Understanding Depressive Illness: Causes, Symptoms, and Impacts

1. The following lecture has been approved for University Undergraduate Students This lecture may contain information, ideas, concepts and discursive anecdotes that may be thought provoking and challenging It is not intended for the content or delivery to cause offence Any issues raised in the lecture may require the viewer to engage in further thought, insight, reflection or critical evaluation

2. Depressive Illness Dr. Craig Jackson Senior Lecturer in Health Psychology Faculty of Health BCU health.bcu.ac.uk/craigjackson craig.jackson@bcu.ac.uk

3. “The good physician treats the disease, but the great physician treats the person.” William Osler

4. Traditional model of Disease Development Pathogen Disease(pathology) Modifiers Lifestyle Individual susceptibility

5. Dominance of the biopsychosocial model Mainstream in last 15 years Hazard Illness (well-being) Psychosocial Factors Attitudes Behaviour Quality of Life Rise of the person as a “psychological entity”

6. Depressive Illness Usually treatable Common Marked disability Reduced survival Increased costs Depression may be Coincidental association Complication of physical illness (i.e. “secondary depression”) Cause of / Exacerbation of somatic symptoms

7. Psychiatry in Pictures – Steve Blundell Digital Cry Stapled Red

8. Depressive Illness 2% of population suffer frompure depression (evenly distributed between mild, moderate,and severe) Further 8% suffer from a mixture of anxietyand depression Patients with symptoms not severe enoughto qualify for diagnosis of either anxiety or depression..... ??? Impaired working and social lives and many unexplainedphysical symptoms Greater use of medical services “Walking Well”

9. Spectrum of mood disturbance Mild thru to Severe Transience thru to Persistence Continuous distribution in population Clinically significant when: (1) interferes with normal activities (2) persists for min. 2 weeks Diagnosis of depression / depressive disorder “Persistent & pervasive low mood” “Loss of interest or pleasure in activities” “Ennui”

10. Epidemiology 2nd biggest cause of disability worldwide by 2020 (WHO) (IHD still the biggest) Associated with increased physical illness • 5% during lifetime have MDD • 1 in 20 consultations • 100 patients per GP • MDD & Dysthmia > in females • 20% develop chronic depression • 30% of in-patients have depressive symptoms

11. Suicide

12. Suicide Final clinical pathway 1 million deaths per year, 10-12 million attempts UK Males – most common in older Female – most common in middle age Steady decline since 1990 5,554 suicide deaths in UK 2006 15 per 100,000 deaths males 6 per 100,000 deaths females

13. Almost 50% fail on first attempt Previous attempters 23 times more likely to dies from suicide than those without previous attempts Internal stress Pre-existing psychiatric morbidity Stack 2001 Demographics Opportunities

14. Behavioural Indicators - recent bereavement or other life-altering loss -recent break-up of a close relationship -major disappointment (failed exams or missed job promotion) - change in circumstances (retire, redundant or children leaving home) - physical illness - mental illness - substance misuse / addiction - deliberate self-harm, (particularly in women) - previous suicide attempts - loss of close friend / relative by suicidal means - loss of status - feelings of hopelessness, powerlessness and worthlessness - declining performance in work / activities (sometimes this can be reversed) - declining interest in friends, sex, or previous activities - neglect of personal welfare and hygiene - alterations in sleeping habits (either direction) or eating habits

15. Case Summary of a Depressed Patient #1 Date Symptoms Referral 1985 (16) Anorexia Secure unit teenagers 1986 (17) Suicide attempt Secure unit teenagers 1986 (17) Self-harm Secure unit CAMHS (A levels) Psychiatry - ECT unsubstantiated 1987-9 Self-harm. Anorexia UMC (18-20) (university) 1990 Working as au pair GP monitoring & anti-depressants (21) (left university) 1993 Self-harm Secure unit admission (24) (joined commune) Female. Abused by father from 6 to 15. Moved to boarding school, then to grandparents Insomnia - Feeling worthless – Guilt - Recurrent morbid thought - Bleak views - Self harm – Suicide Ideation Scholastically bright. University. Dropped out. Tried own business. Business failed. Admin working.

