Download Major Depressive Disorder Recognition and Management

Major Depressive Disorder:
Recognition and Management
in Primary Care
Dr. Levkovitz Y.
Director Day-Hospital & Cognitive and Emotional
Laboratory,
Shalvata Mental Health Center,
School of Medicine, Tel Aviv University, Israel.
Objectives


To be more knowledgeable about
recognizing and treating depression
To increase comfort in managing
depression in primary care
Causes of Disability by Illness Category
United States and Canada
15-44 years old
Mental Illness*
Alcohol and drug use
Injuries, including self-inflicted
Respiratory disease
Musculoskeletal disease
Sense organ disease
Cardiovascular disease
Migraine
Infectious disease, excluding HIV
0
5
WHO World Health Report 2002
10
15
20
25
30
35
40
Causes of Disability by Specific Illness
United States and Canada
15-44 years old
Unipolar depression
Alcohol use
Drug use
Bipolar disorder
Schizophrenia
Hearing loss
Migraine
Iron deficient anemia
Diabetes mellitus
0
5
WHO World Health Report 2002
10
15
20
25
30
Epidemiology
 Major
Depressive Disorder (MDD) is
the one of the most common mental
disorders in primary care settings
 The
prevalence of current MDD in
primary care settings has been found to
range from 9.2% to 13.5%
 MDD
may occur at any age
Natural History of Major Depression
Recurrent, episodic disorder in > 50%
 Residual symptoms persist between
episodes in 20-35% (partial remission)
 Systemic disorder .
 Most serious complication is suicide;
others include marital, parental, social,
and vocational difficulties.

‫מקרה מספר ‪1‬‬
‫מורן בת ‪ , 30‬נשואה ואם לבת (בת ‪. )5‬‬
‫הגיע לרופא המשפחה ומתארת עייפות רבה בחודשיים‬
‫האחרונים‪ .‬מורן עובדת כמזכירה ומתארת כי היא מבצעת‬
‫שגיאות רבות בעבודתה‪ .‬המעסיק שלה מעיר לה לאחרונה‬
‫על שגיאותיה‪ .‬מרגישה כי לאחרונה קשה לה יותר‬
‫להתרכז‪ .‬מדווחת על מריבות ומחלוקות בזמן האחרון עם‬
‫בעלה בשל לחץ כלכלי בבית‪ .‬כשמתעוררת בבוקר מרגישה‬
‫עייפה ו "לחוצה מהמחשבה שהיא צריכה ללכת לעבודה"‪.‬‬
‫דיווח על התקפי פלפיטציות וכאבים בחזה‪.‬‬
‫פחות מתעניינת בילדים ומרגישה שפחות משקיעה בהם‪.‬‬
‫דיון ( מקרה ‪)1‬‬
‫• איזה שאלות היית רוצה לשאול את מורן?‬
‫מקרה מספר ‪( 1‬המשך)‬
‫לאחר שנשאלה מספרת כי מקיצה משנתה בשלוש לפנות‬
‫בוקר עם מועקה בחזה‪ .‬לא הולכת לשיעורי "פילאטיס"‬
‫והתעמלות במועדון השכונתי‪ .‬מבשלת למשפחתה אך‬
‫קיימת ירידה בתאבון ‪ .‬לא בטוחה אם יש שינוי במשקל‪.‬‬
‫מרגישה בטוחה בנישואיה אבל מרגישה כי בעלה פחות‬
‫מתעניין בה כי היא שווה פחות במיוחד כי יש לה פחות‬
‫עניין בקיום יחסי מין עימו‪ .‬מפחדת כי בעלה יעזוב אותה‪.‬‬
‫מרגישה אשמה ביחס לילדיה ולבעלה‪ .‬מרגישה כי צריכה‬
‫להיענש והתאבדות תפתור את בעיותיה‪ .‬משתמשת יותר‬
‫ביין אדום כדי שתוכל לישון‪.‬‬
‫דיון ( מקרה ‪)1‬‬
‫•האם אתה צריך לראות את בעלה?‬
‫•מה תעשה אם היא מסרבת לדבר עם בעלה‬
‫כי היא מפחדת שידע כי היא חוששת‬
‫לנאמנותו?‬
‫מקרה מספר ‪1‬‬
‫מורן בת ‪ , 30‬נשואה ואם לבת (בת ‪. )5‬‬
‫הגיע לרופא המשפחה ומתארת עייפות רבה (עצב ?)‬
‫בחודשיים האחרונים‪ .‬מורן עובדת כמזכירה ומתארת כי‬
‫היא מבצעת שגיאות רבות בעבודתה‪ .‬המעסיק שלה מעיר‬
‫לה לאחרונה על שגיאותיה‪ .‬מרגישה כי לאחרונה קשה לה‬
‫יותר להתרכז ‪ .‬מדווחת על מריבות ומחלוקות בזמן האחרון‬
‫עם בעלה בשל לחץ כלכלי בבית‪ .‬כשמתעוררת בבוקר‬
‫מרגישה עייפה ו"לחוצה מהמחשבה שהיא צריכה ללכת‬
‫לעבודה"‪ .‬דיווח על התקפי פלפיטציות וכאבים בחזה‪.‬‬
‫פחות מתעניינת בילדים ומרגישה פחות משקיעה בהם‪.‬‬
‫מקרה מספר ‪( 1‬המשך)‬
‫לאחר שנשאלה מספרת כי מקיצה בשנתה בשלוש לפנות‬
‫בוקר עם מועקה בחזה‪ .‬לא הולכת לשיעורי "פילאטיס"‬
‫והתעמלות במועדון השכונתי‪ .‬מבשלת למשפחתה אך‬
‫קימת ירידה בתאבון ‪ .‬לא בטוחה אם יש שינוי במשקל‪.‬‬
‫מרגישה בטוחה בנישואיה אבל מרגישה כי בעלה פחות‬
‫מתעניין בה כי היא שווה פחות במיוחד כי יש לה פחות‬
‫עניין בקיום יחסי מין עימו‪ .‬מפחדת כי בעלה יעזוב אותה‪.‬‬
‫מרגישה אשמה ביחס לילדיה ולבעלה‪ .‬מרגישה כי צריכה‬
‫להיענש והתאבדות תפתור את בעיותיה‪ .‬משתמשת יותר‬
‫ביין אדום כדי שתוכל לישון‪.‬‬
Recognition

