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THE DIAGNOSIS AND MANAGEMENT OF DEPRESSION Louis T. Joseph, M.D. Hospital Psychiatry and Consultation Service Brain Stimulation Service Addiction Psychiatry Service Henry Ford Health System Consult Question: Please evaluate for depression. WHAT DEPRESSION ISN’T AN ALL TO COMMON CONSULT… 42 year old female with past history of HTN and no past psychiatric history admitted to the hospital with several weeks of fatigue. Found to have a leukocytosis on CBC with predominance of blasts. Patient diagnosed earlier today with AML and has been crying for 2 hours. Mood euthymic on admission. Please evaluate for depression medications. MAJOR DEPRESSIVE EPISODE 5 or more symptoms of depression for a 2 week period. At least one symptom is depressed mood or anhedonia. SIG E CAPS DEPRESSED MOOD How are you feeling? Up to 50% of patients will report they feel fine when in fact they meet all the other criteria for depression. -How can you diagnose depression in a patient who says they feel “fine”? 50% of patients will report a diurnal variation in their mood SLEEP Hypersomnia or Insomnia can occur 80% of depressed patients report insomnia How does one define insomnia? -1. difficulty initiating or maintaining sleep, or suffering from non-restorative sleep. -2. sleep disturbance (or associated daytime fatigue) causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. INTEREST (ANHEDONIA) Key Point: Diminished interest and pleasure needs to occur with almost all activities every day for all day! Ask about favorite foods and sex drive Palpate the Limbic System during the interview GUILT Needs to be excessive or inappropriate Can also be feelings of worthlessness ENERGY 95% of depressed patients report decreased energy Do you feel fatigued? CONCENTRATION 85% of depressed patients report difficulty concentrating Can also count Indecisiveness or Trouble thinking APPETITE Can also ask about weight change which also counts. 5% change in body weight over past month PSYCHOMOTOR Can be agitation or retardation How do we ask about this? SUICIDAL IDEATION Incredibly common in depression, ~66% 10-15% complete suicide OTHER SYMPTOMS Anxiety- 90% Pain- 60-70% Delusions and Hallucinations -Mood congruent symptoms in MDD -Hospitalize patient ASAP ADDITIONAL QUESTIONS ABOUT DEPRESSION Past mood episodes? Symptoms first noticed by patient and family? NECESSARY RULE OUTS Bipolar Disorder Substance Use Demoralization Bereavement BIPOLAR DISORDER Need to rule our a history of mania or hypomania Can be difficult because only 50% of the time, patients recall mania O T H E R F E AT U R E S S U G G E S T I V E O F BIPOLAR DISORDER Early age of onset Psychotic Depression before age 25yo Co-morbid substance use disorder Postpartum Depression or Postpartum Psychosis Rapid onset and offset of depressive episodes of short duration (<3 months) O T H E R F E AT U R E S S U G G E S T I V E O F BIPOLAR DISORDER Family History of Bipolar Disorder High density, three generation pedigrees Hypomania associated with antidepressants Repeated loss of efficacy of antidepressants after initial response (at least 3 times) Depressive mixed state (with psychomotor agitation, irritable hostility, racing thoughts, and sexual arousal during depressive episode) SUBSTANCE USE Timeline, timeline, timeline! DEMORALIZATION Various degrees of despair, helplessness, hopelessness, confusion, and subjective incompetence that people feel when they are failing to cope with life’s adversities. Can have the same symptoms of MDD BEREAVEMENT Realm of ‘normal’ human Marked Psychomotor experience Retardation When to consider depression versus bereavement? -Suicidal Ideation -Severe loss of functioning -Severe worthlessness -Severe guilt -Hallucinations Mummification BEREAVEMENT: TO TREAT OR NOT TO TREAT Counseling or Psychotherapy is always helpful What about antidepressants? -Sparse evidence suggesting that they can be effective if patient meets criteria for MDD WHEN TO CONSIDER PSYCHIATRY REFERRAL 1. Non-response to medications you are trying 2. Any case of bipolar disorder 3. Practicing outside your scope of expertise PROGNOSIS OF DEPRESSION Untreated Depressive episodes last 6-13 months 50% reoccurrence rate within the next 2 years After first episode- 50-60% chance of having a second episode. After second episode-70% chance of having a third episode After third episode-90% chance of having a fourth episode PROGNOSIS OF DEPRESSION Untreated Episodes typically occur more frequently, become longer, and are more severe the more untreated episodes one has Psychological stress typically plays a role in triggering the first 1-2 episodes but not subsequent ones PROGNOSIS OF DEPRESSION Treated 1. Treated episodes last 3 months in length 2. Cessation of antidepressant treatment within the first 3-6 months almost always leads to a relapse TREATMENT EFFICACY 1. Medications 35% for initial trial 75% after 4 treatment trials 2. ECT 90% remission 70% remission for medication refractory patients 3. Psychotherapy Equivalent efficacy to medications for mild-moderate depression N U M B E R O F S U I C I D E S I N H E N RY F O R D H E A LT H S Y S T E M H M O P E R YEAR 13 REFERENCES Coffey MJ: “Suicide in and HMO Population.” Presented at the Henry Ford Hospital Department of Psychiatry Grand Rounds, Detroit, Michigan, September 13th, 2012. Coffey CE: Building a System of Perfect Depression Care in Behavioral Health. Joint Commission Journal on Quality and Patient Safety. April 2007; 33 (4): 193-199. Mankad MV et al.: Clinical Manual of Electroconvulsive Therapy. Washington D.C., American Psychiatric Publishing, 2010. Griffith J, Gaby L: Brief Psychotherapy at the Bedside: Countering Demoralization from Medical Illness. Psychosomatics. March-April 2005; 46(2): 109-16. Rush AJ et al.: Acute and Longer-Term Outcomes in Depressed Outpatients Requiring One or Several Treatment Steps: A STAR*D Report. Am J Psychiatry. 2006 Nov; 163(11):1905-17. Rupke SJ et al.: Cognitive Therapy for Depression. Am Fam Physician. 2006 Jan 1; 73(1):83-86. Saddock BJ, Sadock VA: Kaplan and Saddock’s Synopsis of Psychiatry. Philadelphia, Lippincott, 2007. Stern TA et al.: Massachusetts General Hospital Handbook of General Hospital Psychiatry. Philadelphia, Saunders, 2010. Styron, William: Darkness Visible: A Memoir of Madness. New York, Random House, 1990. REFERENCES CONT. Spitzer R, Kroenke K, Williams J. Validation and utility of a self-report version of PRIME-MD: the PHQ Primary Care Study. Journal of the American Medical Association 1999; 282: 1737-1744. Kroenke K, Spitzer R L, Williams J B. The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine 2001; 16(9): 606-613 Rost K, Smith J. Retooling multiple levels to improve primary care depression treatment. Journal of General Internal Medicine 16: 644-645, 2001 Kroenke K, Spitzer RL. The PHQ-9: A new depression and diagnostic severity measure.Psychiatric Annals 2002; 32: 509-521. Williams JW, Noel PH, Cordes J A, Ramirez G,Pignone M. Is this patient clinically depressed? Journal of the American Medical Association 2002; 287: 1160-1170. Lowe B, Unutzer J, Callahan CM, Perkins AJ, Kroenke K. Monitoring depression treatment outcomes with the patient health questionnaire-9. Medical Care, 2004. 42(12): 1194-201. Pinto-Meza A, Serrano-Blanco A, Penarrubia MT, Blanco E, Haro JM. Assessing depression in primary care with the PHQ-9: can it be carried out over the telephone? Journal of General Internal Medicine, 2005. 20(8): 738-42.