16. Epidemiology • Depression more common in those with: • Life threatened / limited / chronic physical illness • Unpleasant / demanding treatment • Low social support • Adverse social circumstances • Personal / family history of depression / psychological vulnerability • Substance misuse • Anti-hypertensive / Corticosteroid / Chemotherapy use Q o L

17. Aetiology Most depressions have triggering life events - Reactive depression Especially ina first episode Many patients present initially with physicalsymptoms (somatization) Some may show multiple symptoms ofdepression in the apparent absence of low mood - “Masked Depression” Some depression has no triggering cause - “Endogenous Depression” More persistent and resistant to treatment

18. Clinical Features • Adjustment Disorders mild short-lived reactive episodes • Major Depressive Disorder (MDD) • 5 symptoms displayed in 14 days • Dysthymia • depressed mood for 2+ years • not severe • chronic depression • unhealthy lifestyle associations • Bipolar Disorder / manic depression major depression & mania

19. Major depression (DSM IV) 5 or more….. • decreased interest / pleasure * • depressed mood * • reduced energy • weight gain / loss • insomnia / hypersomnia • feeling worthless • guilt • recurrent morbid thought • psychomotor changes • fatigue • poor concentration • pessimism / bleak views • self harm ideas / actions • suicide ideation

20. Classification of Depression (ICD-10) • PrimaryUnipolar • Mixed anxiety and depressive disorder (prominent anxiety) • Depressive episode (single episode) • Recurrent depressive disorder (recurrent episodes) • Dysthymia - Persistent and mild ("depressive personality") • Bipolar • Bipolar affective disorder - manic episodes ("manic depression") • Cyclothymia - Persistent instability of mood • Other primary • Seasonal affective disorder • Brief recurrent depression • Depressive episode may be • Moderate or severe • With/Without somatic syndrome • With/Without psychotic symptoms

21. Somatization Syndrome (DSM IV) 4 or more….. Anhedonia Loss of emotional reactivity Early waking (>2 hours early) Psychomotor retardation or agitation Marked loss of appetite Weight loss >5% of body mass in one month Loss of libido

22. Linking Emotions with Physical Symptoms

23. Case Summary of a Depressed Patient #2 Date Symptoms Referral 1985 (17) Pervasive low mood GP monitors 1986 (18) Suicide attempt Child Psychiatry 1986 (18) Self-harm Psychiatry 1987 (19) Anorexia. Self-harm Psychiatry – CPN 1988 (20) Suicide attempt Psychiatry – CPN (failed romance) 1989 (21) Suicide attempt Psychiatry – CPN (failed romance) 1990 (22) Fertility worries Psychiatry – CPN – fertility counselling 1990 (22) Working in office GP monitoring & anti-depressants 1992 (24) Self-harm MH unit (open door policy) CPN 1996 (26) Chronic Fatigue MH unit (open door policy) CPN 1998 (28) Fibromyalgia MH unit (open door policy) CPN

24. Risk Factors – Existing Health Conditions

25. Depressed Patients and “Positive Symptoms” Rosemary Carson Sensations of maggots moving within her body Depressed, attemptedsuicide at the age of 15 Spent long periods of earlyadult life in psychiatric hospitals Treated with medication and electro convulsive therapy 17-year remission in affective symptoms and sensations of maggots By 1996 became ill again - began to hear voices Her art captures memories of fellow patientsand situations from earlier admissions

26. Depressed Patients and Positive Symptoms Rosemary Carson - The Hospital Ward at Night

27. Classification • Many patients do not fit neatly into categories of either anxietyor depression • Mixed anxiety and depressionis now recognised • Presence of physical symptoms indicatesa somatic syndrome • Value of somatic features in predicting response to treatmentis not clear • Presence of psychotic features has major implicationsfor treatment • Brief episodes of more severe depression arealso recognised • (brief recurrent depression) • More prolongedrecurrence is now termed recurrent depressive disorder

