Diagnosing depression
Download
1 / 46

Diagnosing Depression - PowerPoint PPT Presentation


  • 266 Views
  • Updated On :

Diagnosing Depression. Public Health Detailers’ Training NYC Department of Health and Mental Hygiene Ann M. Sullivan, M.D. Regional Director of Psychiatry for the Queens Health Network New York City Health and Hospitals Corporation . Outline. Diagnosis Risk Factors DSM-IV Criteria MDD

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Diagnosing Depression' - LionelDale


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Diagnosing depression l.jpg

Diagnosing Depression

Public Health Detailers’ Training

NYC Department of Health and Mental Hygiene

Ann M. Sullivan, M.D.

Regional Director of Psychiatry for the Queens Health Network

New York City Health and Hospitals Corporation


Outline l.jpg
Outline

  • Diagnosis

  • Risk Factors

  • DSM-IV Criteria

    • MDD

    • Dysthymia

    • Bipolar

    • Minor Depression

  • Depression-Anxiety Continuum


Outline3 l.jpg
Outline

  • Other Causes

  • Assessment Elements

  • Suicide Assessment

    • Epidemiology

    • Risk Factors

    • Myths

  • Care Management


Diagnosis of mood disorders l.jpg
Diagnosis of Mood Disorders

DSM-IV Diagnostic Manual:

  • Dysthymic Disorder

  • Major Depressive Disorder

  • Cyclothymic Disorder

  • Bipolar Disorder

  • Mood Disorder due to: medical disorder, or substance induced

  • Other: “Minor Depression/Depressive Symptoms”


What differentiates the various diagnoses l.jpg
What Differentiates The Various Diagnoses?

  • Severity

  • Time present

  • High or low mood

  • Specific symptoms and the number of symptoms present

  • Clearly definable “external” direct cause e.g. substance induced mood disorder

  • History



Risk factors red flags to screen for depression l.jpg
RISK FACTORS/RED FLAGS TO SCREEN FOR DEPRESSION

HISTORY:

  • Personal History Depression/Bipolar Disorder

  • Family History Depression/Bipolar Disorder/Alcoholism

  • History of abuse, physical, sexual, emotional

  • History of Anxiety Disorder

  • History of Substance Abuse/Alcoholism

    CURRENT:

  • Significant stressors: loss of job, family loss, family conflict, etc.

  • Substance abuse: drugs or alcohol

  • Weight loss, sleep disturbance, multiple somatic complaints with no clear diagnosis

  • Anxiety: moderate to severe

  • Poor job or social functioning; change in functioning

  • Self-Destructive behavior

  • Mood changes: “I can’t cope” “I’m overwhelmed”

  • Self-Destructive Behavior/wish to die

  • Medical Illness


Dsm iv criteria for major depression l.jpg
DSM-IV Criteria For Major Depression

  • Four hallmarks, nine symptoms:

    • depressed mood

    • anhedonia (loss of interest/pleasure)

    • four physical symptoms

    • three psychological symptoms

  • For diagnosis-depressed mood or anhedonia & at least 5 of the 9 symptoms

  • Symptoms most of time for 2 weeks

    *MacArthur Foundation Tool Kit


Depressed mood l.jpg
Depressed Mood

Hallmark 1

  • Neither necessary nor sufficient for the diagnosis

  • Can be misleading

  • Don’t hang everything on the question “Are you depressed?”

    *MacArthur Foundation Tool Kit


Anhedonia l.jpg
Anhedonia

Hallmark 2

  • Loss of interest or pleasure in things that you normally enjoy

  • May be the most important and useful hallmark

    * MacArthur Foundation Tool Kit


Physical symptoms l.jpg
Physical Symptoms

Hallmark 3

  • Sleep disturbance

  • Appetite or weight change

  • Low energy or fatigue

  • Psychomotor retardation or agitation

    *MacArthur Foundation Tool Kit


Psychological symptoms l.jpg
Psychological Symptoms

Hallmark 4

  • Low self-esteem or guilt

  • Poor concentration

  • Suicidal ideation or persistent thoughts of death

    *MacArthur Foundation Tool Kit


Dysthymia l.jpg
Dysthymia

  • Long term problem with moderate symptoms

  • Depressed mood most of time for 2 years

  • Plus 2 other symptoms of depression

  • High level of chronic impairment

  • Increased risk for major depression

    *MacArthur Foundation Tool Kit


Bipolar disorder l.jpg
Bipolar Disorder

  • Episodes of mania or hypomania along with depressive episodes

  • Mania may be overlooked; patient may hide symptoms or not see as problem

  • Often misdiagnosed and managed as unipolar depression

    *MacArthur Foundation Tool Kit


Misdiagnosis of bipolar patients l.jpg
Misdiagnosis of Bipolar Patients

  • Potential risks from antidepressants

    • May induce mania or hypomania

    • Can cause rapid cycling

  • Requires mood stabilizer (e.g. lithium or valproic acid) before brief use of antidepressant

