Epidemiology - Seattle Healing Arts
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Transcript Epidemiology - Seattle Healing Arts
The Diagnosis and Treatment of Depression
Angela Heithaus, MD
Seattle Healing Arts
January 3, 2007
Depressive Disorder
Illness that involves the body, mood and
thought
Can affect eating, sleeping, thoughts about
self and thoughts about other things
Without treatment, symptoms can last for
weeks, months, or years
3 most common types
Major depression
Dysthymia
Bipolar disorder
? inheritance
Epidemiology
4th leading cause of worldwide disese in 1990,
causing more disability than either ischemic
heart disease or cerebrovascular disease
Prevalence of Major Depressive Disorder (MDD)
in Western industrialized nations is
2.3-3.2 % males
4.5-9.3 % females
Lifetime risk
7-12 % males
20-25 % females
Major Depression US
Impact on Economy
Lost productivity cost employers
> $ 31 billion
Most loss due to reduced performance
while at work
Risk Factors
Increased risk
female, native american, middle-aged,
widowed, separated or divorced, low
income
Decreased risk
asian, hispanic or black
Other Risk Factors
History of depressive illness in first
degree relatives
Prior episodes of major depression
Significant association with other
specific psychiatric d/o such as:
substance dependence, panic and
generalized anxiety d/o and
personality d/o
Precipitants
Psychosocial stressors
Adverse living conditions, war, environmental
changes
Bereavement
Loss of a loved one
Loss
Housing, relationships, health
Meds/Supplements
Corticosteroids
Many patients experience a sense of wellbeing
Larger doses can cause hypomanic and/or
depressive symptoms
Omega 3 fatty acids
Low levels correlate with depressive
symptoms
Medical Conditions Associated
with Depression
Hypothyroidism
Fibromyalgia
Systemic lupus erythematosus
Diabetes mellitus
Cardiovascular disease
Chronic pain
Others
Hypercalcemia, sjogren’s syndrome,
seizure d/o
Depression vs Other Medical
Conditions
Ask closed-ended questions about the nine
diagnostic criteria for depression
Ask about alcohol and substance abuse
and the use of other medications
Conduct a medical review of systems that
may elicit the presence of medical disorders
(TSH, electrolytes, folate, vitamin B12,
ECG)
Ask about other psychiatric conditions such
as anxiety disorder
Exclude alternative causes for depressive
symptoms or syndromes to diagnose a
primary mood disorder
Primary Care Setting
10-40% of patients have significant depressive
symptoms
5-10 % of patients meet criteria for DSM-IV MDD
10% of patients meet criteria for minor
depression
3-5 % of patients meet criteria for dysthymic
disorder
Approximately 50% of depressed patients
present with somatic complaints
Male vs Female
Men
Less likely to admit depressive symptoms
Practitioners less likely to suspect
Rate of suicide four times that of women
Depression often masked by alcohol, drugs, long
work hours
Symptoms more likely to involve irritability, anger,
discouragement
women
More attempts at suicide
Symptoms more likely to involve hopelessness,
helplessness
Screening
The U.S. Preventive Services Task Force
(USPSTF) recommends screening adults
for depression in clinical practices that
have systems in place to assure accurate
diagnosis, effective treatment, and follow
up
Clinical Considerations
Screening tools
Zung self assessment depression scale, Beck
depression inventory, General Health
Questionnaire
Or 2 simple questions
over the past two weeks have you felt down,
depressed or hopeless?
over the past two weeks have you felt little
pleasure and interest in doing things?
