Download No Slide Title

Disability of depressed workers –
how to recognize, treat and prevent depression
in OHS
Teija Honkonen
MD, Psychiatrist, FIOH
14.1.2004
The term 'Depression' may refer to
• Affect
• Symptom
• Syndrome (disorder)
Essential in the recognition of depressive
disorders in OHS
• Syndromatic approach
• Longitudinal information and follow-up
• Differential diagnostic reassessments
• Assessment of co-morbidity
Depressive disorders / syndromes
• Major depression
– unipolar depression
– bipolar disorder
• Dysthymic disorder
• Recurrent non-major depressive syndromes
– seasonal affective disorder
– premenstrual dysphoric disorder
• Cyclothymic disorder
• Adjustment disorder with depressed mood
• Organic mood disorders
Diagnostic criteria for Major Depressive
Disorder (ICD 10: F32-33)
• The following symptoms have been present during
the same 2-week period:
• A) at least two of the following
– depressed mood most of the day, nearly every day
– markedly diminished interest or pleasure in almost all
activities
– fatigue or loss of energy nearly every day
Diagnostic criteria for Major Depressive
Episode (ICD 10: F32-33)
• B) in addition, some of the following symptoms
(altogether at least 4/10 symptoms)
– feelings of worthlessness or diminished self-esteem
– feelings of excessive or inappropriate guilt
– diminished ability to think or concentrate, or
indeciveness
– recurrent thought of death or suicidal ideation
– insomnia or hypersomnia
– decrease/increase in appetite
– psychomotor agitation or retardation
Severity of depression
• Mild depression: at least 4 symptoms
• Moderate depression: at least 6 symptoms
• Severe depression: at least 8 symptoms
• Psychotic depression
• Diminished functional capacity correlates usually with the
severity of depression
Psychotic major depression
(ICD 10- F32-33.3)
• About 10-15% of depressive episodes are psychotic
• Often boundary between non-psychotic and psychotic
depression is not clear
• Symptoms:
– delusions (including deep hopelessness)
– hallucinations
– often major changes in psychomotoric functioning
Diagnostic Criteria for Dysthymic
Disorder (ICD 10: F34.1)
• Depressive or irritabile mood for at least 2 years
• In addition, at least 3/11 of the following symptoms
– diminished energy, insomnia, diminished self-esteem,
poor concentration, tearfulness, diminished interest on
pleasure, hopelessness, feelings of incapacity,
pessimism, social withdrawal or diminished
talkativeness
Diagnostic criteria for Adjustment
Disorder with depressed mood
(ICD-10: F43.2)
• Symptoms in response to an identifiable stressor occurring
within a month of the onset of the stressor
• The disturbance does not meet the criteria for another
specific mental disorder
• Once the stressor has terminated, the symptoms do not
persist for more than an additional 6 months
Important symptoms associated with
depressive disorders
• Anxiety
• Physical symptoms
• Fear of illness, hypochondriasis
Co-morbidity
• Psychiatric co-morbidity
– concurrent mental disorders / syndromes
• Somatopsychiatric co-morbidity
– concurrent mental disorder and somatic illness
Co-morbidity of depression
• Psychiatric co-morbidity
– anxiety disorders 40-60%
– personality disorders 40-50%
– substance abuse 20-40%
• Somatopsychiatric co-morbidity
– among elderly patients up to 90%
Depression and functional disability
• WHO's Global Burden of Disease study:
– Unipolar major depression is the fourth most important
illness in terms of functional disability
– The role of depression is expected to become even
more important by the year 2020
Murray & Lopez 1997
Quality of life and functioning of
depressed primary care patients
• Primary care patients with depressive conditions have
poorer mental, role-emotional, and social functioning than
patients with common chronic medical conditions
• Depressed patients have worse physical functioning than
patients with asthma, hypertension, gastrointestinal tract
problems, or migraines
Wells et al. 1999
Disability pensions due to depression
in Finland
• In Finland, about 40 % of the disability pensions
are granted due to mental disorders
• Depression is now among the most common
causes of disability pensions
Causes of increase in disability pensions
due to depression
• Changes in illness behaviour in population ?
• Increase in incidence of depression ?
• Changes in diagnostics ?
• Changes in treatment methods ?
• Increased demands of work ?
Health 2000 Survey:
The prevalence of major depression
• In Finland, within the last 12 months
– a diagnosis of major depressive disorder was
found among 4.9 % of the subjects
– major depression was more common among
females than males
• The prevalence of depression has not increased
during the last 20 years
Pirkola et al. 2002
Depression and cognitive symptoms
• Depression causes
– diminished ability to think or concentrate
– diminished ability to learn or remember
– decreased motivation to undertake new tasks
– difficulty in finishing tasks
– reduced energy
– indecisiveness
– slowness of psychomotor performances
Need for sick-leave in depression
• Individual case-specific assessment
• Even in case of a severely depressed patient work
may have positive impact in preventing patient
from social withdrawal
Early recognition and treatment of
depression is important, because
• 75-80% (90%) of depressed patients will benefit
from adequate treatment
• Effective and early treatment may prevent
unnecessary suffering, disability and suicides
Treatment of depression includes
• Comprehensive evaluation of the patient
– diagnosis
– comorbidity
– suicidality
– psychosocial functioning
– current life events
– social support
– socio-economic situation
• Well-planned treatment
• Prevention of the recurrences
Why is it not always easy to diagnose
depression ?
• Patient
– may not talk about it, because he/she is not able
to recognize his/her own state of mood
– may be unwilling to discuss it due to fear of
potential negative consequences
Why is it not always easy to diagnose
depression ?
