the diagnosis and treatment of depression angela heithaus, md seattle healing arts january 3, 2007...
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The Diagnosis and Treatment of Depression
Angela Heithaus, MDSeattle Healing ArtsJanuary 3, 2007
Depressive DisorderDepressive Disorder Illness that involves the body, mood and Illness that involves the body, mood and
thoughtthought Can affect eating, sleeping, thoughts about self Can affect eating, sleeping, thoughts about self
and thoughts about other thingsand thoughts about other things Without treatment, symptoms can last for Without treatment, symptoms can last for
weeks, months, or yearsweeks, months, or years 3 most common types3 most common types
Major depressionMajor depression DysthymiaDysthymia Bipolar disorderBipolar disorder
? inheritance? inheritance
EpidemiologyEpidemiology 4th leading cause of worldwide disese in 1990, 4th leading cause of worldwide disese in 1990,
causing more disability than either ischemic causing more disability than either ischemic heart disease or cerebrovascular disease heart disease or cerebrovascular disease
Prevalence of Major Depressive Disorder (MDD) Prevalence of Major Depressive Disorder (MDD) in Western industrialized nations isin Western industrialized nations is 2.3-3.2 % males2.3-3.2 % males 4.5-9.3 % females4.5-9.3 % females
Lifetime riskLifetime risk 7-12 % males7-12 % males 20-25 % females20-25 % females
Major Depression US Major Depression US Impact on EconomyImpact on Economy
Lost productivity cost employers Lost productivity cost employers > $ 31 billion > $ 31 billion Most loss due to reduced performance Most loss due to reduced performance
while at workwhile at work
Risk FactorsRisk Factors
Increased riskIncreased risk female, native american, middle-aged, female, native american, middle-aged,
widowed, separated or divorced, low widowed, separated or divorced, low incomeincome
Decreased riskDecreased risk asian, hispanic or blackasian, hispanic or black
Other Risk FactorsOther Risk Factors
History of depressive illness in first History of depressive illness in first degree relativesdegree relatives
Prior episodes of major depressionPrior episodes of major depression Significant association with other Significant association with other
specific psychiatric d/o such as: specific psychiatric d/o such as: substance dependence, panic and substance dependence, panic and generalized anxiety d/o and generalized anxiety d/o and personality d/opersonality d/o
PrecipitantsPrecipitants
Psychosocial stressorsPsychosocial stressors Adverse living conditions, war, environmental Adverse living conditions, war, environmental
changeschanges
BereavementBereavement Loss of a loved oneLoss of a loved one
LossLoss Housing, relationships, healthHousing, relationships, health
Meds/SupplementsMeds/Supplements
CorticosteroidsCorticosteroids Many patients experience a sense of well-Many patients experience a sense of well-
beingbeing Larger doses can cause hypomanic and/or Larger doses can cause hypomanic and/or
depressive symptomsdepressive symptoms
Omega 3 fatty acidsOmega 3 fatty acids Low levels correlate with depressive Low levels correlate with depressive
symptomssymptoms
Medical Conditions Associated Medical Conditions Associated with Depressionwith Depression
HypothyroidismHypothyroidism FibromyalgiaFibromyalgia Systemic lupus erythematosusSystemic lupus erythematosus Diabetes mellitusDiabetes mellitus Cardiovascular diseaseCardiovascular disease Chronic painChronic pain OthersOthers
Hypercalcemia, sjogren’s syndrome, seizure d/oHypercalcemia, sjogren’s syndrome, seizure d/o
Depression vs Other Medical Depression vs Other Medical ConditionsConditions
Ask closed-ended questions about the nine Ask closed-ended questions about the nine diagnostic criteria for depressiondiagnostic criteria for depression
Ask about alcohol and substance abuse and the Ask about alcohol and substance abuse and the use of other medicationsuse of other medications
Conduct a medical review of systems that may Conduct a medical review of systems that may elicit the presence of medical disorders (TSH, elicit the presence of medical disorders (TSH, electrolytes, folate, vitamin B12, ECG)electrolytes, folate, vitamin B12, ECG)
Ask about other psychiatric conditions such as Ask about other psychiatric conditions such as anxiety disorderanxiety disorder