Depression is difficult to diagnosis in
primary care and often goes
undetected:
 depressed mood typically not
presenting complaint
 competing demands (acute and chronic
illnesses)
 limited resources and time
Major Depression: Four Hallmarks
Depressed Mood.
 Anhedonia: loss of interest or pleasure
 Physical Symptoms:
 sleep disturbance, low energy,
appetite or weight change,
psychomotor changes
 Psychological Symptoms:
 low self-esteem, poor concentration,
suicidal ideation/obsession
surrounding death.

Assessing for Depression
and Anhedonia


Do not ask patient: “Are you Depressed?”,
INSTEAD, Ask: “How has your mood
been?”
Ask about Anhedonia: “What are you
doing for fun?” OR: “Does your
(pain,anxiety, grief, whatever symptoms
patient mentions) keep you from doing all
the things you enjoy?”
‫דיון ( מקרה ‪)1‬‬
‫• מה הצעד הבא?‬
‫•האם תרצה לדעת פרטים נוספים על משפחתה‬
‫?‬
‫•האם תרצה לדעת פרטים עליה או על עברה?‬
‫•אילו בדיקות דם תרצה להזמין?‬
Risk Factors
Prior episode of depression
 Family history of depressive disorder
 Prior suicide attempt
 Female gender
 Medical conditions
 Lack of social support
 Stressful life events
 Current substance use

)1 ‫דיון ( מקרה‬
‫אבחנה מבדלת‬
•Substance Induced Disorder ?
•Mood Disorder ?
•Anxiety Disorder ?
•Personality Disorder ?
•Relationship distress, financial
stress related ??
•Medical Conditions ?
•Medications ?
Dependence/Withdrawal
- 9.2% (Warner, 1995)
- 20% (Hall, 1994 )
- anger, irritability, aggression
- aches, pains, chills
- depression
- inability to concentrate
- sleep disturbance
- slight tremors
- decrease in appetite
- sweating
- craving
3 to 7 days, to several weeks after abstinence
(Haney, 1999)
Organic Illnesses Associated with
Depression
 Rheumatologic
- systemic lupus
erythematosus, rheumatoid
arthritis
 Cardiac - mitral valve prolapse.
 Endocrine - hyperthyroidism,
hypothyroidism, diabetes mellitus,
hypercalcemia, Cushing’s syndrome
University
of NSW
Chronic fatigue syndrome
What is chronic fatigue syndrome?
Definition
• Unexplained,
persistent or
relapsing fatigue, that
is:
–
–
–
–
University
of NSW
• Four or more of:
– impaired short term
memory or
concentration
– sore throat
of new, definite onset and – tender lymph nodes
– muscle pain
not due to exertion
– joint pain
not relieved by rest
– headaches
associated with a
– unrefreshing sleep
substantial reduction
in daily activities
– post-exertional malaise
Fukuda K et al. Ann Intern Med 1994; 121: 953-9.
Drugs Commonly Associated with
Depression
•
•
•
•
•
•
Benzodiazepines
Cimetidine
Beta-blockers
Corticosteriods
Oral contraceptives
Indomethacin
University
of NSW
Assessing Risk of Suicide

