The Diagnosis and Treatment of Depression

1. The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3, 2007

2. 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

3. 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

4. Major Depression US Impact on Economy • Lost productivity cost employers • > $ 31 billion • Most loss due to reduced performance while at work

5. Risk Factors • Increased risk • female, native american, middle-aged, widowed, separated or divorced, low income • Decreased risk • asian, hispanic or black

6. 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

7. Precipitants • Psychosocial stressors • Adverse living conditions, war, environmental changes • Bereavement • Loss of a loved one • Loss • Housing, relationships, health

8. Meds/Supplements • Corticosteroids • Many patients experience a sense of well-being • Larger doses can cause hypomanic and/or depressive symptoms • Omega 3 fatty acids • Low levels correlate with depressive symptoms

10. Medical Conditions Associated with Depression • Hypothyroidism • Fibromyalgia • Systemic lupus erythematosus • Diabetes mellitus • Cardiovascular disease • Chronic pain • Others • Hypercalcemia, sjogren’s syndrome, seizure d/o

11. Depression vs Other Medical Conditions • Ask closed-ended questions about the nine 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

12. 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

13. Male vs Female • Men • 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

15. 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

16. 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?

17. PHQ-9 Questionnaire

18. 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

19. 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) • 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

21. 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

22. 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

23. Pharmacotherapyvs 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

24. 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

25. Bush using drugs to control depression and erratic behavior

26. 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

27. 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

28. 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

29. 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, bananas • TCs • 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

33. 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

34. 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)

35. Response to Medication • 50% of patients respond to the first choice • 20% stop due to side effects • 30% have no response

37. Hypericum Perforatum • St John’s Wort • European studies suggest more effective than placebo and equal to TC and SSRIs in short-term tx • US studies do not support efficacy in tx of severe depression • Consider for mild acute depression • Avoid concomitnt use with SSRI

40. National Library of Medicine       (www.nlm.nih.gov/medlineplus/healthtopics.html) National Institute of Mental Health      (www.nimh.nih.gov) American Psychiatric Association      (www.psych.org) American Psychological Association      (www.apa.org) American Academy of Child and Adolescent Psychiatry      (www.aacap.org) Depression and Related Affective Disorders Association      (www.drada.org) Depression and Bipolar Support Alliance (DBSA)      (www.DBSAlliance.org) National Foundation For Depressive Illness      (www.depression.org) National Mental Health Association      (www.nmha.org) National Alliance for the Mentally Ill      (www.nami.org) Resources

41. THANK-YOU FOR YOUR ATTENTION!