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Diagnosing Depression

Diagnosing Depression. Public Health Detailers’ Training NYC Department of Health and Mental Hygiene Ann M. Sullivan, M.D. Regional Director of Psychiatry for the Queens Health Network New York City Health and Hospitals Corporation . Outline. Diagnosis Risk Factors DSM-IV Criteria MDD

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Diagnosing Depression

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  1. Diagnosing Depression Public Health Detailers’ Training NYC Department of Health and Mental Hygiene Ann M. Sullivan, M.D. Regional Director of Psychiatry for the Queens Health Network New York City Health and Hospitals Corporation

  2. Outline • Diagnosis • Risk Factors • DSM-IV Criteria • MDD • Dysthymia • Bipolar • Minor Depression • Depression-Anxiety Continuum

  3. Outline • Other Causes • Assessment Elements • Suicide Assessment • Epidemiology • Risk Factors • Myths • Care Management

  4. Diagnosis of Mood Disorders DSM-IV Diagnostic Manual: • Dysthymic Disorder • Major Depressive Disorder • Cyclothymic Disorder • Bipolar Disorder • Mood Disorder due to: medical disorder, or substance induced • Other: “Minor Depression/Depressive Symptoms”

  5. What Differentiates The Various Diagnoses? • Severity • Time present • High or low mood • Specific symptoms and the number of symptoms present • Clearly definable “external” direct cause e.g. substance induced mood disorder • History

  6. How Diagnosis Made?

  7. RISK FACTORS/RED FLAGS TO SCREEN FOR DEPRESSION HISTORY: • Personal History Depression/Bipolar Disorder • Family History Depression/Bipolar Disorder/Alcoholism • History of abuse, physical, sexual, emotional • History of Anxiety Disorder • History of Substance Abuse/Alcoholism CURRENT: • Significant stressors: loss of job, family loss, family conflict, etc. • Substance abuse: drugs or alcohol • Weight loss, sleep disturbance, multiple somatic complaints with no clear diagnosis • Anxiety: moderate to severe • Poor job or social functioning; change in functioning • Self-Destructive behavior • Mood changes: “I can’t cope” “I’m overwhelmed” • Self-Destructive Behavior/wish to die • Medical Illness

  8. DSM-IV Criteria For Major Depression • Four hallmarks, nine symptoms: • depressed mood • anhedonia (loss of interest/pleasure) • four physical symptoms • three psychological symptoms • For diagnosis-depressed mood or anhedonia & at least 5 of the 9 symptoms • Symptoms most of time for 2 weeks *MacArthur Foundation Tool Kit

  9. Depressed Mood Hallmark 1 • Neither necessary nor sufficient for the diagnosis • Can be misleading • Don’t hang everything on the question “Are you depressed?” *MacArthur Foundation Tool Kit

  10. Anhedonia Hallmark 2 • Loss of interest or pleasure in things that you normally enjoy • May be the most important and useful hallmark * MacArthur Foundation Tool Kit

  11. Physical Symptoms Hallmark 3 • Sleep disturbance • Appetite or weight change • Low energy or fatigue • Psychomotor retardation or agitation *MacArthur Foundation Tool Kit

  12. Psychological Symptoms Hallmark 4 • Low self-esteem or guilt • Poor concentration • Suicidal ideation or persistent thoughts of death *MacArthur Foundation Tool Kit

  13. Dysthymia • Long term problem with moderate symptoms • Depressed mood most of time for 2 years • Plus 2 other symptoms of depression • High level of chronic impairment • Increased risk for major depression *MacArthur Foundation Tool Kit

  14. Bipolar Disorder • Episodes of mania or hypomania along with depressive episodes • Mania may be overlooked; patient may hide symptoms or not see as problem • Often misdiagnosed and managed as unipolar depression *MacArthur Foundation Tool Kit

  15. Misdiagnosis of Bipolar Patients • Potential risks from antidepressants • May induce mania or hypomania • Can cause rapid cycling • Requires mood stabilizer (e.g. lithium or valproic acid) before brief use of antidepressant • Generally need psychiatry consultation or referral *MacArthur Foundation Tool Kit

