Depression

1. Depression

2. Which patients are at especially high risk for depression? • Risk factors for depression • Alcohol dependence • Comorbid chronic medical conditions • Female sex • Personal or family history of depression • Recent childbirth • Recent stressful events

3. Should clinicians screen for depression? • Screen all adults (USPSTF) provided adequate resources for diagnosis, treatment, and follow-up are available • Including pregnant and postpartum women, older adults • Utility depends on prevalence in population assessed • Optimum rescreening interval is unknown • Screen patients with identified risk factors • Screen patients with unexplained somatic symptoms, chronic pain, anxiety, substance misuse, or nonresponse to effective treatments

4. What methods should clinicians use to screen for depression? • 2-item patient health questionnaire (PHQ-2) • “Over the past 2 weeks have you felt down, depressed, hopeless?” • “Over the past 2 weeks have you felt little interest or pleasure in doing things?” • “Yes” to ≥1 question: more complete assessment needed • Patient Health Questionnaire (PHQ-9) • Edinburgh Postnatal Depression Scale • Hopkins Symptom Checklist-25 (refugees)

5. CLINICAL BOTTOM LINE: Screening... • Screening all adults • First step in systematic evaluation of mood disorders • PHQ-2 widely used and efficient • Adults at increased risk • Postpartum • Personal or family history of depression • Comorbid medical illnesses

6. What are the diagnostic criteria for depression? • 5 or more DSM-5 symptoms occur in the same 2 weeks with a change from previous functioning: • Depressed mood most of the day, nearly every day as self-reported or observed by others • Diminished interest or pleasure in all or almost all activities most of the day, nearly every day • Significant weight loss when not dieting, or weight gain; or decrease or increase in appetite nearly every day • Insomnia or hypersomnia nearly every day • Psychomotor agitation or retardation nearly every day • Fatigue or loss of energy nearly every day continued…

7. Feelings of worthlessness or excessive or inappropriate guilt nearly every day • Diminished ability to think or concentrate nearly every day • Recurrent thoughts of death, recurrent suicidal ideation without a specific plan • Symptoms cause clinically significant distress or impairment in social, occupational, other areas of functioning • Symptoms not attributable to the direct physiologic effects of a substance or a general medical condition • Occurrence of the major depressive disorder is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorders • There has never been a manic or a hypomanic episode

8. How can clinicians determine the severity of depression? • Clinical interview • Validated depression screening tool (PHQ-9) • Assessment of severity guides treatment • Mild: may not require medication • Mild-to-moderate: responds equally to medication or psychotherapy • Severe: benefits more from medication alone or combined with psychotherapy

9. Patient Health Questionnaire-9 Over the last 2 weeks, how often have you been bothered by any of the following problems? (0 = not at all; 1 = several days; 2 = more than one half the days; 3 = nearly every day): • Little interest or pleasure in doing things • Feeling down, depressed, or hopeless • Trouble falling or staying asleep or sleeping too much • Feeling tired or having little energy • Poor appetite or overeating • Feeling bad about yourself or that you are a failure or have let yourself or your family down • Trouble concentrating on things, such as reading the newspaper or watching television • Moving or speaking so slowly that others have noticed, or the opposite • Thoughts that you would be better off dead or hurting yourself in some way • If you have checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

10. How should clinicians assess a depressed patient's risk for self-harm, including suicide? • Assess acute risk for suicide at each visit for depression • Ask about and reduce access to lethal means (firearms) • Consult psychiatrist for any uncertainty regarding suicidal risk • Telephone follow-up by experienced psychiatrist can reduce suicide risk after a previous attempt

11. When should clinicians consult a mental health professional for help diagnosing depression or a related mood disorder? • Diagnostic uncertainty • Psychiatric comorbid conditions • Significant risk for suicide • Suboptimal response to treatment

12. CLINICAL BOTTOM LINE: Diagnosis... • DSM-5 criteria: standard for diagnosing major depression • Assess risk for suicide and comorbid mental and physical illness in each patient • Consider psychiatric consultation when there is • Uncertainty about the diagnosis • Risk for suicide • Need for hospitalization

13. How should clinicians decide whether to recommend psychotherapy, drug therapy, or both? • Factors that influence treatment decision • Patient preference, prior treatment, depression severity • Psychotherapy barriers (therapist availability, insurance) • Exclude bipolar spectrum disorder • Mild-to-moderate major depression • Benefits equally from psychotherapy or medication • Exercise may be appropriate; close follow up warranted • Moderate-to-severe depression • Use medication, either with or without psychotherapy

14. What types of behavioral interventions and psychotherapy are most likely to be effective for depression? • Cognitive behavioral therapy • Identifies and modifies dysfunctional or inaccurate thoughts and behaviors • Interpersonal therapy • Targets conflicts and role transitions • Patient needs capacity for psychological insight • Problem-solving therapy • Practical approaches to coping with everyday problems

