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Gangguan Afektif Depresi

dr. Rina Amtarina, MSc, SpKJ


SMF Psikiatri FKUR/RSJ Tampan
• Gangguan Depresi
• Gangguan Distimik
• Post Partum Depression
Kriteria Diagnosis berdasarkan
DSM IV - TR
• Episode Mania
• Episode Hipomania
• Episode Depresi
• Episode Campuran

• Gangguan Depresi mayor episode tunggal


• Gangguan Depresi Mayor berulang
• Gangguan distimik
• Gangguan Bipolar I episode manik tunggal
• Gangguan Bipolar I episode paling akhir hipomanik
• Gangguan Bipolar I episode paling akhir manik
• Gangguan Bipolar I episode paling akhir campuran
• Gangguan Bipolar episode I paling akhir depresi
• Gangguan Bipolar I episode paling akhir tidak ditentukan
• Gangguan Bipolar II
• Gangguan siklotimik
Gangguan Depresi
Etiology
Biological theory
CRF System-HPA Axis and Depression
• hypersecretion of hypothalamic CRF increased
baseline cortisol levels (hypercortisolemia)  alterations
in the glucocorticoid receptors, which become less
functional, or downregulated, or "glucocorticoid
resistant," in some depressed patients.

HPT Axis and Depression


• This hypersecretion of TRH may lead to downregulation of TRH
receptors on thyrotropic cells of the anterior pituitary, which
accounts for the widely documented blunted TSH response to
exogenous TRH. However, this blunted TSH response is somewhat
diagnostically nonspecific because it is often observed in manic and
alcoholic patients as well. [24]
Growth Hormone and Depression
• Depressed patients demonstrate a blunting of the
diurnal rhythm of GH secretion, especially the
nighttime peak. This blunting may be due to the
interrupted sleep that accompanies depression.
Norepinephrine and serotonin roles
Stress-diathesis
model

Sumber : Update on Neurobiological of Depression, NEUROBIOLOGICAL ALTERATIONS THAT RESULT FROM EARLY LIFE TRAUMA
http://www.medscape.org/viewarticle/412866_3
Etiology
Familiality
• Family data indicate that if one parent has a mood disorder, a
child will have a risk of between 10 and 25 percent for mood
disorder.
• If both parents are affected, this risk roughly doubles.
• The more members of the family who are affected, the
greater the risk is to a child.
• The risk is greater if the affected family members are first-
degree relatives rather than more distant relatives.
Etiology
Personality Factors

• No single personality trait or type uniquely predisposes a


person to depression;
• Persons with certain personality disorders : OCD, histrionic,
and borderline may be at greater risk for depression than
persons with antisocial or paranoid personality disorder
• Recent stressful events are the most powerful predictors of
the onset of a depressive episode.
• Stressors that the patient experiences as reflecting
negatively on his or her self-esteem are more likely to
produce depression.
Etiology
Life Events
• crucial life events, particularly the death or loss of
a loved one, can precede the onset of depression
• However, such losses precede only a small
(though substantial) number of cases of
depression.
• Fewer than 20% of individuals experiencing losses
become clinically depressed.
• These observations argue strongly for a
predisposing factor, possibly genetic,
psychosocial, or characterological in nature.
Etiology
Learned Helplessness
• a behaviour in which an organism forced to endure aversive,
painful or otherwise unpleasant stimuli, becomes unable or
unwilling to avoid subsequent encounters with those stimuli,
even if they are escapable.
• Connects depressive phenomena to the experience of
uncontrollable events.
• In the reformulated view of learned helplessness as applied to
human depression, internal causal explanations are thought
to produce a loss of self-esteem after adverse external events.
Major Depressive Disorder
• Without a history of manic, mixed or
hypomanic episode
• Must at least 2 weeks
• Trias depresi: mood depresif, hilang minat dan
kegembiraan, berkurangnya energi (mudah
lelah)
Pedoman diagnosis depresi berat pada PPDGJ III
Pedoman Diagnosis Depresi Berat pada PPDGJ-III
F32.3 Episode depresif berat dengan gejala psikotik
Pedoman diagnostik :