Assess risk factors:
 PRIOR ATTEMPTS
 Family history of suicide
 Hopelessness
 Demographics
Caucasian, male, elderly, lives alone
 Clinical
Substance abuse, psychosis,
potentially terminal illness
Assessing for Suicide

Use a gradual, sensitive approach to raise
the subject:
 How does the future look to you?
 Living with (pain/anxiety/patients’
symptoms) can be very difficult. Do you
sometimes wish your life was over?
 Have you had thoughts that you would be
better off dead?
 Have you had thoughts of hurting
yourself?
 Have you thought about how you might
hurt yourself?
When to Consider Involving Psychiatry
 Suicidal
ideation
 Psychotic symptoms
 Manic symptoms
 Current substance abuse
 Severe psychosocial problems
Interventions: What can be done?
Depression is one of the most treatable
mental illnesses
• 70% - 75% of all depressed people
respond to treatment
• almost all who receive treatment
experience some relief in symptoms
 Medication
 Psychotherapy
 Electroconvulsive Therapy
 Watchful waiting

Management of Depression





Give an adequate trial of treatment
(therapeutic dose for 6-8 weeks)
Follow closely until patient responds
Change treatment if patient doesn’t respond
Continue medication for 6-9 months
minimum.
If patient has a history of 2 or more
previous depression episodes, continue for 2
years or more.
Overview of Antidepressants




Selective Serotonin Reuptake Inhibitors (SSRIs):
 fluoxetine (Prozac), sertraline (Zoloft),
paroxetine (Paxet), citalopram (Lustral)
Selective Serotonin Norepinepherine Reuptake
Inhibitors (SNRIs):
 venlafaxine (Effexor), Duloxetine (Cymbalta).
Medications With Unique Mechanism of Actions
(MOA):
 bupropion (Wellbutrin), mirtazapine (Remeron),
nefazodone (Serzone)
Older Agents (Tricyclic antidepressants or
TCAs):
 desipramine, nortriptyline
Therapeutic vs. Side Effects
Therapeutic
effects
Effects of
antidepressant
treatment
Side
effects
0
1
2
3
Time in weeks
4
Side Effects
Are relatively common
 Are the #1 reason patients give for stopping
medications
Therefore:
 Talk to patients about common side effects
 Wait - many side effects resolve with time
 Consider reducing the dose temporarily
 Consider changing to another type of
medication
 Consider changing timing of medication

