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D epression in Primary care

Learn about the prevalence, assessment, and suicide risk factors of affective disorders, including depressive and bipolar types. Explore DSM classifications and ICD standards.

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D epression in Primary care

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  1. Depression in Primary care

  2. Assoc.Prof.Guldal Izbirak,MD • Affective disorders are highly prevalent illnesses that significantly impair functioning, interpersonal relationships, and quality of life. *Vincent van Gogh’s 1890 painting at Eternity’s Gate

  3. Assoc.Prof.Guldal Izbirak,MD • The mood disorders may be subdivided into unipolar and bipolar types: • those that are characterized by depression only • those that are characterized by manic episode either alone or in combination with depression

  4. Assoc.Prof.Guldal Izbirak,MD Epidemiology • Major depression is a common disorder with a life-time prevalence of 17% and primary care practice prevalence of up to 21%. Depression is the most common cause ( 44% of patients ) of high use of medical services. • The life-time prevalence rate for dysthymia is around 6.4 %.

  5. Assoc.Prof.Guldal Izbirak,MD • Women suffer from depressive episodes about twice (10-20%) as often as men (5-10%) - a sex difference that begins in early adolescence and persists into midlife. • The prevalence of affective disorders does not vary significantly by race or ethnicity.

  6. Assoc.Prof.Guldal Izbirak,MD • Epidemiologic studies reveal that mood disorders are more prevalent among individuals under the age of 45 (the average age of onset is 20-40 years). Nonethless, depression in older adults is often unrecognized and undertreated.

  7. Assoc.Prof.Guldal Izbirak,MD • These disorders underlie 50% to 70% of all cases of suicide, and individuals with serious depression (i.e., requiring hospitalization) have a 15% suicide rate.

  8. Assoc.Prof.Guldal Izbirak,MD Assessment of suicide risk • Ask about suicidal ideas or plans in a sensitive but probing way. It is a common conception that asking about suicide can plant the idea into a patient’s head and make suicide more likely. Evidence is to the contrary.

  9. Assoc.Prof.Guldal Izbirak,MD Assessment of suicide risk • Risk factors include • M < F, past psychiatric history, • recent admission to psychiatric hospital, • history of suicide attempt/self harm, • age 40-60years, • alcohol/drug misuse, • chronic psychiatric illness, • unemployment, • living alone

  10. Classification

  11. Assoc.Prof.Guldal Izbirak,MD • The Diagnostic and Statistical Manual of Mental Disorders (DSM) is published by the American Psychiatric Association and provides a common language and standard criteria for the classification of mental disorders.

  12. Assoc.Prof.Guldal Izbirak,MD • The last major revision was the fourth edition ("DSM-IV"), published in 1994, although a "text revision" was produced in 2000. • The fifth edition DSM 5 was published on May 18, 2013. • In most respects DSM-5 is not greatly changed from DSM-IV-TR. Notable changes include dropping the "bereavement exclusion" for depressive disorders

  13. Assoc.Prof.Guldal Izbirak,MD • The DSM-IV-TR was organized into a five-part axial system. • The first axis incorporated clinical disorders. • The second axis covered personality disorders and intellectual disabilities. • The remaining axes covered medical, psychosocial, environmental, and childhood factors functionally necessary to provide diagnostic criteria for health care assessments.

  14. Assoc.Prof.Guldal Izbirak,MD • Personality disorders are a class of mental disorderscharacterised by enduring maladaptive patterns of behavior, cognition and inner experience, exhibited across many contexts and deviating markedly from those accepted by the individual's culture.

  15. Assoc.Prof.Guldal Izbirak,MD • ICD-10 Chapter V: Mental and behavioral disorders, part of the International Classification of Diseases produced by the World health Organization (WHO), is another commonly used guide, more so in Europe and other parts of the world.

  16. Assoc.Prof.Guldal Izbirak,MD ICD-10 • ICD is an international standard diagnostic classification for a wide variety of health conditions. Chapter V focuses on "mental and behavioural disorders" and consists of 10 main groups which also include: • F3: Mood [affective] disorders

  17. Assoc.Prof.Guldal Izbirak,MD • The coding system used in the DSM-IV is designed to correspond with the codes used in the ICD, although not all codes may match at all times because the two publications are not revised synchronously.

