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Doc I need Sleeping PillsMajor Depressive Disorder

ContentsIntroductionSleep ProblemDepressionHistoryExaminationTreatment

IntroductionDifferential Diagnosis of Sleep ProblemMajor DepressionEndocrine disorderFootball Season

DepressionA significant mental health problem that disrupts a person's mood and adversely affects his psychosocial and occupational functioningBy the year 2020 major depression is projected to be the second largest contributor to the global burden of disease, after heart diseaseThe risk for suicide associated with depressive disorders is elevated 12 to 20 fold compared to the general population

Diagnosis Criteria DSM IVAt least five 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 2) loss of interest or pleasure

Most of the day, nearly every day For 2 WeeksDepressed moodDiminished interest or pleasureweight lossInsomnia or hypersomniaPsychomotor agitation or retardation (Slow)loss of energyWorthlessness/guiltDiminished ability to think or concentrateRecurrent thoughts of death

SeverityMildfew, if any, symptoms in excess of those required to make the diagnosis and symptoms result in only minor impairment in occupational functioning or in usual social activities or relationships with others.

SeverityModeratesymptoms or functional impairment between mild and severeSevere without psychotic symptoms several symptoms in excess of those required to make the diagnosis, and symptoms markedly interfere with occupational functioning or with usual social activities or relationships with others.

SeveritySevere with psychotic symptomsdelusions or hallucinationsIn partial remissionsymptoms of a major depressive episode are present but full criteria are not met, or there is a period without any significant symptoms of a major depressive episode lasting less than 2 months following the end of the major depressive episode

SeverityIn full remission : during the last 2 months, no significant signs or symptoms of thedisturbance were present.

Risk Of SuicideLoss of relationshipFinancial or occupational difficultiesPoor social supportPast suicide attemptFamily history of suicideAlcohol abuse/dependenceOther co-morbiditiesSuicidal ideationSeverity of depressionPsychomotor agitationLow self-esteemHopelessness

HistoryPresenting symptomsMode of onsetDuration and severity of symptomsNumber and severity of past episodesResponse to treatmentHospitalisationsPsychosocial stressorsFamily historySuicide attemptsPast history of manic or hypomanic episodesSubstance abuse or other psychiatric illnessesSocial history and social support

Presenting symptomsDuring the past month, have you often been bothered by feeling down, depressed or hopeless?"During the past month, have you often been bothered by having little interest or pleasure in doing things?"Common complaintsDifficulty to sleepMultiple pain symptoms

Mode of onsetDeath of love oneFinancial problemHeartbroken

Duration and severity of symptomsDays/weeksAssess severity according to social/occupational functioning

Number and severity of past episodesPrevious eventsHistory of taking antidepressants or sleeping pills e.g. Lorazepam, Stillnox

Response to treatmentDuration of taking antidepressantsAny counselling session

HospitalisationsDuration of hospitalizaionMedicationsbeta-blockers, methyldopa, clonidine, nifedipine, digoxin, L-dopa, tetrabenazine

Psychosocial stressorsOngoing stressorsFamily crisisDebtWork stress

Family historySuicideAttempt suicideOther Mental Ilness e.g. Schizophenia, BMDAnxiety disorder

Suicide attempts

Type of attemptHangCut WristJump from high building

Past history of manic or hypomanic episodesExcessively HappyGrandiosityTalkativeLess need of sleep & not tiredIncrease goal directed activity

Substance abuse or other psychiatric illnessesAmphetamine/MetamphetaminePill Kuda, ICE, SyabuGlue SniffingGam cap SenapangSleeping Pills

Social history and social supportGood & Supporting Family, Good financial status will bring a good outcome

Indications for referral to Psychiatric ServicesUnsure of diagnosisAttempted suicideActive suicidal ideas / plansFailure to respond to treatmentAdvice on further treatmentClinical deteriorationRecurrent episode within 1 yearPsychotic symptomsSevere agitationSelf neglect

Indications for admissionRisk of harm to selfPsychotic symptomsInability to care for selfLack of impulse controlDanger to others

ExaminationMSEAppearance e.g. well kempt, clothing, hair style, appropriateness, calmnessFacial expressionCooperativenessSpeech e.g relevant/rational/coherentMood e.g. Low Mood/euthymic/elatedAffect e.g Restricted/depressed/broadHallucination e.g Hearing Voices (Through ears, clearly heard, nor before/after sleep)Delusion e.g People want to harm him, etcInsight e.g willingness to seek treatment

InvestigationTRO Hypothyroidism, hypercalcaemia, Cushings diseaseThyroid FunctionBaseline Renal Function, LFT, Serum Cholestrol

TreatmentRefer PsychiatryPsychoterapyMedicationSSRI (1st Line)Fluvoxamine 50 mg ON x 3/7, then 100mg ON for 2/52Take Effect at least 2 weeksCommon side effect - anxiety. Weight gainShort Course BenzodiazepineT.Lorazepam 1mg ON x 3-5 Days