Exclude alternative causes for depressive Exclude alternative causes for depressive symptoms or syndromes to diagnose a primary symptoms or syndromes to diagnose a primary mood disordermood disorder
Primary Care SettingPrimary Care Setting
10-40% of patients have significant depressive 10-40% of patients have significant depressive symptomssymptoms
5-10 % of patients meet criteria for DSM-IV MDD5-10 % of patients meet criteria for DSM-IV MDD 10% of patients meet criteria for minor 10% of patients meet criteria for minor
depressiondepression 3-5 % of patients meet criteria for dysthymic 3-5 % of patients meet criteria for dysthymic
disorderdisorder
Approximately 50% of depressed patients Approximately 50% of depressed patients present with somatic complaintspresent with somatic complaints
Male vs FemaleMale vs Female
MenMen Less likely to admit depressive symptomsLess likely to admit depressive symptoms Practitioners less likely to suspectPractitioners less likely to suspect Rate of suicide four times that of womenRate of suicide four times that of women Depression often masked by alcohol, drugs, long Depression often masked by alcohol, drugs, long
work hourswork hours Symptoms more likely to involve irritability, anger, Symptoms more likely to involve irritability, anger,
discouragement discouragement women women
More attempts at suicideMore attempts at suicide Symptoms more likely to involve hopelessness, Symptoms more likely to involve hopelessness,
helplessnesshelplessness
ScreeningScreening
The U.S. Preventive Services Task Force The U.S. Preventive Services Task Force (USPSTF) recommends screening adults (USPSTF) recommends screening adults for depression in clinical practices that for depression in clinical practices that have systems in place to assure accurate have systems in place to assure accurate diagnosis, effective treatment, and follow diagnosis, effective treatment, and follow upup
Clinical ConsiderationsClinical Considerations
Screening toolsScreening tools Zung self assessment depression scale, Beck Zung self assessment depression scale, Beck
depression inventory, General Health depression inventory, General Health QuestionnaireQuestionnaire
Or 2 simple questionsOr 2 simple questions
over the past two weeks have you felt down, over the past two weeks have you felt down, depressed or hopeless?depressed or hopeless?
over the past two weeks have you felt little over the past two weeks have you felt little pleasure and interest in doing things?pleasure and interest in doing things?
PHQ-9 QuestionnairePHQ-9 Questionnaire
DSM-IV Criteria (SIG E CAPS)DSM-IV Criteria (SIG E CAPS) Major depression-5 or more symptoms present Major depression-5 or more symptoms present
during same 2 week periodduring same 2 week period Depressed mood most of the dayDepressed mood most of the day Diminished interest and pleasure in all or almost all Diminished interest and pleasure in all or almost all
activitiesactivities Decrease or increase in weight and/or appetiteDecrease or increase in weight and/or appetite Diminished ability to think, indecisivenessDiminished ability to think, indecisiveness Insomnia or hypersomniaInsomnia or hypersomnia Psychomotor agitation or retardationPsychomotor agitation or retardation Fatigue or loss of energy nearly dailyFatigue or loss of energy nearly daily Feelings of worthlessness or excessive or inappropriate Feelings of worthlessness or excessive or inappropriate
guiltguilt Recurrent thoughts of death (not just fear of Recurrent thoughts of death (not just fear of
dying),recurrent suicidal ideation without specific plandying),recurrent suicidal ideation without specific plan
Dysthymic Disorder-CriteriaDysthymic Disorder-Criteria
Depressed modd for most of the day, for more Depressed modd for most of the day, for more days than not, for at least 2 yearsdays than not, for at least 2 years
Presence, while depressed, of two (or more)Presence, while depressed, of two (or more) Poor appetite or overeatingPoor appetite or overeating Insomnia or hypersomniaInsomnia or hypersomnia Low energy or fatigueLow energy or fatigue Low self-esteemLow self-esteem Poor concentration or indecisivenessPoor concentration or indecisiveness Feelings of hopelessnessFeelings of hopelessness
During 2 year period, never been without the first During 2 year period, never been without the first two criteria for more than 2 months at a timetwo criteria for more than 2 months at a time
Assessing Suicidal RiskAssessing Suicidal Risk
Suicide is 11Suicide is 11thth leading cause of death in US leading cause of death in US (2000)(2000)
