Major Depressive Disorder: Recognition and Management in Primary Care

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Major Depressive DisorderRecognition and
Management in Primary Care
Dr. Levkovitz Y.Director Day-Hospital
Cognitive and Emotional Laboratory, Shalvata
Mental Health Center,School of Medicine, Tel
Aviv University, Israel.
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Objectives

• To be more knowledgeable about recognizing and
  treating depression
• To increase comfort in managing depression in
  primary care

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Causes of Disability by Illness CategoryUnited
States and Canada15-44 years old
WHO World Health Report 2002
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Causes of Disability by Specific IllnessUnited
States and Canada15-44 years old
WHO World Health Report 2002
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Epidemiology

• Major Depressive Disorder (MDD) is the one of the
  most common mental disorders in primary care
  settings
• The prevalence of current MDD in primary care
  settings has been found to range from 9.2 to
  13.5
• MDD may occur at any age

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Natural History of Major Depression

• Recurrent, episodic disorder in gt 50
• Residual symptoms persist between episodes in
  20-35 (partial remission)
• Systemic disorder .
• Most serious complication is suicide others
  include marital, parental, social, and vocational
  difficulties.

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Recognition

• Depression is difficult to diagnosis in primary
  care and often goes undetected
• depressed mood typically not presenting complaint
  
• competing demands (acute and chronic illnesses)
• limited resources and time

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Major Depression Four Hallmarks

• Depressed Mood.
• Anhedonia loss of interest or pleasure
• Physical Symptoms
• sleep disturbance, low energy, appetite or weight
  change, psychomotor changes
• Psychological Symptoms
• low self-esteem, poor concentration, suicidal
  ideation/obsession surrounding death.

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Assessing for Depression and Anhedonia

• Do not ask patient Are you Depressed?,
  INSTEAD, Ask How has your mood been?
• Ask about Anhedonia What are you doing for
  fun? OR Does your (pain,anxiety, grief,
  whatever symptoms patient mentions) keep you from
  doing all the things you enjoy?

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Risk Factors

• Prior episode of depression
• Family history of depressive disorder
• Prior suicide attempt
• Female gender
• Medical conditions
• Lack of social support
• Stressful life events
• Current substance use

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???? ( ???? 1)????? ?????

• Substance Induced Disorder ?
• Mood Disorder ?
• Anxiety Disorder ?
• Personality Disorder ?
• Relationship distress, financial
• stress related ??
• Medical Conditions ?
• Medications ?

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Marijuana User
Dependence/Withdrawal - 9.2 (Warner, 1995) -
20 (Hall, 1994 ) - anger, irritability,
aggression - aches, pains, chills - depression
- inability to concentrate - sleep
disturbance - slight tremors -
decrease in appetite - sweating - craving 3 to
7 days, to several weeks after abstinence
(Haney, 1999)
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Organic Illnesses Associated with Depression

• Rheumatologic - systemic lupus erythematosus,
  rheumatoid arthritis
• Cardiac - mitral valve prolapse.
• Endocrine - hyperthyroidism, hypothyroidism,
  diabetes mellitus, hypercalcemia, Cushings
  syndrome

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Chronic fatigue syndrome
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What is chronic fatigue syndrome?
Definition

• Four or more of
• impaired short term memory or concentration
• sore throat
• tender lymph nodes
• muscle pain
• joint pain
• headaches
• unrefreshing sleep
• post-exertional malaise

• Unexplained, persistent or relapsing fatigue,
  that is
• of new, definite onset
• not due to exertion
• not relieved by rest
• associated with a substantial reduction in daily
  activities

and
Fukuda K et al. Ann Intern Med 1994 121 953-9.
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Drugs Commonly Associated with Depression

• Benzodiazepines
• Cimetidine
• Beta-blockers
• Corticosteriods
• Oral contraceptives
• Indomethacin

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Assessing Risk of Suicide

• Assess risk factors
• PRIOR ATTEMPTS
• Family history of suicide
• Hopelessness
• Demographics
• Caucasian, male, elderly, lives alone
• Clinical
• Substance abuse, psychosis, potentially terminal
  illness

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Assessing for Suicide

• Use a gradual, sensitive approach to raise the
  subject
• How does the future look to you?
• Living with (pain/anxiety/patients symptoms) can
  be very difficult. Do you sometimes wish your
  life was over?
• Have you had thoughts that you would be better
  off dead?
• Have you had thoughts of hurting yourself?
• Have you thought about how you might hurt
  yourself?

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When to Consider Involving Psychiatry

• Suicidal ideation
• Psychotic symptoms
• Manic symptoms
• Current substance abuse
• Severe psychosocial problems

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Interventions What can be done?

