Download Clinical Slide Set. Depression

In the Clinic
Depression
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (4): ITC4-1.
Which patients are at especially high risk
for depression?
 Risk factors for depression
 Alcohol dependence
 Comorbid chronic medical conditions
 Female sex
 Personal or family history of depression
 Recent childbirth
 Recent stressful events
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (4): ITC4-1.
Should clinicians screen for depression?
 Screen all adults (USPSTF) provided adequate
resources for diagnosis, treatment, and follow-up are
available
 Including pregnant and postpartum women, older adults
 Utility depends on prevalence in population assessed
 Optimum rescreening interval is unknown
 Screen patients with identified risk factors
 Screen patients with unexplained somatic symptoms,
chronic pain, anxiety, substance misuse, or
nonresponse to effective treatments
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (4): ITC4-1.
What methods should clinicians use to
screen for depression?
 2-item patient health questionnaire (PHQ-2)
 “Over the past 2 weeks have you felt down, depressed,
hopeless?”
 “Over the past 2 weeks have you felt little interest or
pleasure in doing things?”
 “Yes” to ≥1 question: more complete assessment needed
 Patient Health Questionnaire (PHQ-9)
 Edinburgh Postnatal Depression Scale
 Hopkins Symptom Checklist-25 (refugees)
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (4): ITC4-1.
CLINICAL BOTTOM LINE: Screening...
 Screening all adults
 First step in systematic evaluation of mood disorders
 PHQ-2 widely used and efficient
 Adults at increased risk
 Postpartum
 Personal or family history of depression
 Comorbid medical illnesses
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (4): ITC4-1.
What are the diagnostic criteria for
depression?
 5 or more DSM-5 symptoms occur in the same 2 weeks
with a change from previous functioning:
 Depressed mood most of the day, nearly every day as selfreported or observed by others
 Diminished interest or pleasure in all or almost all activities
most of the day, nearly every day
 Significant weight loss when not dieting, or weight gain; or
decrease or increase in appetite nearly every day
 Insomnia or hypersomnia nearly every day
 Psychomotor agitation or retardation nearly every day
 Fatigue or loss of energy nearly every day
continued…
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (4): ITC4-1.
 Feelings of worthlessness or excessive or inappropriate
guilt nearly every day
 Diminished ability to think or concentrate nearly every day
 Recurrent thoughts of death, recurrent suicidal ideation
without a specific plan
 Symptoms cause clinically significant distress or
impairment in social, occupational, other areas of
functioning
 Symptoms not attributable to the direct physiologic effects
of a substance or a general medical condition
 Occurrence of the major depressive disorder is not better
explained by schizoaffective disorder, schizophrenia,
schizophreniform disorder, or other specified or
unspecified schizophrenia spectrum and other psychotic
disorders
 There has never been a manic or a hypomanic episode
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (4): ITC4-1.
How can clinicians determine the severity
of depression?
 Clinical interview
 Validated depression screening tool (PHQ-9)
 Assessment of severity guides treatment
 Mild: may not require medication
 Mild-to-moderate: responds equally to medication or
psychotherapy
 Severe: benefits more from medication alone or combined
with psychotherapy
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (4): ITC4-1.
Patient Health Questionnaire-9
Over the last 2 weeks, how often have you been bothered by any of the
following problems? (0 = not at all; 1 = several days; 2 = more than one half the
days; 3 = nearly every day):
1.Little interest or pleasure in doing things
2.Feeling down, depressed, or hopeless
3.Trouble falling or staying asleep or sleeping too much
4.Feeling tired or having little energy
5.Poor appetite or overeating
6.Feeling bad about yourself or that you are a failure or have let yourself or
your family down
7.Trouble concentrating on things, such as reading the newspaper or watching
television
8.Moving or speaking so slowly that others have noticed, or the opposite
9.Thoughts that you would be better off dead or hurting yourself in some way
10.If you have checked off any problems, how difficult have these problems
made it for you to do your work, take care of things at home, or get along with
other people?
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (4): ITC4-1.
How should clinicians assess a depressed
patient's risk for self-harm, including suicide?
 Assess acute risk for suicide at each visit for depression
 Ask about and reduce access to lethal means (firearms)
 Consult psychiatrist for any uncertainty regarding
suicidal risk
 Telephone follow-up by experienced psychiatrist can
reduce suicide risk after a previous attempt
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (4): ITC4-1.
When should clinicians consult a mental
health professional for help diagnosing
depression or a related mood disorder?
 Diagnostic uncertainty
 Psychiatric comorbid conditions
 Significant risk for suicide
 Suboptimal response to treatment
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (4): ITC4-1.
CLINICAL BOTTOM LINE: Diagnosis...
 DSM-5 criteria: standard for diagnosing major depression
 Assess risk for suicide and comorbid mental and physical
illness in each patient
 Consider psychiatric consultation when there is
 Uncertainty about the diagnosis
 Risk for suicide
 Need for hospitalization
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (4): ITC4-1.
How should clinicians decide whether to
recommend psychotherapy, drug therapy,
or both?
 Factors that influence treatment decision
 Patient preference, prior treatment, depression severity
 Psychotherapy barriers (therapist availability, insurance)
 Exclude bipolar spectrum disorder
 Mild-to-moderate major depression
 Benefits equally from psychotherapy or medication
 Exercise may be appropriate; close follow up warranted
 Moderate-to-severe depression
 Use medication, either with or without psychotherapy
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (4): ITC4-1.
What types of behavioral interventions and
psychotherapy are most likely to be
effective for depression?
 Cognitive behavioral therapy
 Identifies and modifies dysfunctional or inaccurate
thoughts and behaviors
 Interpersonal therapy
 Targets conflicts and role transitions
 Patient needs capacity for psychological insight
 Problem-solving therapy
 Practical approaches to coping with everyday problems
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (4): ITC4-1.
