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 AB OUT 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

OTHER FEATURES SUGGESTIVE OF 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 A T U R E S S U G G E S T I V E O F B I P O L A R D I S O R D E R

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

Realm of ‘normal’ human

experience

When to consider depression

versus bereavement?

-Suicidal Ideation

-Severe loss of functioning

-Severe worthlessness

-Severe guilt

-Hallucinations

BEREAVEMENT

Marked Psychomotor

Retardation

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

UntreatedDepressive 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

UntreatedEpisodes 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

NUMBER OF SUICIDES IN HENRY FORD HEALTH

SYSTEM HMO PER YEAR

13

REFERENCESCoffey 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.