Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Depressive Disorder Illness that involves the body, mood and thought Can affect eating, sleeping, thoughts about self and thoughts about other things Without treatment, symptoms can last for weeks, months, or years 3 most common types Major depression Dysthymia Bipolar disorder ? inheritance Epidemiology 4th leading cause of worldwide disese in 1990, causing more disability than either ischemic heart disease or cerebrovascular disease Prevalence of Major Depressive Disorder (MDD) in Western industrialized nations is 2.3-3.2 % males 4.5-9.3 % females Lifetime risk 7-12 % males 20-25 % females Major Depression US Impact on Economy Lost productivity cost employers > $ 31 billion Most loss due to reduced performance while at work Risk Factors Increased risk female, native american, middle-aged, widowed, separated or divorced, low income Decreased risk asian, hispanic or black Other Risk Factors History of depressive illness in first degree relatives Prior episodes of major depression Significant association with other specific psychiatric d/o such as: substance dependence, panic and generalized anxiety d/o and personality d/o Precipitants Psychosocial stressors Adverse living conditions, war, environmental changes Bereavement Loss of a loved one Loss Housing, relationships, health Meds/Supplements Corticosteroids Many patients experience a sense of wellbeing Larger doses can cause hypomanic and/or depressive symptoms Omega 3 fatty acids Low levels correlate with depressive symptoms Medical Conditions Associated with Depression Hypothyroidism Fibromyalgia Systemic lupus erythematosus Diabetes mellitus Cardiovascular disease Chronic pain Others Hypercalcemia, sjogren’s syndrome, seizure d/o Depression vs Other Medical Conditions Ask closed-ended questions about the nine diagnostic criteria for depression Ask about alcohol and substance abuse and the use of other medications Conduct a medical review of systems that may elicit the presence of medical disorders (TSH, electrolytes, folate, vitamin B12, ECG) Ask about other psychiatric conditions such as anxiety disorder Exclude alternative causes for depressive symptoms or syndromes to diagnose a primary mood disorder Primary Care Setting 10-40% of patients have significant depressive symptoms 5-10 % of patients meet criteria for DSM-IV MDD 10% of patients meet criteria for minor depression 3-5 % of patients meet criteria for dysthymic disorder Approximately 50% of depressed patients present with somatic complaints Male vs Female Men Less likely to admit depressive symptoms Practitioners less likely to suspect Rate of suicide four times that of women Depression often masked by alcohol, drugs, long work hours Symptoms more likely to involve irritability, anger, discouragement women More attempts at suicide Symptoms more likely to involve hopelessness, helplessness Screening The U.S. Preventive Services Task Force (USPSTF) recommends screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow up Clinical Considerations Screening tools Zung self assessment depression scale, Beck depression inventory, General Health Questionnaire Or 2 simple questions over the past two weeks have you felt down, depressed or hopeless? over the past two weeks have you felt little pleasure and interest in doing things? PHQ-9 Questionnaire DSM-IV Criteria (SIG E CAPS) Major depression-5 or more symptoms present during same 2 week period Depressed mood most of the day Diminished interest and pleasure in all or almost all activities Decrease or increase in weight and/or appetite Diminished ability to think, indecisiveness Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy nearly daily Feelings of worthlessness or excessive or inappropriate guilt Recurrent thoughts of death (not just fear of dying),recurrent suicidal ideation without specific plan Dysthymic Disorder-Criteria Depressed modd for most of the day, for more days than not, for at least 2 years Presence, while depressed, of two (or more) Poor appetite or overeating Insomnia or hypersomnia Low energy or fatigue Low self-esteem Poor concentration or indecisiveness Feelings of hopelessness During 2 year period, never been without the first two criteria for more than 2 months at a time Assessing Suicidal Risk Suicide is 11th leading cause of death in US (2000) Depression is one of most common psychiatric disorders associated with