1. DEPRESSION & SUICIDE
DR.SARATH MENON.R
DEPARTMENT OF NEUROLOGY
MGM MEDICAL COLLEGE,INDORE

2. INTRODUCTION
 Mood disorder
 Syndrome- set of symptoms
- definite time period
 For atleast 2 weeks
 Distress to self and others
 Social & vocational impairment

3. EPIDEMIOLOGY
 Global prevalance
1.9 % (men) 3.3 % (women)
 In India
 Prevalence – 26.8 % (2011)
 Suicidal mortality rate- 10.5/1L (2011)
Studies
 Chandrasekhar & Reddy etal (Hyderabad)
prevalence -7.9 to 8.9 /1000
double prevalance rate in urban population

4. STUDIES
 South India- Chennai based study
prevalence of 15.6 %
 Srinath etal study ( Andhra)
1.61/1000 children – unipolar depression

5. DETERMINANTS OF DEPRESSION
 Female gender
 Old age
 Economic impoverishment
 Illiteracy
 Violence /trauma
 Substance abuse –alcoholism
 Chronic medical illness

6. IMPACT ON MORTALITY
 Around 8,00,000 commit suicide
 India has highest suicidal rate among young people
 70 % increase in mortality in people age > 65 yr

7. THREE TYPES OF DEPRESSION
 Major depression
 Minor depression (dysthymia)
 Bipolar depression

8. MAJOR DEPRESSION- DSM IV CRITERIA
 2 week duration
 5 or more symptoms
- depressed mood most of the days
- diminished interest or pleasure
- significant weight loss (>5% in a month)
- insomnia/hypersomnia nearly every day
- psychomotor agitation/ retardation
- fatigue/ loss of energy
- feeling of worthlessness/guilt
- recurrent thoughts of death/suicidal ideation

9. MINOR DEPRESSION
 Often referred as dysthymia
 Symptoms are same as major depression
 Low level doesn’t disrupt one’s life
 Duration of atleast 2 yrs
 Chances to develop into major depression if
untreated

10. BIPOLAR DEPRESSION
 Two sides of highs & lows
 Symptoms of mania/hypomania in one side &
major depression on other
 Can fluctuate between these stages
 Rapid or sudden fluctuations seen at times

11. CLINICAL SUBTYPES OF DEPRESSION
 Retarded depression
 Agitated depression
 Psychotic depression
 Paranoid depression
 Peuperial depression
 Seasonal depression
 Chronic depression

12. ETIOLOGY
 Biological factors
- serotonin
- norepinephrine
- dopamine
 Neuroendocrine regulation
- thyroid axis
- adrenal axis
- growth hormone
 Sleep abnormalities
- delayed sleep onset
- shortened REM latency

13.  Brain imaging
- Bipolar – enlarged cerebral ventricle
- SPECT /PET scan-
decreased blood flow esp. frontal cortex
 Genetics
- Psychisocial factors
stress
premorbid personality
cognitive factors
negative distortion of factors
- negative self evaluation
- pessimism
- hopelessness

14.  Positron Emission
Tomography (PET) Scan often
used to see shrinkage of the
hippocampus and frontal lobe
.
(“Position Emission Tomography
Scan of the Brain for Depression”)

16. SEROTONIN
 Imbalance in Serotonin can
influence mood and emotions
 Problems in the brain with low
levels of Serotonin: the brain being
unable to receive Serotonin and/or
an overall shortage of Serotonin in
the brain are being linked to
Depression and it’s symptoms

17. PATHOPHYSIOLOGY & CLINCAL
PRESENTATION OF DEPRESSION
 Mood disturbances
- painful arousal
- hypersensitivity to unpleasant event
- insensitivity to unpleasant event
- depressed mood
- anhedonia
- reduced anticipatory pleasure
 Psychomotor disturbances
- pyschomotor retardation
- agitation
- pseudi dementia/stupor

18.  Cognitive disturbances
- ideas of deprivation & loss
- low self esteem & self confidence
- self reproach & pathological guilt
- recurrent thought of death & suicide
 Vegetative disturbances
-anorexia, weight loss or gain
-insomnia/hypersomnia
- sexual dysfunction
 Suicide
 Anxiety
 Guilt

19. SYMPTOMS OF DEPRESSION
 Feeling sad, empty, nervous for a long time
 Feeling hopeless, helpless, pessimistic
 Problems sleeping, waking early in the morning and unable to get
back to sleep
 Loss of interest or enjoyment in hobbies, activities previously enjoyed
 Feeling worthless, guilty, overwhelmed, inadequate
 Feeling tired, lazy, no energy or zest
 Problems concentrating, thinking clearly, remembering things
 Ambivalence, can’t make decisions
 No appetite with weight loss or overeating with weight gain
 Agitation, irritability, physical restlessness
 Loss of interest or enjoyment in sex
 Persistent thoughts of death or suicide
 Physical symptoms (such as headaches, stomach distress, chest pain,
chronic pain) that won’t go away despite treatment

