Diagnosis and Classification of Depression

1. Diagnosis and Classification of Depression POST IT … Write down 7 characteristics of depression? Aim: Can I outline the clinical characteristics of depression? Can I discuss issues relating to the reliability and validity of diagnosis and/or classification of depression?

2. http://www.healthtalkonline.org/mental_health/Depression/Topic/1495/Interview/875/Clip/3322/http://www.healthtalkonline.org/mental_health/Depression/Topic/1495/Interview/875/Clip/3322/

3. Outline • What is depression • Symptoms • Causes • Types • Risk Factors • Women • Elderly • Young Adults

4. Outline • Racial/Ethnic Disparities • Psychosocial/Environmental Factors • Burden • Detailing Messages

5. What Is Depression? • A very common, highly treatable, medical illness. • Affects physical, mental and emotional well-being. • Affects basic, everyday activities like eating and sleeping. • Affects how people think about things and feel about themselves.

6. What is Depression? • In contrast to the normal emotional experiences of sadness, loss, or passing mood states, clinical depression is persistent and can interfere significantly with an individual's ability to function. • People with depressive illness cannot just “pull themselves together” and “get over it.” • Depression often takes on a life of its own – without treatment, symptoms can last months or even years.

7. Symptoms of Depression • Feeling sad, blue, or down in the dumps • Loss of interest in things you usually enjoy • Feeling slowed down or restless • Having trouble sleeping or sleeping too much

8. Symptoms of Depression • Loss of energy or feeling tired all the time • Having an increase or decrease in appetite or weight • Having problems concentrating, thinking, remembering or making decisions • Feeling worthless or guilty • Having thoughts of death or suicide

9. Symptoms of Depression • People with Major Depression experience at least five of these symptoms all day, nearly every day, for at least 2 weeks. • The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

10. Causes of Depression Causes not known, but current theories include: • Genetic • Runs in families • However, depression can also occur in people who have no family history. • Environmental • A serious loss, difficult relationship, financial problem, or any stressful (unwelcome or even desired) change in life patterns can trigger a depressive episode.

11. Causes of Depression • Personality Characteristics • low self-esteem, pessimistic world view, low stress tolerance • Whether this represents a psychological predisposition or an early form of the illness is not clear. • Biological • Continues to be studied extensively • Current thinking explores problems in brain functioning in the following areas: Limbic system, neurotransmitters and neurons, hormones and the endocrine system

12. Causes of Depression • Combination • a combination of genetic, psychological, environmental, and/ or biological factors may contribute to the onset of a depressive disorder.

13. Forms of Depression • Major Depression • At least 5 of the 9 symptoms of depression present including either loss of interest/pleasure or depressed mood; symptoms interfere with daily functioning • Minor Depression • Fewer symptoms than major depression with significant disability; shorter duration than chronic depression

14. Forms of Depression • Bipolar Disorder • Cycling mood changes with severe highs (mania) and severe lows (depression) • Dysthymia • Low grade chronic symptoms of depression that last for a minimum of 2 years

15. Depression and Suicide • Of those with MDD, close to 50% report feelings of wanting to die, 33% consider suicide and 8.8% report a suicide attempt. • More than 90% of those who commit suicide have a diagnosable psychiatric illness at the time of death, usually depression, alcohol abuse or both

16. Who is at risk for Depression? Anyone is potentially at risk for a depressive illness. Yet, these groups are believed to be at higher risk: • Older adults • Young adults • Women, pregnant and post partum women • Note: women report depression about twice as often as men. This may result from a greater likelihood to discuss depression or to seek help.

17. Depression in Women • Depression is the second leading cause of disease-related disability among women • 1 in 4 women will suffer from a Major Depressive Episode during the course of their lives as compared to 1 in 10 men. • Women may be more likely to discuss depression or to seek help. • Women of childbearing age are at increased risk for major depression • Pregnancy and new motherhood may increase the risk of depressive episodes

18. Depression in Older Adults • Of the nearly 35 million Americans age 65 and older, an estimated 2 million have a depressive illness (major depressive disorder, dysthymic disorder, or bipolar disorder). • Symptoms of clinical depression can be triggered by other chronic illnesses common in later life, such as Alzheimer’s disease, Parkinson’s disease, heart disease, cancer and arthritis. • Depression is one of the most common conditions associated with suicide in older adults. • Individuals age 65 and older have highest rates of suicide • High suicide rate among older people (85 and older) is largely accounted for by White men.