15. How should clinicians select from the many antidepressant drug therapies? • Discuss treatment factors with patient • Tolerability, safety, effectiveness • Cost, age, family history • Drug-drug interactions, comorbid medical conditions • Initiate treatment with SSRI or SNRI • Mirtazapine and bupropion may also be appropriate choices • Newer agents may be more costly and lack broad experience • TCAs and MAOIs may offer similar or greater effectiveness but with less receptor specificity and more toxicity

16. How should clinicians monitor response to drug therapy? • Treat at least 6 to 9 months with close follow-up • See patients within 1 to 2 weeks of starting therapy • Modify treatment at 6 to 8 weeks if response is inadequate • Monitor especially closely in first few months • Possible increased suicide risk in children, adolescents, young adults • High rate of nonadherence in early months • Educate patients pre-emptively about potential side effects • Continue surveillance for recurrence/relapse indefinitely

17. Follow-up for Depression • Minor depression • Watchful waiting, re-evaluate in 4-8 wk • Mild depression (PHQ-9 score of 10–14) • Contact by phone or in-person monthly • Moderate depression (PHQ-9 score of 15–19) • Contact by phone or in-person every 2–4 wk • Severe depression (PHQ-9 score of ≥20) • Contact by phone or in-person every 2–4 wk until PHQ-9 score improves by ≥5 points • No active treatment, receiving ongoing stable antidepressants or counseling • Contact by phone or in-person every 2–3 mo after remission

18. How long should clinicians treat depressed patients with drugs? When should they consider long-term maintenance on drug therapy? • First episode • Treatment may take 1 to several months until remission • Continue for another 4 to 9 months • Some clinicians advocate treating at least 1 year • Multiple episodes of depression • Even longer duration of therapy may be beneficial • Older patients (>70 years) who respond to an SSRI • Consider treating for 2 years to prevent recurrence

19. When should clinicians consider switching drugs because of a suboptimum response to initial drug therapy? • Partial response • First maximize dose of initial agent as tolerated • Switch to another medication or add second drug if needed • When partial response continues • Add psychotherapy • Change antidepressants • Augment with bupropion, mirtazapine, nontraditional agent • Combination therapy may offer benefits over withdrawing 1 drug and starting another

20. What are the common adverse effects of antidepressant drugs? How should clinicians manage these effects? • SSRIs • Sexual side effects: pretreatment counseling; switch to/ augment with bupropion, mirtazapine; sildenafil for erectile dysfunction • Undesired weight gain: switch to bupropion • Agitation: switch to another SSRI; consider mixed mania • Insomnia: add mirtazapine, trazodone, or sedative-hypnotic • Anxiety: short course of benzodiazepines during initiation • Elderly: beware hyponatremia, may promote osteoporosis

21. When should clinicians consult a psychiatrist for help in managing drug therapy? • Treatment-resistant depression • No response to agents familiar to the primary care provider • Repeated treatment failures • Side effects difficult to manage • Electroconvulsive therapy • Transcranial magnetic stimulation • Severe symptoms • Heightened suicide risk • Comorbid, psychiatric, or substance abuse problems

22. When should clinicians consider hospitalizing depressed patients? • Significant suicidal ideation or intent without safeguards • Intent to hurt others is expressed • Unable to care for self • Close observation needed (assess self-care, adherence) • Detoxification or substance abuse treatment • Electroconvulsive therapy initiated • Dysfunctional family systems worsen depression or interfere with treatment • Patient's life is in jeopardy

23. What should clinicians advise patients about complementary-alternative treatments for depression? • St. John's wort (0.3% hypericin, 300 mg 3x/d) • Treatment of subsyndromal or mild depression only • Serious adverse effects are uncommon • Don’t use with SSRIs to avoid serotonin excess symptoms • May reduce concentrations of certain medications (digoxin, theophylline, simvastatin, and warfarin; protease inhibitors and nonnucleoside reverse transcriptase inhibitors) • Severe drug interactions reported with ARVs • At high dose, may harm sperm cells, reduce fertility

24. If a patient relapses after cessation of depression treatment, should clinicians resume previously effective therapy or select a new therapy? • Use antidepressant that previously led to remission • Initiate long-term maintenance therapy • Lifetime therapy may be required • ≥3 episodes • First recurrence and risk factors for more recurrences

25. How should clinicians advise women receiving drug therapy for depression who are or who wish to become pregnant? • SSRIs • Unclear if cause of persistent pulmonary hypertension • Class C teratogens (except paroxetine is class D) • Possible association between cardiac defects and paroxetine use in early pregnancy • Tricyclic antidepressants • Neonatal withdrawal syndrome may occur if not tapered • Desipramine or nortriptyline cause fewer side effects • Stopping antidepressants carries relapse risk

26. CLINICAL BOTTOM LINE: Treatment... • Depression is highly treatable • Primary care physicians play an important role in treatment • Clinicians familiar with 2 SSRIs, an SNRI, and sustained-release bupropion are well-equipped to treat most cases • Refer patients to a psychiatrist as needed • Become familiar with local psychotherapy options • Know options for addressing common side effects