suicide Evaluation of patient includes assessment of ideation, plan and intent Risk of suicide imminent in those who have an active plan or intent to harm themselves and have a lethal means that is readily assessable Discussing Diagnosis Depression is common Depression increases perception and impact of physical symptoms such as fatigue, headache, and abdominal pain Depression is a physical illness, which is associated with biologic changes in the brain (depletion of catecholamines) Treatment of depression with medication and/or psychotherapy can shorten duration Pharmacotherapy vs Psychotherapy Drug tx alone for severely depressed Either drug tx or psychotherapy equally effective for moderate to mild depression New public health model of telephone psycotherapy and care management + drug tx Antidepressants Meta-analysis of 28 randomized, controlled trials involving 5940 patients with major depression, dysthymic, or mixed anxiety depression, newer antidepressants were significantly more effective than placebo but similar to TC Bush using drugs to control depression and erratic behavior Classes of Antidepressants MAO inhibitors Tranylcypromine, phenelzine, selegiline Heterocyclics/TC Desipramine, nortriptyline, imipramine, amitriptylint SSRIs Fluoxetine, sertraline, paroxetine, citalopram, escitalopram Others Bupropion, venlafaxine, duloxetine, trazodone, mirtazapine Mechanisms of Action MAO inhibitors Irreversibly blocking monoamine oxidase responsible for the oxidative deamination of serotonin, norepinephrine and dopamine Heterocyclics/TCs Increase concentration of serotonin and/or norepinephrine by inhibiting reuptake SSRIs Increase concentration of serotonin Others Buproprion enhances dopamine levels especially in ‘reward’ area of the brain Venlafaxine increases serotonin levels, inhibits norepinephrine reuptake Considerations Prior success of an antidepressant A positive response to a particular antidepressant by a first degree relative Practitioner drug familiarity and drug side effects Major Side Effects MAO inhibitors Can cause increased sympathic activity and severe hypertension with concomitant ingestion of tyramine containing foods Fermented cheeses, imported beer, Chianti, soy sauce, avocados, TCs bananas Anticholinergic effects such as: dry mouth, blurred vision, constipation, urinary retention Similar to Class 1A antiarrhythmics, which can prolong QT interval and increase risk of sudden cardiac death Weight gain SSRIs Jitteriness, restlessness, agitation, headache, diarrhea, nausea, insomnia, sexual dysfunction, weight gain Others Mirtazapine: sedation, weight gain Bupropion: fewer adverse effects related to sexual dysfunction and weight Timing of Response and Follow-up Initial response usually within 2-6 weeks Treatment time to maximal response may be longer If no response by 8-12 weeks at a maximum therapeutic dose, consider another antidepressant from same or different class or refer Follow-up at least q 1-2 weeks during initial phase Duration of Treatment 6-9 months after first episode If there is an unresolved known precipitant such as: psychosocial stress, bereavement, or loss consider further treatment When tx discontinued, taper over 2-4 weeks AHCPR Guideline Panel recommendation of maintenance therapy for patients with 3 or more depressive episodes 2 previous episodes plus risk factors Double depression (dysthymia and major depression) Response to Medication 50% of patients respond to the first choice 20% stop due to side effects 30% have no response Hypericum Perforatum St John’s Wort European studies suggest more effective than placebo and equal to TC and SSRIs in shortterm tx US studies do not support efficacy in tx of severe depression Consider for mild acute depression Avoid concomitnt use with SSRI Resources National Library of Medicine American Psychiatric Association American Psychological Association Depression and Bipolar Support Alliance (DBSA) National Foundation For Depressive Illness National Alliance for the Mentally Ill (www.nlm.nih.gov/medlineplus/healthtopics.html) National Institute of Mental Health (www.nimh.nih.gov) (www.psych.org) (www.apa.org) American Academy of Child and Adolescent Psychiatry Depression and Related Affective Disorders Association National Mental Health Association (www.aacap.org) (www.drada.org) (www.DBSAlliance.org) (www.depression.org) (www.nmha.org) (www.nami.org) THANK-YOU FOR YOUR ATTENTION!