HOW TO APPROACH A PT WITH DEPRESSION IN PRIMARY CARE

Dr Hanan abbas Assistant Professor of family Medicine

Learning Objectives
Prevalence of depression in primary care Consequences of undiagnosed and untreated

depression Presentations of depression in primary care Diagnostic criteria for depression Depression, diabetes & other co-morbidities Tools for screening, diagnosis of mental disorders in primary care

Mental disorders in primary care

25% of patients have a mental disorder
88% of patients with mental disorder seek

primary care first Diagnosis missed half the time for depression

Depression

usually untreated

or undertreated in Primary

Care

Treated Appropriately (only 1/6)

Untreated

Undertreated

Hirschfeld et al. JAMA. 1997;277:333-340.

Obstacles to diagnosis
Insufficient training Insufficient time Presentation with

somatic symptoms Competing problems Stigmatization Minimization

Physical complaints are rarely organic

10

3-Year Incidence (%)

No organic cause identified Organic cause

0
Chest Pain Fatigue Dizziness Headache Edema Back Pain Insomnia Dyspnea Abdominal Pain Numbness

Kroenke K, Mangelsdorff AD. Am J Med. 1989;86:262-266.

The Burden of Depression

Total costs = $44 billion per year in 1990 dollars Direct costs = $12.4 billion per year in 1990 dollars
Direct Costs
Absenteeism 25% Direct Costs 3% Indirect Costs Pharmaceuticals 28% Reduced Productivity 17% Mortality

27%

Greenberg et al. J Clin Psychiatry. 1993;54:405-418.

The Personal Price of Depression

Mental anguish

Poor physical functioning

Poor social and

occupational functioning Pain, somatic symptoms Family frustration Suicide and other mortality risks
Wells et al. JAMA. 1989;262:914-919.

The Personal Price of Depression

To most of us who have experienced it, the horror of depression is so overwhelming as to be quite beyond expression. . . it kills in many instances because its anguish can no longer be borne.
Styron. Darkness Visible: A Memoir of Madness. 1990.

Diagnostic Criteria for Major Depressive Disorder

Five or more of the following for at least 2

weeks

Depressed mood* Loss of interest or pleasure* Appetite/weight change Sleep disturbance Psychomotor disturbance Fatigue or low energy Feelings of worthlessness or inappropriate guilt Impaired ability to think or concentrate Recurrent thoughts of death or suicide

*At least one of these symptoms must be present.

Adapted from Diagnostic and Statistical Manual of Mental Disorders. 4th ed. (DSM-IV). 1994:327, 339.

Diagnosis Pathway*

Adapted from US Dept of Health and Human Services. Depression in Primary Care: Volume 1. Detection and diagnosis. AHCPR Publication No. 93-0550, Agency for Health Care Policy and Research, Rockville, MD 1993, p. 20

Screening: Good History a Must!

Suicide Risk
Psychiatric co-morbidities Family history Past history Substance Abuse Prescription Medications Occult medical illness

Risk Factors for depression

Family History

Depression Bipolar disorder Alcohol abuse Other psychiatric illness

Patient History

Age of onset of depression Gender Periods of significant depression in the past Previous episodes of other psychiatric disorder(s) Previous treatments

Differential diagnosis of depression

Rule out underlying medical

conditions (eg, CNS disease, hypothyroidism)

Rule out medications causing

depression
Screen for substance abuse

Depression and Comorbidity

Prevalence of Depression as a Concomitant Condition Cancer: 25% Diabetes: 32.5%
Postpartum: Post stroke: Post-myocardial

10%20% 32%

infarction:

16%

Massie, Holland. J Clin Psychiatry, 1990. Lustman et al. Diabetes Care, 1988. Dobie and Walker. J Am Board Fam Pract, 1992. Morris et al. Int J Psychiatry Med, 1990. Frasure-Smith et al. Circulation, 1995.

RR=2.2

Diabetes Mellitus RR=2

Major Depression

Potential Explanations
Depression as reaction to DM?
But, depression often precedes Type II DM

Depression>>>metabolic changes>>>DM?

Common neuro endocrine pathway?

Medication or lifestyle induced?

