[PDF] - Financial Disclosures none Descartes Li, M.D. Clinical Professor PDF Document

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Depression in Prim ary Care Mourning or Melancholia?

Descartes Li, M.D. Clinical Professor University of California, San Francisco descartes.li@ucsf.edu

By Max Halberstadt - http://politiken.dk/kultur/boger/faglitteratur_boger/ECE1851485/psykoanalysen-har-stadig-noget- at-sige-i-noejagtigt-betitlet-bog/, Public Domain, https://commons.wikimedia.org/w/index.php?curid=5234443

Financial Disclosures

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Outline

Introduction and Epidemiology
“Normal sadness”
Trap of Meaning
Bipolar Depression
Depression with Apathy, r/ o dementia
Perspectives Approach
Treatment implications

Outline

I ntroduction and Epidem iology
“Normal sadness”
Trap of Meaning
Bipolar Depression
Depression with Apathy, r/ o dementia
Perspectives Approach
Treatment implications

SLIDE 2

2 Case Vignette

72yo man is depressed in the context of the death of his wife one month ago.

Which of the following is the best diagnosis? a) Normal bereavement b) Major depressive disorder c) Bipolar depression d) Neurocognitive disorder with apathy

Diagnosis of Depression Key issues 1) Rule out Medical conditions causing psychiatric symptoms 2) Rule out Substance abuse or iatrogenic medications 3) Rule out Bipolar disorder (ie, screen for mania or hypomania) The Three S’s of the Psychiatric Interview

1) S – Stressors/ triggers 2) S – Suicidality 3) S – Substance Abuse

Prevalence of Psychiatric Disorders*

Disorder Lifetime prevalence(%) Any mood disorder 19.54 Major depression 16.54 Dysthymia 4.30 Bipolar I 3.31 Bipolar II 2.33

Any anxiety disorder 16.16 Social anxiety 4.97 Any drug use disorder 10.33

*Conway KP et al. Lifetime Comorbidity of DSM-IV Mood and Anxiety Disorders and Specific Drug Use Disorders: Results of the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry 2006;67:247-257.

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Prevalence of Psychiatric Disorders

Disorder Lifetime prevalence(%)

Post-traumatic stress disorder in women (1)

10.1

Post-traumatic stress disorder in men (1)

4.9

Suicidal ideation (2)

13.5

Suicidal plan (2)

3.9

Suicide attempt (2)

4.6

1. Bromet E et al. Risk Factors for DSM-III-R Posttraumatic Stress Disorder:

Findings from the National Comorbidity Survey. Am J Epidemiol 1998; 147:353-61.

2. Kessler RC et al. Prevalence of and Risk Factors for Lifetime Suicide

Attempts in the National Comorbidity Survey. Arch Gen

Psychiatry. 1999;56:617-626.

Why shouldn’t I be depressed? Life means suffering

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How about insulin, Lipitor? Is there a glut of coffee, alcohol? http://well.blogs.nytimes.com/2013/08/12/a

glut-of-antidepressants/?_r=0

http://psychcentral.com/blog/archives/2013/08/19/is-a- glut-of-antidepressants-really-so-bad/

The Crazy State of Psychiatry, by Marcia Angell

Turner E et al. Selective Publication of Antidepressant Trials and I ts I nfluence on Apparent Efficacy. NEJM 2008 358(3): 252

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I n Defense of Antidepressants

American Psychiatric Association Practice Guidelines for Depression Agency for Health Care Policy and Research, Clinical Practice Guidelines Cochrane Review http: / / www2.cochrane.org/ reviews/ en/ ab0079 54.html “In Defense of Antidepressants”, by Peter Kramer (The New York Times, July 9, 2011)

Bottom Line: For mild depression, watchful waiting is a reasonable option

Outline

Epidemiology
“Norm al sadness”
Trap of Meaning
Bipolar Depression
Depression with Apathy, r/ o dementia
Perspectives Approach
Treatment implications

Case Vignette

72yo man is depressed in the context of the death

f his wife.

