Depression Can it ever be cured?

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1 Depression Can it ever be cured? Disability, Relapses, and the Effect of Treatment Presented by Dr Julian Parmegiani MB BS FRANZCP 1208/370 Pitt St Sydney NSW August 2008 Claims & Underwriting Monthly Technical Seminar

2 Talk Outline Depression The clinical entity Prevalence Diagnosis and Management Clinical course and prognosis Relapse rate Associated medical conditions

3 DSM IV-TR Criteria A. Five (or more) present during the same 2-week period including (1) depressed mood or (2) loss of interest or pleasure. (1) depressed mood most of the day, nearly every day. (2) markedly diminished interest or pleasure in all activities (3) significant weight loss or decrease or increase in appetite nearly every day. (4) insomnia or hypersomnia nearly every day (5) psychomotor agitation or retardation (6) fatigue or loss of energy nearly every day (7) feelings of worthlessness or excessive or inappropriate guilt (8) diminished ability to think or concentrate, or indecisiveness (9) recurrent thoughts of death C. Impairment in social, occupational, or other important areas of functioning. D. Not due to drug of abuse, medication or a medical condition E. Not bereavement,

4 Prevalence UK Lifetime Prevalence Persons who experience at least one episode of depression requiring treatment during their lifetime: Men 10% Women 25% National Depression Campaign (1999) National Depression Campaign Survey. London US Lifetime Prevalence Men 4 6% Women 9 12% A 40-Year Perspective on the Prevalence of Depression The Stirling County Study Jane M. Murphy,Arch Gen Psychiatry. 2000;57:

5 Prevalence 12 Month Prevalence - Australia 2000 Men 4.2% Women 12% Australia s mental health: an overview of the general population survey* Scott Henderson, Gavin Andrews, Wayne Hall Australian and New Zealand Journal of Psychiatry 2000; 34: Month Prevalence - US 2002 Men 5% Women 9% The 12-month prevalence of Major depression among adults in the United States doubled between and Changes in the Prevalence of Major Depression Wilson M. Compton M et A Am J Psychiatry 2006; 163:

6 Underwriting Challenges 1. Wrong diagnosis Normal emotional response becomes medicalized Bereavement Relationship breakdown Family crisis, loss of employment etc 2. Antidepressants prescribed when depression not present Insomnia Anxiety Irritability Pain Difficult personality Neurotic 3. Depression present but not recognized

7 Underwriting Challenges Depression present but not recognized Less than 50% of patients presenting to their general practitioner with a psychiatric disorder receive a diagnosis. Less than 50% of those who are diagnosed receive specific pharmacological treatment. (These statistics are similar for the US) Prevalence and Treatment of Mental Disorders, 1990 to 2003 Ronald C. Kessler et al, N Engl J Med 2005;352: Primary care psychiatry is not specialist psychiatry in general practice. Ian B Hickie MJA 1999; 170:

8 Underwriting Challenges Medical records not perfect Possible approaches Initial policy application: Include screening questionnaire with focus on» Past impairment of role function» Past symptoms» Medication» Contact with mental health professionals 1. PBS (Pharmaceutical Benefit Scheme) records 2. HIC (Health Insurance Commission) records 3. Medical practitioner s report to insurer 4. IME /CMO

9 Underwriting Challenges Does the applicant have a history of depression? YES Was it really depression or a false positive? NO Was it undetected? False negative Is it worth taking a risk?» Loss of business opportunity vs liability

10 Depression Outcome 3-month initial treatment and 12-month follow-up, no maintenance therapy Treatment options in moderate and severe depression: decision analysis supporting a clinical guideline J. SIMON et al British Journal of Psychiatry ( ), 18 9,

11 Depression Outcome Six Months of Treatment for Depression: Outcome and Predictors of the Course of Illness Roger T. Mulder Am J Psychiatry 2006; 163:95 100

12 Depression Outcome LifeInsure Pty ltd Large Building 330 George Street Sydney 2000 Australia Dear Underwriter, I have now been well for over five years, All antidepressants were stopped four years ago. I am not under the care of a psychiatrist or psychologist, and I have worked in a managerial position during this period. In fact, I received a promotion in the past six months. I disagree with the exclusion of mental disorders from my policy. I find your decision discriminatory, and based on little more than prejudice and preconceived ideas about mental illness. Unless you reconsider, my solicitor will refer the matter to FICS and HREOC. Mr D T Jones

13 What do you do?

14 Depression Outcome 5yrs 10yrs Recurrence After Recovery From Major Depressive Disorder During 15 Years of Observational Follow-Up Timothy I. MuellerAm J Psychiatry 1999; 156:

15 Depression Outcome 5yrs 10yrs 15yrs Recurrence After Recovery From Major Depressive Disorder During 15 Years of Observational Follow-Up Timothy I. MuellerAm J Psychiatry 1999; 156:

16 Depression Any other exclusions with your policy sir? Recurrence After Recovery From Major Depressive Disorder During 15 Years of Observational Follow-Up Timothy I. MuellerAm J Psychiatry 1999; 156:

17 25,916 patients at 15 primary care centers in 14 countries on 5 continents The range of patients with depression who reported only somatic symptoms was 45 to 95 percent (overall prevalence, 69 percent; P=0.002 for the comparison among centers

18 37 prospective studies reviewed Conclusions: Psychological factors play a significant role not only in chronic pain, but also in the etiology of acute pain, particularly in the transition to chronic problems.

19 Depression Chronic Pain syndromes: Lower back Whiplash RSI Etc But wait.there is more! Recurrence After Recovery From Major Depressive Disorder During 15 Years of Observational Follow-Up Timothy I. MuellerAm J Psychiatry 1999; 156:

20 Depression Depression as a Risk Factor for Coronary Artery Disease: Evidence, Mechanisms, and Treatment HEATHER S. LETT, Psychosomatic Medicine 66: (2004)

21 Depression Depression confers a relative risk between 1.5 and 2.0 for the onset of CAD (Coronary Artery Disease) in healthy individuals, whereas depression in patients with existing CAD confers a relative risk between 1.5 and 2.5 for cardiac morbidity and mortality Depression as a Risk Factor for Coronary Artery Disease: Evidence, Mechanisms, and Treatment HEATHER S. LETT, Psychosomatic Medicine 66: (2004)

22 Myocardial Infarction Relative Risk Depression = 1.5 and 2.5* Smoking = Diabetes = Hypertension = *Depression as a Risk Factor for Coronary Artery Disease: Evidence, Mechanisms, and Treatment HEATHER S. LETT, Psychosomatic Medicine 66: (2004) **Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): casecontrol study Salim Yusuf Lancet 2004; 364:

23 Depression Medical disorders in people with recurrent depression Anne Farmer The British Journal of Psychiatry (2008) 192,

24 Depression Does ongoing pharmacological treatment prevent relapse?

25 Average = 66% vs. 30% Continuation and maintenance therapy in depression E S Paykel British Medical Bulletin 2001;57:

26 Depression - Summary 30-40% patient do not recover fully from their first depressive episode While 60-70% make a full recovery, most will relapse over the next 15 years Staying well for 5 years does not reduce risk of relapse Depression is associated with many medical conditions, including chronic pain syndromes, cardiac disease, diabetes,osteoarthritis, osteoporosis etc

27 Questions?

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