Depression is one of most common psychiatric Depression is one of most common psychiatric disorders associated with suicidedisorders associated with suicide
Evaluation of patient includes assessment of Evaluation of patient includes assessment of ideation, plan and intentideation, plan and intent
Risk of suicide imminent in those who have an Risk of suicide imminent in those who have an active plan or intent to harm themselves and active plan or intent to harm themselves and have a lethal means that is readily assessablehave a lethal means that is readily assessable
Discussing DiagnosisDiscussing Diagnosis
Depression is commonDepression is common Depression increases perception and Depression increases perception and
impact of physical symptoms such as impact of physical symptoms such as fatigue, headache, and abdominal painfatigue, headache, and abdominal pain
Depression is a physical illness, which is Depression is a physical illness, which is associated with biologic changes in the associated with biologic changes in the brain (depletion of catecholamines)brain (depletion of catecholamines)
Treatment of depression with medication Treatment of depression with medication and/or psychotherapy can shorten durationand/or psychotherapy can shorten duration
PharmacotherapyPharmacotherapyvs Psychotherapyvs Psychotherapy
Drug tx alone for severely depressedDrug tx alone for severely depressed Either drug tx or psychotherapy equally Either drug tx or psychotherapy equally
effective for moderate to mild depressioneffective for moderate to mild depression New public health model of telephone New public health model of telephone
psycotherapy and care management + psycotherapy and care management + drug txdrug tx
AntidepressantsAntidepressants
Meta-analysis of 28 randomized, Meta-analysis of 28 randomized, controlled trials involving 5940 patients controlled trials involving 5940 patients with major depression, dysthymic, or with major depression, dysthymic, or mixed anxiety depression, newer mixed anxiety depression, newer antidepressants were significantly more antidepressants were significantly more effective than placebo but similar to TCeffective than placebo but similar to TC
Bush using drugs to control depression and erratic behaviorBush using drugs to control depression and erratic behavior
Classes of AntidepressantsClasses of Antidepressants
MAO inhibitorsMAO inhibitors Tranylcypromine, phenelzine, selegilineTranylcypromine, phenelzine, selegiline
Heterocyclics/TCHeterocyclics/TC Desipramine, nortriptyline, imipramine, amitriptylintDesipramine, nortriptyline, imipramine, amitriptylint
SSRIsSSRIs Fluoxetine, sertraline, paroxetine, citalopram, Fluoxetine, sertraline, paroxetine, citalopram,
escitalopramescitalopram OthersOthers
Bupropion, venlafaxine, duloxetine, trazodone, Bupropion, venlafaxine, duloxetine, trazodone, mirtazapinemirtazapine
Mechanisms of ActionMechanisms of Action MAO inhibitorsMAO inhibitors
Irreversibly blocking monoamine oxidase responsible for the Irreversibly blocking monoamine oxidase responsible for the oxidative deamination of serotonin, norepinephrine and dopamineoxidative deamination of serotonin, norepinephrine and dopamine
Heterocyclics/TCsHeterocyclics/TCs Increase concentration of serotonin and/or norepinephrine by Increase concentration of serotonin and/or norepinephrine by
inhibiting reuptakeinhibiting reuptake SSRIsSSRIs
Increase concentration of serotoninIncrease concentration of serotonin OthersOthers
Buproprion enhances dopamine levels especially in ‘reward’ area Buproprion enhances dopamine levels especially in ‘reward’ area of the brainof the brain
Venlafaxine increases serotonin levels, inhibits norepinephrine Venlafaxine increases serotonin levels, inhibits norepinephrine reuptakereuptake
ConsiderationsConsiderations
Prior success of an antidepressant Prior success of an antidepressant A positive response to a particular A positive response to a particular
antidepressant by a first degree relativeantidepressant by a first degree relative Practitioner drug familiarity and drug side Practitioner drug familiarity and drug side
effectseffects
Major Side EffectsMajor Side Effects MAO inhibitorsMAO inhibitors
Can cause increased sympathic activity and severe hypertension Can cause increased sympathic activity and severe hypertension with concomitant ingestion of tyramine containing foodswith concomitant ingestion of tyramine containing foods Fermented cheeses, imported beer, Chianti, soy sauce, avocados, Fermented cheeses, imported beer, Chianti, soy sauce, avocados,
