final lecture 2
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Transcript final lecture 2
Assessment of Depression
Diagnosis
Risk Assessment
Risk Management
Formulation
Treatment
Outcome
Associated symptoms in
increasing importance:
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
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
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?
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
Stimulus-Response-Reward-Repetition
Risk Assessment
Risk Management – current and FUTURE
Therapeutic Risk/ Responsiblity
PRESCRIPTIVE DISASTER
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
Disclosure.
Further enquiry.
Normalisation
Informed choices.
Agreed plan.
Consequences of risk
management
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
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