Adjunctive Medications



Anxiety
 Consider short term use of a
benzodiazepine
Insomnia
 Trazodone – warn about priapism
 Antihistamines (hydroxyzine,
diphenhydramine)
Sexual Dysfunction
 sildenafil
‫מקרה מספר ‪1‬‬
‫ליאם‪ ,‬בן ‪ ,24‬סטודנט באוניברסיטת תל אביב‪.‬‬
‫מתואר כ "ביישן ומופנם"‪ .‬יש לו קשיים בחברה‬
‫ואפיזודות של פאניקה באירועים חברתיים‪.‬‬
‫לאחרונה הבחין בעליה בתדירות התקפי החרדה‬
‫באירועים בהם היה צריך להציג מעבודותיו‪.‬‬
‫ב ‪ 4‬חודשים האחרונים מדווח על ישנוניות ועייפות‪.‬‬
‫הוא מאחר לכיתה ונרדם בשיעורים‪ .‬כשהוא נמצא בכיתה‬
‫הוא מרגיש דחף לספור את חבריו לכיתה ‪ 3‬פעמים‬
‫ולאחר לספור את התלמידים הלובשים חולצות‬
‫כחולות‪ .‬הוא מוצא את הספירה "מלחיצה"‪.‬‬
‫הוא מרגיש חייב לספור כל פרק בספר פעמים‪.‬‬
‫דיון ( מקרה ‪)1‬‬
‫• איזה שאלות היית רוצה לשאול את ליאם ?‬
‫מקרה מספר ‪( 1‬המשך)‬
‫ליאם מדלג על ארוחות כי איננו רעב‪ .‬הוא הפסיק לראות‬
‫את תכנית הטלויזיה האהובה עליו ולצאת עם הכלב שלו‪.‬‬
‫הוא מדווח על ירידה משמעותית בריכוז וחווה ירידה‬
‫בזיכרון‪.‬‬
‫מרגיש כי הוא חייב להפסיק ללמוד כי הוא מבזבז את‬
‫כספם של הוריו והוא "כאב ראש" למרצים‪.‬‬
‫הוא משתמש במריחואנה כדי להרגיע את עצמו‬
‫‪ ,‬אבל כעת לא מרגיש כי זה עוזר לו‪.‬‬
‫נמאס לו להמשיך ככה‪.‬‬
)1 ‫דיון ( מקרה‬
‫אבחנה מבדלת‬
•Major Depressive Episode with
some Atipycal features, with
obsessions and compulsions, History
of Social Anxiety Disorder ?
•Why not just SAD?
•Why not Mixed Anxiety and
Depression?
Depression Features Specifiers
Melancolia:
•Either loss of pleasure or lack of reactivity to
usually pleasurable stimuli.
>3 of: prevasive non reactive sadness-melancholic,
depression
worse in the morning, early morning awakening,
marked psychomotor retardation or agitation
significant anorexia or weight loss, excessive or
inappropriate guilt.
Atypical:
•Reactivity of mood to positive events.
•>2 of: significant weight gain or increased appetite,
hypersomnia, “leaden paralysis” or long standing
pattern of interpersonal rejection sensitivity.
Thanks !
Depression in Primary Care

Depression In Western Industrialized Nations
(DSM-IV):
Males: 2-3% of population at any given time, and
5-12% for population in lifetime.
 Females:5-9% of population at any given time,
and 10-25% for population in lifetime.
Percent of mental disorders accounted for by
depression: Males (up to) 15%, Females (up to) 45%
(rough estimate).
In primary care practices 5-9% patients at any
given time have Major Depression (it is estimated
that only one third to one half are recognized by
practitioners).



Consequences of Untreated Depression



Depression is the 2nd leading cause of
disability in industrialized countries
Depression associated with:
 2x increased risk of death overall
 26x increased risk of suicide
Impaired social functioning
Consequences of Untreated Depression
(continued)



Depressed patients visit primary care
provider 3x more than non-depressed
patients
2-5x increase in days absent from work
Cost of depression in US in 1990
estimated to be $44 billion
Making the Diagnosis
 Depression
Disorders
 Major depressive disorder (MDD)
 Minor (subthreshold) depression
 Adjustment disorder with
depressed mood
 Dysthymia
Diagnostic Criteria for
Major Depression (DSM-IV)
Major depression is present when the
patient has had at least 5 of the 9
following symptoms for a minimum of two
weeks. One of the symptoms must be
either:
1.
2.
Depressed mood-- or -Loss of interest or pleasure -- and -
Diagnostic Criteria (continued)
3. Significant change in weight or
appetite
4. Insomnia or hypersomnia
5. Psychomotor agitation or
retardation
6. Fatigue or loss of energy
7. Feelings of worthlessness or guilt
8. Impaired concentration or ability
to
make decisions
9. Thoughts of suicide or self-harm
Diagnostic Criteria (continued)

Symptoms must be accompanied by
functional impairment in one or more of the
following domains:




work/school
doing things at home
relationships with other people
PHQ9 includes 10th question addressing
functional impairment
Depression Coexisting with
Other Behavioral Disorders
Alcohol Dependency
 Anxiety Disorders (panic attacks,
phobias)
 Eating Disorders
 Obsessive Compulsive Disorder
 Somatization Disorders
 Personality Disorders
 Grief and Adjustment Reactions

Minor depression
Patient has 2 to 4 of the 9 symptoms
listed above
 Symptoms present for at least two weeks
 One of the symptoms must be either item
1 (depressed mood) or item 2 (loss of
interest or pleasure)

