MOOD DISORDER IN PRIMARY CARE
▪ Impact not only on the individual but also on famiies
Dr. Renato A. Carasig
March 23, 2021
OVERVIEW:
• One’s general state is distorted or inconsistent with one’s
circumstances and interferes with ones’ ability to function
• Classification:
1. Major depressive disorder
o At least 2 weeks
o Persistent feeling of sadness, loss of interest,
tiredness, irritation, sudden weight loss or
weight gain
o Common for ages 15-45
o More common in females
2. Bipolar disorder
o Mood swings from depression to mania
o Change of attitude
o Cannot make difference between joyful or
sadness
o Can last several years or be lifelong
o Common for ages 18-35
3. Seasonal affective disorder (SAD)
o Why does people feel sad more during winter?
Because of the gloomy feeling (Lighting
therapy→Melatonin???)
o Feeling depressed and worthless on most
days
o Related to season
o Time taken for recovery
o For at least 2 consecutive weeks
o Can last several months or years
o Common for ages 18-35
o More common in females
o Perineal
o Starts from fall continues to winter
4. Cyclothymic disorder
o Rare disorder
o A mild mood disorder characterized by mood
swings with periods of depression and
hypomania.
o Similar to bipolar I and II but change is not as
extreme as the two
o Mild form of depression
5. Persistent depressive disorder (dysthymia)
o Continuous and long term
o May take 6 months or more
6. Disruptive mood dysregulation disorder
o Extreme irritability or anger
o Temper outburst
o Impairs relationship with classmates, family, or
people around you
7. Depression related to medical illness
o They are not sleeping well
o They feel like they are a burden to the family
o Physical economic burden
8. Depression induced by substance use or medication
WHY PRIMARY CARE?
1. The majority of patients with mental health care, especially
mood disorders are treated in primary care – because not all
are severe cases. Some cases can be managed in primary
health care
2. Primary care professionals and primary care team members
are usually the first and often the only health professionals
who manage people with mental health problems. – because
some patients do not have the resources or capacity to go to
tertiary hospital to seek for advance treatment.
3. The risk of mental illness in adult life; around half of adults with
mental health problems are likely to have met criteria for
disorder by the age of 15
4. Dysthymia is also common in primary care patients, affecting
3-5% of primary care attendees
5. The prevalence of any psychotic illness in primary care
comprises patients with schizophrenia, schizo-affective
disorder, bipolar affective disorder and psychotic depression.
▪ Burden of mood disorders
health services and society in general
▪ The Global burden of Disease projects analysis
revealed that 37% of healthy years lost due to
disability were attributable to neuropsychiatric
conditions, and that mental disorders.
▪ Accounted for 4 of the 10 leading causes of
disability worldwide.
▪ Depression alone accounts for more disability than
any other causes globally, amounting to almost
12% in high-income countries.
▪ Worldwide studies have shown medical costs up to
two-fold higher for primary care attendees,
▪ Depression confers an increased risk of death from
a broad range of physical conditions, and, together
with the high risk of suicide, underlines the fact that
mood disorders are potentially fatal diseases
WHAT’S NEW?
• There is increasing recognition that long-term care
approaches are required for a significant proportion of
depressed patients in primary care
• Case management, medication management and telephone
support are important factors in improving outcomes
• Patients with coexisting depression and physical illness have
particular risks and needs
• The improving access to psychological therapies programs,
together with computer and web-based delivery system, is
assisting access to psychological therapy
• A step care model should be used for the management of
depression in primary care
EPIDEMIOLOGY OF MOOD DISORDERS IN PRIMARY CARE
• Depressive disorders are common within the general
population, affecting around 10% of people at any time, with
mixed depression anxiety the most frequently occurring
presentation
RECOGNITION OF MOOD DISORDERS IN PRIMARY CARE
A. Patient factors – some patients are not cooperative; some
patients are having a hard time opening themselves to the
physician
B. Clinician Factors – insufficient number of health care
providers that can cater to the needs of patients with
psychiatric conditions
C. Issues in diagnosis
SOMATIZATION
-The process whereby psychological distress is expressed through
physical symptoms
Two groups of somatizers:
1. Facultative, who presents with physical symptoms but can
express their psychological symptoms IF INTERVIEWED
appropriately
SUICIDE IN PRIMARY CARE
• The finding is 15% of people with depression are likely to
commit suicide
• Lifetime suicide risk in people with depression appears to be
2% and 5%
• Up to 22% of people who commit suicide will have their GP in
the week before their death
SCREENING FOR DEPRESSIO IN PRIMARY CARE
• Filter 1 - Illness behavior by screening incidents in the
COMMUNITY
• Filter 2 - Incidence of mental illness in people who seek help
from their primary care physician
• Filter 3 - Incidence of mental illness recognized by General
Practitioner doctors
• Filter 4 - People referred by primary care physicians
Sombilla & Soliven
CASE FINDING
• During the last month, have you often been bothered by
feeling down, hopeless or depressed?
• During the last month, have you often been bothered by little
interest or pleasure in doing things?
1. Some 90% of patients with mental health problems or
managed entirely in primary care comma and primary
care teams have to meet the needs of these large
proportion of patients who do not need referral to
specialist services
2. Antidepressant medications, cognitive and behavioral
management techniques, problem solving techniques
2. Selective serotonin reuptake inhibitors (SSRI’s) - Block the
update of absorption, of serotonin in the brain, facilitating
receiving and sending messages in the CNS resulting in better
and more stable mood
Examples: Citaloptsm, escitalopram, fluoxetine, (Prozac)
3. Tricyclic antidepressants
Examples: Amyttiptyline, amoxapine, clompipramine,
doxepin, imipramine, nortryptiline, protriptyline, trimipramine

