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Disability of depressed workers – how to recognize, treat and prevent depression in OHS. Teija Honkonen MD, Psychiatrist, FIOH 14.1.2004. The term 'Depression' may refer to. Affect Symptom Syndrome (disorder). Essential in the recognition of depressive disorders in OHS.

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Disability of depressed workers – how to recognize, treat and prevent depression in OHS

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Disability of depressed workers – how to recognize, treat and prevent depression in OHS

Teija Honkonen

MD, Psychiatrist, FIOH


The term 'Depression' may refer to

  • Affect

  • Symptom

  • Syndrome (disorder)

Essential in the recognition of depressive disorders in OHS

  • Syndromatic approach

  • Longitudinal information and follow-up

  • Differential diagnostic reassessments

  • Assessment of co-morbidity

Depressive disorders / syndromes

  • Major depression

    • unipolar depression

    • bipolar disorder

  • Dysthymic disorder

  • Recurrent non-major depressive syndromes

    • seasonal affective disorder

    • premenstrual dysphoric disorder

  • Cyclothymic disorder

  • Adjustment disorder with depressed mood

  • Organic mood disorders

Diagnostic criteria for Major Depressive Disorder (ICD 10: F32-33)

  • The following symptoms have been present during the same 2-week period:

  • A) at least two of the following

    • depressed mood most of the day, nearly every day

    • markedly diminished interest or pleasure in almost all activities

    • fatigue or loss of energy nearly every day

Diagnostic criteria for Major Depressive Episode (ICD 10: F32-33)

  • B) in addition, some of the following symptoms (altogether at least 4/10 symptoms)

    • feelings of worthlessness or diminished self-esteem

    • feelings of excessive or inappropriate guilt

    • diminished ability to think or concentrate, or indeciveness

    • recurrent thought of death or suicidal ideation

    • insomnia or hypersomnia

    • decrease/increase in appetite

    • psychomotor agitation or retardation

Severity of depression

  • Mild depression: at least 4 symptoms

  • Moderate depression: at least 6 symptoms

  • Severe depression: at least 8 symptoms

  • Psychotic depression

  • Diminished functional capacity correlates usually with the severity of depression

Psychotic major depression (ICD 10- F32-33.3)

  • About 10-15% of depressive episodes are psychotic

  • Often boundary between non-psychotic and psychotic depression is not clear

  • Symptoms:

    • delusions (including deep hopelessness)

    • hallucinations

    • often major changes in psychomotoric functioning

Diagnostic Criteria for Dysthymic Disorder(ICD 10: F34.1)

  • Depressive or irritabile mood for at least 2 years

  • In addition, at least 3/11 of the following symptoms

    • diminished energy, insomnia, diminished self-esteem, poor concentration, tearfulness, diminished interest on pleasure, hopelessness, feelings of incapacity, pessimism, social withdrawal or diminished talkativeness

Diagnostic criteria for Adjustment Disorder with depressed mood (ICD-10: F43.2)

  • Symptoms in response to an identifiable stressor occurring within a month of the onset of the stressor

  • The disturbance does not meet the criteria for another specific mental disorder

  • Once the stressor has terminated, the symptoms do not persist for more than an additional 6 months

Important symptoms associated with depressive disorders

  • Anxiety

  • Physical symptoms

  • Fear of illness, hypochondriasis


  • Psychiatric co-morbidity

    • concurrent mental disorders / syndromes

  • Somatopsychiatric co-morbidity

    • concurrent mental disorder and somatic illness

Co-morbidity of depression

  • Psychiatric co-morbidity

    • anxiety disorders 40-60%

    • personality disorders 40-50%

    • substance abuse 20-40%

  • Somatopsychiatric co-morbidity

    • among elderly patients up to 90%

Depression and functional disability

  • WHO's Global Burden of Disease study:

    • Unipolar major depression is the fourth most important illness in terms of functional disability

    • The role of depression is expected to become even more important by the year 2020

      Murray & Lopez 1997

Quality of life and functioning of depressed primary care patients

  • Primary care patients with depressive conditions have poorer mental, role-emotional, and social functioning than patients with common chronic medical conditions

  • Depressed patients have worse physical functioning than patients with asthma, hypertension, gastrointestinal tract problems, or migraines

Wells et al. 1999

Disability pensions due to depression in Finland

  • In Finland, about 40 % of the disability pensions are granted due to mental disorders

  • Depression is now among the most common causes of disability pensions

Causes of increase in disability pensions due to depression

  • Changes in illness behaviour in population ?