Metabolic change
...a surplus of insulin antagonists are present during severe depressions. These include epinephrine, growth

hormone, and cortisol. ... poor metabolic control was demonstrated by the psychiatrically ill group, both at index and follow-up evaluations."
Lustman et al, 1988

Medication Effects
Antidepressants and antipsychotics can affect glycemic control Consider both therapeutic and life-

threatening effects May require adjusting dose of insulin or oral agents for diabetes May influence choice of medication when treating mood disorder or neuropathy

SSRIs
inhibit reuptake of serotonin at neuronal membrane Side Effects

Anxiety/agitation, insomnia Sexual side effects GI nausea, vomiting Can lower seizure threshold Serotonin syndrome Rare hypoglycemia, anemia, visual disturbance, SIADH

SSRIs
Advantages
Safety Less orthostatic hypotension, anticholinergic side effects,

adverse cardiac effects Increased patient satisfaction Weekly formulation of fluoxetine available

Disadvantages

Cost - $50-150 per month Potential for interactions with other drugs Lack of sedation Development of serotonin syndrome Some distressing side effects

Antidepressants
Selective serotonin re-uptake inhibitors (SSRIs) tend to improve glycemic control, & may lead to the need to reduce insulin

or oral medication doses

Follow Up
Assess every 2-4 weeks
Titrate dose for total remission Maintain effective dose for 4-9 months Consider maintenance therapy

What do warnings mean for family docs?

Patients with new prescriptions for antidepressants & their family members should be warned of the risks of suicide Patients on a new antidepressant medication should have regular (e.g. every 1-2 week) appts. until they are stable

Drug Selection General Considerations

History of previous response Impact of antidepressant on concurrent medical

conditions
Bupropion with epilepsy Venlafaxine with severe hypertension Nefazodone with liver disease

Safety in overdose Potential for drug interactions Ease of administration Cost

Treatment Guidelines
Titrate agent to achieve therapeutic dose or remission
Full effect may take 4-6 weeks

Treat for 4-9 months after full remission

Continue medication indefinitely for

recurrent depression

Partial or No Response
Check for adherence
Re-evaluate diagnosis Adjust dose Change medication Add psychotherapy Obtain psychiatric consultation

Screening Instruments
What are the ideal features? Brief, compatible with time constraints Easy to administer & inexpensive Makes accurate diagnoses Educates the provider Educates the patient/fosters realization Overcomes stigmatization Associated with improved outcomes

Short instruments for depression

Original PRIME-MD: 2 questions

During the past month, have you 1) Often been bothered by feeling down, depressed, or hopeless? 2) Had little interest or pleasure in doing things? Sensitivity 86-96%, specificity 57-75%, comparable to more cumbersome measures

Clinician Time Requirements

45 40 35 30 25 20 15 10 5 0 < 1 min 1-2 mins 3-5 mins >5 mins % of total

Refer when:

Severe depression that is endangering the life of the patient (ie, suicidality or inability to care for self) or others (aggressivity or inability to care for dependent others). Depression that has failed to respond to initial treatment trials, whether due to patient adherence, perceived side effects, or treatment-refractoriness. Desire to treat with psychotherapy, light therapy, electroconvulsive therapy, or other modalities requiring specialty expertise. Psychotic depression. Depression that is part of the course of bipolar disorder, schizoaffective disorder, or another major psychiatric illness. Depression whose presentation or management is complicated by significant psychiatric comorbidity. Patients for whom the diagnosis of depression (or its comorbidities) is uncertain

Discussing Results With Patients

Review questionnaire results with patient Explain
You are not alone; this illness affects many people.
Depression/anxiety is a medical illness. Physical symptomslike yoursare common in ... is a medical illness like hypertension or diabetes

not a character defect or weakness.

Effective treatment is available.

When you cant do it alone

Assessing Suicidal Ideation

Studies show that more than 70% of suicide

victims visit a physician within 2 months preceding their death

Over the last 2 weeks, how often have you been bothered by thoughts that you would be better off dead, or of hurting yourself in some way? If the answer is yes: Tell me about it.

Spitzer et al. JAMA. 1994;272:1749-1756.

Suicidal Potential
Evaluate suicidal potential if during evaluation

patient admits to suicidal ideation by considering:

Degree of hopelessness about situation Any reason to stay alive (eg, for children) Thoughts of a specific method of suicide

Personal or family history of suicide attempts

If there is significant suicidal potential: refer to

psychiatrist

Key Points
Screening can be simple
Diagnoses missed half the time or more High prevalence and associated disability

make strong argument for routine screening

Questions?