  18. Assoc.Prof.Guldal Izbirak,MD Depressive disorders • The bereavement exclusion in DSM-IV was removed from depressive disorders in DSM-5.[8] • New disruptive mood dysregulation disorder (DMDD)[9] for children up to age 18 years.[2] • Premenstrual dysphoric disorder moved from an appendix for further study, and became a disorder.[2] • Specifiers were added for mixed symptoms and for anxiety, along with guidance to physicians for suicidality.[2] • The term dysthymia now also would be called persistent depressive disorder.

  19. Assoc.Prof.Guldal Izbirak,MD • 1.1 Depressive disorders • 1.2 Bipolar disorders • 1.3 Substance induced mood disorders

  20. Assoc.Prof.Guldal Izbirak,MD The Diagnostic and Statistical Manual of Mental Disorders IV / Affective (Mood) Disorders / Depressive Disorders • 1.1 Depressive disorders • Major Depressive Disorder • Dysthymia • Depressive Disorder Not Otherwise Specified • Minor Depressive disorder

  21. Assoc.Prof.Guldal Izbirak,MD • Bipolar disorder (BD), a mood disorder formerly known as "manic depression" and described by alternating periods of mania and depression (and in some cases rapid cycling, mixed states, and psychotic symptoms).

  22. Assoc.Prof.Guldal Izbirak,MD Subtypes include • Bipolar I is distinguished by the presence or history of one or more manic episodesor mixed episodeswith or without major depressive episodes. • Bipolar II consisting of recurrent intermittent hypomanicand depressive episodes. • Cyclothymia is a form of bipolar disorder, consisting of recurrent hypomanicand dysthymic episodes, but no full manic episodes or full major depressive episodes.

  23. Assoc.Prof.Guldal Izbirak,MD • DSM Diagnostic Codes for Depression • Major Depressive Disorder, Recurrent 296.36 In Full Remission 296.35 In Partial Remission 296.31 Mild 296.32 Moderate 296.33 Severe Without Psychotic Features 296.34 Severe With Psychotic Features 296.30 Unspecified

  24. Assoc.Prof.Guldal Izbirak,MD • Major Depressive Disorder, Single Episode • 296.26 In Full Remission 296.25 In Partial Remission 296 21 Mild 296.22 Moderate 296.23 Severe Without Psychotic Features 296.24 Severe With Psychotic Features 296.20 Unspecified

  25. HT & PE

  26. Assoc.Prof.Guldal Izbirak,MD Medical history should include • Symptoms, • onset(inc. Precipitating events) and past history of similar symptoms, • severity and affect of life, • current life events (stressors at home and at work), • past psychiatric history, • FH, • co-existing medical conditions, • current medications( prescribed and non-prescribed).

  27. Assoc.Prof.Guldal Izbirak,MD Examination • General appearance (self-neglect, smell of alcohol, evidence weight loss), • assessment of mood (looks depressed and/or tired, speech mono-tone, avoids eye contact, tearful, anxious, feeling of distance, poor concentration), • psychotic symptoms (hallucinations, delusions)

  28. Assoc.Prof.Guldal Izbirak,MD Clinical presentation • Over half of depressed patients present with somatic complaints in primary care settings ; only one-fifth present with psychological symptoms. Persistent pain, such as headache or backache is common.

  29. Assoc.Prof.Guldal Izbirak,MD Clinical presentation • The elderly tend to somatize more , express anhedonia more than dysphoria, and may have paranoia or agitation when depressed.

  30. Assoc.Prof.Guldal Izbirak,MD • In children and adolescents, • school avoidance, • seperation anxiety, • irritability or aggressiveness, • drug abuse, or • school problems are signals for possible depression.

  31. Diagnosis

  32. Assoc.Prof.Guldal Izbirak,MD Multi-axial system • The DSM-IV organizes each psychiatric diagnosis into five dimensions (axes) relating to different aspects of disorder or disability: • Axis I: All psychological diagnostic categories except mental retardation and personality disorder • Axis II:Personality disorders and mental retardation • Axis III: General medical condition; acute medical conditions and physical disorders • Axis IV: Psychosocial and environmental factors contributing to the disorder • Axis V:Global Assessment of Functioning or Children’s Global Assessment Scale for children and teens under the age of 18

  33. Assoc.Prof.Guldal Izbirak,MD • Common Axis I disorders include depression, anxiety disorders, bipolar disorder, ADHD, autism spectrum disorders, anorexia nervosa, bulimia nervosa, and schizophrenia. • Common Axis II disorders include personality disorders: paranoid personality disorder, schizoid personality disorder, schizotypal personality disorder, borderline personality disorder, antisocial personality disorder, narcissistic personality disorder, histrionic personality disorder, avoidant personality disorder, dependent personality disorder, obsessive-compulsive personality disorder; and intellectual disabilities. • Common Axis III disorders include brain injuries and other medical/physical disorders which may aggravate existing diseases or present symptoms similar to other disorders.