  16. Minor Depression • Fewer symptoms than major depression • Shorter duration than chronic depression • Best management probably watchful waiting with regular follow-up • May Proceed with pharmacologic treatment or psychotherapy if symptoms persistent or worsening or significant disability/poor functioning *MacArthur Foundation Tool Kit

  17. Depression Anxiety Continuum • National Co-Morbidity Screening 1999: 8098 Respondents Depression & Anxiety: • 14.9% a major depression/non bipolar disorder at some time in their life • 28.7% an anxiety disorder: generalized, panic, phobia, PTSD, OCD sometime in their life Co-morbidity: • 58% of these with lifetime incidence of depression had lifetime incidence of an anxiety disorder (most often Generalized Anxiety Disorder, Panic Disorder & PTSD) • Tendency to co-occur > each individually Treatment: • Anxiety and Depressive: either CBT or medication • Medication: SSRT’s effective in both. Benzodiazepines treat anxiety, not depression

  18. Depression Anxiety Continuum When do they occur or co-occur: • 2/3 lifetime history MDD & Anxiety Disorder reported Anxiety Disorder occurred at earlier date • 15.4% reported that MDD started before first Anxiety Disorder • 16% started at the same time

  19. Depression Anxiety Continuum Characteristics of Co-Morbid Anxiety & Depression • Illness is more persistent • Illness is more likely recurrent over time • Co-morbid anxiety has a significant increase in the persistence of depression • Co-morbid anxiety often predicts more severe depression • Some variation by type of anxiety disorder, e.g. all of the above are less likely with Panic Disorder

  20. OTHER CAUSES OF DEPRESSION • Medications • Substance induced • Medical Disorders

  21. ELEMENTS OF ASSESSMENT Quantify severity of assessment Assess and document impairment of function Evaluate pertinent history and co-morbid conditions: • Past history of depression or other mental health problems • Past history of mental health treatment • Past history of substance use or substance use treatment • Family history of mental illness (particularly bipolar illness or alcoholism) • History suicide attempt • History physical or sexual abuse • Stressful life events • Social Isolation • Current substance use • Bipolar Illness • Current Medications

  22. SUICIDE ASSESSMENT

  23. EPIDEMIOLOGY • Suicide was the 11th leading cause of death in the US in 1999. Preliminary data indicate that suicide was 9th leading cause of death in the US in 2001. • Suicide was the 8th leading cause of death for males, and 19th leading cause of death for females. • Suicide was the 3rd leading cause of death for young people aged 15-24

  24. EPIDEMIOLOGY • Suicides in that year accounted for 1.3% of all deaths, compared with 30.3% from heart disease, 23% from cancer, and 7% from stroke (top three causes of death in the US). • Same number of people died by suicide as did from homicide. In 1996, there were three suicides in the US for every two homicides committed.

  25. EPIDEMIOLOGY • Affective Disorder: 15% lifetime risk of suicide; 60% of all suicides. • Schizophrenia: 10% lifetime risk of suicide; 10% of all suicides. • Alcohol/Substance abuse: 3-5% lifetime risk of suicide; 25% of all suicides. • Highest suicide rates were for white men over 85, who had a rate of 59/100,000.

  26. Three Tasks of Suicide Assessment • Gathering information about the patient’s risk factors for suicide • Gathering information about the patients suicidal ideation and plan • Clinical decision making using the information gathered

  27. ADULTS MALES MORE THAN FEMALES PEOPLE WHO ARE WIDOWED,DIVORCED,SINGLE. LACK OF SOCIAL SUPPORTS UNEMPLOYMENT DROP IN SOCIAL OR ECONOMIC STATUS ADOLESCENTS MALES MORE THAN FEMALES MARRIED PEOPLE MORE THAN UNMARRIED HISTORY OF PERINATAL DISTRESS STATUS OF BEING UNWED AND PREGNANT PARENTAL ABSENCE, ABUSE ACADEMIC PROBLEMS MAJOR RISK FACTORS

