or more of body weight in the past month) and marked loss of libido. It is important to note that for the diagnosis of depressive disorder these symptoms need to be present for at least 2 weeks and need to be associated with psychosocial dysfunction. Some of the patients with depression may present with predominant complaints of aches, pains and fatigue and they may not report sadness of mood on their own. A careful evaluation of these patients often reveals the underlying features of depression. However, it is important to note that many patients with depression will also have associated anxiety symptoms. With increasing severity of depression patients may report psychotic symptoms and may also present with catatonic features. Thorough assessment also ought to focus on evaluation for comorbid substance abuse/dependence. Careful history of substance intake need to be taken to evaluate the relationship of depression with substance intoxication, withdrawal and abstinence. Whenever required appropriate tests like, urine or blood screens (with prior consent) may be used to confirm the existence of comorbid substance abuse/dependence. Many physical illnesses are known to have high rates of depression. In some situations the physical illnesses have causative role in development of depression, whereas in other situations the relationship/co-occurrence is due to common etiology. Some of the physical illnesses commonly associated with depression are listed in Table-2. When depression occurs in relation to physical illness attempt may be made to clearly delineate the symptoms of depression and physical illness. Further, while making the diagnosis, it maybe clearly mentioned as to which diagnostic approach [i.e., inclusive approach (symptoms are counted whether or not they might be attributable to physical illness), substitute approach (nonsomatic symptoms are substituted with somatic symptoms), exclusive approach (somatic symptoms are deleted from the diagnostic criteria) or best estimate approach] was followed. Further, while reviewing the treatment history of medical illnesses, medication induced depression must be kept in mind, as many medic