Depressive Disorders in Primary Care Parinda Khatri, Ph.D. Director of Integrated Care Tennessee Primary Care Association Clinical Conference April 15, 2011 Nashville, TN Forms of Depression Major Depressive Disorder Dysthymic Disorder Depression with Psychotic Features Post Partum Depression Seasonal Affective Disorder Grief/Bereavement 1
Major Depressive Disorder A leading cause of disability world wide Can be diagnosed and treated in Primary Care Lifetime prevalence of 10-25% in women, 5-12% in men Etiology: bio-psycho-social factors Major Depressive Disorder Episodic Defined by one or more Major Depressive Episodes Lifetime prevalence of 10-25% in women, 5-12% in men Female: Male = 2:1 10-15% go on to commit suicide Etiology: bio-psycho-social factors 2
Major Depressive Disorder DSM IV-TR A- At least 5 or more of the following for > 2 weeks: 1- Dysphoria - (Powerful Screening Tool) 2- Anhedonia - (Powerful Screening Tool) 3- Weight Change 4- Insomnia (or Hypersomnia) 5- Psychomotor agitation or retardation 6- Decreased energy 7- Feelings of inappropriate guilt or worthlessness 8- Decreased concentration or inability to make decisions 9- Preoccupation with thoughts of death or dying B- Not a mixed episode C- Significant Disruption of functioning D- Sx NOT due to CD or medical disorder E- Not due to bereavement (unless > 2 months evolution) Major Depressive Disorder Diagnosis Sleep Disturbance Interest Decreased (Anhedonia) Guilty Ruminations Energy decrease Concentration Impairment Appetite Disturbance Psychomotor Agitation/Retardation Suicidal Ideas/Plans/Means 3
Major Depressive Disorder Co-Morbid Disorders Substance Use Anxiety Disorders Personality Disorders Medical Conditions Post MI (up to 60%) Post CVA (Left Frontal) Hypothyroidism Pancreatic CA Major Depressive Disorder Differential Diagnosis Adjustment Disorder Bereavement Dysthimic Disorder Substance Use Disorder Bipolar Disorder Schizophrenic Disorder Eating Disorder Somatoform Disorder Medical Disorders 4
Screening in Primary Care Red Flag Questions During the past 2 weeks, have you felt down, depressed or hopeless? During the past 2 weeks, have you felt little interest or pleasure in doing things? Patient Health Questionnaire (PHQ-9) The US Preventive Services Task Force. JAMA, June 18, 2003 (23) Effective Treatments Psychotherapy CBT, Problem Focused, Solution Focused, IPT, ACT Exercise Psychopharmacology TMAP, ICSI, APA guidelines Combination Therapy 5
Treatment Recommendations * Adapted from Kroenke and Spitzer, 2002 Mild Moderate Depression Moderately Severe Depression Severe Education, Exercise Psychotherapy, or Psychopharmotherapy Education, Exercise Psychotherapy and/or Pharmacotherapy Education, Pharmacotherapy, and Psychotherapy Factors to consider in choosing a treatment Symptom severity Cultural beliefs Psychosocial Resources (i.e. stressors transportation, Co-morbid condition childcare) Patient preference Health beliefs (i.e. perception of selfcontrol) 6
Behavioral Activation: A Quick Behavioral Intervention for PC Step 1. Rationale. Explain that when we feel down, we sometimes stop doing many activities that we used to like to do. Step 2. Select activities that increase pleasure/enjoyment and/or sense of mastery/accomplishment. Ask the patient about activities they used to enjoy and any activities they already do but would like to do more often (e.g., exercise, talk to friends). You may want to ask if there is something that they need to do that they have been unable to do or avoiding. Step 3. Review, Reinforce, Reset. In follow up visits, the primary care provider reviews progress on goals, reinforces positive behavior, and resets goals as needed. Bipolar Disorder Bipolar Disorder Sub-Types Bipolar I Mania Depression Bipolar II Hypomania Depression Cyclothymia Hypomania Dysthymia 7
Bipolar Disorder I Defined by 1 Manic or Mixed episode Most will have MDE as well Specify rapid cycling if patient has 4 or more mood episodes in a given year Earlier onset than MDD Male: Female ratio is equal Strong genetic component: Twin studies show concordance between 30-90% Bipolar Disorder Diagnosis Depression Disphoria Anhedonia Sleep Appetite Suicidality Crying Spells Mania Grandiose/Irritable Thought racing Pressured speech Impulsivity Hyper-sexuality Recklessness Decreased need for sleep Psychosis 8