• Episode depresi berat yang memenuhi kriteria menurut F32.2


• Disertai waham, halusinasi atau stupor depresif. Waham melibatkan
ide tentang dosa, kemiskinan atau malapetaka yang mengancam
dan pasien merasa bertanggung jawab atas hal itu. Halusinasi
auditorik atau olfaktorik biasanya berupa suara yang menghina atau
menuduh atau bau kotoran atau bau daging membusuk. Retardasi
psikomotor yang berat dapat menuju pada stupor
• Jika diperlukan, waham atau halusinasi dapat ditentukan sebagai
serasi atau tidak serasi dengan afek (mood congruent)
Diagnosis Banding
Gangguan medis
• Gangguan fungsi tiroid dan adrenal
• obat-obatan :
Pharmacological Causes of Depression

1.Cardiac and antihypertensive drugs


2.Sedatives and hypnotics
3.Steroids and hormones
4.Stimulants and appetite suppressants
5.Psychotropic drugs
6.Neurological agents
7.Analgesics and anti-inflammatory drugs
8.Antibacterial and antifungal drugs
9.Antineoplastic drugs
10.Nonsteroidal anti-inflammatory drugs (NSAIDs)
11.Anticholinesterases
Kondisi neurologis
• Penyakit Parkinson
• Penyakit yang menimbulkan demensia (termasuk demensia
Alzheimer)
• Epilepsi
• Penyakit serebrovaskuler,
• Tumor

Uncomplicated bereavement (berkabung)


• Gejala berkabung setelah kehilangan orang yang dicintai. Depressed
mood, insomnia, kehilangan nafsu makan, penurunan berat badan,
guilty and hopelessness
• Biasanya teratasi dalam satu tahun
Treatment and Management
Three phases :
• Acute -> aim: full symptom remission and
restoration full function
• Continuation -> mempertahankan remisi dan
mencegah kembalinya episode
• Maintenance -> mencegah rekurensi
Type of treatment :
• Pharmacologic
• Psychotherapy
• ECT
• combination
Pharmacologic treatments
• Monoamine Oxidase Inhibitors
• Tricyclics (NE & 5-HT) : amitriptyline, imipramine
• SSRIs : fluoxetine, sertraline, paroxetine
• NE reuptake inhibitors: despiramine, maprotiline
• Dopamine reuptake inhibitor : bupropion
• Heterocyclic : trazodone
Disthymic disorder

(Persistent Depressive Disorder)


Distimia
USIA GANGGUAN SUBAFEKTIF
• ”Merasa depresi sejak lahir” • ringan dan kronis berlangsung
• Dimulai dari anak atau remaja: selama 2 tahun
gejala iritabel • kejadiannya menetap atau
hilang timbul

PREVALENSI
• Distimia = 5-6%
• Belum menikah, pendapatan rendah
• Bersamaan dgn gangguan lain seperti : depresi berat, anxietas,
substance abuse, ggn kepribadian ambang
• Riwayat keluarga dengan gangguan depresi berat (+)
• Riwayat pemakaian obat psikiatri: antidepressants, antimanik,
hipnotik sedatif
Etiologi
1. Faktor biologi
• Gejala gangguan distimik ~ gangguan depresi
berat
• Dasar psikopatologi berbeda.
• Neurotransmiter: serotonin dan noradrenergik
Etiologi
2. Faktor psikososial
gangguan ini berasal dari perkembangan ego dan
kepribadian dan berpuncak pada kesulitan dalam
beradaptasi pada masa remaja dan dewasa.