RE-ATTRIBUTION SKILLS IN SOMATIZATION 4. MAO’s inhibitor - Inhibits the action of MAO with lead
• Counselling skills serotonin broken down leading to stabilized mood
• Exercise
• Self-help and bibliotherapy Examples: Phenelzine, tranylcypromine. Isocarboxazid
• Structured assessments
5. Noradrenaline and specific serotoninergic antidepressants –
CARE PLAN OR THOSE WITH AFFECTIVE PSYCHOSES mostly used as antidepressants

Management: Examples: Mianserin, mirtazipine

1. Mild depression
-Watchful waiting
-Exercise

2. Moderate to severe depression

-antidepressant medications
-collaborative care

3. Bipolar affective disorder

-Very uncommon in primary health care

THE STEPPED CARE MODEL

1. Who is responsible?

STEP 1 - Primary care physician, practice nurse

STEP 2 - Primary care team, primary care mental health
worker
STEP 3 - Primary care team, primary care mental health
worker
STEP 4 - Mental health specialists
STEP 5 – In-patient, crisis teams

2. What is the focus?

STEP 1 - Recognition
STEP 2 - Mild depression
STEP 3 - Moderate to severe
STEP 4 - Treatment resistant, recurrent, atypical and
psychotic depression, and those with significant risks
STEP 5 - Risk to life, severe self-harm

3. What do they do?

STEP 1 - Assessment
STEP 2 - Watch full waiting, guided self-help, computerized
cognitive-behavioral therapy, exercise, brief psychological
intervention
STEP 3 - Medications, psychological interventions, social
support
STEP 4 - Medications, complex psychological interventions
STEP 5 – Medications, combine treatments ECT
(electroconvulsive therapy)

MOST COMMONLY PRESCRIBED ANTIDEPRESSANTS

1. Serotonin and nor adrenaline reuptake inhibitors (SNRI’s) –

Raise level of serotonin and norepinephrine in the brain to
stabilize mood

Examples: Duloxitine, venlafaxine, desvenlafaxine

Sombilla & Soliven