20. TREATMENT
 Psychosocial therapy
 Pharmacotherapy

21. PSYCHOSOCIAL THERAPY
 Interpersonal therapy
 Cognitive therapy
 Behaviour therapy

22. PHARMACOTHERAPY-
GENERAL GUIDELINES
 Usual recovery by 1 month
 3-4 weeks for anti-depressants to act
 Choice of antidepressents determined by side
effect profile,physical status,lifestyle
 Dosage raised to max.recommended level &
maintained for 4 or 5 wks

23. DURATION & PROPHYLAXIS
 Atleast 6 months or length of previous episode
 Prophylactic Rx
- seriousness of previous episodes
- suicidal ideation
- impairment of psychosocial functions

24. INITIAL MEDICATION SELECTION
 Depending on
- chronicity
- family history
- prior treatment response
- concurrent psychiatric / general
condition
- patient preference

25. ACUTE TREATMENT FAILURE
 Cannot tolerate side effects
 idiosyncratic adverse side effects
 inadequate clinical response
 wrong diagnosis
 Lack of partial response ( 25% symptom
reduction) in 4 – 6 wks - change treatment
 Can have a 2nd trial for another 4-6 wks.

26. SELECTION OF 2ND TREATMENT OPTIONS
 Switching to alternate treatment (preferred)
 augmentation of current treatment
 combination therapy of SSRI & Bupropion –
widely employed
 ECT effective in non responsive cases & acute
severe depression.

27. ANTIDEPRESSANTS
Name Usual daily dose(mg) Side effects
NE reuptake inhibitor
Desipramine 75-300 Drowsiness,insomnia,agita
tion, arrythmia.weight
gain, anti cholinergic
Nortriptyline 40-200 - Do-
5-HT reuptake inhibitors
(SSRI)
Citalopram 20-60 Insomnia, agitation,
sexual dysfunction,GI
distress, sedation
Escitalopram 10-20 -do-
Fluoxetine 10-40 -do-
Fluvoxamine 100-300 -do-
Paroxetine 20-50 -do-
Sertraline 50-150 -do-

28. Name Usual daily dose(mg) Side effects
NE& 5-HT reuptake
inhibitors
Amitriptyline 75-300 Drowsiness,OSH,arrythmi
a,weight
gain,anticholinergic
Imipramine 75-300 -do- + agitation,insomnia
Venlafaxine 150-375 Sleep changes,GI
distress.discontinuation
syndrome
Duloxetine 30-60 GI
distress.discontinuation
syndrome
Pre & post synaptic active
agents
Mirtazapine 15-30 Sedation,weight gain

29. Name Usual daily dose (mg) Side effects
Dopamine reuptake
inhibitor
Bupropion 200-400 Insomnia,agitation,GI
distress
Mixed action agents
Amoxapine 100-600 Drowsiness,insomnia/agita
tion,arrythmia,weight
gain,OSH,anticholinergic
Clomipramine 75-300 drowsiness.,weight gain

30. Discuss Choice of drug with
patient Include :
Therapeutic effects
Adverse effects
Discontinuation effects
Start antidepressant
Titrate to recognised
therapeutic dose.
Assess efficacy
over 4-6 weeks
Increase Dose
Assess over a further
2-4 weeks
Continue for 4-6
months at full treatment
dose
Consider longer–term treatment
in recurrent depression
Give an antidepressant
from a different class
Titrate to therapeutic dose.
Assess over 4-6 weeks
Give an antidepressant
from a different class
Titrate to therapeutic dose.
Assess over 4-6 weeks,
increase dose as necessary
Refer to Suggested treatments
for refractory depression
No Effect
Poorly tolerated
Poorly
tolerated
or
no effect
No Effect
Effective
No
Effect
Effective
Effective
Effective

31. Treatment of refractory
depression
OTHER REPORTED TREATMENTS
(may be worth trying, but limited published support)
Treatment
Add bupropion 300 mg /day
Add clonazepam 0.5- 1.0 mg at night
Add mirtazapine 15-30 mg ON
Add modafinil 100-200 mg/day
Add risperidone 0.5-1.0 mg /day
Ketoconazole 400-800 mg /day
Oestrogens (various regimes used)
SSRI + TCA (e.g. citalopram 20 mg / day with amitriptyline 50 mg /day
Try S-adenosyl – I – methionine 400 mg / day im
SNRI = reboxetine
Add omega – 3 fatty acid (EPA 1 g daily)

32. DEPRESSION IN MEDICAL DISORDERS
 Neurological
- CVA - migraine
- dementia - Parkinons d/s
- epilepsy - multiple sclerosis
- Huntingtons d/s - Wilsons d/s
 Endocrine
- adrenal- cushings,addisons
- hypothroidism
- hyper/hypo parathyroidism
 Infections/inflammatory
- HIV,IMN,SLE, temporal arteritis

