Recognizing and Treating Depression in Primary Care

1. Recognizing and Treating Depressionin Primary Care October 1, 2002 Swedish Family Practice Didactics

2. Who diagnoses and treats patients with depression? • The majority of patients with depression are treated by their primary care providers • The majority of psychotropic medications are prescribed by primary care providers

3. Who should diagnose and treat patients with depression? • Care by a patient’s primary provider has been shown to be as effective as brief psychotherapy in the treatment of mild to moderate depression • Medications are more effective than psychotherapy in the treatment of moderate to severe depression

4. Who should diagnose and treat patients with depression? • Brief psychotherapy has been shown to be as effective as care by a patient’s primary provider in the treatment of mild to moderate depression • The combination of psychotherapy and medications has been shown to be more effective than medications alone in preventing recurrence of depression

5. Are we doing a good enough job at recognizing and treating depression? • 50% of cases of depression are undiagnosed in primary care settings • Primary care providers under treat patients with depression • Primary care providers generally have little training in brief psychotherapeutic techniques

6. Consequences of Undiagnosed and Untreated Depression • Decreased quality of life • Increased suicide risk • Decreased productivity • Increased health care use

7. Cost of Untreated Depression 30 billion dollars a year in lost productivity Cost of all mental illness is equal to cost of heart disease in total health care costs and loss in productivity (300 billion dollars)

8. Morbidity and mortality of depression • Prevalence of mental illness and depression • Diagnosing depression • “Antidepressant Decision Tree”

9. Morbidity of Depression Worldwide • WHO identified major depression as the fourth leading cause of worldwide disease in 1990 • Worldwide, depression causes more disability than either ischemic heart disease or cerebrovascular disease

10. Morbidity of Depression in the US • Depression – 20,000,000 • Heart Disease – 60,000,000 • Cancer – 1,250,000

11. Mortality of Depression in Women in the US Suicide is the 5th leading cause of death in women ages 15 to 55 • Cancer – 38,207 • Heart Disease – 16,385 • Injury – 13,689 • CVA – 4,526 • Suicide – 3,719

12. Mortality of Depression in Men in the US Suicide is the 4th leading cause of death in men ages 15 to 55 • Heart Disease – 41,347 • Injury – 39,581 • Cancer – 37,768 • Suicide – 16,720 • Homicide – 11,145

13. Mortality in the US • Suicide – 30,000 • Homicide – 17,000 • HIV – 14,000

14. Mental Illness in Primary Care • General population vs. your clinic waiting room • Multiple diagnoses and co-morbid conditions are the norm

15. Common Psychiatric Disorders Mood Disorders 12.5% • Depression 5% Major depressive disorder, Minor depressive disorder, PMDD, PPD • Dysthymia 5.4% • Bipolar Disorders 2.1-2.7% • Depression due to illness, medications, drugs, bereavement, adjustment • In your office 20-30% or more

16. Common Psychiatric Disorders Anxiety Disorders 12.6% • Specific Phobias 3.2% (10-11.3%) • Social Phobia 2.7% (3-13%) • PTSD 2.6% • GAD 2% (5%) • OCD 2.1% • Panic Disorder 1.3% • Anxiety due to illness, medications, drugs, etc. • In your office 25-35% or more

17. ADHD 2.2-9.9% Conduct Disorder 1.5-5.5% Separation Anxiety 2.3-9.2% Specific Phobias 2.3-9.2% Major Depressive Disorder 1% in young children to8.3% in adolescents Bulemia 1.1-4.2% of adolescents Anorexia .5-3.7% of adolescents Psychiatric Disorders in ChildrenAll Mental Disorders 12-15%

18. Other Psychiatric Disorders • Schizophrenia 1% • Cognitive Disturbance Delirium Dementia 2.7% (20% over 85) • Substance Abuse Alcohol (13%) Other drugs (1%) • Sleep disturbance 30-40%

19. Other Psychiatric Disorders Unexplained physical symptoms (25% of visits) • Hypochondriasis 4-9% • Somatization disorder (.2-2%) • Conversion disorder • Pain disorder • Malingering • Factitious disorder

20. Prevalence of Psychiatric Disorders in Primary Care Clinics 40% to 80%!

21. Prevalence of Depression • Twelve to fifteen percent of the US population suffer from mood disorders • Worldwide, depressive illness is twice as common in women as in men • One in every eight men and one in every four women in the the US will suffer from a depressive illness in their lifetime

22. Postpartum Depression • For women with a history of depression the incidence is 30% • For adolescents the incidence is also 30% • Recurrence of postpartum depression is 70% • If a woman has postpartum blues and a history of postpartum depression her risk is 85% of developing of major depressive illness postpartum

23. US Preventive Services Task Force Recommendation (Old) Maintain an especially high index of suspicion for depressive illness in • Adolescents and young adults • Persons with a family or personal history of depression • Persons with chronic illness or chronic pain or unexplained somatic complaints • Persons with a recent loss

24. US Preventive Services Task Force Recommendation(New) Screen adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment and followup. The benefits of screening are likely to outweigh any potential harms. The benefits of routinely screening children and adolescents for depression are not known.

