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
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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
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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)
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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
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National Library of Medicine
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American Psychiatric Association
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American Psychological Association
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Depression and Bipolar Support Alliance (DBSA)
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National Foundation For Depressive Illness
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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!