  34. Assoc.Prof.Guldal Izbirak,MD • Disruptive Mood Dysregulation Disorder, for temper tantrums • Major Depressive Disorder, includes normal grief • Wright J, O'Connor KM.Fatigue.Med Clin North Am. 2014 May;98(3):597-608. doi: 10.1016/j.mcna.2014.01.010. Review.

  35. Assoc.Prof.Guldal Izbirak,MD • Criteria. The DSM-IV criteria for the diagnosis of major depression must include one of the two major symptoms; anhedonia (loss of ability to experience pleasure) or dysphoria(feeling depressed). • In addition, four minor symptoms must be present.

  36. Assoc.Prof.Guldal Izbirak,MD • Sleep (early awakening or excessive sleep) • Interest (motivation to take an action) • Guilt (hopeless, helpless, worthless feelings) • Energy (fatique in morning, may improve in evening) • Concentration (includes short-term memory problems) • Appetite (overeating and undereating) • Psychomotor agitation (irritability or anxiety) or retardation (slowed speech, movement, depressed affect) • Suicidal ideation or plans

  37. Assoc.Prof.Guldal Izbirak,MD Diagnosis • The symptoms must be present more days than not, for 2 weeks or longer, and not associated with mania, delusional or psychotic symptoms, normal grief, or caused by another disease, such as hypothyroidism, etc.

  38. Assoc.Prof.Guldal Izbirak,MD • Minor depressive disorder, or simply minor depression, which refers to a depression that does not meet full criteria for major depression but in which at least two symptoms are present for two weeks.

  39. Assoc.Prof.Guldal Izbirak,MD Dysthymia • Chronic but milder form of depression • Depressed mood for most of the day, for more days than not, for  2 years, and the presence of  2 of the following: • poor appetite or overeating • insomnia or hypersomnia • low energy or fatique • low self-esteem • feeling of hopelessness • poor concentration or difficulty making decision

  40. Assoc.Prof.Guldal Izbirak,MD • The symptoms are not as severe as those for major depression, although people with dysthymia are vulnerable to secondary episodes of major depressionwith a range of 25%*sometimes referred to as double depression

  41. Assoc.Prof.Guldal Izbirak,MD Differential Diagnosis • The term depression can mean many different things. Therefore, when patient’s say they are depressed, it is important to ask, • “What do you mean by “depressed” ?”

  42. Assoc.Prof.Guldal Izbirak,MD The term depression may refer to any of the following • MDD • Depression secondary to some medical cause • Dysthymia • Grief, etc.

  43. Assoc.Prof.Guldal Izbirak,MD The relationship between anxiety and depression • Depression and anxiety often coexist. An anxiolytic medication is often useful, especially around the initiation of treatment with an antidepressant. SSRIs and other newer antidepressants are efficacious in the treatment of many primary anxiety disorders as well as depression.

  44. Assoc.Prof.Guldal Izbirak,MD The relation ship between anxiety and depression • Of special importance is the fact that anxiety associated with the depression is a recognized risk factor for suicide in the depressed individual. This provides further support for the recommendation to monitor and treat the associated anxiety.

  45. Assoc.Prof.Guldal Izbirak,MD How To Differentiate AD and Depression (Pseudodementia) • Depression is common in dementia patients, also in elderlies. • Clinically when they are found together it may be very difficult to differentiate. • In every patient you think dementia, try to differentiate pseudodementia- depression. • Treatment of depression may improve cognitive problems.

  46. Treatment

  47. Assoc.Prof.Guldal Izbirak,MD • Treatment success is predicted by appropriate use of counseling, patient education, regular follow-up, proper diagnosis, and proper drug selection and dosage.

  48. Assoc.Prof.Guldal Izbirak,MD Treatment • Currently, the first-line treatment for depressive disorders consists of the use of SSRIs and other newer antidepressants.

  49. Assoc.Prof.Guldal Izbirak,MD • Compared with MAO inhibitors and TCAs, the SSRIs provide • comparable efficacy at alleviating depressive symptoms, • without the risk of lethality in overdose, • with a more favorable side effect profile and easier dosing.

  50. Assoc.Prof.Guldal Izbirak,MD • When the depression is the result of a general medical condition or substance, the underlying disorder must be treated, although the use of antidepressant medications also may be indicated.

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