Pair discussion: How long would you wait before diagnosing MDD? a) One month b) Two months c) Six months d) One year or more

SLIDE 6

6 Mourning and Melancholia

Major Depressive Episode —Diagnostic Criteria

signif wt ∆ (↓ or ↑)
insomnia or hypersomnia
Ψmotor agitation/retardation

(PMA/PMR)

fatigue or anergia
guilt/worthlessness (G/W)
↓’d concentration
recurrent thoughts of death or

SI

↓’d mood
anhedonia

Sleep Interest Guilt Energy Concentration Appetite Psychomotor Suicide

5 symptoms (with ≥1 sx in blue)

MDE = ≥2wks of

Criterion A. Five or more of the following…

Major Depressive Episode —Diagnostic Criteria ( cont.)

Criterion B. The symptoms cause clinically significant distress or impairment in social,

ccupational, or other important areas of

functioning. Criterion C. The episode is not attributable to the physiological effects of a substance

r to another medical condition.

Criteria A-C represent a major depressive episode

Major Depressive Disorder —Diagnostic Criteria ( cont.)

*note: deletion of Bereavement exclusion in DSM 5

Criterion D. The occurrence of the MDE is not better explained by schizoaffective disorder, schizophrenia, etc. Criterion E. There has never been a manic episode or a hypomanic episode.

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7 No Bereavement in DSM-5

No Bereavement exclusion in DSM-5 Grief is still exists Mild depressive episodes can be treated with psychotherapy alone

http: / / www.dsm5.org/ Documents/ Bereavement% 20Exclusion % 20Fact% 20Sheet.pdf

“Norm al Sadness”

Per Horvitz and Wakefield, 3 criteria:

Has an environmental trigger
Roughly proportionate in intensity to

loss

Ends when loss situation ends

Horwitz AV, Wakefield JC. The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder. New York, NY: Oxford University Press; 2007. (p.16)

Problem s w ith “norm al sadness”

What constitutes a trigger?
When is the response proportionate

to the loss?

Does the presence of a recent major

loss somehow make it more likely that depression will spontaneously resolve?

Depression vs. Grief

SLIDE 8

8 Case Vignette

He has had 6 prior episodes of depression in the

past. Each episode lasted 2-9 months and he met

DSM criteria for depression in each of them.

72yo man is depressed in the context of the death

f his wife.

Pair discussion: Which of the following is the best diagnosis? a) Normal bereavement b) Major depressive disorder c) Bipolar depression d) Neurocognitive disorder with apathy

Depression vs. Grief

Beware the Trap of Meaning!
Individuals who fulfill MDD criteria

after loss of significant other have NOT been shown to recover at a greater rate than MDD alone

Specifiers for Major Depressive Episodes

Atypical
Catatonia
Melancholic
Mixed features
Postpartum onset
Psychotic features

W hat is m elancholic depression?

Melancholic depression is characterized by significant psychomotor symptoms, insomnia, early morning awakening, worsening of mood in the morning (called diurnal variation in mood), significant anorexia, and a lack of reactivity to pleasurable stimuli.

SLIDE 9

9 Outline

Epidemiology
“Normal sadness”
Trap of Meaning
Bipolar Depression
Depression with Apathy, r/ o dementia
Perspectives Approach
Treatment implications

Case vignette

http://commons.wikimedia.org/wiki/File:Portrait-as-an-artist-as-a-young-man.jpg

28yo man, recently married 6m ago, appears well, but quickly breaks down: He says he’s made a terrible mistake for imposing himself on his wife. “I’m a terrible person who cheated on my wife and on my taxes.” He reports two months of depressed mood, crying spells, as well as oversleeping and not being able to get out of bed. In addition, his energy has been low, he has no appetite, and he can’t focus at work.

Would you diagnose him with Major Depressive Disorder? Would you prescribe an antidepressant?

Case vignette

http://commons.wikimedia.org/wiki/File:Portrait-as-an-artist-as-a-young-man.jpg

“I cheated on my wife and on my taxes.” Do we accept his reasons as the causes of his depression? Even when confronted with an intuitively plausible set of reasons, we must look for

bjective causes.

The Trap of Meaning

“Finding an explanation that appears meaningful and adopting it as causal.”

Lyketsos CG, Chisolm MS. The trap of meaning: a public health

tragedy. JAMA. 2009 Jul 22;302(4):432-3. doi:

10.1001/jama.2009.1059.