  • Generally need psychiatry consultation or referral

    *MacArthur Foundation Tool Kit


Minor depression l.jpg
Minor Depression

  • Fewer symptoms than major depression

  • Shorter duration than chronic depression

  • Best management probably watchful waiting with regular follow-up

  • May Proceed with pharmacologic treatment or psychotherapy if symptoms persistent or worsening or significant disability/poor functioning

    *MacArthur Foundation Tool Kit


Depression anxiety continuum l.jpg
Depression Anxiety Continuum

  • National Co-Morbidity Screening 1999: 8098 Respondents

    Depression & Anxiety:

  • 14.9% a major depression/non bipolar disorder at some time in their life

  • 28.7% an anxiety disorder: generalized, panic, phobia, PTSD, OCD sometime in their life

    Co-morbidity:

  • 58% of these with lifetime incidence of depression had lifetime incidence of an anxiety disorder (most often Generalized Anxiety Disorder, Panic Disorder & PTSD)

  • Tendency to co-occur > each individually

    Treatment:

  • Anxiety and Depressive: either CBT or medication

  • Medication: SSRT’s effective in both. Benzodiazepines treat anxiety, not depression


Depression anxiety continuum18 l.jpg
Depression Anxiety Continuum

When do they occur or co-occur:

  • 2/3 lifetime history MDD & Anxiety Disorder reported Anxiety Disorder occurred at earlier date

  • 15.4% reported that MDD started before first Anxiety Disorder

  • 16% started at the same time


Depression anxiety continuum19 l.jpg
Depression Anxiety Continuum

Characteristics of Co-Morbid Anxiety & Depression

  • Illness is more persistent

  • Illness is more likely recurrent over time

  • Co-morbid anxiety has a significant increase in the persistence of depression

  • Co-morbid anxiety often predicts more severe depression

  • Some variation by type of anxiety disorder, e.g. all of the above are less likely with Panic Disorder


Other causes of depression l.jpg
OTHER CAUSES OF DEPRESSION

  • Medications

  • Substance induced

  • Medical Disorders


Elements of assessment l.jpg
ELEMENTS OF ASSESSMENT

Quantify severity of assessment

Assess and document impairment of function

Evaluate pertinent history and co-morbid conditions:

  • Past history of depression or other mental health problems

  • Past history of mental health treatment

  • Past history of substance use or substance use treatment

  • Family history of mental illness (particularly bipolar illness or alcoholism)

  • History suicide attempt

  • History physical or sexual abuse

  • Stressful life events

  • Social Isolation

  • Current substance use

  • Bipolar Illness

  • Current Medications



Epidemiology l.jpg
EPIDEMIOLOGY

  • Suicide was the 11th leading cause of death in the US in 1999. Preliminary data indicate that suicide was 9th leading cause of death in the US in 2001.

  • Suicide was the 8th leading cause of death for males, and 19th leading cause of death for females.

  • Suicide was the 3rd leading cause of death for young people aged 15-24


Epidemiology26 l.jpg
EPIDEMIOLOGY

  • Suicides in that year accounted for 1.3% of all deaths, compared with 30.3% from heart disease, 23% from cancer, and 7% from stroke (top three causes of death in the US).

  • Same number of people died by suicide as did from homicide. In 1996, there were three suicides in the US for every two homicides committed.


Epidemiology27 l.jpg
EPIDEMIOLOGY

  • Affective Disorder: 15% lifetime risk of suicide; 60% of all suicides.

  • Schizophrenia: 10% lifetime risk of suicide; 10% of all suicides.

  • Alcohol/Substance abuse: 3-5% lifetime risk of suicide; 25% of all suicides.

  • Highest suicide rates were for white men over 85, who had a rate of 59/100,000.


Three tasks of suicide assessment l.jpg
Three Tasks of Suicide Assessment

  • Gathering information about the patient’s risk factors for suicide

  • Gathering information about the patients suicidal ideation and plan

  • Clinical decision making using the information gathered


Major risk factors l.jpg

ADULTS

MALES MORE THAN FEMALES

PEOPLE WHO ARE WIDOWED,DIVORCED,SINGLE.

