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

1. Disability of depressed workers – how to recognize, treat and prevent depression in OHS Teija Honkonen MD, Psychiatrist, FIOH 14.1.2004

2. The term 'Depression' may refer to • Affect • Symptom • Syndrome (disorder)

3. Essential in the recognition of depressive disorders in OHS • Syndromatic approach • Longitudinal information and follow-up • Differential diagnostic reassessments • Assessment of co-morbidity

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. Important symptoms associated with depressive disorders • Anxiety • Physical symptoms • Fear of illness, hypochondriasis

12. Co-morbidity • Psychiatric co-morbidity • concurrent mental disorders / syndromes • Somatopsychiatric co-morbidity • concurrent mental disorder and somatic illness

13. 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%

14. 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

15. 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

16. 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

17. 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 ?

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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)

26. Main treatment methods of depression in OHS • Psychotherapy • mild – moderate depression • Antidepressant medication • moderate – severe depression • Psychotherapy and medication have a synergistic effect

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. Risk for recurrency of depression • After one episode 50% • After two episodes 70% • After three episodes > 90% • Long-term prophylactic treatment with antidepressant medication

34. Psychotherapy in depression • Supportive treatment • listening, understanding, offering practical advice and help, psychoeducation, maintaining hope • Specific short psychotherapies • cognitive • interpersonal (IPT) • problem focused • psychodynamic

35. Interpersonal psychotherapy, IPT • Time-limited • 12-16 sessions • three phases • Manualized • Active • Demonstrated efficacy Markowitz 2000

36. 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

37. 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

38. 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

39. Termination sessions (13-16) • Assessment of gains • Prevention of relapse • Graduation • Addressing non-response • Continuation / booster sessions ? Markowitz 2000

40. 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

41. 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

42. 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

43. 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

44. Primary prevention of depression? • Crisis interventions • Prevention of burnout • Physical exercise • Social support • Preventive treatment of seasonal affective disorder

45. 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