DEPRESSION

DEPRESSION

 Terminologi
Mood ???
Afek

Jenis

depresi

Bipolar
Unipolar

Projected Global Burden of Disease

(DALYs, 2020)
1.
2.
3.
4.
5.
6.
7.
8.

Ischemic heart disease

Unipolar major depression
Road traffic accidents
CVA
COPD
Lower respiratory infection
TB
War
(WHO, 2000)

Female > male (20%:12%)

The rate of depression in medical illness
varies from 10-40%
Comorbidity of depression and medical illness
will worsen the prognostic
Depression in medical illness can be treated

*Goodnick, PJ, Treatment of deression in medical illness, Ashley Publication, 2000

Depression in Primary Care

74

% of patients in US go to GP
rather than to a psychiatrist for
depressive symptoms1
20 to 30 % of primary care
patients present with depressive
symptoms2
The severity of medical conditions
in correlation with clinical
depression1
1 Montano B, J Clin Psychiatry, 1994;55(12):18-33
2 Zung, WK et al, J Fam Practice, 1993;37;337-344

Current Treatment Patterns:

Depression is still

Underdiagnosed
Less than of patients with major
depression are explicitly recognized as
being depressed
Inadequately
Only about of all depressed patients
receive some form of therapy for their
illness
Only about of depressed patients
receive an adequate dose and duration
of antidepressant
treatment

Katon W, et el, Med Care, 1992; 39 (1);67-76

Why
The

physician: poor recognition of

depressive illness, misdiagnosis of
physical complaints (symptom overlap :
fatigue and insomnia can be
symptoms of medical illness i.e.cardiac
illness, cancer), depressive symptoms
perceived as understandable reactions
to circumstances, inadequate time to
counsel and treat psychiatric illness

Depression
Past Understanding

Depression

is a character defect
or weakness
Patients could handle depression
by themselves
Treatments are not effective

Depression
Current Understanding
Depression

= a medical illness
(not a character defect or
weakness)
Recovery is the rule, not the
exception
Treatments are effective
Doctors should be alert to early
signs & symptoms
9

The need to treat Depression

15% patients with depression will die from

suicide
(Guze & Robins, 1970; Henriksson, Aro, Marttunen, 1993)

Depression is present in >50% completed

suicide
(Asgard, 1990)

Diminished immune response caused by

depression
(Schliefe, Keller. Camerino, Thornton, Steik 1983)

Major depression morbidity is higher than:

HT, CRF & DM causes loss of US$ 50
billion/year in USA
(Greenberg, Stiglin, Finkelstein & Berndt, 1993)
10

What should be treated?

Disability
Social

functioning impaired
Significant suffering
Seek for care
Seek for help
Occupational impairment

Hergueta & Lecrubier, 2000

11

Depressive Disorders: Aims of

Treatment

Treatment

Minimize
relapse/recurrence
risk

Reduce/remove
signs, symptoms
Restore
role
function

12

ETIOLOGY
Unknown
Factor

multiple factor

:
Genetic
Non Genetic: biogenic amin disregulation, neuroendocrin
disregulation, neurofisiology changes, psycho dinamic,
psychosocial factor (loss of object)
HPA (hypothalamic pituitary adrenal) axis
hypersensitivity??
Neurotransmitter that involve:
Serotonin
Norepinephrin
Dopamin
GABA
Glutamat

Bio-Psycho-Social model

Psycho-cognitive

Biological

MODEL

Socio-environmental
Hergueta & Lecrubier, 2000

14

Duration of treatment
Past Understanding
Depression

treatment :

2 weeks, 3 weeks, 4 weeks ???

