Evaluation and Treatment of Depression and Suicide

1. Evaluation and Treatment of Depression and Suicide Cindy Boyack, MD, FRCPC Maine Medical Center Department of Psychiatry April 12, 2018

2. Case • 51 yo male, welder, out of work due to work injury (hand injury- recovering well) for past 4 months presents with complaint of low energy, myalgias. His wife made the appointment and has been nagging him for weeks to see the doctor. • His symptoms have been more pronounced over past month, he has been “laying around the house- not like me at all doc”

3. Depression • Common in Primary Care • Lifetime risk 10-25% for women • Lifetime risk 5-12% for men • 60% recurrence rate after a single episode • Prevalence unrelated to ethnicity, education, or social status (though presentation can differ) • Age of onset often in 20’s, but appears to be trending towards earlier in life.

4. Depression • 5-10% will subsequently have a manic episode • 15-20 % will have a co-occurring anxiety disorder • Resolve completely in 2/3 of cases, 1/3 only recover partially or not at all • Chronic medical illness or substance use can contribute to onset or exacerbate symptoms

5. Depression • Multiple studies show depression worsens morbidity for other chronic illnesses such as CAD, diabetes • Individuals with chronic psychiatric disorders generally more likely to have chronic medical illnesses, life expectance 20 years less than general population

6. Case (cont) • You ask questions for PHQ-2, pt reports he is feeling very guilty about not being the breadwinner of late, and not getting chores done around the house. • You have pt complete a PHQ-9- his score is 16. • What next????

7. DepressionSymptoms (DSM-V Criteria) • At least five of the following: • Depressed mood most of the day • Diminished pleasure, and interest • Significant wt loss or wt gain, or significant change in appetite • Insomnia or hypersomnia

8. Depression Symptoms • Psychomotor agitation or retardation • Loss of energy or fatigue • Decreased concentration or memory or indecisiveness • Recurrent thoughts of death or suicide

9. DepressionDiagnostic Criteria • Symptoms cause significant impairment in important areas of functioning • Not due to the direct result of a substance or general medical condition • Not better accounted for by bereavement

10. Case (cont) • Obtain further history of current sx: • Pt is lethargic, sleeps all the time • Appetite is off some, eats once per day, has lost 5 lbs • Not getting out, doesn’t answer phone • Doing ADL’s and not much else

11. Case (cont) • More irritable with wife and family • Screen for manic sx is negative • Pt not using illicit substances or ETOH, no longer requiring pain medications • Wishes he could fall asleep and not wake up sometimes, denies active suicidal ideation

12. Treatment of Depressive Disorders • Pharmacotherapy: • Serotonergic drugs- anxiety and depression • Noradrenergic- depression • Dopaminergic- depression • Gabaergic- anxiety

13. Treatment of Depression • Pharmacotherapy • Selective Serotonin Reuptake Inhibitors • Fluoxetine-20-80mg per day • Paroxetine-20-60mg per day • Fluvoxamine-150-300mg per day • Sertraline-50-200mg per day • Citalopram (40mg) and Escitalopram-(10-20mg) • Side effects-Insomnia, jitteriness, sleepiness, headache, upset stomach, sexual side effects

14. Pharmacotherapy • Dual Action Antidepressants (norepinephrine and serotonin) • Mirtazapine- 15-60mg per day • Side effects- sedation, weight gain, dizziness, flu like symptoms, dry mouth, constipation • Venlafaxine-150-300mg per day • Side effects-headache, insomnia, somnolence, nausea, dizziness, increase in blood pressure, sexual side effects

15. Pharmacotherapy • Dual action agents (serotonin and norepinephrine) • Duloxetine 30-60mg per day • Side effects include nausea and vomiting, dry mouth, insomnia, somnolence, dizziness, sexual side effects

16. Pharmacotherapy • Tricyclic Antidepressants • Imipramine, desipramine, amitryptiline, nortryptiline, clomipramine, doxepin • Side effects- dry mouth, dizziness, somnolence, constipation, blurry vision, urinary hesitancy, CARDIAC, sexual side effects • Bupropion- 300-450mg per day • Side effects-seizures in eating disordered patients, insomnia, jitteriness, dry mouth, headache, nausea

17. Case (cont) You discuss your diagnosis with pt. He recalls that his mother was probably depressed, never treated. He agrees to take medication. What next???????

