the diagnosis and management of depression louis t. joseph, m.d. hospital psychiatry and...
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THE DIAGNOSIS AND MANAGEMENT OF
DEPRESSION
Louis T. Joseph, M.D.
Hospital Psychiatry and Consultation Service
Brain Stimulation Service
Addiction Psychiatry Service
Henry Ford Health System
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Consult Question: Please evaluate for depression.
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WHAT DEPRESSION ISN’T
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AN ALL TO COMMON CONSULT…
42 year old female with past history of HTN and no past psychiatric history admitted to the hospital with several weeks of fatigue. Found to have a leukocytosis on CBC with predominance of blasts. Patient diagnosed earlier today with AML and has been crying for 2 hours. Mood euthymic on admission. Please evaluate for depression medications.
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MAJOR DEPRESSIVE EPISODE
5 or more symptoms of depression for a 2 week
period. At least one symptom is depressed mood or
anhedonia.
SIG E CAPS
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DEPRESSED MOOD
How are you feeling?
Up to 50% of patients will report they feel fine
when in fact they meet all the other criteria for
depression.
-How can you diagnose depression in a
patient who says they feel “fine”?
50% of patients will report a diurnal variation in
their mood
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SLEEP
Hypersomnia or Insomnia can occur
80% of depressed patients report insomnia
How does one define insomnia?
-1. difficulty initiating or maintaining sleep, or suffering
from non-restorative sleep.
-2. sleep disturbance (or associated daytime fatigue)
causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
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INTEREST (ANHEDONIA)
Key Point: Diminished interest and pleasure needs
to occur with almost all activities every day for all
day!
Ask about favorite foods and sex drive
Palpate the Limbic System during the interview
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GUILT
Needs to be excessive or inappropriate
Can also be feelings of worthlessness
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ENERGY
95% of depressed patients report decreased
energy
Do you feel fatigued?
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CONCENTRATION
85% of depressed patients report difficulty
concentrating
Can also count Indecisiveness or Trouble
thinking
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APPETITE
Can also ask about weight change which also
counts.
5% change in body weight over past month
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PSYCHOMOTOR
Can be agitation or retardation
How do we ask about this?
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SUICIDAL IDEATION
Incredibly common in depression, ~66%
10-15% complete suicide
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OTHER SYMPTOMS
Anxiety- 90%
Pain- 60-70%
Delusions and Hallucinations
-Mood congruent symptoms in MDD
-Hospitalize patient ASAP
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ADDITIONAL QUESTIONS AB OUT DEPRESSION
Past mood episodes?
Symptoms first noticed by patient and family?
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NECESSARY RULE OUTS
Bipolar Disorder
Substance Use
Demoralization
Bereavement
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BIPOLAR DISORDER
Need to rule our a history of mania or hypomania
Can be difficult because only 50% of the time,
patients recall mania
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OTHER FEATURES SUGGESTIVE OF BIPOLAR
DISORDER
Early age of onset
Psychotic Depression before age 25yo
Co-morbid substance use disorder
Postpartum Depression or Postpartum Psychosis
Rapid onset and offset of depressive episodes of
short duration (<3 months)
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O T H E R F E A T U R E S S U G G E S T I V E O F B I P O L A R D I S O R D E R
Family History of Bipolar Disorder
High density, three generation pedigrees
Hypomania associated with antidepressants
Repeated loss of efficacy of antidepressants after initial
response (at least 3 times)
Depressive mixed state (with psychomotor agitation, irritable
hostility, racing thoughts, and sexual arousal during depressive
episode)
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SUBSTANCE USE
Timeline, timeline, timeline!
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DEMORALIZATION
Various degrees of despair, helplessness,
hopelessness, confusion, and subjective
incompetence that people feel when they are failing
to cope with life’s adversities.
Can have the same symptoms of MDD
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Realm of ‘normal’ human
experience
When to consider depression
versus bereavement?
-Suicidal Ideation
-Severe loss of functioning
-Severe worthlessness
-Severe guilt
-Hallucinations
BEREAVEMENT
Marked Psychomotor
Retardation
Mummification
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BEREAVEMENT: TO TREAT OR NOT TO TREAT
Counseling or Psychotherapy is always helpful
What about antidepressants?