LACK OF SOCIAL SUPPORTS

UNEMPLOYMENT

DROP IN SOCIAL OR ECONOMIC STATUS

ADOLESCENTS

MALES MORE THAN FEMALES

MARRIED PEOPLE MORE THAN UNMARRIED

HISTORY OF PERINATAL DISTRESS

STATUS OF BEING UNWED AND PREGNANT

PARENTAL ABSENCE, ABUSE

ACADEMIC PROBLEMS

MAJOR RISK FACTORS


Major risk factors30 l.jpg

ADULTS

PRESENCE OF PSYCHIATRIC DIAGNOSIS, ESPECIALLY MAJOR AFFECTIVE DISORDERS

COMORBIDITY

PHYSICAL ILLNESS

FAMILY HISTORY

PSYCHOLOGICAL TURMOIL

HUMILIATION

EMBARASSMENT

PREVIOUS ATTEMPTS

ALCOHOL USE OR ABUSE

PRESENCE OF FIREARMS

ADOLESCENTS

AFFECTIVE ILLNESS, ESPECIALLY BIPOLAR

SUBSTANCE ABUSE, ATTENTION DEFICIT HYPERACTIVITY DISORDER,EPILEPSY

CONDUCT DISORDERS, IMPULSIVITY, EXPLOSIVENESS

FAMILY HISTORY

DISCIPLINARY CRISIS, HUMILIATION

PREVIOUS ATTEMPTS

EXPOSURE TO SUICIDE

PRESENCE OF FIREARMS AND ALCOHOL

MAJOR RISK FACTORS


Lethal triad of risk factors l.jpg
Lethal Triad of Risk Factors

Lethal triad of risk factors:

  • The patient presents immediately after attempting a serious suicidal act.

  • The patient presents with a dangerous display of the psychotic processes suggestive of lethality.

  • The patient shares suicidal planning or intent in the interview, suggesting that he or she is seriously planning imminent suicide ( or corroborative sources supply information suggestive of such planning).


Myths that become traps for the clinician in assessing suicide potential l.jpg
MYTHSthat become traps for the clinician in assessing suicide potential

  • Asking about suicidal plans will somehow “give the patient ideas.”

  • No known case where discussion of suicide gives patient “ideas.”

  • Reports of suicide are common in society – films, media, TV, games, lyrics


Myths that become traps for the clinician in assessing suicide potential33 l.jpg
MYTHSthat become traps for the clinician in assessing suicide potential

  • False belief that in the interview, the patient will give off clues or hints that they are at risk. (Leakage myth).

  • An ambivalent person may give some hint or frankly discuss this. Suicide is a topic that is seen as shame-producing or conversationally taboo. People more frequently keep thoughts of suicide private unless used for dramatic manipulation.


Common resistances to sharing suicidal thoughts l.jpg
Common resistances to sharing suicidal thoughts:

  • The client feels that suicide is a sign of weakness and is ashamed.

  • The client feels that suicide is immoral or a sin.

  • The client feels that discussion of suicide is literally a taboo subject.

  • The client is worried that the interviewer will perceive the client as crazy.

  • The client fears that he or she will be “locked up” if suicidal ideation is admitted.

  • The client truly wants to die and does not want anyone to know.

  • The client does not think that anyone can help.


What to look for in an assessment l.jpg
What to look for in an assessment

  • Direct Verbal Warnings

  • Depressed Behavior

  • Changes in Social Behavior

  • Making final plans

  • Suicidal History

  • Use of drugs and or alcohol

  • Intuition of a person close to the patient


Decreasing client reluctance to discuss suicide l.jpg
DECREASING CLIENT RELUCTANCE TO DISCUSS SUICIDE:

  • Use specific Wording

  • Listen for Hesitancy in Patient’s response

  • The no not really answer

  • Body Language

  • Don’t take notes

  • Take your time and try to appear at ease and unhurried


Direct verbal warning l.jpg
Direct Verbal Warning

  • Inability to keep going

  • Feelings of hopelessness and despair

  • Bids for Reaction from another person

  • Hints as to specific Plans


Hopeless helpless l.jpg
HOPELESS/HELPLESS

  • NO MOTIVATION NO INCENTIVE TO DO SOMETHING POSITIVE

  • BREEDS A FEELING THAT THIS IS AS GOOD AS IT IS GOING TO GET

  • IT IS A SENSE OF NOTHINGNESS- TOTAL EXISTENTIAL EMPTINESS

  • NO CONNECTION, NO FUTURE, NO LOVE

  • NO WISH, NO DESIRE TO GET BETTER


Worthless l.jpg
WORTHLESS

  • I AM NO GOOD

  • I AM USELESS

  • THERE IS NO REASON FOR THE PATIENT TO BE IN THE WORLD

  • IT IS ALL ABOUT HOW BAD THEY ARE


Helplessness l.jpg
HELPLESSNESS

  • No Ability To Change Anything

  • No Different From Day To Day

  • The Practitioner Can’t Help Either

  • No Power/ Feeling Like They Are Not Able To Do Anything For Themselves



Phq 9 l.jpg
PHQ-9

  • 0-5 Not depressed

  • 5-10 “watchful waiting” “Needs Follow up”

  • > 10 Diagnosable/treatable Diagnosis: Major Depression/Dysthymic Disorder

  • 10-20 referred to Primary Care M.D. if no serious risk factors: Suicide

    Homicide

    Severe Psychosis

    Severe Substance Abuse

  • If > 20 or serious risk factors may refer to Psychiatry for consultation and treatment


Phq 9 compared to clinician assessment of mdd l.jpg
PHQ-9 Compared to Clinician Assessment of MDD

Kroenke, J Gen Int Med, 2002