Antidepressants

are addictive: the

longer treatment you give, the
more addictive patients will be

15

Duration of treatment
Current Understanding
Depression

need a long term

treatment
No antidepressants have been
proven to create addiction
Relapse and recurrence are high.
Risk of recurrence :
50% after one episode
70% after two episodes
90% after three episodes
16

Gejala umum depresi

1. Di bidang mood, motivasi,
psikologik
>murung terus menerus
>kehilangan minat/gairah
>putus asa
>tak berdaya
>merasa diri tak berharga

>rasa bersalah/sikap negatif

terhadap diri
sendiri
>konsentrasi/memori terganggu
>pikiran tentang kematian/bunuh
diri
>mudah menangis

2. Gejala fisik
>motorik lamban atau agitasi
>cepat lelah/kurang tenaga
>gangguan tidur
>gangguan nafsu makan (berat
badan
berkurang atau bertambah)

KRITERIA DIAGNOSTIK
(PPDGJ III)
Episode

depresi ringan

Tanpa gejala somatik

Dengan gejala somatik

Episode

depresi sedang

Tanpa gejala somatik

Dengan gejala somatik

Episode

depresi berat

Tanpa gejala psikotik

Dengan gejala psikotik

Penatalaksanaan
Farmakoterapi
ECT
Psikoterapi :
- Individual
- CBT (Cognitive Behavioural
Therapy)
- Stress Management Training

FARMAKOTERAPI
Pemberian

farmakoterapi
disesuaikan dengan manifestasi
gejala
Dasar pemilihan antidepresan
sbb :
>efektifitas setara dengan
antidepresi
terdahulu (TCA)
>efek samping minimal
>interaksi dengan obat lain
minimal

Farmakoterapi
Antidepresan
Waktu 3-4 mgg

efek terapi

signifikan
Terapi diteruskan min 6 bln sejak
perbaikan
Jenis SSRI (fluoxetin, paroxetin, sertralin)
Trisiklik (amitriptilin), tetrasiklik
(maproptilin)
Jenis lain: bupropion, venlavaxin,
nefazodon, mirtazapin (remeron)

Efek samping: mual, muntah,

Psikoterapi
CBT

(Cognitive Behavioral Therapy)

- Membuat pasien menyadari
pandangannya terhadap situasi
stress, bahwa pandangan tersebut
akan mempengaruhi timbulnya
emosi dan respons perilaku negatif,
- Mengajari pasien untuk
mengubah pola pandangnya.

Electro Convulsive Therapi

Tidak

berespon dengan
farmakoterapi adekuat
Tidak dapat mentoleransi
farmakoterapi
Tentamen suicide
Tampilan klinis yang sangat berat

 Latihan

manajemen stress, yang

terdiri dari
- self-observation
- cognitive restructuring
- relaxation training
- time management
- problem solving

Prognosis
Cenderung

kronik dan kambuh-

kambuhan
Kekambuhan 50 % dalam 1 tahun
pada episode pertama depresi berat
Jumlah relap perburuk prognosis
Perlu terapi profilaksis pada pasien
yg alami > 2x episode
Prognosis baik: gejala psikotik (-),
rawat inap singkat, faktor psikososial
baik, komorbiditas ggn psikiatri lain

Alternatif pertanyaan yang dapat

diajukan untuk mengungkap depresi

1.
2.

3.

Apakah anda merasa sedih atau

murung ?
Apakah anda kehilangan minat atau
rasa senang terhadap hal-hal yang
dulunya anda minati ?
Apakah anda merasa tenaga anda
menurun dan/atau lelah sepanjang
waktu?

4. Apakah anda mengalami masalah

masuk tidur atau bangun jauh
lebih awal dari sebelumnya ?
5. Apakah anda kehilangan nafsu
makan atau makan lebih dari
biasanya ?
6. Apakah anda sulit konsentrasi ?
7. Apakah anda menjadi lebih
lambat dalam berpikir atau waktu
bergerak ?

8. Apakah minat seksual anda

kurang ?
9. Apakah anda menilai negatif
terhadap diri sendiri ?
10. Apakah anda berpikir tentang
kematian ?
11. Apakah anda sering merasa
bersalah ?

Pertanyaan selanjutnya adalah

tentang aktivitas sehari-hari
(khususnya yang berhubungan
dengan fungsi sosial dan
pekerjaan) seperti, hubungan
dengan keluarga, pasangan, anak,
kerabat, aktivitas sosial,
pergaulan, produktivitas dan mutu
kerja, serta absensi

Thank you