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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%.

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Major Depressive Disorder

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    1. Major Depressive Disorder A clinical review Barry J. Fenton, M.D.

    2. Depression—an Overview • Prevalence • Comorbidity • Impact on society • Diagnosis • Treatment options • Treatment guidelines • Treatment compliance

    3. 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.

    4. 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.

    5. 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.

    6. 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.

    7. 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.

    8. Depression Depression With Anxiety Symptoms 90% Anxiety Is a Common Symptom of Depression Sadock and Sadock 2003.

    9. 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.

    10. 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.

    11. 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.

    12. 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.

    13. 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.

    14. 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.

    15. 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.

    16. PHQ-9 Symptom Checklist Kroenke 2001.

    17. Translating PHQ-9 Depression Scores into Practice Kroenke 2001.

    18. Depression—Common Treatment Options IMS America February 2003; Sadock and Sadock 2003; Depression in Primary Care 2 (AHCPR), 1993.

    19. 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.

    20. 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.

    21. 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.

    22. 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.

    23. 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.

    24. 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.

    25. Life Explained

    26. References • 1. Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12-month prevalence of DSM-III-R: psychiatric disorders in the United States: results from the National Comorbidity Survey. Arch Gen Psychiatry. 1994;51:8-19. • 2. US Census Bureau. Profile of general demographic characteristics: 2000. Available at: Accessed March 26, 2003. • 3. Depression Guideline Panel. Clinical Practice Guideline Number 5. Depression in Primary Care, 1: Detection and Diagnosis. Rockville, Md: US Dept of Health and Human Services, Agency for Health Care Policy and Research; 1993. AHCPR publication 93-0550:23,52,58,60,61,62. • 4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000:349, 356, 371-372, 435. • 5. Kessler RC, Zhao S, Katz S, et al. Past-year use of outpatient services for psychiatric problems in the National Comorbidity Survey. Am J Psychiatry. 1999;156:115-123. • 6. Carney RM, Rich MW, Tevelde A, Saini, J, Clark K, Jaffe AS. Major depressive disorder in coronary artery disease. Am J Cardiol. 1987;60:1273-1275. • 7. Frasure-Smith N, Lespérance F, Talajic M. Depression following myocardioa infarction: impact on 6-month survival. JAMA. 1993;270:1819-1825. • 8. Anderson RJ, Freedland KE, Clouse RE, Lustman PJ. The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care. 2001;24:1069-1078. • 9. Bing EG, Burnham MA, Longshore D, et al. Psychiatric disorders and drug use among human immunodeficiency virus–infected adults in the United States. Arch Gen Psychiatry. 2001;58:721-728. • 10. Reifler BV, Larson E, Teri L, Poulsen M. Dementia of the Alzheimer’s type and depression. J Am Geriatr Soc. 1986:34:855-859. • 11. Rovner BW, Broadhead J, Spencer M, Carson K, Folstein MF. Depression and Alzheimer’s disease. Am J Psychiatry. 1989;146:350-353. • 12. Breslau N, Davis CG, Andreski P. Migraine, psychiatric disorders, and suicide attempts: an epidmiologic study of young adults. Psychiatry Res. 1991;37:11-23. • 13. Minden SL, Orav J. Reich P. Depression in multiple sclerosis. Gen Hosp Psychiatry. 1987;9:426-434. • 14. Joffe RT, Lippert GP, Gray TA, Sawa G, Horvath Z. Mood disorder in multiple sclerosis. Arch Neurol. 1987;44:376-378.

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    28. References • 29. Verbosky LA, Franco KN, Zrull JP. The relationship between depression and length of stay in the general hospital patient. J Clin Psychiatry. 1993;54:177-181. • 30. Wells KB, Stewart A, Hays RD, et al. The functioning and well-being of depressed patients: results from the Medical Outcomes Study. JAMA. 1989;262: 914-919. • 31. Hirschfeld RMA, Keller MB, Panico S, et al. The National Depressive and Manic-Depressive Association Consensus Statement on the Undertreatment of Depression. JAMA. 1997;277:333-340. • 32. US Department of Health and Human Services. Mental Health: a Report of the Surgeon General. Rockville, Md: Dept of Health and Human Services, Substance Abuse and Mental Health Services Administration; 1999:254-329. • 33. Simon GE, Goldberg SD, Tiemens BG, Ustun TB. Outcomes of recognized and unrecognized depression in an international primary care study. Gen Hosp Psychiatry. 1999;21:97-105. • 34. Simon GE, VonKorff M. Recognition, management, and outcomes of depression in primary care. Arch Fam Med. 1995;4:99-105. • 35. Callahan EJ, Bertakis KD, Azari R, Robbins J, Helms LJ, Miller J. The influence of depression on physician-patient interaction in primary care. Fam Med. 1996;28:346-351. • 36. Simon GE, VonKorff M, Piccinelli M, Fullerton C, Ormel J. An international study of the relation between somatic symptoms and depression. N Engl J Med. 1999;341:1329-1335. • 37. Kroenke K, Spitzer RL, Williams JBW. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16:606-613. • 38. IMS America. National Prescription Audit, February 2003. • 39. Depression Guideline Panel. Clinical Practice Guideline Number 5: Depression in Primary Care, 2: Treatment of Major Depression. Rockville, Md: US Dept of Health and Human Services, Agency for Health Care Policy and Research; 1993. AHCPR publication 93-0551:7, 28, 29, 109-112. • 40. Kupfer DJ. Long-term treatment of depression. J Clin Psychiatry. 1991;52(5, suppl):28-34. • 41. Young AS, Klap R, Sherbourne CD, Wells KB. The quality of care for depressive and anxiety disorders in the United States. Arch Gen Psych. 2001;58:55-61. • 42. Lin EHB, Von Korff M, Katon W, et al. The role of the primary care physician in patients’ adherence to antidepressant therapy. Med Care. 1995;33:67-74. • 43. Hirschfeld RMA, Montgomery SA, Keller MB, et al. Social functioning in depression: a review. J Clin Psychiatry. 2000;61:268-275.