How should clinicians select from the
many antidepressant drug therapies?
 Discuss treatment factors with patient
 Tolerability, safety, effectiveness
 Cost, age, family history
 Drug-drug interactions, comorbid medical conditions
 Initiate treatment with SSRI or SNRI
 Mirtazapine and bupropion may also be appropriate choices
 Newer agents may be more costly and lack broad experience
 TCAs and MAOIs may offer similar or greater effectiveness
but with less receptor specificity and more toxicity
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (4): ITC4-1.
How should clinicians monitor response
to drug therapy?
 Treat at least 6 to 9 months with close follow-up
 See patients within 1 to 2 weeks of starting therapy
 Modify treatment at 6 to 8 weeks if response is inadequate
 Monitor especially closely in first few months
 Possible increased suicide risk in children, adolescents,
young adults
 High rate of nonadherence in early months
 Educate patients pre-emptively about potential side effects
 Continue surveillance for recurrence/relapse indefinitely
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (4): ITC4-1.
Follow-up for Depression
 Minor depression
 Watchful waiting, re-evaluate in 4-8 wk
 Mild depression (PHQ-9 score of 10–14)
 Contact by phone or in-person monthly
 Moderate depression (PHQ-9 score of 15–19)
 Contact by phone or in-person every 2–4 wk
 Severe depression (PHQ-9 score of ≥20)
 Contact by phone or in-person every 2–4 wk until PHQ-9
score improves by ≥5 points
 No active treatment, receiving ongoing stable
antidepressants or counseling
 Contact by phone or in-person every 2–3 mo after remission
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (4): ITC4-1.
How long should clinicians treat depressed
patients with drugs? When should they
consider long-term maintenance on drug
therapy?
 First episode
 Treatment may take 1 to several months until remission
 Continue for another 4 to 9 months
 Some clinicians advocate treating at least 1 year
 Multiple episodes of depression
 Even longer duration of therapy may be beneficial
 Older patients (>70 years) who respond to an SSRI
 Consider treating for 2 years to prevent recurrence
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (4): ITC4-1.
When should clinicians consider switching
drugs because of a suboptimum response
to initial drug therapy?
 Partial response
 First maximize dose of initial agent as tolerated
 Switch to another medication or add second drug if needed
 When partial response continues
 Add psychotherapy
 Change antidepressants
 Augment with bupropion, mirtazapine, nontraditional agent
 Combination therapy may offer benefits over
withdrawing 1 drug and starting another
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (4): ITC4-1.
What are the common adverse effects of
antidepressant drugs? How should
clinicians manage these effects?
 SSRIs
 Sexual side effects: pretreatment counseling; switch to/
augment with bupropion, mirtazapine; sildenafil for erectile
dysfunction
 Undesired weight gain: switch to bupropion
 Agitation: switch to another SSRI; consider mixed mania
 Insomnia: add mirtazapine, trazodone, or sedative-hypnotic
 Anxiety: short course of benzodiazepines during initiation
 Elderly: beware hyponatremia, may promote osteoporosis
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (4): ITC4-1.
When should clinicians consult a psychiatrist
for help in managing drug therapy?
 Treatment-resistant depression
 No response to agents familiar to the primary care provider
 Repeated treatment failures
 Side effects difficult to manage
 Electroconvulsive therapy
 Transcranial magnetic stimulation
 Severe symptoms
 Heightened suicide risk
 Comorbid, psychiatric, or substance abuse problems
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (4): ITC4-1.
When should clinicians consider
hospitalizing depressed patients?
 Significant suicidal ideation or intent without safeguards
 Intent to hurt others is expressed
 Unable to care for self
 Close observation needed (assess self-care, adherence)
 Detoxification or substance abuse treatment
 Electroconvulsive therapy initiated
 Dysfunctional family systems worsen depression or
interfere with treatment
 Patient's life is in jeopardy
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (4): ITC4-1.
What should clinicians advise patients
about complementary-alternative
treatments for depression?
 St. John's wort (0.3% hypericin, 300 mg 3x/d)
 Treatment of subsyndromal or mild depression only
 Serious adverse effects are uncommon
 Don’t use with SSRIs to avoid serotonin excess symptoms
 May reduce concentrations of certain medications (digoxin,
theophylline, simvastatin, and warfarin; protease inhibitors
and nonnucleoside reverse transcriptase inhibitors)
 Severe drug interactions reported with ARVs
 At high dose, may harm sperm cells, reduce fertility
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (4): ITC4-1.
If a patient relapses after cessation of
depression treatment, should clinicians
resume previously effective therapy or
select a new therapy?
 Use antidepressant that previously led to remission
 Initiate long-term maintenance therapy
 Lifetime therapy may be required
 ≥3 episodes
 First recurrence and risk factors for more recurrences
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (4): ITC4-1.
How should clinicians advise women
receiving drug therapy for depression who
are or who wish to become pregnant?
 SSRIs
 Unclear if cause of persistent pulmonary hypertension
 Class C teratogens (except paroxetine is class D)
 Possible association between cardiac defects and
paroxetine use in early pregnancy
 Tricyclic antidepressants
 Neonatal withdrawal syndrome may occur if not tapered
 Desipramine or nortriptyline cause fewer side effects
 Stopping antidepressants carries relapse risk
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (4): ITC4-1.
CLINICAL BOTTOM LINE: Treatment...
 Depression is highly treatable
 Primary care physicians play an important role in treatment
 Clinicians familiar with 2 SSRIs, an SNRI, and sustainedrelease bupropion are well-equipped to treat most cases
 Refer patients to a psychiatrist as needed
 Become familiar with local psychotherapy options
 Know options for addressing common side effects
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 165 (4): ITC4-1.