Non-Psychiatric Causes Neurological MS, Frontal Lobe Stroke, Head Trauma Encephalitis, HIV Sub-Cortica Dementia Medications Steriods, AD, L-Dopa Substance Use ETOH, Amphetamine Cocaine, Caffeine Metabolic Autoinmune Infections Herpes, HIV, Syphilis Parasite, fungus Endocrine Hyperthyroid Cushing Bipolar Disorder II Defined by one or more MDE (depression) and at least one Hypomanic Episode No Manic or Mixed Episodes Some percentage will go on to BD I 9
Cyclothymic Disorder Chronic Duration of 2 or more years Numerous Hypomanic and Minor Depressive Episodes Few periods of euthymia (ie., never symptom-free for more than 2 months) Diff Dx includes: BD II, Borderline Personality Bipolar Disorder NOS When distinction between Type I vs. II cannot be made When underlying cause (ex. Substance or GMC) has not yet been ruled out Emergency setting Lazy clinician 10
MANIA-DIGFAST Distractability Insomnia Grandiosity Flight of Ideas Activities Speech Thoughtlessness Bipolar Spectrum 1.5%-5.5% Prevalence Up to 40% Depressed Pts may be Bipolar Lifetime risk for suicide attempts 25-50% Completed suicide attempts 10-15% Suicide attempts 30x more likely Depressed Phase Prolonged suffering and functional impairment 11
Bipolar Mixed State Unrelenting dysphoria or irascibility Severe agitation Refractory anxiety Unendurable sexual excitement Intractable insomnia Suicidal obsessions or impulses Histrionic demeanor Diagnoses Depression/Mania/Hypomania Family History Treatment Response-treatment emergent mania/hypomania, rapid cycling states, emergence of treatment resistance Course Mood Disorder Questionnaire (MDQ) 12
Typical Presentation Treatment resistant depression Antidepressant misadventures Panic, generalized anxiety, or other anxiety Borderline or other Cluster B Polysubstance Abuse ADHD Features of Bipolar Depression Early onset (<25) Atypical features-hypersomnia, wt gain, psychomotor retardation Cycle acceleration with antidepressant tx Loss of response during antidepressant tx Substance abuse comorbidity 13
Destabilizing Factors Antidepressants Alcohol Steroids Sleep Deprivation Stress Management Mood Stabilization with Meds Patient Education/Resources Encourage Mood Stabilizing Lifestyle Regulating Sleep/Wake/Activity/Eat Exercise Enhance Treatment Compliance Psychotherapy 14
Psychotherapuetic Interventions Prodrome Detection Psychoeducation Cognitive Behavioral Therapy Interpersonal/Social Rhythm Family Focused Therapy Typical Warning Signs of Hypomania and Mania Decreased NEED for sleep Increase in anxiety High levels of optimism Increased gregariousness Diminished concentration Increased Libido Increased goal-directed behavior 15
Typical Indicators of Normal Good Mood Able to sit down and enjoy reading, without becoming bored/distracted Capable of listening, less talking No urge to push limits Can complete tasks without distraction Mild-mod. Anxiety expected Enjoys quietude and serenity Sleeps well at night Can accept criticism without irritability Major Support Groups National Depressive and Manic Depressive Association (NDMDA) National Alliance for the Mentally Ill Depression and Related Affective Disorders Association 16
Guidelines for Primary Care The MacArthur Initiative on Depression Primary Care www.depression-primarycare.org/clinicians/toolkits Institute for Clinical Systems Improvement Health Care Guideline: Major Depression in Adults in Primary Care www.icsi.org National Institute for Health and Clinical Excellence (NHS) NICE Guidelines www.nice.org.uk/nicemedia/pdf/cg38niceguideline.pdf American Psychiatric Association Depression and Bipolar Disorder Guideilnes http://www.psych.org/mainmenu/psychiatricpractice/practiceguidelines_1. aspx Reading for Patients Burns, D. The Feeling Good Handbook Copeland, M.E. The Depression Workbook: A guide for living with depression and manic depression. Copeland, M.E. Living without depression and manic depression: A workbook for maintaining mood stability. Court, B.L. and Nelson, G.E. Bipolar Puzzle Solution: A mental health clients perspective. Ellis, T.E. and Newman, C.F. Choosing to Live: How to defeat suicide through cognitive therapy. Greenberger, D. and Padesky, C. Mind over mood: A cognitive therapy treatment manual for clients. 17