PHQ-9 Questionnaire
DSM-IV Criteria (SIG E CAPS)
Major depression-5 or more symptoms
present during same 2 week period
Depressed mood most of the day
Diminished interest and pleasure in all or almost
all activities
Decrease or increase in weight and/or appetite
Diminished ability to think, indecisiveness
Insomnia or hypersomnia
Psychomotor agitation or retardation
Fatigue or loss of energy nearly daily
Feelings of worthlessness or excessive or
inappropriate guilt
Recurrent thoughts of death (not just fear of
dying),recurrent suicidal ideation without specific
plan
Dysthymic Disorder-Criteria
Depressed modd for most of the day, for
more days than not, for at least 2 years
Presence, while depressed, of two (or
more)
Poor appetite or overeating
Insomnia or hypersomnia
Low energy or fatigue
Low self-esteem
Poor concentration or indecisiveness
Feelings of hopelessness
During 2 year period, never been without
the first two criteria for more than 2 months
at a time
Assessing Suicidal Risk
Suicide is 11th leading cause of death in US
(2000)
Depression is one of most common psychiatric
disorders associated with suicide
Evaluation of patient includes assessment of
ideation, plan and intent
Risk of suicide imminent in those who have an
active plan or intent to harm themselves and
have a lethal means that is readily assessable
Discussing Diagnosis
Depression is common
Depression increases perception and
impact of physical symptoms such as
fatigue, headache, and abdominal pain
Depression is a physical illness, which is
associated with biologic changes in the
brain (depletion of catecholamines)
Treatment of depression with medication
and/or psychotherapy can shorten duration
Pharmacotherapy
vs Psychotherapy
Drug tx alone for severely depressed
Either drug tx or psychotherapy equally
effective for moderate to mild depression
New public health model of telephone
psycotherapy and care management +
drug tx
Antidepressants
Meta-analysis of 28 randomized,
controlled trials involving 5940 patients
with major depression, dysthymic, or
mixed anxiety depression, newer
antidepressants were significantly more
effective than placebo but similar to TC
Bush using drugs to control depression and erratic behavior
Classes of Antidepressants
MAO inhibitors
Tranylcypromine, phenelzine, selegiline
Heterocyclics/TC
Desipramine, nortriptyline, imipramine, amitriptylint
SSRIs
Fluoxetine, sertraline, paroxetine, citalopram,
escitalopram
Others
Bupropion, venlafaxine, duloxetine, trazodone,
mirtazapine
Mechanisms of Action
MAO inhibitors
Irreversibly blocking monoamine oxidase
responsible for the oxidative deamination of
serotonin, norepinephrine and dopamine
Heterocyclics/TCs
Increase concentration of serotonin and/or
norepinephrine by inhibiting reuptake
SSRIs
Increase concentration of serotonin
Others
Buproprion enhances dopamine levels especially
in ‘reward’ area of the brain
Venlafaxine increases serotonin levels, inhibits
norepinephrine reuptake
Considerations
Prior success of an antidepressant
A positive response to a particular
antidepressant by a first degree relative
Practitioner drug familiarity and drug side
effects
Major Side Effects
MAO inhibitors
Can cause increased sympathic activity and severe hypertension
with concomitant ingestion of tyramine containing foods
Fermented cheeses, imported beer, Chianti, soy sauce, avocados,
TCs
bananas
Anticholinergic effects such as: dry mouth, blurred vision,
constipation, urinary retention
Similar to Class 1A antiarrhythmics, which can prolong QT interval
and increase risk of sudden cardiac death
Weight gain
SSRIs
Jitteriness, restlessness, agitation, headache, diarrhea, nausea,
insomnia, sexual dysfunction, weight gain
Others
Mirtazapine: sedation, weight gain
Bupropion: fewer adverse effects related to sexual dysfunction
and weight
Timing of Response
and Follow-up
Initial response usually within 2-6 weeks
Treatment time to maximal response
may be longer
If no response by 8-12 weeks at a
maximum therapeutic dose, consider
another antidepressant from same or
different class or refer
Follow-up at least q 1-2 weeks during
initial phase
Duration of Treatment
6-9 months after first episode
If there is an unresolved known precipitant such
as: psychosocial stress, bereavement, or loss
consider further treatment
When tx discontinued, taper over 2-4 weeks
AHCPR Guideline Panel recommendation of
maintenance therapy for patients with
3 or more depressive episodes
2 previous episodes plus risk factors
Double depression (dysthymia and major depression)
Response to Medication
50% of patients respond to the first choice
20% stop due to side effects
30% have no response
Hypericum Perforatum
St John’s Wort
European studies suggest more effective than
placebo and equal to TC and SSRIs in shortterm tx
US studies do not support efficacy in tx of
severe depression
Consider for mild acute depression
Avoid concomitnt use with SSRI
Resources
National Library of Medicine
American Psychiatric Association
American Psychological Association
Depression and Bipolar Support Alliance (DBSA)
National Foundation For Depressive Illness
National Alliance for the Mentally Ill
(www.nlm.nih.gov/medlineplus/healthtopics.html)
National Institute of Mental Health
(www.nimh.nih.gov)
(www.psych.org)
(www.apa.org)
American Academy of Child and Adolescent Psychiatry
Depression and Related Affective Disorders Association
National Mental Health Association
(www.aacap.org)
(www.drada.org)
(www.DBSAlliance.org)
(www.depression.org)
(www.nmha.org)
(www.nami.org)
THANK-YOU FOR YOUR ATTENTION!