• Depression is one of the most treatable mental
  illnesses
• 70 - 75 of all depressed people respond to
  treatment
• almost all who receive treatment experience some
  relief in symptoms
• Medication
• Psychotherapy
• Electroconvulsive Therapy
• Watchful waiting

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Management of Depression

• Give an adequate trial of treatment (therapeutic
  dose for 6-8 weeks)
• Follow closely until patient responds
• Change treatment if patient doesnt respond
• Continue medication for 6-9 months minimum.
• If patient has a history of 2 or more previous
  depression episodes, continue for 2 years or more.

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Overview of Antidepressants

• Selective Serotonin Reuptake Inhibitors (SSRIs)
• fluoxetine (Prozac), sertraline (Zoloft),
  paroxetine (Paxet), citalopram (Lustral)
• Selective Serotonin Norepinepherine Reuptake
  Inhibitors (SNRIs)
• venlafaxine (Effexor), Duloxetine (Cymbalta).
• Medications With Unique Mechanism of Actions
  (MOA)
• bupropion (Wellbutrin), mirtazapine (Remeron),
  nefazodone (Serzone)
• Older Agents (Tricyclic antidepressants or TCAs)
• desipramine, nortriptyline
  

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Therapeutic vs. Side Effects
Therapeutic effects
Effects of antidepressant treatment
Side effects
0
1
2
3
4
Time in weeks
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Side Effects

• Are relatively common
• Are the 1 reason patients give for stopping
  medications
• Therefore
• Talk to patients about common side effects
• Wait - many side effects resolve with time
• Consider reducing the dose temporarily
• Consider changing to another type of medication
• Consider changing timing of medication

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Adjunctive Medications

• Anxiety
• Consider short term use of a benzodiazepine
• Insomnia
• Trazodone warn about priapism
• Antihistamines (hydroxyzine, diphenhydramine)
• Sexual Dysfunction
• sildenafil

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???? ( ???? 1)????? ?????

• Major Depressive Episode with some Atipycal
  features, with obsessions and compulsions,
  History of Social Anxiety Disorder ?
• Why not just SAD?
• Why not Mixed Anxiety and
• Depression?

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Depression Features Specifiers

• Melancolia
• Either loss of pleasure or lack of reactivity to
  usually pleasurable stimuli.
• gt3 of prevasive non reactive sadness-melancholic,
  depression
• worse in the morning, early morning awakening,
  marked psychomotor retardation or agitation
  significant anorexia or weight loss, excessive or
  inappropriate guilt.
• Atypical
• Reactivity of mood to positive events.
• gt2 of significant weight gain or increased
  appetite, hypersomnia, leaden paralysis or long
  standing pattern of interpersonal rejection
  sensitivity.

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• Thanks !

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Depression in Primary Care

• Depression In Western Industrialized Nations
  (DSM-IV)
• Males 2-3 of population at any given time, and
  5-12 for population in lifetime.
• Females5-9 of population at any given time, and
  10-25 for population in lifetime.
• Percent of mental disorders accounted for by
  depression Males (up to) 15, Females (up to)
  45 (rough estimate).
• In primary care practices 5-9 patients at any
  given time have Major Depression (it is estimated
  that only one third to one half are recognized by
  practitioners).

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Consequences of Untreated Depression

• Depression is the 2nd leading cause of disability
  in industrialized countries
• Depression associated with
• 2x increased risk of death overall
• 26x increased risk of suicide
• Impaired social functioning

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Consequences of Untreated Depression (continued)

• Depressed patients visit primary care provider 3x
  more than non-depressed patients
• 2-5x increase in days absent from work
• Cost of depression in US in 1990 estimated to be
  44 billion

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Making the Diagnosis

• Depression Disorders
• Major depressive disorder (MDD)
• Minor (subthreshold) depression
• Adjustment disorder with depressed mood
• Dysthymia

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Diagnostic Criteria for Major Depression
(DSM-IV)

• Major depression is present when the patient has
  had at least 5 of the 9 following symptoms for a
  minimum of two weeks. One of the symptoms must
  be either
• Depressed mood -- or --
• Loss of interest or pleasure -- and --

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Diagnostic Criteria (continued)

• 3. Significant change in weight or appetite
• 4. Insomnia or hypersomnia
• 5. Psychomotor agitation or retardation
• 6. Fatigue or loss of energy
• 7. Feelings of worthlessness or guilt
• 8. Impaired concentration or ability to
  make decisions
• 9. Thoughts of suicide or self-harm

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Diagnostic Criteria (continued)

• Symptoms must be accompanied by functional
  impairment in one or more of the following
  domains
• work/school
• doing things at home
• relationships with other people
• PHQ9 includes 10th question addressing functional
  impairment

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Depression Coexisting with Other Behavioral
Disorders