28. 10 20 30 40 50 60 70 80 90 100 % returning to work <1 2 4 6 8 10 12 14 16 18 20 22 24 months not working • Return to Work • Longer off work = Less likely to return to work Waddell, 1994

29. Risk Factors • Anxiety + Sadness + Somatic discomfort • Normal psychological response to life stress • Clinical depression is a “final common pathway” • Resulting from interaction of biological, psychological, and social factors • Likelihood of this outcome depends on many factors: • geneticand family predisposition • clinical course of concurrentmedical illness • nature of any treatment • functional disability • individual coping style • social and other support

30. Risk Factors - Causality Certainillnesses such (stroke, Parkinson's disease, multiple sclerosis,and pancreatic cancer) may cause depression via direct biomechanisms. Stroke received most attention, butstudies fail to show convincing direct aetiology

31. Psychological Consequences of Chronic Illness • e.g. Cancer • Distress • Reduced QoL • Delay seeking help Fear Denial • Depressed / Anxious • Increased somatic complaints (Pain Fatigue Breathlessness) • Adjustment Disorder – commonest psychiatric diagnosis • Neuropsychiatric complications • Increased risk of suicide in early stages

32. Depression in Cancer Patients • Response to perceived loss • Awareness of losses to come = bereavement • Loss of body, family, friends, role, life • Severe depression X4 likely in cancer patients • 10-20% of cancer patients

33. Behavioural Responses to Diagnoses Hedonism Put life in order Premature grieving Sick Role Illness Behaviour Over-sensitivity to symptoms Premature death ADAPTIVE COPING Talk about it Planning Changes MALADAPTIVE COPING Drink Eat Substance use

34. Neuropsychiatric Complications • Brain metastases: • Delirium • Dementia • Depression • Produce psych. symptoms before discovery • Paraneoplastic Syndromes • Neuropsychiatric problems in absence of metastases • Orig. lung, ovary, breast, stomach, or Hodgkin’s

35. Neuropsychiatric syndromes • 61 yr old female • Frontal headaches for 3 months • Lethargic and weak • Difficulty walking • Diffuse areas of nodular destructive • lesions • Consistent with multiple myeloma or • metastatic disease • Skeleton is common site for mets from carcinomas and occasionally sarcomas • Lesions may be “silent” or symptomatic, such as pain, swelling, deformity, • compression of the spinal cord, nerve roots, or pathologic fractures.

36. Recognition & Diagnosis • Often missed in diagnoses • Distinguish depressed behaviour (sadness and loss of interest), from realistic expected response to stress / physical illness • Confusion of whether physical symptoms of depression are due to underlying medical condition • Negative attitudes to diagnosis of depression • Unsuitability of clinical setting for discussing personal & emotional matters • Patients' unwilling to report symptoms of depression

37. Recognition & Diagnosis • Depressive illness is often under-diagnosed and under-treated • Especially if it coexists with physical illness • This oftencauses great distress for patients: mistakenly assumed • that symptoms (weakness or fatigue) are due to an underlyingmedical • condition. • Practitioners must be able to diagnose and manage depressive illness • Alertness to clues in interviews • Patients' manner • Use of screening questions can detect up to 95% of patients with major • depression.

38. Screening Questionnaires • “How have you been feeling recently?” • “Have you been low in spirits?” • “Have you been able to enjoy the things you usually enjoy?” • “Have you had your usual level of energy, or have you been feeling tired?” • “How has your sleep been?” • “Have you been able to concentrate on your favourite tv shows?” • Self-report screening instruments • Beck Depression Inventory (BDI) General Health Questionnaire (GHQ) • Hospital Anxiety Depression Scale (HAD) • Can’t replace systematic clinical assessment – LISTENING • Persistent low mood and lackof interest and pleasure in life cannot be • accounted for by severephysical illness alone

