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- Prof YK Wing
- Department of Psychiatry
- CUHK
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2
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- Depression
- Presence of depressive symptoms: depressed mood, negative thoughts
including suicidal ideation, biological symptoms such as sleep
disturbance & low libido
- Persisted symptoms for months
- Functional impairment
- Somatoform pain disorder
- Definition: persistent, severe & distressing pain which cannot =
be
explained fully by a physiological process or a physical disorder=
li>
- Against: presence of prominent depressive symptoms
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- Insomnia
- High prevalence even in the absence of depression
- Related to pain & distress
- Use of pain mediation e.g. opioid, steroids
- Anxiety
- Generalized anxiety disorder
- Panic disorder
- Agoraphobia, social phobia
- PTSD, OCD
- Depression
- Melanocholic, psychotic, atypical depression
- Dysthymia
- Adjustment disorder
- 4. &nb=
sp;
Substance abuse
- 5. &nb=
sp;
Somatoform disorder
- Presence of physical symptoms that cannot be fully explained by med=
ical
disorder, substance abuse or another mental disorder
- E.g. somatoform pain disorder, conversion disorder, somatization
disorder, body dysmorphic disorder, hypochondriasis
- Symptoms not feigned or intentionally produced
- Female> male
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- Depression is a medical disorder
- Analogous to diabetes or hypertension
- Depression is both a chronic and recurrent disease
- Requires maintenance or long-term treatment
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- Normal unhappiness vs ‘pathological depression’: how to
differentiate, why we need to
- Quantitative and qualitative differences, outcome and treatment
implication
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- Core symptoms:
- Low mood
- Loss of interest (anhedon=
ia)
- Fatigue or reduced energy=
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- Additional features
-
Negative cognition (excessive guilt, hopelessness, worthlessn=
ess)
- Suicidal ideation
- Disturbed sleep
- Change in appetite and we=
ight
- Inattention and poor memo=
ry
- Psychomotor retardation or
agitation
- 1. Persistent symptoms for more than two weeks
- 2. ICD-10 classification requires 2 out of 3 core symptoms
- 3. DSM IV classification requires either low mood or anhedonia
- 4. Atypical symptoms like hypersomnia, increased appetite, weight ga=
in
also present in a proportion of depressed patients
- 5. Anxiety, irritability, anger ,hostility may be present
- 6. Psychotic symptoms eg. Delusion of persecution, guilty, poverty,
hypochondriasis; hallucination
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- Depression is a common illness
- Depression occurs twice as often in women as it does in men
- Depression is seen in all age, racial, socioeconomic, and ethnic gro=
ups
- Diagnosis of depression is missed in (primary care) up to 50% of cas=
es
eg. primary care
- Increasing in prevalence rate and younger patients
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- Lifetime prevalence ~2-4% (Chen, 1993)
- Lower than America, United Kingdom, Australia
- Similar to Taiwan Chinese
- ? related to under-reporting, less alcoholic, better social support,
more anxiety
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- Prevalence of depression among patient with persistent pain: 30-54% =
(Banks
and Kerns 1996)
- Severity of pain proportional to severity of depression
- Increased risk of suicidal ideation, attempts & completed suicide
with increasing severity of pain
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- Prevalence of suicidal ideation: 5-20.6%
- Suicidal attempt: ranges from 5.2%- 13.7%
- Tang NKY et al. Psychological Medicine 2006 (Review)
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- FHx of suicide
- Previous suicide attempt
- Co-morbid depression, insomnia
- Nature of pain: longer pain duration, high pain intensity, widespread
body pain & back pain
- Tang NKY et al. Psychological Medicine 2006 (Review)
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- Multifactorial
- complex and multiple interactions among biological, psychological,
sociocultural and political domains
- Stress-diathesis concept
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- Early detection of co-morbid psychiatric morbidity e.g. insomnia,
depression, alcohol & substance abuse
- Risk assessment: suicidal risk
- Adequate treatment for co-morbid depression and psychiatric morbidit=
ies
- Adequate pain management
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- Direct questioning about suicide do not increase risk of suicide
- Multi-axial assessment: current suicidal thoughts, past history, fam=
ily
history, presence of psychiatric illnesses, psychosocial assessment =
and
coping stratgies
- Questionnaires: Beck depression inventory (BDI)
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- Pharmacological treatment
- Psychosocial intervention
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- Antidepressants: not only antidepressant effect but also analgesic
effects
- Demonstration of analgesic effect among chronic pain patients with =
no
concomitant depression
- Dosage required to achieve an optimum analgesic response is usually
lower than the therapeutic dose for antidepressant effect
- Delay of action of antidepressants in chronic pain management is
shorter than that observed in depression
- Anticonvulsants: neuropathic pain
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- Tricyclics (TCA):
- Established analgesic effect esp for neuropathic pain
- Risk of lethal overdose & undesirable side effects
- Selective serotonin reuptake inhibitors (SSRI):
- Less toxic when overdose
- Better tolerability
- Relatively lower efficacy when compared to TCAs
- Serotonin & noradrenalin reuptake inhibitors (SNRI):
- Better tolerability
- Duloxetine: first antidepressant approved by FDA for treating
neuropathic pain in diabetic patients
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- TCAs
- Dry mouth
- Blurred vision
- Sedation
- Weight gain
- Postural hypotension and fall
- Cardiac arrhythmia
- Constipation
- Cognitive impairments
- SSRIs
- Nausea
- Headache
- Sleep disturbances
- Sexual dysfunction
- Anxiety
- Apathy
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- Cognitive Behavioral Therapy
- Marital: marital therapy, management of sexual dysfunction
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- Early & more aggressive management of pain
- Prevent development of biological & psychological mechanisms that
contribute to the maintenance of chronic pain and disability (Taylor=
et
al 2001)
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- Adequate treatment duration
- Adequate dosage
- Acute phase :following the onset of depressive symptoms aims at
stabilisation of symptoms.
- Continuation phase: continue to stabilise the patient for further 3-6
months
- If the depressive symptoms return during this period, it is consider=
ed
as a relapse of the same depressive episode.
- Maintenance phase: aims to prevent the future recurrence of a new
depressive episode
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