• Alcohol Dependency
• Anxiety Disorders (panic attacks, phobias)
• Eating Disorders
• Obsessive Compulsive Disorder
• Somatization Disorders
• Personality Disorders
• Grief and Adjustment Reactions

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Minor depression

• Patient has 2 to 4 of the 9 symptoms listed above
  
• Symptoms present for at least two weeks
• One of the symptoms must be either item 1
  (depressed mood) or item 2 (loss of interest or
  pleasure)

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Selective Serotonin Reuptake Inhibitors (SSRIs)

• fluoxetine (Prozac), sertraline (Zoloft),
  paroxetine (Paxil), citalopram (Celexa)
• Side effects
• Insomnia or sedation, agitation/restlessness, GI
  distress, sexual dysfunction, headache
• Absolute contraindication
• MAOI (not selegiline)
• Relative contraindication
• Mania history (manic depression)

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Dysthymia

• Depression present more days than not, for 2
  years or more
• Well period can not last more than 2 months
  during this time

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Depression Coexisting with Other Medical Disorders

• Stroke
• Dementia
• Diabetes
• Coronary Artery Disease
• Cancer
• Chronic Fatigue Syndrome
• Fibromyalgia

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Response and Remission defined
Hamilton Depression Rating Scale (HAM-D) 17
Items, Total Score 0 - 52
HAM-D17 Scores
Depression (Major Depressive Disorder)
15

• Response
• ? 50 reduction from baseline HAM-D score
• Remission HAM-D Score ? 7

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References 1. Frank E. Conceptualization and
rationale for consensus definition terms in MDD,
Arch Gen Psych. 1991 48851-855.
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Drug Interactions

• Sertraline and citalopram have no clinically
  significant drug interactions through the CYP450
  system
• Fluoxetine and paroxetine are potent 2D6
  inhibitors
• Nefazodone is a potent 3A4 inhibitor

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Common Barriers to Treatment

• Practical Barriers
• Ethnic/Cultural barriers
• Patient doesnt agree with diagnosis or plan
• Patient doesnt understand treatment plan
• Patient is afraid of becoming addicted to
  antidepressants

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Common Barriers to Treatment (Continued)

• Side effects
• Patient forgets to take medications or runs out
  early
• Formulary restrictions
• Friends or family are not supportive
• Treatment is not working patient feels
  hopeless
• Treatment is working patient is better and
  wants off

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Adherence

• 20-50 of patients drop out in the first month
  of treatment
• 30-50 of patients dont have a complete response
  to the initial treatment
• If patient is not better at 8 weeks, consider
  changing medication, adding psychotherapy, or
  getting a psychiatric consultation

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Improving Medication Adherence

• Tell patients
• Medications take time to work
• Medications are not addictive
• Take medications every day as ordered
• Take medications even if you feel better
• Do not stop medication before first contacting
  your physician
• Engage in pleasant activities
• Call your provider if you have questions

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What To Do If Patients Dont Get Better

• Wrong diagnosis?
• Insufficient dose?
• Insufficient length of treatment?
• Problems with barriers to adherence?
• Side effects?
• Other complicating factors?
• Wrong treatment?

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Continue Medication for 6-9 Months or More

• Medications should be continued for 6-9 months
  after the patient gets better
• People at high risk for relapse (those with at
  least two prior episodes of major depression,
  dysthymia, or residual depressive symptoms)
  should get a full dose of medication for 2 years
  or more to prevent recurrences
• See patients at least every 3 months

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What To Do If Patients Relapse

• Assess adherence to medication regimen
• Examine for new stressors
• Restart treatment at the last effective dose of
  antidepressants or consider an increase in dose
  if patient is still taking medication
• Consider adding psychotherapy
• Consider psychiatric consultation

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Preparing the Patient for a Mental Health Referral

• Bring up the possibility of a mental health
  consultation when first presenting the diagnosis
  of depression to the patient.
• The request for a mental health consultation is
  simply a matter of obtaining another professional
  opinion.
• Draw the analogy of referrals made to other
  medical specialist, like cardiologists,
  endocrinologists, etc.

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Side Effects of Other Antidepressants

• bupropion (Wellbutrin)
• Main contraindication is seizure disorder or
  eating disorder
• Also effective for smoking cessation
• Less sexual dysfunction than others
• mirtazapine (Remeron)
• Sedation
• Weight gain
• venlafaxine (Effexor) Relative contraindication
  if HTN is present
• nefazodone (Serzone) Carries a black box warning
  for liver failure

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Antidepressant Dosing

• Once a day dosing
• Give sedating meds at bedtime (paroxetine,
  mirtazapine, nefazodone)
• Activating meds (fluoxetine) in the morning
• Starting dose is lower with the elderly, with the
  medically ill, and if there is a comorbid panic
  disorder.
• Titrate to therapeutic dose as tolerated by side
  effects