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"...humans are incredibly good at linking cause and effect—sometimes too good..."

"... it means that when you see something occur in a complex adaptive system, your mind is going to create a narrative to explain what happened—even though cause and effect are not comprehensible in that kind of system."

Embracing Complexity, An interview with Michael Mauboussin by Tim Sullivan Harvard Business Review 2011

https://hbr.org/2011/09/embracing-complexity/

Reason vs. Cause

“Reason" and "cause" are not

contradictory, nor are they synonymous

Confusion between them: delays

mental health care for mood disorders much more than care for diabetes, heart disease, stroke and cancer (?)

Does the Trap of Meaning

ccur with mania or

hypomania?

Yes!

Trap of Meaning references:

Kendler KS, Gardner CO. Dependent Stressful Life Events and Prior Depressive Episodes in the Prediction of Major Depression: The Problem of Causal Inference in Psychiatric Epidemiology. Arch Gen Psychiatry. 2010;67(11):1120-1127. Kendler KS, Myers J, and Halberstadt LJ. Do reasons for major depression act as causes? Molecular Psychiatry (2011) 16, 626–633; doi:10.1038/mp.2011.22; published online 8 March 2011. Kendler KS, Myers J, and Halberstadt LJ. Should the Diagnosis of Major Depression made Independent of or Dependent upon the Psychosocial Context? Psychol Med. 2010 May ; 40(5): 771–780. doi:10.1017/S0033291709990845.

Lyketsos CG, Chisolm MS. The trap of meaning: a public health tragedy. JAMA. 2009 Jul 22;302(4):432-3. doi: 10.1001/jama.2009.1059.

SLIDE 11

11 What are the Validated Risk Factors for Depression?

Major Depressive Episode: SIG E CAPS criteria

Depressed mood (or anhedonia), plus: S –Sleep symptoms I —lack of Interest. G—feelings of Guilt E—lack of Energy. C--lack of Concentration. A--lack of Appetite. P--Psychomotor changes S--thoughts of Suicide

Take Hom e Message

Be aware of "explaining away" mood episodes.

Lyketsos CG, Chisolm MS. The trap of meaning: a public health tragedy. JAMA. 2009 Jul 22;302(4):432-3. doi: 10.1001/jama.2009.1059.

http://jama.jamanetwork.com/article.aspx?articleid=184281

Outline

Epidemiology
“Normal sadness”
Trap of Meaning
Bipolar Depression
Depression with Apathy, r/ o dementia
Perspectives Approach
Treatment implications

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Dysthymic Disorder Major Depressive Disorder Cyclothymic Disorder Bipolar I Disorder Bipolar II Disorder

National Com orbidity Study ( NCS) 2 0 0 7

Lifetime (and 12-month) prevalence estimates: [ 9 2 8 2 Respondents]

for BP-I 1 .0 % (0.6% ),
for BP-II, 1 .1 % (0.8% )
for subthreshold BPD 2 .4 % (1.4% ).

Subthreshold BPD was defined as recurrent hypomania without a major depressive episode or with fewer symptoms than required for threshold hypomania. Merikangas, K. R. et al. Arch Gen Psychiatry 2007; 64: 543-552.

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Bipolar Disorder Sym ptom s Are Chronic and Predom inantly Depressive

Study 1

Asymptomatic Depressed Hypo/ manic Cycling/ mixed % of Weeks 1 4 6 Bipolar I Patients follow ed 1 2 .8 yrs 8 6 Bipolar I I Patients follow ed 1 3 .4 yrs

Study 2

6% 9% 32% 53% 46% 50% 2% 1%

1. Judd LL, et al. Arch Gen Psychiatry 2002.59:530-537.
2. Judd LL, et al. Arch Gen Psychiatry 2003;60:261-269.

Conversion refers to when individuals previously diagnosed with unipolar depression develop a mania or hypomania.

St Paul’s Conversion

The individual “converts” to bipolar disorder.

SLIDE 13

13 Test Question

A 22yo woman is admitted to the hospital for severe depression with suicidal

ideation. What is the likelihood that

she will have a hypomanic or manic episode in the next five years?