-Sparse evidence suggesting that they can be
effective if patient meets criteria for MDD
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WHEN TO CONSIDER PSYCHIATRY REFERRAL
1. Non-response to medications you are trying
2. Any case of bipolar disorder
3. Practicing outside your scope of expertise
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PROGNOSIS OF DEPRESSION
UntreatedDepressive episodes last 6-13 months
50% reoccurrence rate within the next 2 years
After first episode- 50-60% chance of having a second
episode.
After second episode-70% chance of having a third episode
After third episode-90% chance of having a fourth episode
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PROGNOSIS OF DEPRESSION
UntreatedEpisodes typically occur more frequently, become
longer, and are more severe the more untreated
episodes one has
Psychological stress typically plays a role in triggering
the first 1-2
episodes but not subsequent ones
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PROGNOSIS OF DEPRESSION
Treated
1. Treated episodes last 3 months in length
2. Cessation of antidepressant
treatment within the first 3-6 months
almost always leads to a relapse
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TREATMENT EFFICACY
1. Medications
35% for initial trial
75% after 4 treatment trials
2. ECT
90% remission
70% remission for medication refractory patients
3. Psychotherapy
Equivalent efficacy to medications for mild-moderate
depression
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NUMBER OF SUICIDES IN HENRY FORD HEALTH
SYSTEM HMO PER YEAR
13
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REFERENCESCoffey MJ: “Suicide in and HMO Population.” Presented at the Henry Ford Hospital Department of Psychiatry Grand Rounds, Detroit, Michigan, September 13th, 2012.
Coffey CE: Building a System of Perfect Depression Care in Behavioral Health. Joint Commission Journal on Quality and Patient Safety. April 2007; 33 (4): 193-199.
Mankad MV et al.: Clinical Manual of Electroconvulsive Therapy. Washington D.C., American Psychiatric Publishing, 2010.
Griffith J, Gaby L: Brief Psychotherapy at the Bedside: Countering Demoralization from Medical Illness. Psychosomatics. March-April 2005; 46(2): 109-16.
Rush AJ et al.: Acute and Longer-Term Outcomes in Depressed Outpatients Requiring One or Several Treatment Steps: A STAR*D Report. Am J Psychiatry. 2006 Nov; 163(11):1905-17.
Rupke SJ et al.: Cognitive Therapy for Depression. Am Fam Physician. 2006 Jan 1; 73(1):83-86.
Saddock BJ, Sadock VA: Kaplan and Saddock’s Synopsis of Psychiatry. Philadelphia, Lippincott, 2007.
Stern TA et al.: Massachusetts General Hospital Handbook of General Hospital Psychiatry. Philadelphia, Saunders, 2010.
Styron, William: Darkness Visible: A Memoir of Madness. New York, Random House, 1990.
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REFERENCES CONT.
Spitzer R, Kroenke K, Williams J. Validation and utility of a self-report version of PRIME-MD: the PHQ Primary Care Study. Journal of the American Medical Association 1999; 282: 1737-1744.
Kroenke K, Spitzer R L, Williams J B. The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine 2001; 16(9): 606-613
Rost K, Smith J. Retooling multiple levels to improve primary care depression treatment. Journal of General Internal Medicine 16: 644-645, 2001
Kroenke K, Spitzer RL. The PHQ-9: A new depression and diagnostic severity measure.Psychiatric Annals 2002; 32: 509-521.
Williams JW, Noel PH, Cordes J A, Ramirez G,Pignone M. Is this patient clinically depressed? Journal of the American Medical Association 2002; 287: 1160-1170.
Lowe B, Unutzer J, Callahan CM, Perkins AJ, Kroenke K. Monitoring depression treatment outcomes with the patient health questionnaire-9. Medical Care, 2004. 42(12): 1194-201.
Pinto-Meza A, Serrano-Blanco A, Penarrubia MT, Blanco E, Haro JM. Assessing depression in primary care with the PHQ-9: can it be carried out over the telephone? Journal of General Internal Medicine, 2005. 20(8): 738-42.