  • Increase in incidence of depression ?

  • Changes in diagnostics ?

  • Changes in treatment methods ?

  • Increased demands of work ?

Health 2000 Survey:The prevalence of major depression

  • In Finland, within the last 12 months

    • a diagnosis of major depressive disorder was found among 4.9 % of the subjects

    • major depression was more common among females than males

  • The prevalence of depression has not increased during the last 20 years

Pirkola et al. 2002

Depression and cognitive symptoms

  • Depression causes

    • diminished ability to think or concentrate

    • diminished ability to learn or remember

    • decreased motivation to undertake new tasks

    • difficulty in finishing tasks

    • reduced energy

    • indecisiveness

    • slowness of psychomotor performances

Need for sick-leave in depression

  • Individual case-specific assessment

  • Even in case of a severely depressed patient work may have positive impact in preventing patient from social withdrawal

Early recognition and treatment of depression is important, because

  • 75-80% (90%) of depressed patients will benefit from adequate treatment

  • Effective and early treatment may prevent unnecessary suffering, disability and suicides

Treatment ofdepression includes

  • Comprehensive evaluation of the patient

    • diagnosis

    • comorbidity

    • suicidality

    • psychosocial functioning

    • current life events

    • social support

    • socio-economic situation

  • Well-planned treatment

  • Prevention of the recurrences

Why is it not always easyto diagnose depression ?

  • Patient

    • may not talk about it, because he/she is not able to recognize his/her own state of mood

    • may be unwilling to discuss it due to fear of potential negative consequences

Why is it not always easy to diagnose depression ?

  • Physician

    • is not able to recognize depression

    • is able to recognize it but he/ she has not enough time for that

    • does not want to recognize it because he/ she thinks it is untreatable

Methods of measuring depression

  • Semi-structured interviews

    • Schedules for Clinical Assessment in Neuropsychiatry (SCAN)

  • Fully structured interviews

    • Composite International Diagnostic Interview (CIDI)

  • Rating scales

    • Hamilton Rating Scales for Depression (HAMD)

    • Montgomery-Åsberg Depression Rating Scale (MADRS)

  • Self-administered questionnares

    • Beck Depression Inventory (BDI)

Main treatment methods of depression in OHS

  • Psychotherapy

    • mild – moderate depression

  • Antidepressant medication

    • moderate – severe depression

  • Psychotherapy and medication have a synergistic effect

Other treatment options of depression

  • Bright light treatment

    • effective in treatment and prevention of seasonal affective disorder

  • Physical exercise

    • effective as additional treatment of mild-moderate depression

  • Sleep deprivation

    • duration of efficiency unknown; not widely used in Finland

  • Electroconvulsive treatment (ECT)

    • most effective treatment for severe depression

  • Transcranial magnetic stimulation (TMS)

    • promising future treatment, efficiency not yet known

Selective serotonin reuptake inhibitors (SSRIs)

  • 70-80% of patients respond to treatment if indication of medication is correct

  • SSRIs are usually safe in overdose and in terms of interaction

  • As a side-effect, in the beginning of treatment SSRIs may cause nausea and sometimes increased anxiety; about 30% may also suffer from sexual dysfunction

Antidepressant medication

  • Medication without any psychotherapeutic physician-patient relationship is not adeqaute treatment

