وصف
One of the most frequent mental health issues seen in primary care is depression, which is also a major contributor to disability globally. Depression is most effectively treated as a chronic illness since it is frequently a recurrent or chronic condition. Additionally, patients with depressive disorders who are medically unwell are more likely to experience chronic depression or less full recovery. Many, if not most, depressed people can benefit from antidepressant drugs and psychotherapies, but millions of patients in primary care do not receive adequate treatment. A systematic, population-based approach is necessary for the effective management of depression in the primary care setting. This approach includes systematic case finding and diagnosis, patient engagement and education, use of evidence-based treatments, such as medications and/or psychotherapy, and close follow-up to ensure that patients are receiving the care they need.
ملخص
- The presentation covers depression as a medical illness, emphasizing that it is a functional neurological disorder rather than simply a mental issue. Diagnosis requires meeting specific criteria outlined in the DSM, including depressed or irritable mood and/or anhedonia, along with other symptoms like weight changes, sleep disturbances, agitation, fatigue, feelings of worthlessness, and suicidal thoughts, for a minimum of two weeks.
- The neurobiology of depression involves neurotransmitters like dopamine, serotonin, and norepinephrine. Dopamine is associated with pleasure and motivation, serotonin with mood, memory, and cognition, and norepinephrine with alertness and energy. Drug selection should be based on the specific symptoms and the underlying neurotransmitter imbalances.
- Treatment principles for depression involve discussing medication options, non-pharmacological therapies (like CBT and lifestyle changes), and realistic outcomes with the patient. Effective doses of antidepressants are necessary, and treatment should continue for 6-9 months after symptom resolution to prevent relapse. Medication withdrawal should be gradual to avoid discontinuation symptoms.
- Common antidepressants include SSRIs, SNRIs, and other groups. While tricyclics are older and less frequently used due to side effects, SSRIs are commonly prescribed. The presentation highlights specific minimum doses for various medications and their potential side effects, such as sedation, orthostatic hypotension, and sexual dysfunction. Interactions of fluoxetine and paroxetine with other drugs are discussed.
- Serotonin syndrome, although rare, can occur with rapid dose increases or combinations of SSRIs/SNRIs, presenting with mental status changes, autonomic instability, and neuromuscular abnormalities. Serotonin withdrawal or discontinuation syndrome is more common, with symptoms like irritability, gastrointestinal issues, neuromotor symptoms, paresthesias, and sleep disturbances.
- Antidepressants, particularly SSRIs, are recommended in cardiac conditions, with sertraline being the most studied in post-MI patients. Hyponatremia and hyperprolactinemia are potential side effects of antidepressants. Sexual side effects are common, but often reversible, and certain antidepressants like bupropion and trazodone have fewer sexual side effects. The risk of bleeding with SSRIs should be considered, especially in patients on antiplatelet medications.
- The presentation addresses specific considerations for depression in various medical conditions. SSRIs are the treatment of choice for depression in heart disease and post-stroke. Depression is linked to poor glycemic control in diabetes, with better control achieved with antidepressant use. Maternal depression during pregnancy and postpartum can affect fetal growth and development, with SSRIs generally considered safe during pregnancy and lactation.
- Finally, the presentation highlights the common comorbidity of depression with dermatological conditions, suggesting SSRIs as a first-line treatment option. In treating elderly individuals with depression, SSRIs are preferred, but care must be taken due to risks of bleeding, hyponatremia, and postural hypotension.
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