Major Depressive Disorder . A clinical review Barry J. Fenton, M.D. Depression—an Overview. Prevalence Comorbidity Impact on society Diagnosis Treatment options Treatment guidelines Treatment compliance. 17.1%. Major depressive disorder. Alcohol dependence. 14.1%. 13.3%.
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Major Depressive Disorder A clinical review Barry J. Fenton, M.D.
Depression—an Overview • Prevalence • Comorbidity • Impact on society • Diagnosis • Treatment options • Treatment guidelines • Treatment compliance
17.1% Major depressive disorder Alcohol dependence 14.1% 13.3% Social anxiety disorder Posttraumatic stress disorder (PTSD) 7.8% Generalized anxiety disorder (GAD) 5.1% Premenstrual dysphoricdisorder (PMDD) 5%* 3.5% Panic disorder Obsessive-compulsive disorder (OCD) 2.5% 16 14 18 0 2 4 6 8 10 12 Lifetime prevalence (%) Lifetime Prevalence of Common Psychiatric Disorders *In menstruating women. Kessler 1994; Kessler 1995; DSM-IV-TR™2000.
Depression—Prevalence • In any given year, about 21 million American adults suffer a major depressive episode • Nearly 1 out of 6 American adults experience depression at some time in their lives • 21% of women • 13% of men Kessler 1994; US Bureau of the Census 2000; Depression in Primary Care, 1 (AHCPR) 1993; DSM-IV-TR 2000.
Depression—Medical Comorbidities Kessler 1999; Carney 1987; Frasure-Smith 1993; AHCPR Guidelines 1993; Anderson 2001; Bing 2001; Reifler 1986; Rovner 1989; Breslau 1991; Minden 1987; Joffe 1987.
Medical Conditions—Implications of Comorbid Depression • Increased somatic symptoms, eg, multiple pain complaints • Excess functional disability • Increased morbidity/mortality • Increased healthcare utilization and costs • Poor self-care • Decreased adherence to treatment regimens • Higher drug interaction potential due to polypharmacy Katon 1990; Gregor 1997.
48% of patients with PTSD Up to 65% of patients with panic disorder* Posttraumatic stress disorder Panic disorder 42% of patients with generalized anxiety disorder Depression GAD Social anxiety disorder OCD 34% to 70% of patients with social anxiety disorder 67% of patients with obsessive-compulsive disorder Depression—Anxiety Comorbidities Many patients with anxiety disorders have depression at some time during their lives *Figures for panic disorder and depression not specified as lifetime in DSM-IV-TR™. Kessler 1995; DSM-IV-TR™ 2000; Brawman-Mintzer 1993; Rasmussen 1992; Stein 2000; Van Ameringen 1991; Wittchen 1999.
Depression Depression With Anxiety Symptoms 90% Anxiety Is a Common Symptom of Depression Sadock and Sadock 2003.
Depression—Implications of Anxiety Comorbidities • Increased severity of symptoms • Increased impairment of mental and physical functioning • Delayed recovery In patients with comorbid panic disorder and depression, • Increased prevalence of suicide attempts • Decreased work productivity and attendance • Increased service use (medical, mental health, social services) Brown 1996; Coryell 1988; Roy-Byrne 2000.
Direct Costs = $12.4 billion per year Indirect Costs = $31.3 billion per year Absenteeism Mortality 27% 25% 17% Direct Costs (inpatient, outpatient, and partial care) 28% 3% Reduced Productivity Pharmaceuticals Depression—Economic Impact Cost of depression in the US estimated at $43.7 billion (1990 dollars) Prevalence-based analysis of direct and indirect costs of depression, including direct costs of medical, psychiatric, and pharmacologic care; mortality costs from depression-related suicides; and morbidity costs (reduced productivity and absenteeism) associated with depression in the workplace. Greenberg 1993.
Depression—Impact on the Healthcare System • Compared with those without depression, depressed individuals may • Utilize all types of healthcare services more often • Incur 1½ to 2 times greater healthcare costs • Have an increased length of hospital stay • Report significant worsening of physical, social, and role functioning Simon 1995; Luber 2000; Verbosky 1993; Wells 1989.
Major Depressive Disorder—Diagnostic Criteria Five or more of the following symptoms are present most of the day, nearly every day, during a period of at least 2 consecutive weeks At least 1 of these2 symptoms • Symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning DSM-IV-TR™ 2000.