18. Case (continued) • You decide to treat with bupropion, given his low energy and absence of anxiety sx. • Time has run out on this visit • What next????

19. Psychotherapy • Interpersonal Psychotherapy • Evidence based, manualized, time limited • Psychoeducation, reconnection with supports, cognitive in focus • Variably available in this area

20. Psychotherapy • Cognitive Behavioral Psychotherapy • Evidence based, manualized, time limited • Individual and group settings • Effective in depressive and anxiety disorders • Widely available in this area • Bibliotherapy: “Feeling Good, The New Mood Therapy” by David Burns

21. Psychotherapy • Acceptance and Commitment Therapy- CBT based model gaining popularity in primary care, can be adapted to quick interventions. Focus is on improving function

22. Psychotherapy • Supportive Psychotherapy • Designed to bolster individual strengths • Problem solving • Stress or crisis management

23. Combined Therapy • A combination of psychotherapy and pharmacotherapy is more effective than either one alone • Now confirmed by multiple studies

24. Case (continued) • Pt returns for follow-up in 2 weeks. He is tolerating medications well, feels “a little better, more energy, not as snappy with kids • You introduce the possibility of seeing the BHS for further support and possible referral for therapy • Pt says he “isn’t into that touchy-feely stuff.” • What next??????

25. Brief Interventions You Can Use In Your Office • Education • Call pt’s attention to negative or catastrophic thinking as depressive thoughts, define as symptoms • Encourage exercise • Encourage re-establishing routine

26. Case (continued) • Pt sets goal to get renovate the bathroom in the next week, run 30 min 5 x per week, change the oil, and put a new carburetor in his truck…… • What next?????

27. Brief Interventions You Can Use In Your Office • Work with patient to set attainable goals for next week- e.g.: eat twice per day, shower 3/week, get dressed every day, etc • Work with pt to establish simple schedule- which includes down time • Work with patient to reconnect with supports/social contacts • Encourage pt to review above goals daily, and celebrate accomplishments

28. SuicideRisk Factors • Male>Female 3.5 to1 • Age-peak: middle aged men • Mental Disorder of some type, more likely after initial episodes of illness • Race: Caucasians top list, Native Americans second

29. SuicideRisk Factors • Previous suicide attempt (esp in males) • Access to firearms (49.8% of all suicides) or other means (drugs, rope, etc) • LGBT-increased suicidal behaviors • Occupation- dentists and physicians highest! • Living alone, divorced separated, widowed

30. Suicide • Tenth leading cause of death in the US • One half of persons who complete suicide saw a physician within 1 month of suicide. • 44,000 suicides per year • 13.6/100,000- gradual increase over past decades • 90% have diagnosable mental illness

31. SuicideProtective Factors • Children in the home • Pregnancy • Responsibility to family • Religion/spirituality • Social support • Positive coping skills • Life satisfaction

32. How to assess suicidal risk? • Screen for and identify risk factors • Assess current contributing factors-e.g. family or life crisis, medical illness • Specific suicidal inquiry • Identify available interventions, family and social supports • Formulate diagnosis that includes assessment of suicidal risk, identify treatment plan • DOCUMENT!

33. Specific Questions around Suicidal Risk • Sometimes people lose hope when faced with such problems- have you? • What do you think about when you are so down? • Do you ever think of running away, wishing you could just disappear? • Have you ever thought of hurting or killing yourself? • How would you do it? • What would your happen to your family and loved ones? • What has kept you from acting on these thoughts?

34. SuicideTreatment and Prevention • Screening! • Treat underlying disorders • When to refer for further psychiatric evaluation or hospitalization? • Use of crisis services • Removal of means • Involvement of family, social supports

35. Contack Dr. Cindy Boyack Maine Medical Center Department of Psychiatry boyacc@mmc.org