25. US Preventive Services Task Force Recommendation(Old) • Physician education in recognizing and treating affective disorders is recommended • Persons with depressive symptoms should be evaluated further and if diagnosed with major depressive disorder, either treated or referred for treatment

26. US Preventive Services Task Force Recommendation(New) • There is good evidence that screening improves the accurate identification of depressed patients • Treatment of depressed adults decreases clinical morbidity

27. Adults who may be at increased risk of depression • Patients with a history of domestic violence • Women who are pregnant or postpartum • Women who are menopausal or peri-menopausal • Patients who are poor, homeless, socially isolated, displaced, oppressed • Patients who are stressed

28. Prevalence of depression in your clinic • On any one day up to 4 in 10 (or more) of the women in your waiting room may meet the criteria for a depressive disorder and half of them are not diagnosed • Twenty-six percent of patients in an internal medicine residency clinic met the criteria for major depressive disorder and another sixteen percent met the criteria for dysthymia

29. Screen all adults for depression

30. US Preventive Services Task Force Recommendation(New) • Many formal screening tools are available but there is little evidence to recommend one over another • All positive screening tests should trigger full diagnostic interviews • The optimal interval for screening is unknown • Treatment may include antidepressants or specific psychotherapeutic approaches alone or in combination

31. Screen All Patients for Depression • How is your mood? • How is your sleep, appetite, energy, general health? • Are you as interested in life as you have always been? • Do you ever think about suicide? OR • Seven Question Beck Depression Inventory or other questionnaire

32. Two questions are just as good as using a questionnaire • Over the past two weeks, have you felt down, depressed, or hopeless? • Over the past two weeks, have you felt little interest or pleasure in doing things? • 96% sensitive (similar to six other case-finding instruments) • 66% specific if substance abuse is ruled out

33. To make the diagnosis of depression* • Take a complete psychiatric and medical history Use DSM-IV-PC • Take several visits to confirm your diagnosis • Treatment does not need to wait for a complete history if your patient is acutely ill *Major Depressive Disorder, Minor Depressive Disorder, Bipolar Disorders, Dysthymic Disorder, PMDD

34. Don’t forget – • medical conditions • medications • alcohol and drug abuse • co-morbid psychiatric disorders when diagnosing depression and deciding which medications and treatments to use to treat depression.

35. Differential Diagnoses • Drug or alcohol abuse • Medication side effects • Anemia, hypothyroidism, other medical illnesses • Schizoaffective disorder • Schizophrenia with major depression

36. Co-morbid Conditions • Generalized anxiety disorder • Panic disorder • PTSD • OCD • Somatoform disorders • Eating disorders • Grief reaction

37. Antidepressant Decision Tree • Notes • Dealing with side effects • Caveats • Keep up-to-date on new studies Harvard Mental Health Letter - $59/yr Psychiatric Drug Alerts - $67/yr

38. Choosing an Antidepressant • All antidepressants are somewhat effective in 70% of patients • SSRI’s are generally the first line therapy and quite safe in pregnancy and lactation • All SSRI’s can cause sexual dysfunction and often the only thing to do is change to a non-SSRI antidepressant • Bupropion does not treat anxiety disorders and should be avoided in patients with seizure or eating disorders

39. Choosing an Antidepressant • Patient’s personal history of treatment • Patient’s family history of treatment • Use less activating medications in patients with co-morbid anxiety disorders • Twenty-five percent of patients treated for depression have undiagnosed bipolar disorder • If a patient has psychotic symptoms, the newer anti-psychotics also help treat depression

40. Choosing an Antidepressant • Major depressive disorders and bipolar disorders require medications • Dysthymia and minor depressive disorders also respond to medications • Counseling alone may work for minor depressive disorder and dysthymia • Short term counseling for mild to moderate depression works but so does care by a patient’s primary provider

41. Choosing an Antidepressant • Use SSRI’s or venlafaxine in pregnancy and lactation • Avoid tricyclics, lithium, MAOI’s and anticonvulsant mood stabilizers, if possible, during pregnancy and lactation • HRT may be effective in the treatment of perimenopausal and postmenopausal depression

42. Summary • Screen all adult patients for depression and pregnant women for a history of postpartum depression • Do a thorough medical history and family and personal psychiatric history to confirm your diagnosis and rule out co-morbid conditions • If you consider co-morbid psychiatric conditions and medical conditions there is usually a medication that is safe and effective • Avoid high risk medications during pregnancy and lactation if possible

43. Thank You

44. What can you do in a short clinic visit beyond asking how a patient is doing, adjusting medications if appropriate and doing some supportive listening to help your patients deal with their depression?