bananasbananas TCsTCs
Anticholinergic effects such as: dry mouth, blurred vision, Anticholinergic effects such as: dry mouth, blurred vision, constipation, urinary retentionconstipation, urinary retention
Similar to Class 1A antiarrhythmics, which can prolong QT interval Similar to Class 1A antiarrhythmics, which can prolong QT interval and increase risk of sudden cardiac deathand increase risk of sudden cardiac death
Weight gain Weight gain SSRIsSSRIs
Jitteriness, restlessness, agitation, headache, diarrhea, nausea, Jitteriness, restlessness, agitation, headache, diarrhea, nausea, insomnia, sexual dysfunction, weight gaininsomnia, sexual dysfunction, weight gain
OthersOthers Mirtazapine: sedation, weight gainMirtazapine: sedation, weight gain Bupropion: fewer adverse effects related to sexual dysfunction Bupropion: fewer adverse effects related to sexual dysfunction
and weightand weight
Timing of Response Timing of Response and Follow-upand Follow-up
Initial response usually within 2-6 weeksInitial response usually within 2-6 weeks Treatment time to maximal response Treatment time to maximal response
may be longermay be longer If no response by 8-12 weeks at a If no response by 8-12 weeks at a
maximum therapeutic dose, consider maximum therapeutic dose, consider another antidepressant from same or another antidepressant from same or different class or referdifferent class or refer
Follow-up at least q 1-2 weeks during Follow-up at least q 1-2 weeks during initial phaseinitial phase
Duration of TreatmentDuration of Treatment
6-9 months after first episode6-9 months after first episode If there is an unresolved known precipitant such If there is an unresolved known precipitant such
as: psychosocial stress, bereavement, or loss as: psychosocial stress, bereavement, or loss consider further treatmentconsider further treatment
When tx discontinued, taper over 2-4 weeksWhen tx discontinued, taper over 2-4 weeks AHCPR Guideline Panel recommendation of AHCPR Guideline Panel recommendation of
maintenance therapy for patients withmaintenance therapy for patients with 3 or more depressive episodes3 or more depressive episodes 2 previous episodes plus risk factors2 previous episodes plus risk factors Double depression (dysthymia and major depression)Double depression (dysthymia and major depression)
Response to MedicationResponse to Medication
50% of patients respond to the first choice50% of patients respond to the first choice
20% stop due to side effects20% stop due to side effects
30% have no response30% have no response
Hypericum PerforatumHypericum Perforatum
St John’s WortSt John’s Wort European studies suggest more effective than European studies suggest more effective than
placebo and equal to TC and SSRIs in short-placebo and equal to TC and SSRIs in short-term txterm tx
US studies do not support efficacy in tx of US studies do not support efficacy in tx of severe depressionsevere depression
Consider for mild acute depressionConsider for mild acute depression Avoid concomitnt use with SSRIAvoid concomitnt use with SSRI
National Library of Medicine (National Library of Medicine (www.nlm.nih.gov/medlineplus/healthtopics.htmlwww.nlm.nih.gov/medlineplus/healthtopics.html)) National Institute of Mental Health (National Institute of Mental Health (www.nimh.nih.govwww.nimh.nih.gov ) )
American Psychiatric Association (American Psychiatric Association (www.psych.orgwww.psych.org ) )
American Psychological Association (American Psychological Association (www.apa.orgwww.apa.org)) American Academy of Child and Adolescent Psychiatry (American Academy of Child and Adolescent Psychiatry (www.aacap.orgwww.aacap.org)) Depression and Related Affective Disorders Association (Depression and Related Affective Disorders Association (www.drada.orgwww.drada.org ) )
Depression and Bipolar Support Alliance (DBSA) (Depression and Bipolar Support Alliance (DBSA) (www.DBSAlliance.orgwww.DBSAlliance.org ) )
National Foundation For Depressive Illness (National Foundation For Depressive Illness (www.depression.orgwww.depression.org)) National Mental Health Association (National Mental Health Association (www.nmha.orgwww.nmha.org ) )
National Alliance for the Mentally Ill (National Alliance for the Mentally Ill (www.nami.orgwww.nami.org) )
ResourcesResources
THANK-YOU FOR YOUR ATTENTION!