19. Depression in Young Adults • 10% of college students have been diagnosed with depression, including 13% of college women. • Lifetime prevalence for MDE highest among young adults age 18-25 (10%) • Suicide is the third leading cause of death for those aged 15-24

20. Additional Risk Factors for Depression • Family or personal history of depression • Current substance abuse problem • A major life stressor or change in life events; i.e.: loss of a loved one or a job • Chronic disease

21. Depression in Racial/Ethnic Minorities • Mental health needs of minority racial/ ethnic groups remain largely unmet . • Certain groups have higher rates of major depression • Native Americans • Women (middle aged, separated or divorced, low-income) • Mexican- American and white individuals • Have significantly earlier onset of major depressive disorder compared with African Americans.

22. Depression in Racial/Ethnic Minorities • Latinos with self reported depression are less likely to: • receive any treatment for depression • fill an antidepressant prescription • receive adequate course of psychotherapy • African American and Latinos are more likely than Whites to be under-diagnosed and under-treated • Minorities are less likely than Whites to receive treatments that adhere to treatment guidelines

23. Explanatory Factors • Lack of insurance coverage • Poor access to appropriate screening and early detection • Tendency to attribute mental health problems to religious and other cultural belief systems • Lack of access to receptive and culturally compatible providers

24. Psychosocial/Environmental Factors • Psychosocial health has been associated with mental health in general and with depression in particular • Neighborhood social disorganization is associated with depressive symptoms, • Living in socio-economically deprived areas is associated with depression. A recent study found • 29 % - 58% were more likely to report part 6 month depression • 36% - 64 % were more likely to report lifetime depression

25. Depression Burden • Untreated depression causes distress, disability, and, most tragically suicide. • Depressive disorders are associated with increased prevalence of chronic diseases (e.g. asthma, diabetes) • Increased use of general medical services as well as costlier health services, such as Emergency Room and Inpatient.

26. Depression Burden • Patients who are depressed are more likely to engage in behaviors that contribute to poor health, such as smoking, limited or no exercise, poor eating habits and are likely to have greater difficulty managing their co-morbid conditions.  Depressive disorders are projected to become the leading cause of disability and the second leading contributor to the global burden of disease by 2020 • US workers with depression cost employers an estimated $44 billion per year.

27. Detailing Messages • Primary care physicians can effectively detect and manage depression. • Routinely screen for depression using a simple 2-question tool (PHQ2) • Depression can be treated! Medication and psychotherapy, alone or in combination, can help most patients.

28. Detailing Messages • Primary care physicians can effectively detect and manage depression.

29. Detection of Depression: Why Screen and Manage in primary care? • Primary care is the 1st line of defense = To find people who may be depressed or at risk for depression who don’t know it • Screening for depression in the primary care setting improves detection rates • US Preventative Service Task Force (USPSTF) recommends screening adults for depression in clinical practices that have systems in place for accurate diagnosis, effective treatment, and follow-up. • Only 50% of those referred to specialty mental health practitioners complete more than one visit

30. Detailing Messages • Routinely screen for depression using a simple 2-question tool (PHQ2)

31. Depression Screening: PHQ2 • A physician can simply and quickly screen for depression by asking 2 questions (PHQ2): During the past 2 weeks, have you been bothered by: 1. little interest or pleasure in doing things? 2. feeling down, depressed, or hopeless? • The PHQ-2 is a valid and practical tool for depression screening in busy medical settings.

32. Detailing Messages • Depression can be treated! Medication and psychotherapy, alone or in combination, can help most patients.

