When Will I Get Better? Prognostic Factors Related to Mood Disorders

1. When Will I Get Better? Prognostic Factors Related to Mood Disorders Todd Finnerty, Psy.D. PsychContinuingEd.com OPA 2010

2. “It may be a matter of weeks, or a matter of years”

3. My main goals • To encourage researchers to look at this question • To encourage practitioners to focus on these issues

4. Why assess for severity and prognosis?

5. ? • Select Interventions • Identify potential roadblocks • Predict the course of treatment

6. Expectations • The clinical course of depression is “highly variable” • Depressive episodes may often improve relatively quickly. • Two people who are diagnosed with depression may not appear the same

7. Client #1 (fewer factors) Client #2 (more factors ) A Tale of Two Clients

8. Client Number One • 20 something male • In the psych unit overnight • Resistant to discussing feelings • Had made a suicide-related statement in an e-mail • Denied suicidal ideation, denied psychosis, denied a history of depression or anxiety

9. Client Number One (cont.) • The psychiatrist felt there was “no serious intent when he made the suicidal statement. It appears to be more an act of frustration. He was counseled about the need to act responsibly…” • There was no diagnosis at discharge, no medications prescribed.

10. Client Number Two • 20 something male • In the psych unit overnight • Resistant to discussing feelings • Based on the client and collateral contacts:

11. Client Number Two (cont.) • Very early onset of psych difficulties (childhood) • Also diagnosed w/ depression and selective mutism in the 8th grade • Comorbidity: History of depression, anxiety, learning and speech difficulties

12. Client Number Two (still cont.) • Hx of failed treatments/recurrent problems • Hx of interpersonal problems and a perception of poor social support • Potentially negative and angry view towards others and the world.

13. We’re still on Client #2 • Suicidal and homicidal ideation (planning/intent?) • He owns knives and firearms • Possible hx of psychotic symptoms/ paranoid delusions

14. Does Client #1 have less severity and a better prognosis than #2?

15. Less severity or… …did we just have less information?

16. Client 1 & Client 2 are the same person

18. and I quote…

19. “no serious intent when he made the suicidal statement. It appears to be more an act of frustration. He was counseled about the need to act responsibly…”

20. What happened?

21. Would we have thought the same thing?

22. An Imperfect Science

23. Can the science and practice be improved upon?

24. Good Fair Guarded Poor

25. Specific Factors: Physiological Cognitive Clinical

26. “Physiological” factors • Ex: potential “biomarkers;” lab tests- factors linked to vascular disease; genetic testing; sleep EEG/brain waves • Most “physiological” research studies are generally designed to predict medication response • Hx of conflicting findings • Currently have limited utility in your office

27. Still waiting for the flying car • Don’t ignore co-occurrence with physical concerns (ex: pain) which will significantly impact prognosis.

28. “Cognitive” Factors • Psychomotor slowing- vegetative sxs • Executive Functioning • Controlling yourself • Managing emotions • Sustaining attention and effort Predictive of worse clinical, social and occupational outcomes in mood disorders.

29. What does this mean for someone with a comorbid ADHD, LD or language disorder? (+ mood dysregulation?)

30. Some specific “Clinical” factors • Overall Severity and comorbidity • The nature of onset • A chronic or recurrent course • Prior failed and intensive treatments • Suicidal intent • Interpersonal concerns • Stable “trait” factors

31. Determining Overall Severity • Clinical impressions • Screeners such as the Beck scales, PHQs • As easy as Mild, Moderate and Severe?

32. The “middle ground” may have the best prognosis- both in terms of severity and age of onset***

33. The nature of onset • Age of first episode • Quick vs more gradual • Patterns of decompensation/deterioration • Ex: “the downward spiral”

34. Chronicity

35. We want to know where the client has been to help determine where they are going. Those who do not learn from history…

36. DSM-5 ETA 5/2013 Is a diagnosis of “Dysthymic Disorder” necessarily less severe than a diagnosis of “Major Depressive Disorder?” -A dx may not always communicate px -Potentially longer tx and more long- term impairment when chronic regardless of the dx.

37. A proposed new Chronic Depression diagnosis • Chronic Depressive Disorder? • Dysthymic disorder and chronic MDD combined for DSM-5? • See dysthymic disorder at dsm5.org

38. Caution: • Client #1 had no chronic history • Relying on self report alone can lead to dichotomies like Client #1 & Client #2 being the same person • You are counseled to use self report “responsibly”

39. What can we do?

40. Focus on the Fundamentals • The “devil” is in the details (follow up) • Frequency, Intensity, Duration • Ex: A one minute, one-time panic attack vs regular, prolonged attacks.

41. Symptoms do not equal Severity (focus on functioning)

42. Focus on Functioning • All symptoms are not created equally • The same symptoms do not effect different people in the same ways • We all live in “different worlds”

43. No Man is an Island • What type of assistance/ accommodations allows them to function the way they do? • Can someone’s environment swing their prognosis one way or the other? • Social support (!)

44. Case Example The apparent functioning of an anxious and depressed person with a supportive significant other vs one without that support. How would they appear if they were both thrown in an environment without those supports?

45. Involve others • Is it “taboo” to get collateral information from family/significant others in treatment? • Can involving others in an individual’s treatment help them perceive social support? • Did collateral reports make a difference in our client #1 vs client #2 scenario?

46. Social Support = muy importante

47. Interpersonal factors Some people behave in ways which “create” negative interpersonal experiences even when not depressed “Stress-generating behaviors” -their interpersonal problem solving difficulties lead to conflict

48. Interpersonal Factors • Negative feedback-seeking • People with negative opinions of themselves may try to convince others of their “worthlessness.” • People may “look for” and sometimes obtain interpersonal rejection

49. Excessive Reassurance Seeking • Significant others may start out comforting, but proceed to annoyed and potentially rejecting • An eventual negative effect on perceived social support?

50. Excessive Reassurance Seeking: By the way, how is my presentation so far?