Freud “Mourning and Melancholia“


kekecewaan interpersonal di awal kehidupan →
rentan depresi → ambivalensi hubungan cinta →
kehilangan atau ancaman akan kehilangan pada
kehidupan dewasa → depresi.
Teori Kognitif: berpegang pada perbedaan
kenyataan dan khayalan → berkurangnya
harga diri dan rasa tidak berdaya.
A. Depressed mood for most of the day, for more days than not, as indicated by either subjective
account or observation by others, for at least 2 years. Note: In children and adolescents, mood
can be irritable and duration must be at least 1 year.
B. Presence, while depressed, of two (or more) of the following:
1. Poor appetite or overeating.
2. Insomnia or hypersomnia.
3. Low energy or fatigue.
4. Low self-esteem.
5. Poor concentration or difficulty making decisions.
6. Feelings of hopelessness.
C. During the 2-year period (1 year for children or adolescents) of the disturbance, the individual
has never been without the symptoms in Criteria A and B for more than 2 months at a time.
D. Criteria for a major depressive disorder may be continuously present for 2 years.
E. There has never been a manic episode or a hypomanie episode, and criteria have never been met
for cyclothymic disorder.
F. The disturbance is not better explained by a persistent schizoaffective disorder, schizophrenia,
delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic
disorder.
G. The symptoms are not attributable to the physiological effects of a substance (e.g., a drug of
abuse, a medication) or another medical condition (e.g. hypothyroidism).
H. The symptoms cause clinically significant distress or impairment in social, occupational, or other
important areas of functioning.
Terapi
• Psikoterapi:
– Cognitive therapy: mengubah cara pikir pasien yang negatif
– Behaviour therapy: fokus untuk meningkatkan aktivitas dan
memberikan kondisi yang nyaman
– Individual insight oriented therapy: menyelesaikan konflik di masa lalu
– Interpersonal therapy: cara coping dengan stres, mengurangi depresi,
dan meningkatkan kepercayaan diri
– Terapi keluarga dan kelompok
• Farmakoterapi:
– SSRI
– MAOI:
• Phenelzine - sudah ditarik karena menyebabkan krisis serotonin akibat
menghambat monoamin secara permanen
• moclobemide: Reversible Monoamine oxidase inhibitor, sehingga monoamine
masih bisa bekerja
Rawat inap
• Gejala berat
• Gangguan sosial atau profesi yang berat
• Butuh prosedur diagnosis
• Ide bunuh diri
• Baby Blues
• Post Partum Depression
• Post partum Psychosis
Baby Blues
• Gejala afektif/transient mood disturbance 4-6
minggu setelah melahirkan
• Mood labil, kesedihan, disforia, confusion,
tearfulness.
• Dapat berlangsung beberapa hari
• Bergantung pada hormonal, stres setelah
melahirkan, adanya beban tanggung jawab sebagai
ibu.
• Tidak dibutuhkan pengobatan khusus
• Terapi: edukasi dan dukungan terhadap ibu
Post Partum Depression
• Gejala baby blues lebih dari dua minggu
• Depressed mood, kecemasan menetap,
insomnia, perubahan berat badan.
• Terjadi dalam 12 minggu pasca melahirkan
• Meningkatkan risiko depresi mayor.
Post Partum Psychosis
• Puerperal psychosis
• Depresi, delusi/waham, pikiran menyakiti diri sendiri
atau bayinya
• Ide bunuh diri atau infanticide
• Terjadi pada wanita dengan riwayat keluarga
gangguan mood
• Terjadi pada wanita dengan riwayat gangguan mood
sebelumnya
• Penyebab: hormonal atau juga proses melahirkan
tersebut.
Post Partum Psychosis
• Dapat terjadi dalam bebrapa hari setelah melahirkan,
rata-rata dalam 2-3 minggu dan terkadang dalam 8
minggu pasca melahirkan
• Gejala awal: fatigue, insomnia, restlessness, dan ada
episode tearfullness dan emotional lability.
• Gejala lanjut: kecurigaan, kebingungan, inkoheren,
irrational statements, obsessive concern about the
baby’s health. Ada waham terkait ide bahwa bayi
sudah meninggal atau defective, menyangkal
kelahiran dengan mengekspresikan pikiran belum
menikah.
Post Partum Psychosis
• Halusinasi auditorik  membunuh bayi atau diri
sendiri.
• Terapi : antipsikotik, mood stabilizer, anti depresan