33. Detailing Messages • More than 80% of people with clinical depression can be successfully treated. • Antidepressants are the 1st line treatment for moderate to severe depression • About half of the moderate to severe episodes of depression will improve with antidepressant treatment • A combination of pharmacotherapy and psychotherapy may improve treatment response , reduce risk of relapse, enhance quality of life, and increase adherence to pharmacotherapy.

34. How RELIABLE are current methods of diagnosing depression? • Are the measuring instruments used such as questionnaires or scales CONSISTENT? • I will know if… • Two independent assessors give the similar diagnosis = INTER-RATER RELIABILITY or • Test used to deliver the diagnosis are the same over time = TEST – RETEST RELIABILITY Kraemer et al (2012) – much research on evaluation of medical treatments, but little on quality of diagnosis

35. How VALID are diagnostic measures/classification systems? • Does it measure something that is real and distinct from other disorders? • Does it measure what it claims to measure? • Comorbidity – extent that 2 or more condition co-occur • Content validity– does it measure what is sets out to measure? • Concurrent validity – extent to which it agrees/corresponds with (concurs) with other existing standards

36. Why are reliability and validity important? • Faulty diagnosis • Incorrect treatment

37. How is depression diagnosed and measured? • Structured Clinical Interview for the assessment of major depressive disorder • Beck Depression Inventory (BDI) • International Classification of Diseases (ICD) • Diagnostic and Statistical Manual of Mental Disorders (DSM) • GP diagnosis/primary care diagnosis

38. DSM Used in America Requires that 5 of the clinical characteristics occur every day for 2 weeks +depressed mood or disinterest in pleasure +impair functioning/cause significant distress +not simply be attributed to bereavement Endogenous depression = hormones Reactive depression = triggered by external events

39. Evaluation… • Equally valid to ICD • Keller (1995) – ‘fair to good’ inter-rater reliability but • ‘fair’ at best test-retest reliability • This is supported by Zanarini (2000) • Keller suggested that this may be because: • sometimes 1 item disagreement makes a crucial difference for diagnosis on the threshold (5/9 must be present) • Zimmerman (2010) deems the DSM-IV too lengthy • Krupski and Tiller (2001) found only 1/4 Aus and NZ doctors could list 5 symptoms which could lead to unreliable diagnosis • Zimmerman created a brief version based on DSM based only on the mood and cognitive symptoms and found 95% agreement with full DSM IV

40. ICD-10 • Used in the UK and Europe • Very similar to DSM but requires that TWO of three key symptoms must be present: • (sad, depressed mood; loss of interest and/or lack of energy) • Andrews (1999) found this difference not to produce a significant number of discrepant responses = equal validity

41. Research into reliability Beck Depression Inventory (BDI) 21-item self-report questionnaire designed to measure severity thus helping to distinguish between e.g. major depression and dysthemia • Lobbesteal et al (2011) = inter-reliability tested the Structured Clinical Interview mixed sample of patients and non-patient controls found moderate agreement (coefficient of .66) • Beck et al (1996) = test-retest reliability tested responses of 26 outpatients at 2 therapy sessions one week apart using the BDI found significant reliability (coefficient.93) The BDI is also high in content validity ( as the criteria based on consensus among clinicians and based on psychiatric patients) AND concurrent validity ( as it concurs with other measures such as the Hamilton Depression Scale)

42. Research into validity • McCullough (2003) found few differences on a range of clinical, psychosocial and treatment response variables when comparing outpatients with different types of depression = invalid distinctions between different sub-types of depression • Weel-Baumgarten (2006) suggests that GP diagnoses may be biased based on previous patient knowledge = invalid * Comorbidity – often two or more condition co-occur. Specifically, anxiety disorders and major depression. Goodwin (2001) found suicidal thoughts with just depression vs no psychiatric disorder to be 5x more likely and tripple that if depression was combined with an panic disorder.

43. Cultural Differences • Karanz (2005) – NY (36 South Asian and 37 European American) • Tested cultural differences and found that • Ethnic minorities = identified the ‘problem’ in terms of social and moral terms with suggested treatments self-management and referral to non-professional help. European Americans = emphasised biological explanations for the symptoms, including hormonal imbalance’ and ‘neurological problems’.