  • Not prescriping antidepressant medication may also be inadequate treatment

  • All patients do not benefit from medication

  • Antidepressant medication does not cause addiction

Common problems with medication in OHS

  • Lack of systematic follow-up of treatment response and side-effects

    • problems with compliance

    • no optimal treatment

  • Acceptance of partial remission leading into

    • recurrent depressions

    • difficulties in decreasing disability

  • Continuation of inefficient medication

  • Lack of sequential medication trials

Depression and disability

  • The severity of depression is the most important factor affecting the disability

  • Symptoms of depression improve more rapidly than functional disability caused by depression

Psychosocial disability during long-term course of MDD

  • Psychosocial functioning during an average of 10 years’ follow-up of 371 patients with MDD was assessed

  • Disability is pervasive and chronic but disappears when patients become asymptomatic

  • As long as any level of depressive symptoms and disability are present effective and continued treatment is necessary

  • Treatment to full recovery should be the goal

    Judd et al. 2000

Risk for recurrency of depression

  • After one episode 50%

  • After two episodes 70%

  • After three episodes > 90%

  • Long-term prophylactic treatment with antidepressant medication

Psychotherapy in depression

  • Supportive treatment

    • listening, understanding, offering practical advice and help, psychoeducation, maintaining hope

  • Specific short psychotherapies

    • cognitive

    • interpersonal (IPT)

    • problem focused

    • psychodynamic

Interpersonal psychotherapy, IPT

  • Time-limited

    • 12-16 sessions

    • three phases

  • Manualized

  • Active

  • Demonstrated efficacy

    Markowitz 2000

Characteristics of IPT

  • 'Here and now' focus

  • Non-neutral, active therapist

  • Affective engagement on one of 4 problem areas:

    • grief

    • role dispute

    • role transition

    • interpersonal deficits

  • Exploration of options

  • Socialization and activity Markowitz 2000

Initial sessions (1-3)

  • Diagnosing the depression

  • Eliciting the interpersonal inventory

  • Establishing the interpersonal problem area

  • Giving the patient the 'sick role’

  • Making the interpersonal formulation

  • Beginning psychoeducation

  • Instilling hope Markowitz 2000

Middle sessions (4-12)

  • Focus on one or more of the four problem areas

    • grief (complicated bereavement)

    • role dispute

    • role transition

    • interpersonal deficits Markowitz 2000

Termination sessions (13-16)

  • Assessment of gains

  • Prevention of relapse

  • Graduation

  • Addressing non-response

  • Continuation / booster sessions ?Markowitz 2000

Training primary-care physicians to recognize and manage depression

  • In Netherlands, a 20- hour training programme was developed, that sought to improve primary care physicians' ability to detect and manage depression

  • 17 physicians participated in the study

  • Training physicians can improve short-term patient outcomes, especially for patients with a recent onset of depressionTiemens et al. 1999

Impact of improved depression treatment in primary care on daily functioning

  • MDD- patients were randomly assigned to usual care or to a collaborative management programme

  • More effective acute-phase depression treatment reduced somatic distress and improved self-rated overall health at 4 and 7 month

  • There was no significant intervention effect on other disability measures

    Simon et al 1998

Factors predicting chronic outcome of depression

  • Duration of depressive episode before beginning of treatment

  • Severity of depression

  • Some personality traits

  • Poor social support

  • Negative life events during depression

  • Co-morbidity (substance abuse, somatic illness)

  • Inadequate treatment

Inadequate treatment and disability pension

  • In Finland, patients who were pensioned during 1993-1994 due to depression:

  • 87%had used antidepressants

    • 2/3 had received antidepressants at adequate dose

    • about 60% had received only one antidepressant before disability pension was granted

  • Weekly psychotherapy was rare (9%)

  • Electro-convulsive therapy was rare (4%)

    Isometsä et al 2001

Primary prevention of depression?

  • Crisis interventions

  • Prevention of burnout

  • Physical exercise

  • Social support

  • Preventive treatment of seasonal affective disorder

Secondary and tertiary prevention of depression

  • Sofar, the majority of subjects with major depression suffer from a chronic illness with either fluctuating or chronic course

  • Early recognition and early, active treatment would constitute the best secondary and tertiary prevention of depression

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