1) 3-5% 2) 6-10% 3) 11-20% 4) 25-50% 5) Greater than 50%

Sum m ary

study n

Conversion rate: ( per year)

Years

f f/ u

com m ent Akiskal HS; et al 1995 559 12.5% (1.1% ) 11 Mood lability predictive Coryell et

al. 1995

381

10.2% (1.0% )

10

Avg. age > 35

Goldberg JF et al. 2001 74 41% (2.7% ) 15 Younger pts (< 25yo) and hospitalized Angst J et

al. 2005

309 39.2% (3.0% ) 13 Linear rate of conversion, severely ill

Specifiers

(that are risk factors for bipolar disorder)

Atypical
Catatonia
Melancholic (not a risk factor)
Mixed features
Postpartum onset
Psychotic features

Take hom e m essages

Several studies looking at the course of major depressive disorder are fairly consistent: Patients initially diagnosed with unipolar depression are at high risk for converting to bipolar disorder. Several risk factors are associated with conversion:

Age of onset (ie, < 25yo)
Family history of bipolar disorder
Number of depressive episodes (ie, > six)
Post-partum onset
Psychotic features
Severity (eg, hospital admission)

The conversion rate is about 1-2% per year, perhaps slightly higher in the first 4 years, but really no obvious plateau’ing of risk (see Angst)

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14 Outline

Epidemiology
“Normal sadness”
Trap of Meaning
Bipolar Depression
Depression w ith Apathy, r/ o

dem entia

Perspectives Approach
Treatment implications

Case Vignette

71yo man complains of poor memory and depressed mood.

How would you differentiate between dementia and depression?

Major Depressive Episode: SIG E CAPS criteria

Depressed mood (or anhedonia), plus: S –Sleep symptoms I —lack of Interest. G—feelings of Guilt E—lack of Energy. C--lack of Concentration. A--lack of Appetite. P--Psychomotor changes S--thoughts of Suicide

Major Neurocognitive Disorder Cognitive impairment due to depression Insight Not aware Aware and concerned Course Slow, often subtle (onset

ver month/years)

More rapid(onset over days and weeks) Social skills Maintained Lost Memory Loss of recent, not remote memory. Random memory loss Effort Fair Poor, or variable

*May not be distinguishable, or may be co-morbid

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15 Dem entia vs. Depression

Depression requires either sad mood
r anhedonia
Depression may be the “prodrome”
f dementia
Depression, even the context of

dementia, may respond well to antidepressants or behavioral activation/ socialization

Outline

Epidemiology
“Normal sadness”
Trap of Meaning
Bipolar Depression
Depression with Apathy, r/ o dementia
Perspectives Approach
Treatment implications

Outline

Epidemiology
“Normal sadness”
Trap of Meaning
Bipolar Depression
Depression with Apathy, r/ o dementia
Perspectives Approach
Treatm ent im plications

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“My treatment fails only in curable cases.”

Galen

129 AD – c. 216

Or so W hat?

Situation treatm ent Life stressor or “normal” sadness Identify predisposing factors Psychotherapy, CBT or existential? Major Depressive disorder Psychotherapy Antidepressants Bipolar depression Avoid antidepressants Mood stabilizers refer to psychiatrist? Depression with apathy

Rule out neuropsychiatric disorder (dementia, Parkinson’s, etc)

“The person who takes medicine must recover twice, once from the disease and once from the medicine.”

Attributed to William Osler

By Unknown - [1], CC BY 4.0, https://commons.wikimedia.org/w/index.php?curid=33071914

Case Vignette

72yo man is depressed in the context of the death of his wife one month ago.

Which of the following is the best diagnosis? a) Normal bereavement b) Major depressive disorder c) Bipolar depression d) Neurocognitive disorder with apathy

SLIDE 17

17 Outline

Epidemiology
“Normal sadness”
Trap of Meaning
Bipolar Depression
Depression with Apathy, r/ o dementia
Perspectives Approach
Treatment implications

Jaspers: “No single method or technique in psychiatry is sufficient to completely understand the patient, we must use them all separately, with a clear knowledge of when they are most useful, based on their strengths, and when they are inaccurate guides, based on their weaknesses.”

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