Selective Serotonin Reuptake Inhibitors
(SSRIs)

fluoxetine (Prozac), sertraline (Zoloft), paroxetine
(Paxil), citalopram (Celexa)
 Side effects:
 Insomnia or sedation, agitation/restlessness, GI
distress, sexual dysfunction, headache
 Absolute contraindication:
 MAOI (not selegiline)
 Relative contraindication:
 Mania history (manic depression)
Dysthymia
Depression present more days than not,
for 2 years or more
 Well period can not last more than 2
months during this time

Depression Coexisting with Other
Medical Disorders







Stroke
Dementia
Diabetes
Coronary Artery Disease
Cancer
Chronic Fatigue Syndrome
Fibromyalgia
Response and Remission defined
Hamilton Depression Rating Scale (HAM-D): 17 Items, Total Score
0 - 52
HAM-D17
Scores
15
7
Depression
(Major Depressive Disorder)
Response
  50% reduction from baseline
HAM-D score
Remission: HAM-D Score  7
References:
1. Frank E. Conceptualization and rationale for consensus definition terms in MDD, Arch Gen Psych. 1991; 48:851-855.
Drug Interactions



Sertraline and citalopram have no
clinically significant drug interactions
through the CYP450 system
Fluoxetine and paroxetine are potent
2D6 inhibitors
Nefazodone is a potent 3A4 inhibitor
Common Barriers to Treatment
Practical Barriers
 Ethnic/Cultural barriers
 Patient doesn’t agree with diagnosis or
plan
 Patient doesn’t understand treatment
plan
 Patient is afraid of becoming addicted
to antidepressants

Common Barriers to Treatment (Continued)
Side effects
 Patient forgets to take medications or
runs out early
 Formulary restrictions
 Friends or family are not supportive
 Treatment is ‘not working’; patient feels
hopeless
 Treatment ‘is working’; patient is better
and wants off

Adherence
20-50% of patients “drop out” in the
first month of treatment
 30-50% of patients don’t have a
complete response to the initial
treatment
 If patient is not better at 8 weeks,
consider changing medication, adding
psychotherapy, or getting a psychiatric
consultation

Improving Medication Adherence

Tell patients:
 Medications take time to work
 Medications are not addictive
 Take medications every day as ordered
 Take medications even if you feel better
 Do not stop medication before first
contacting your physician
 Engage in pleasant activities
 Call your provider if you have questions
What To Do If Patients Don’t Get Better
 Wrong
diagnosis?
 Insufficient dose?
 Insufficient length of treatment?
 Problems with barriers to
adherence?
 Side effects?
 Other complicating factors?
 Wrong treatment?
Continue Medication for 6-9 Months or
More



Medications should be continued for 6-9
months after the patient gets better
People at high risk for relapse (those with at
least two prior episodes of major depression,
dysthymia, or residual depressive symptoms)
should get a full dose of medication for 2
years or more to prevent recurrences
See patients at least every 3 months
What To Do If Patients Relapse
 Assess adherence to medication
regimen
 Examine for new stressors
 Restart treatment at the last
effective dose of antidepressants
or consider an increase in dose if
patient is still taking medication
 Consider adding psychotherapy
 Consider psychiatric consultation
Preparing the Patient for a Mental Health
Referral
Bring up the possibility of a mental
health consultation when first
presenting the diagnosis of depression
to the patient.
 The request for a mental health
consultation is simply a matter of
obtaining another professional opinion.
 Draw the analogy of referrals made to
other medical specialist, like
cardiologists, endocrinologists, etc.

Side Effects of Other Antidepressants




bupropion (Wellbutrin)
 Main contraindication is seizure disorder or
eating disorder
 Also effective for smoking cessation
 Less sexual dysfunction than others
mirtazapine (Remeron)
 Sedation
 Weight gain
venlafaxine (Effexor): Relative contraindication if
HTN is present
nefazodone (Serzone): Carries a black box warning
for liver failure
Antidepressant Dosing

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Once a day dosing:
 Give sedating meds at bedtime
(paroxetine, mirtazapine, nefazodone)
 Activating meds (fluoxetine) in the
morning
Starting dose is lower with the elderly, with
the medically ill, and if there is a comorbid
panic disorder.
Titrate to therapeutic dose as tolerated by
side effects