Transcript final lecture 2

Assessment of Depression
Diagnosis
Risk Assessment
Risk Management
Formulation
Treatment
Outcome
Associated symptoms in
increasing importance:
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Insomnia
Fatigue
loss of interest/pleasure
Morbid self-opinion
Impaired concentration
Hopelessness ± suicidal thoughts. (Blacker
and Clare ‘88)
Diagnostic domains
 Affective symptoms
 Physical symptoms
 Cognitive symptoms
Affective Diagnostic Criteria.
Must haves!
 Depressed mood (irritable in children or
adolescents).
 Or markedly diminished interest or pleasure
 Must be most of the time over at least 2
weeks.
 Change from normal functioning
Physical symptoms
 Weight change when not dieting
 Sleep disturbance –insomnia (particularly
middle insomnia and EMW), hypersomnia.
 Agitation or retardation
 Fatigue/loss of energy
Cognitive symptoms
 Worthlessness, xs/inappropriate guilt
 Diminished ability to think and concentrate
 Recurrent thoughts of death and suicide
Diagnosis
 Eye contact - observe body language.
 Open questions.
 Attend to “distinct quality of mood”
eg.Coldness/deadness/emptiness.
Paykel ’85
Comorbidity and missed
diagnosis
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Presentation affected byGender (Women 2:1 Men)
Age
Insight
Comorbid physical illness
Gotland survey. Pop 56,000
 60% GPs trained in depression diagnosis
1981/2
 By 1985 - ↓ referrals 50%, inpatient by 75%
and sick leave by 50%
 Suicide rates dropped from 20 to 7/100,000
 Antidepressant prescribing increased 60%
 Anxiolytic prescribing decreased 25%
Suicides
 ♀:♂ ratio 2:3 before the programme 1:7
after.
 Of increased px 1/3 ♂, 2/3 ♀
 Of increased ♂ px most were for elderly!
 Improved ability in Primary Care benefits
those in contact with Primary Care i.e.
Women!
Male Depressive Syndrome
 Lowered stress tolerance
 Acting out/aggression/low impulse control/
Transitional sociopathy
 Burnt out feeling/emptiness
 Chronic fatigue
 Irritability/restlessness/dissatisfaction
 Indecision
 Sleep disturbance/morning anxiety
Missed depression
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Depressed mood may be absent
Watch for “inner emptiness or deadness”
Prominent anhedonia
Somatic complaints in patients with poor verbal
skills or the elderly
 Pseudo dementia- behavioural withdrawal,
memory problems
 Unexplained physical symptoms associated with
depression e.g. pain . Impt to rule out organic
cause
Depression – the physical
presentation
In primary care, physical symptoms are often
the chief complaint in depressed patients
In a New England Journal of Medicine
study, 69% of diagnosed depressed
patients reported unexplained physical
symptoms as their chief complaint1
N = 1146 Primary care patients with major depression
Reference:
1. Simon GE, et al. N Engl J Med. 1999;341(18):1329-1335.
Is your depressed patient
bipolar?
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Co morbid substance abuse
Bipolar family history *
Seasonality
Early onset <25 yrs *
Postpartum onset *
Psychotic features <35 yrs */ Atypical features
Rapid on/off pattern, frequent recurrence, <
3mth duration * /Mixed affective state **
 Antidepressant mania/hypomania **
 Ask about symptoms of hypomania just
preceding or following depression either 1st
episode or early-onset depression
Prevalence of Bipolar Spectrum
subtype
 26-39% depressed patients in Primary
Care
 45% depressed outpatients
Allilaire et al “EPIDEP Trial”. Encephale 2001;27:149-158
Risk Assessment
 Risk - aggression to self , others & property
- substance misuse
- vulnerability/ exploitation
 Ask direct questions about suicide – “have you
thought about or are you thinking about hurting or
killing yourself”
 If yes or unsure, enquire about plan.
 If yes but wouldn't do it then “What is stopping you
from doing something?" (protective factors)
Predictors of Risk
 S – lack of significant others, stress events.
 U – unsuccessful attempts, unemployment,
unexplained improvement.
 I – identification with family history/peer group
suicide.
 CI – chronic illness or severe illness of recent
onset
Predictors of Risk 2
 D – depression + hostility/hopelessness or
frustration, decision that suicide is an option
 A – age, alcohol, availability.
 L – lethality of previous attempts e.g. guns,
hanging, jumping
BEHAVIOURAL THEORY
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Stimulus-Response-Reward-Repetition
Risk Assessment
Risk Management – current and FUTURE
Therapeutic Risk/ Responsiblity
PRESCRIPTIVE DISASTER
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DISclosure
Anxiety.
narrowed choiceS
Taking responsibility.
PatiEnt out of control.
Referral to other.
Interview Style
 Be Perceptive- listen and understand, take distress
seriously do not dismiss, minimise or ignore- build
rapport.
 Be Peaceful and calm. Do not appear threatened.
 Partnership approach- they share responsibility for
choosing the treatment approach. Empowerment
reduces helplessness reduces risk!
Interview Style 2
 Be Persuasive- discuss the thoughts/plans in a
reasoned manner- “these are symptoms of a
treatable condition, they are very common and
are often temporary.
 Be Positive – instillation of HOPE is the most
protective thing you can do.
Collaborative risk management
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Disclosure.
Further enquiry.
Normalisation
Informed choices.
Agreed plan.
Consequences of risk
management
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Patient retains responsibility
Patient understood and in control.
Self image stronger.
Risk lower in subsequent stress
What is Case Formulation?
 “Case formulation aims to describe a
person’s presenting problems and use
theory to make explanatory inferences about
causes and maintaining factors that can
inform interventions” Kuyken 2006
Case formulation 2
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Predisposing factors
Precipitating factors
Protective factors
Perpetuating factors
Hypothesis –Inferred mechanisms- goals
 Exercise
 Examples
TREATMENT
 Keep taking the tablets!!
– Effective drug & dose
 Psychological – counselling, CBT,
psychodynamic psychotherapy
 Social- don’t forget these interventions;
common sense and can make a lot of
difference!
Outcome – response v remission
 Aim for remission “are you back to your
normal self?”
 Use outcome measure GAF/Honos