Depression—Underdiagnosis • Prevalence • About 1/3 of people experiencing depression do not seek treatment • Approximately 1/3 to 1/2 of patients with depression who present in primary care do not receive a diagnosis of depression • Implications • Increased time spent on history taking and physical examination • Unnecessary diagnostic procedures, particularly in response to patients’ vague somatic complaints Hirschfeld 1997; US Dept of Health and Human Services 1999; Simon 1999; Simon and VonKorff 1995; Callahan 1996.
Depression—Somatic Presentation • Overall, 69% of depressed patients (range 45%-95%; P=.002) present with somatic complaints that can complicate diagnosis, such as • Headaches • Weakness • Constipation • Back pain • Joint pain • Abdominal pain Simon 1999; Depression in Primary Care 1 (AHCPR), 1993.
Patient Health Questionnaire-9 (PHQ-9)— Diagnostic Tool for Primary Care • Validated self-administered questionnaire • Scores interpreted by clinician • Quick and easy to administer • Yields accurate, validated depression diagnoses • Patient rates each of the 9 DSM-IV-TR™ criteria for depression on a scale of 0 (not at all) to 3 (nearly every day) • Brevity and ease of use make it a valuable resource • Tear-off sheets may be used as a diagnostic screener or to monitor disease severity over time Kroenke 2001.
PHQ-9 Symptom Checklist Kroenke 2001.
Translating PHQ-9 Depression Scores into Practice Kroenke 2001.
Depression—Common Treatment Options IMS America February 2003; Sadock and Sadock 2003; Depression in Primary Care 2 (AHCPR), 1993.
PHASE 1: Acute Phase of Treatment PHASE 2: Continuation Phase of Treatment PHASE 3: Maintenance Phase of Treatment Remission Recovery “Normalcy” X o X o o Relapse Symptoms Recurrence Relapse Response Progression to Disorder Syndrome Treatment phases Acute(6-12 weeks) Continuation(4-9 months) Maintenance (1 or more years) Depression—AHCPR* Treatment Guidelines *Agency for Health Care Policy and Research currently known as the Agency for Healthcare Research and Quality (AHRQ), an agency within the US Department of Health and Human Services. Kupfer 1991; Depression in Primary Care, 2 (AHCPR) 1993.
Patients (%) Any antidepressantuse Appropriate antidepressantuse Anycounselinguse Appropriate counselinguse Appropriate treatment Inappropriate or no treatment Depression—Undertreatment In a 12-month period, one study showed, A majority of patients with depressive disorder did not receive adequate treatment Young 2001.
Patients who received appropriate care (%) Female Male White Hispanic Black 18-29 30-39 40-49 50-59 60 Gender Ethnicity Age (yr) Depression—Predictors of Appropriate Care In a 12-month period, one study showed, Receipt of minimally adequate treatment varied by gender, ethnicity, and age Young 2001.
Patients adherence totreatment (%) Treatment month Depression—Adherence to Treatment In a study examining adherence, 28% of patients discontinued antidepressant treatment within the first month • According to AHCPR, patients who discontinue medication early have a relapse rate of about 25% within 2 months Lin 1995; Depression in Primary Care, 2 (AHCPR) 1993.
Risk of recurrence (%) After 1 depressive episode After 2 depressive episodes After 3 depressive episodes Depression—a Highly Recurrent Disorder DSM-IV-TR™ 2000; Kupfer; 1991.
Depression—Summary • Depression will affect nearly 1 in 6 American adults at some time in their lives • Depression has been associated with both chronic medical and psychiatric conditions • Depression is often underdiagnosed and undertreated • Depression can • Be costly to society • Decrease patient quality of life • Effective treatments are available • Treatment guidelines recommend that antidepressant treatment be continued for a minimum of 4 to 9 months after remission Kessler 1994; Bureau of the Census 2000; Depression in Primary Care, 1 (AHCPR), 1993; Kessler 1999; Carney 1987; Frasure-Smith 1993; Anderson 2001; Bing 2001; Reifler 1986; Rovner 1989; Breslau 1991; Minden 1987; Joffe 1987; Kessler 1995; Brawman-Mintzer 1993; Rasmussen 1992; Stein 2000; Van Ameringen 1991; Hirschfeld 1997; US Department of Health and Human Services 1999; Simon 1999; Simon and VonKorff 1995; Callahan 1996; Greenberg 1993; Simon 1995; Luber 2000; Verbosky 1993; Wells 1989; Hirschfeld 2000; Kroenke 2001; Kupfer 1991. Depression in Primary Care, 2 (AHCPR) 1993.
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