  28. ADULTS PRESENCE OF PSYCHIATRIC DIAGNOSIS, ESPECIALLY MAJOR AFFECTIVE DISORDERS COMORBIDITY PHYSICAL ILLNESS FAMILY HISTORY PSYCHOLOGICAL TURMOIL HUMILIATION EMBARASSMENT PREVIOUS ATTEMPTS ALCOHOL USE OR ABUSE PRESENCE OF FIREARMS ADOLESCENTS AFFECTIVE ILLNESS, ESPECIALLY BIPOLAR SUBSTANCE ABUSE, ATTENTION DEFICIT HYPERACTIVITY DISORDER,EPILEPSY CONDUCT DISORDERS, IMPULSIVITY, EXPLOSIVENESS FAMILY HISTORY DISCIPLINARY CRISIS, HUMILIATION PREVIOUS ATTEMPTS EXPOSURE TO SUICIDE PRESENCE OF FIREARMS AND ALCOHOL MAJOR RISK FACTORS

  29. Lethal Triad of Risk Factors Lethal triad of risk factors: • The patient presents immediately after attempting a serious suicidal act. • The patient presents with a dangerous display of the psychotic processes suggestive of lethality. • The patient shares suicidal planning or intent in the interview, suggesting that he or she is seriously planning imminent suicide ( or corroborative sources supply information suggestive of such planning).

  30. MYTHSthat become traps for the clinician in assessing suicide potential • Asking about suicidal plans will somehow “give the patient ideas.” • No known case where discussion of suicide gives patient “ideas.” • Reports of suicide are common in society – films, media, TV, games, lyrics

  31. MYTHSthat become traps for the clinician in assessing suicide potential • False belief that in the interview, the patient will give off clues or hints that they are at risk. (Leakage myth). • An ambivalent person may give some hint or frankly discuss this. Suicide is a topic that is seen as shame-producing or conversationally taboo. People more frequently keep thoughts of suicide private unless used for dramatic manipulation.

  32. Common resistances to sharing suicidal thoughts: • The client feels that suicide is a sign of weakness and is ashamed. • The client feels that suicide is immoral or a sin. • The client feels that discussion of suicide is literally a taboo subject. • The client is worried that the interviewer will perceive the client as crazy. • The client fears that he or she will be “locked up” if suicidal ideation is admitted. • The client truly wants to die and does not want anyone to know. • The client does not think that anyone can help.

  33. What to look for in an assessment • Direct Verbal Warnings • Depressed Behavior • Changes in Social Behavior • Making final plans • Suicidal History • Use of drugs and or alcohol • Intuition of a person close to the patient

  34. DECREASING CLIENT RELUCTANCE TO DISCUSS SUICIDE: • Use specific Wording • Listen for Hesitancy in Patient’s response • The no not really answer • Body Language • Don’t take notes • Take your time and try to appear at ease and unhurried

  35. Direct Verbal Warning • Inability to keep going • Feelings of hopelessness and despair • Bids for Reaction from another person • Hints as to specific Plans

  36. HOPELESS/HELPLESS • NO MOTIVATION NO INCENTIVE TO DO SOMETHING POSITIVE • BREEDS A FEELING THAT THIS IS AS GOOD AS IT IS GOING TO GET • IT IS A SENSE OF NOTHINGNESS- TOTAL EXISTENTIAL EMPTINESS • NO CONNECTION, NO FUTURE, NO LOVE • NO WISH, NO DESIRE TO GET BETTER

  37. WORTHLESS • I AM NO GOOD • I AM USELESS • THERE IS NO REASON FOR THE PATIENT TO BE IN THE WORLD • IT IS ALL ABOUT HOW BAD THEY ARE

  38. HELPLESSNESS • No Ability To Change Anything • No Different From Day To Day • The Practitioner Can’t Help Either • No Power/ Feeling Like They Are Not Able To Do Anything For Themselves

  39. Assessment of Suicide Risk

  40. PHQ-9 • 0-5 Not depressed • 5-10 “watchful waiting” “Needs Follow up” • > 10 Diagnosable/treatable Diagnosis: Major Depression/Dysthymic Disorder • 10-20 referred to Primary Care M.D. if no serious risk factors: Suicide Homicide Severe Psychosis Severe Substance Abuse • If > 20 or serious risk factors may refer to Psychiatry for consultation and treatment

  41. PHQ-9 Compared to Clinician Assessment of MDD Kroenke, J Gen Int Med, 2002

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