33.  Drugs
-analgesics- indometahcin,ibuprofen,opiates
- antibiotics-
ampicillin,metronidazole,tetracyclines
- steroids- corticosteroids,OCP,prednisolone
- antihypertensives- b-blockers,clonidine,reserpine
- anti cancer- bleomycin,vincristine
 Miscellaneous
- cancers
- uremia
- vitamin deficiency
- porphyria

34. SUICIDE –INCIDENCE & PREVALENCE
 1.2 lakh/yr suicidal deaths
 4 lakh/yr attempt suicide
 Majority of suicide (37.8%) -< 30 yr age gp.
 77 % suicide - < 44 yr age- huge burden

35. STUDIES
 Venkoba Rao etal- Madurai
- incidence- 43/1,00,0000
- fatality- 1/12 attempts
 Hegde et al (Karnataka)
- incidence rate- 10.2/1,00,000
- Male preponderance- 67%
 Shukla et al (Jhansi)
- 29/1,00,000
- 34/1lakh (women) & 24 /1 lakh (men)

36. OTHER STUDIES
 Banerjee etal (kolkata)
- incidence – 43/1,00,000
- women – 79.3 %
- 75 % -< 25 yr age

37. SUICIDE & PSYCHIATRIC
DISORDERS
 Psychological autopsy studies done in various countries over
almost 50 years report the same outcomes:
 90% of people who die by suicide are suffering from one
or more psychiatric disorders:
 Major Depressive Disorder
 Bipolar Disorder, Depressive phase
 Alcohol or Substance Abuse
 Schizophrenia
 Personality Disorders such as Borderline

38. RISK FACTORS FOR SUICIDE
 Psychiatric disorders
 Past suicide attempts
 Symptom risk factors
 Sociodemographic risk factors
 Environmental risk factors

39. RISK FACTORS
Psychiatric Disorders
 Most common psychiatric risk factors resulting in suicide:
 Depression*
 Major Depression
 Bipolar Depression
 Alcohol abuse and dependence
 Drug abuse and dependence
 Schizophrenia
*Especially when combined with alcohol and drug abuse

40. RISK FACTORS
 Other psychiatric risk factors with potential to result in
suicide (account for significantly fewer suicides than
Depression):
 Post Traumatic Stress Disorder (PTSD)
 Eating disorders
 Borderline personality disorder
 Antisocial personality disorder

42. RISK FACTORS
 Major physical illness, especially recent
 Chronic physical pain
 History of childhood trauma or abuse
 Family history of death by suicide
 Substance abuse

43. RISK FACTORS
Sociodemographic Risk Factors
Over age 65
White
Separated, widowed or divorced
Living alone
Being unemployed or retired
Occupation: health-related occupations higher
( doctors, nurses, social workers)

44. METHODS OF SUICIDE
 Hanging ( 31.7 %)
 Poisoning –pesticide, drug overdose etc (34.8%)
 Firearms – (8 %)
 Drowning
 Wrist cutting
 Hypothermia
 Electrocution
 Jumping from height
 Vehicular impact-rail,traffic collision
 Immolation

45.  Observable signs of serious depression
 Unrelenting low mood
 Pessimism
 Hopelessness
 Desperation
 Anxiety, psychic pain, inner tension
 Withdrawal
 Sleep problems
 Increased alcohol and/or other drug use
 Recent impulsiveness and taking unnecessary risks
 Threatening suicide or expressing strong wish to die
 Making a plan
 Giving away prized possessions
 Purchasing a firearm
 Obtaining other means of killing oneself
 Unexpected rage or anger
WARNING SIGNS

46. PROPOSED DSM-V SUICIDE ASSESSMENT DIMENSION
Level of concern about
potential suicidal behavior:
(sum of items coded as
present)
1. 0: Lowest concern
2. 1-2: Some concern
3. 3-4: Increased concern
4. 5-7: High concern
Suicide risk factor groups:
1. Any history of a suicide attempt
2. Long-standing tendency to lose temper or
become aggressive with little provocation
3. Living alone, chronic severe pain, or recent
(within 3 months) significant loss
4. Recent psychiatric admission/discharge or
first diagnosis of MDD, bipolar disorder or
schizophrenia
5. Recent increase in alcohol abuse or
worsening of depressive symptoms
6. Current (within last week) preoccupation
with, or plans for, suicide
7. Current psychomotor agitation, marked
anxiety or prominent feelings of
hopelessness

47. PREVENTING SUICIDE
Prevention within our community
 Education
 Screening
 Treatment
 Means Restriction

48. CONCLUSION
 Depression - common disorder
 By 2025, major cause of morbidity & mortality
 India has highest number of suicides among
young people
 Treatable but under diagnosed
 Newer drugs with less side effects available.

49. REFERENCES
 Kaplan & Saddock’s Synopsis of Psychiatry-10th
edition
 Text book of depressive disorders by Maj &
Sartorius -2nd edition
 Indian journal of psychiatry