• Physician
– is not able to recognize depression
– is able to recognize it but he/ she has not
enough time for that
– does not want to recognize it because he/ she
thinks it is untreatable
Methods of measuring depression
• Semi-structured interviews
– Schedules for Clinical Assessment in Neuropsychiatry
(SCAN)
• Fully structured interviews
– Composite International Diagnostic Interview (CIDI)
• Rating scales
– Hamilton Rating Scales for Depression (HAMD)
– Montgomery-Åsberg Depression Rating Scale
(MADRS)
• Self-administered questionnares
– Beck Depression Inventory (BDI)
Main treatment methods of depression
in OHS
• Psychotherapy
– mild – moderate depression
• Antidepressant medication
– moderate – severe depression
• Psychotherapy and medication have a synergistic effect
Other treatment options of depression
• Bright light treatment
– effective in treatment and prevention of seasonal affective disorder
• Physical exercise
– effective as additional treatment of mild-moderate depression
• Sleep deprivation
– duration of efficiency unknown; not widely used in Finland
• Electroconvulsive treatment (ECT)
– most effective treatment for severe depression
• Transcranial magnetic stimulation (TMS)
– promising future treatment, efficiency not yet known
Selective serotonin reuptake inhibitors
(SSRIs)
• 70-80% of patients respond to treatment if indication of
medication is correct
• SSRIs are usually safe in overdose and in terms of
interaction
• As a side-effect, in the beginning of treatment SSRIs may
cause nausea and sometimes increased anxiety; about 30%
may also suffer from sexual dysfunction
Antidepressant medication
• Medication without any psychotherapeutic physicianpatient relationship is not adeqaute treatment
• Not prescriping antidepressant medication may also be
inadequate treatment
• All patients do not benefit from medication
• Antidepressant medication does not cause addiction
Common problems with medication
in OHS
• Lack of systematic follow-up of treatment response and
side-effects
– problems with compliance
– no optimal treatment
• Acceptance of partial remission leading into
– recurrent depressions
– difficulties in decreasing disability
• Continuation of inefficient medication
• Lack of sequential medication trials
Depression and disability
• The severity of depression is the most important
factor affecting the disability
• Symptoms of depression improve more rapidly
than functional disability caused by depression
Psychosocial disability during long-term
course of MDD
• Psychosocial functioning during an average of 10 years’
follow-up of 371 patients with MDD was assessed
• Disability is pervasive and chronic but disappears when
patients become asymptomatic
• As long as any level of depressive symptoms and disability
are present effective and continued treatment is necessary
• Treatment to full recovery should be the goal
Judd et al. 2000
Risk for recurrency of depression
• After one episode 50%
• After two episodes 70%
• After three episodes > 90%
• Long-term prophylactic treatment with antidepressant
medication
Psychotherapy in depression
• Supportive treatment
– listening, understanding, offering practical advice and
help, psychoeducation, maintaining hope
• Specific short psychotherapies
– cognitive
– interpersonal (IPT)
– problem focused
– psychodynamic
Interpersonal psychotherapy, IPT
• Time-limited
– 12-16 sessions
– three phases
• Manualized
• Active
• Demonstrated efficacy
Markowitz 2000
Characteristics of IPT
• 'Here and now' focus
• Non-neutral, active therapist
• Affective engagement on one of 4 problem areas:
– grief
– role dispute
– role transition
– interpersonal deficits
• Exploration of options
• Socialization and activity
Markowitz 2000
Initial sessions (1-3)
•
•
•
•
•
•
•
Diagnosing the depression
Eliciting the interpersonal inventory
Establishing the interpersonal problem area
Giving the patient the 'sick role’
Making the interpersonal formulation
Beginning psychoeducation
Instilling hope
Markowitz 2000
Middle sessions (4-12)
• Focus on one or more of the four problem areas
– grief (complicated bereavement)
– role dispute
– role transition
– interpersonal deficits
Markowitz 2000
Termination sessions (13-16)
•
•
•
•
•
Assessment of gains
Prevention of relapse
Graduation
Addressing non-response
Continuation / booster sessions ?
Markowitz 2000
Training primary-care physicians to
recognize and manage depression
• In Netherlands, a 20- hour training programme was
developed, that sought to improve primary care physicians'
ability to detect and manage depression
• 17 physicians participated in the study
• Training physicians can improve short-term patient
outcomes, especially for patients with a recent onset of
depression
Tiemens et al. 1999
Impact of improved depression treatment
in primary care on daily functioning
• MDD- patients were randomly assigned to usual care or to
a collaborative management programme
• More effective acute-phase depression treatment reduced
somatic distress and improved self-rated overall health at 4
and 7 month
• There was no significant intervention effect on other
disability measures
Simon et al 1998
Factors predicting chronic outcome of
depression
• Duration of depressive episode before beginning of
treatment
• Severity of depression
• Some personality traits
• Poor social support
• Negative life events during depression
• Co-morbidity (substance abuse, somatic illness)
• Inadequate treatment
Inadequate treatment and disability
pension
• In Finland, patients who were pensioned during
1993-1994 due to depression:
• 87% had used antidepressants
– 2/3 had received antidepressants at adequate dose
– about 60% had received only one antidepressant before
disability pension was granted
• Weekly psychotherapy was rare (9%)
• Electro-convulsive therapy was rare (4%)
Isometsä et al 2001
Primary prevention of depression?
• Crisis interventions
• Prevention of burnout
• Physical exercise
• Social support
• Preventive treatment of seasonal affective disorder
Secondary and tertiary prevention of
depression
• Sofar, the majority of subjects with major depression suffer
from a chronic illness with either fluctuating or chronic
course
• Early recognition and early, active treatment would
constitute the best secondary and tertiary prevention of
depression