39. Non-Specific Symptoms Often missed in assessment

40. Modern day complaints Multiple Chemical Sensitivity Chronic Fatigue Syndrome Sick Building Syndrome Gulf War Syndrome Low-level Chemical Exposure Electrical Sensitivity Fibromyalgia Historical complaints Railway Spine Neurasthenia Combat Syndrome Symptom Prevalence % Stuffy nose 46.2 Headaches 33.0 Tiredness 29.8 Cough 25.9 Itchy eyes 24.7 Sore throat 22.4 Skin rash 12.0 Wheezing 10.1 Respiratory 10.0 Nausea 9.0 Diarrhoea 5.7 Vomiting 4.0 Heyworth & McCaul, 2001 Prevalence of Non-Specific Symptoms

41. Drug Treatment Tricyclics since the 1950s effective and cheap limit compliance variable degrees of sedation fatal in overdose (except Lofepramine) dose-related anticholinergic side effects postural hypotension Monoamine Oxidise Inhibitors (MAOI’s) rare fatalities tyramine-free diet Selective Serotonin Re-uptake Inhibitors (SSRI’s) fluoxetine lack sedation no anticholinergic effects improved compliance less immediate benefit for disturbed sleep safe in overdose single or narrow range of doses works

42. Placebo & Nocebo In approx. 30% of pop. Subjected to more clinical trialsthan any other medicament Nearly always does better thananticipated The range of susceptible conditions seems limitless Does not always occur Present in subjective and objective outcomes Negative outcomes can occur (Nocebo effect) Placebo Big pills better than smaller pills Red pills better than blue 4 pills better than 2 30% of pop.

43. Long Term Prognosis

44. Identifying Unhelpful Patient Beliefs Discuss potential unhelpful beliefs Counter any simple aetiological beliefs Outline biopsychosocial perspective Can highlight potential perpetual factors that inhibit recovery Agree on positive open minded approach Do not argue over best name for condition!

45. Treatment • Much depressive illness of all types is successfully treatedin primary care • Four main reasons for referral to specialist psychiatric services: • 1)Condition is severe • 2) Failingto respond to treatment (e.g. Psychomotor retardation) • 3) Complicated by other factors (e.g. Personality disorder) • 4) Presents particular risks (e.g. Agitation and psychotic behaviour) • Principal decision is whether to treat with drugs or a talkingtherapy • Most patients in primary caresettings would prefer a talking therapy • Effectivenessis limited to particular forms of psychotherapy • Mild-Mod. Depression: CBTand antidepressants are equally effective • Severe Depression:antidepressant drugs are more effective

46. Management • The main aims of treatment: • improve mood and quality of life • reduce the risk of medical complications • improve compliancewith and outcome of physical treatment • facilitate the "appropriate"use of healthcare resources • Primarycare staff should be familiar with properties and use of: • 1) common antidepressant drugs & brief psychological treatments • 2) assessment of suicidal thinking and risk • Patients with more enduring or severe symptoms will usually require specific treatment - usually drug therapy • Forpatients with suicidal ideation / whose depression hasnot responded to initial management, specialist referral is thenext step

47. Management Low level risk Clinical picture Action Suicidal ideation Consider referral to mental health but no suicide attempts professional for routine appointment (not always necessary) Supportive environment Physically healthy No history of psychiatric illness

48. Management Moderate level risk Clinical picture Action     Low lethality suicide attempt Refer to mental health professional (patient's perception of lethality) to be seen as soon as possible Frequent thoughts of suicide Previous suicide attempts Persistent depressive symptoms Serious medical illness Inadequate social support History of psychiatric illness

49. Management High level risk Clinical picture Action Definite plan for suicide Refer to mental health professional (When? Where? How?) for immediate assessment Major depressive disorder High lethality suicide attempt or multiple attempts Advanced medical disease Social isolation History of psychiatric illness

50. Summary • Detection can be hard – symptom overlap and patient unaware • Depression a natural occurrence in population • Whole range of depressive conditions with varying severity • Depression can be present in acute or chronic states • Depression can have physiological, biological or social causes • Depression may have a mixture of causes • Depression co-exists with many other symptoms • Depression is a natural reaction to disease diagnosis and presence • Depression and symptomotology are highly related