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An Ancient Illness

  • Depression described in writings from ancient Egypt,
    the old testament and in ancient Chinese
  • Strikes across the sociopolitical spectrum, young
    and old, rich and poor
  • Abraham Lincoln, Theodore Roosevelt, Ludwig von
    Beethoven, Edgar Allen Poe, Mark Twain, Vincent
    van Gogh, and Georgia O'Keefe
  • Depression is a common illness
  • 10-15% of men and 20% of women at any given time in the US
  • Rates of Depression in Pakistan are undoubtedly higher because
    of socio-political conditions
  • Up to 70% of people exposed to a terrorist attack will develop
    some symptoms of Depression or Post Traumatic Stress disorder
  • 1/3 rd of people with Clinical Depression do not seek help for a
    variety of reasons
  • 10-15% of children and adolescents have Depression

Major Depressive Disorder Is a Major
Public Health Concern

  • Leading cause of health-related disability in the US
  • 4th greatest cause of global illness burden
  • Predicted to be the 2nd leading cause in 2020
  • 1 in 6 individuals may experience a major
    depressive episode during his/her lifetime
  • MDD is a potentially fatal disorder
  • 8% of patients with MDD severe enough to require
    hospitalization eventually commit suicide
  • Depression increases risk of all-cause mortality

Economics of Treatment

  • Annual U.S. sales of SSRI/SNRI antidepressants
    amount to more than $7 billion.
  • Often most prescribed drugs in the US (for all
    illnesses), 3 are antidepressants.
  • ‘Alternative treatments’ for depression/anxiety etc is
    a $4000,000,000 industry (and growing fast).

Depression and Medical Illnesses

  • 50% of Stroke patients have depression;
    90% are depressed 6 months later
  • Heart attacks, 15-20% experience depression
  • 30% of cancer patients have depression, as
    do 8.5%-27% of patients with diabetes
  • ¼ of those with major depression also have
    a substance abuse problem
  • Kiani et al 2003
  • 350 patients presenting to general medical clinic
    (Pindi-Holy family Hospital)
  • 60% mis-diagnosed as medical illness
  • GAD 56%
  • Depression 24%
  • Panic d/o 20%

Why more somatic complaints in patients in

  • Education (lack of)
  • No ‘vocabulary’ for mental symptoms
  • No understanding of mental illness
  • Superstitions, magic etc
  • Social stigma
  • Medical illness is more acceptable
  • To patients
  • To caregivers
  • To clinicians
  • Acknowledging a psychological basis means addressing
  • Often, the underlying social factors are irresolvable
  • Marital and family conflicts
  • Economic difficulties
  • Assuming a ‘sick role’ seems easier
  • Sometimes the patient is the ‘container’ for family distress

Resistance by clinicians

  • Doctors also resist psychological explanations of medical
  • Lack of knowledge
  • ‘Fear’ of psychiatric illness
  • The myth that patients never get better
  • Chronic vs acute illness
  • Long term treatment
  • Compliance
  • Cost
  • Lack of adequate psychotherapy resources
    ‘Medical’ Factors
  • A large, tertiary care, public hospital (such as Mayo)
    attracts patients who are prime candidates for psychiatric
  • Acutely sick
  • Long term illness that has been resistant to other interventions
  • Poor
  • Many travel long distances for treatment
  • No regular education for doctors on how to recognize
    and treat psychiatric illness
  • Combination of ignorance and fear
  • Doctors are in the forefront of health education

Social Factors

  • Poverty
  • Political instability
  • Unemployment
  • Terrorism
  • Communicable diseases e.g. Dengue
  • Over crowding
  • Noise pollution
  • Traffic/road rage
  • Increasing evidence that Depression is a cumulative ‘wearing
    down’ of the body’s immune/defense mechanisms
    What can we do?
  • Educate, educate, educate (yourself first)
  • Use the ‘medical model’ (but don’t buy into it
    too much)
  • Use medications (very carefully)
  • Learn (brief) psychotherapy

What can we do (cont’d)

  • Fear of psychiatric patients
  • (see previous, medical model helps)
  • Psychiatric patients never get better
  • Remission rates in MDD/Anxiety are 70-80% (or higher)
    with correct treatment
  • Similar for psychotic illness (with early, aggressive
  • Substance abuse (see above)
  • Use ‘chronic illness’ model
  • E.g. NIDDM, HTN etc
  • Stress need for long term treatment
  • Discourage visits to quacks who promise quick
    fixes (applies to all medical specialties)
  • Encourage compliance (in the absence of
  • Emphasize cost-benefit (and write cheaper meds)
  • Brief therapy
  • Listen empathically
  • Pay undivided attention
  • Explain treatment
  • Remain optimistic
  • Discourage ‘patient role’
  • Encourage return to daily activities ASAP
  • Refer as needed (personality disorders, negative
    transference etc)
  • Brief therapy (cont’d)
  • Try to ensure continuity of care
  • Hospitalize as needed (but minimize stays and
    length of stay).

Length of Treatment

  • 6-9 months after a first episode
  • 18 months to 2 years after 2 episodes
  • Maintenance treatment after 3 or more episodes
    (but stress to the patient that they do not have to be
    on this medicine ‘forever’ or ‘for the rest of their