Depression in Primary Care: Mourning and Financial Disclosures Melancholia none 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 Outline Outline • Introduction and Epidemiology • Introduction and Epidemiology • “Normal sadness” • “Normal sadness” • Trap of Meaning • Trap of Meaning • Antidepressant controversy and • Antidepressant controversy and Placebos Placebos • Stepped pharmacotherapy of • Stepped pharmacotherapy of depression (STAR*D) depression (STAR*D) • Exercise, Light Therapy, Bibliotherapy • Exercise 1
Prevalence of Psychiatric Prevalence in U.S.: Disorders* Disorder Lifetime prevalence(%) Any mood disorder 19.54 1 year = 6.6% Major depression 16.54 (13.1-14.2 million) Dysthymia 4.30 Bipolar I 3.31 Lifetime = 16.2% Bipolar II 2.33 Any anxiety disorder 16.16 (32.6 – 35.1 million) Social anxiety 4.97 Any drug use disorder 10.33 Face-to-face household survey, n = 9090 *Conway KP et al. Lifetime Comorbidity of DSM-IV Mood and Anxiety Disorders and Specific Drug Use Disorders: Results of the National Kessler, RC et al. The Epidemiology of Major Depressive Epidemiologic Survey on Alcohol and Related Conditions. J Clin Disorder: Results From the National Comorbidity Survey Psychiatry 2006;67:247-257. Replication (NCS-R). JAMA. 2003;289:3095-3105. The prevalence of MDD: 4.4% in both 1990 (4.2–4.7%) and 2010 (4.1–4.7%). Challenging the myth of an "epidemic" of common mental disorders: trends in the global prevalence of anxiety and depression between 1990 and 2010. https://www.ncbi.nlm.nih.gov/pubmed/24448889 2
Case Vignette A Outline 72yo man is depressed in the context of the • Introduction and Epidemiology death of his wife. • “Normal sadness” • Trap of Meaning How long would you wait before diagnosing MDD? • Antidepressant controversy and Assume he meets DSM-5 criteria Placebos for MDE. • Stepped pharmacotherapy of a) Two weeks depression (STAR*D) b) One month c) Two months • Exercise d) Six months e) One year or more Mourning and Melancholia “Normal Sadness” Outwardly can look the Per Horvitz and Wakefield, 3 criteria: same 1. Has an environmental trigger Melancholia: 2. Roughly proportionate in intensity to • No conscious object loss loss • Loss of self-regard, but 3. Ends when loss situation ends not ashamed • Difficulty with nourishment, digesting Horwitz AV, Wakefield JC. The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder. New York, NY:Oxford University • Difficulty with sleeping Press; 2007. (p.16) 3
Resilience to Spousal Loss Problems with “normal sadness” 1. What constitutes a trigger? New York Times online Accessed October 8, 2016 http://nyti.ms/2cPiePQ 2. When is the response proportionate to the loss? 3. Does the presence of a recent major “…resilience in the face of spousal bereavement is less common than previously thought” loss somehow make it more likely that depression will spontaneously -Only 8% showed resilience across all five indicators of life satisfaction and general health functioning resolve? Infurna FJ and Luthar SS. Resilience to Major Life Stressors Is Not as Common as Thought. Persp Psychol Sci. 2016 Mar;11(2):175-94. doi: 10.1177/1745691615621271. What the DSM-5 says about Depression vs. Grief bereavement Grief is still exists, but depressive episodes must be diagnosed independently of loss Individuals who fulfill MDD criteria after loss of significant other have NOT been Grief and MDD are different and shown to recover at a greater rate than therefore they should be distinguished MDD alone separately http://www.dsm5.org/Documents/Bereavement%20Exclusion %20Fact%20Sheet.pdf 4
Depression vs. Grief Case Vignette A 72yo man is depressed in the context of the death of his wife. How long would you wait before diagnosing MDD? Assume he meets DSM-5 criteria for MDE. a) Two weeks b) One month c) Two months d) Six months e) One year or more Outline Case vignette B • Introduction and Epidemiology 28yo man, recently married 6m ago, appears well, but quickly breaks down: • “Normal sadness” He says he’s made a terrible mistake for imposing himself on his wife. “I’m a • Trap of Meaning terrible person who cheated on my wife and on my taxes.” He reports two • Antidepressant controversy and months of depressed mood, crying spells, as well as oversleeping and not Placebos being able to get out of bed. In addition, his energy has been low, he • Stepped pharmacotherapy of has no appetite, and he can’t focus at depression (STAR*D) work. http://commons.wikimedia.org/wiki/File:Portrait-as-an-artist-as-a-young-man.jpg Would you diagnose him with • Exercise Major Depressive Disorder? Would you prescribe an antidepressant? 5
Case vignette Reason vs. Cause “I cheated on my wife and on What the difference? my taxes.” Do we accept his reasons as Reason : (noun) Cause : (noun) the causes of his depression? ( 1 ) Motive or justification for ( 1 ) That which produces an Even when confronted with something effect, thing, event, person, an intuitively plausible set of etc…make something happen “Give me the reason for your reasons, we must look for going.” What was the cause of the fire? objective causes. “He has adequate reason for Smoking is one of the causes of http://commons.wikimedia.org/wiki/File:Portrait-as-an-artist-as-a-young-man.jpg doing so.” heart disease. "...humans are incredibly good at linking The Trap of Meaning cause and effect—sometimes too good..." “Finding an explanation that appears meaningful and adopting it as causal.” "... 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 Lyketsos CG, Chisolm MS. The trap of meaning: a public health and effect are not comprehensible in that kind of system." tragedy. JAMA. 2009 Jul 22;302(4):432-3. doi: Embracing Complexity, An interview with Michael https://hbr.org/2011/09/embracing-complexity/ 10.1001/jama.2009.1059. Mauboussin by Tim Sullivan Harvard Business Review 2011 6
Life Events have NOT been What are the Validated Risk associated with MDD Factors for Depression? "in general, MD can be diagnosed independently of the psychosocial context in which it arises." 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. Take Home Message Outline • Introduction and Epidemiology Be aware of "explaining • “Normal sadness” away" mood episodes. • Trap of Meaning • Antidepressant controversy and Anticipate patient’s Placebos explanatory model and • Stepped pharmacotherapy of adherence implications depression (STAR*D) • Exercise 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 7
Prevalence of The Crazy State of Psychiatry, antidepressant usage by Marcia Angell http://well.blogs.nytimes.com/2013/08/12/a -glut-of-antidepressants/?_r=0 Increased antidepressant usage associated with a decrease in overall suicide rates Olfson M, Shaffer D, Marcus SC et al. (2003), Relationship between antidepressant medication treatment and suicide in adolescents. Arch Gen Psychiatry 60(10):978- 982. Gunnell D, Middleton N, Whitley E et al. (2003), Why are suicide rates rising in young men but falling in the elderly?--A time-series analysis of trends in England and Wales 1950-1998. Soc Sci Med 57(4):595-611 Is there a glut of coffee, alcohol? http://psychcentral.com/blog/archives/2013/08/19/is-a- How about insulin, Lipitor? glut-of-antidepressants-really-so-bad/ 8
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