Assessment of Depression

1. Assessment of Depression Diagnosis Risk Assessment Risk Management Formulation Treatment Outcome

2. Associated symptoms in increasing importance: • Insomnia • Fatigue • loss of interest/pleasure • Morbid self-opinion • Impaired concentration • Hopelessness ± suicidal thoughts. (Blacker and Clare ‘88)

3. Diagnostic domains • Affective symptoms • Physical symptoms • Cognitive symptoms

4. Affective Diagnostic Criteria.Must haves! • Depressed mood (irritable in children or adolescents). • Or markedly diminished interest or pleasure • Must be most of the time over at least 2 weeks. • Change from normal functioning

5. Physical symptoms • Weight change when not dieting • Sleep disturbance –insomnia (particularly middle insomnia and EMW), hypersomnia. • Agitation or retardation • Fatigue/loss of energy

6. Cognitive symptoms • Worthlessness, xs/inappropriate guilt • Diminished ability to think and concentrate • Recurrent thoughts of death and suicide

7. Diagnosis • Eye contact - observe body language. • Open questions. • Attend to “distinct quality of mood” eg.Coldness/deadness/emptiness.  Paykel ’85

8. Comorbidity and missed diagnosis • Presentation affected by- • Gender (Women 2:1 Men) • Age • Insight • Comorbid physical illness

9. Gotland survey. Pop 56,000 • 60% GPs trained in depression diagnosis 1981/2 • By 1985 - ↓ referrals 50%, inpatient by 75% and sick leave by 50% • Suicide rates dropped from 20 to 7/100,000 • Antidepressant prescribing increased 60% • Anxiolytic prescribing decreased 25%

10. Suicides • ♀:♂ ratio 2:3 before the programme 1:7 after. • Of increased px 1/3 ♂, 2/3 ♀ • Of increased ♂ px most were for elderly! • Improved ability in Primary Care benefits those in contact with Primary Care i.e. Women!

11. Male Depressive Syndrome • Lowered stress tolerance • Acting out/aggression/low impulse control/ Transitional sociopathy • Burnt out feeling/emptiness • Chronic fatigue • Irritability/restlessness/dissatisfaction • Indecision • Sleep disturbance/morning anxiety

12. Missed depression • Depressed mood may be absent • Watch for “inner emptiness or deadness” • Prominent anhedonia • Somatic complaints in patients with poor verbal skills or the elderly • Pseudo dementia- behavioural withdrawal, memory problems • Unexplained physical symptoms associated with depression e.g. pain . Impt to rule out organic cause

13. Depression – the physical presentation In primary care, physical symptoms are often the chief complaint in depressed patients In a New England Journal of Medicine study, 69% of diagnosed depressed patients reported unexplained physical symptoms as their chief complaint1 N = 1146 Primary care patients with major depression • Reference: • Simon GE, et al. N Engl J Med. 1999;341(18):1329-1335.

15. Is your depressed patient bipolar? • Co morbid substance abuse • Bipolar family history * • Seasonality • Early onset <25 yrs * • Postpartum onset * • Psychotic features <35 yrs */ Atypical features • Rapid on/off pattern, frequent recurrence, < 3mth duration * /Mixed affective state ** • Antidepressant mania/hypomania ** • Ask about symptoms of hypomania just preceding or following depression either 1st episode or early-onset depression

16. Prevalence of Bipolar Spectrum subtype • 26-39% depressed patients in Primary Care • 45% depressed outpatients Allilaire et al “EPIDEP Trial”. Encephale 2001;27:149-158

17. Risk Assessment • Risk - aggression to self , others & property - substance misuse - vulnerability/ exploitation • Ask direct questions about suicide – “have you thought about or are you thinking about hurting or killing yourself” • If yes or unsure, enquire about plan. • If yes but wouldn't do it then “What is stopping you from doing something?" (protective factors)

18. Predictors of Risk • S – lack of significant others, stress events. • U – unsuccessful attempts, unemployment, unexplained improvement. • I – identification with family history/peer group suicide. • CI – chronic illness or severe illness of recent onset

19. Predictors of Risk 2 • D – depression + hostility/hopelessness or frustration, decision that suicide is an option • A – age, alcohol, availability. • L – lethality of previous attempts e.g. guns, hanging, jumping

20. BEHAVIOURAL THEORY • Stimulus-Response-Reward-Repetition • Risk Assessment • Risk Management – current and FUTURE • Therapeutic Risk/ Responsiblity

21. PRESCRIPTIVE DISASTER • DISclosure • Anxiety. • narrowed choiceS • Taking responsibility. • PatiEnt out of control. • Referral to other.

22. Interview Style • Be Perceptive- listen and understand, take distress seriously do not dismiss, minimise or ignore- build rapport. • Be Peaceful and calm. Do not appear threatened. • Partnership approach- they share responsibility for choosing the treatment approach. Empowerment reduces helplessness reduces risk!

23. Interview Style 2 • Be Persuasive- discuss the thoughts/plans in a reasoned manner- “these are symptoms of a treatable condition, they are very common and are often temporary. • Be Positive – instillation of HOPE is the most protective thing you can do.

24. Collaborative risk management • Disclosure. • Further enquiry. • Normalisation • Informed choices. • Agreed plan.

25. Consequences of risk management • Patient retains responsibility • Patient understood and in control. • Self image stronger. • Risk lower in subsequent stress

26. What is Case Formulation? • “Case formulation aims to describe a person’s presenting problems and use theory to make explanatory inferences about causes and maintaining factors that can inform interventions” Kuyken 2006

27. Case formulation 2 • Predisposing factors • Precipitating factors • Protective factors • Perpetuating factors • Hypothesis –Inferred mechanisms- goals • Exercise • Examples

28. TREATMENT • Keep taking the tablets!! • Effective drug & dose • Psychological – counselling, CBT, psychodynamic psychotherapy • Social- don’t forget these interventions; common sense and can make a lot of difference!

29. Outcome – response v remission • Aim for remission “are you back to your normal self?” • Use outcome measure GAF/Honos