1. Hanan abbas Assistant Professor of family Medicine

2. Learning Objectives Prevalence of depression in primary care Consequences of undiagnosed and untreated depression Presentations of depression in primary care Diagnostic criteria for depression Depression, diabetes & other co-morbidities Tools for screening, diagnosis of mental disorders in primary care

3. Mental disorders in primary care  25% of patients have a mental disorder  88% of patients with mental disorder seek primary care first  Diagnosis missed half the time for depression

4. Depression usually untreated or undertreated in Primary Care Treated Appropriately (only 1/6) Hirschfeld et al. JAMA. 1997;277:333-340. Untreated Undertreated

5. Obstacles to diagnosis  Insufficient training  Insufficient time  Presentation with somatic symptoms  Competing problems  Stigmatization  Minimization

6. Physical complaints are rarely organic Kroenke K, Mangelsdorff AD. Am J Med. 1989;86:262-266. 3-Year Incidence (%) DizzinessChest Pain FatigueHead- ache Edema Back Pain Dyspnea InsomniaAbdom- inal Pain Numb- ness

7. Mortality Reduced Productivity Absenteeism Direct Costs Pharmaceuticals The Burden of Depression Indirect Costs Direct Costs Total costs = $44 billion per year in 1990 dollars Direct costs = $12.4 billion per year in 1990 dollars Greenberg et al. J Clin Psychiatry. 1993;54:405-418. 27% 28% 17% 3% 25%

8. The Personal Price of Depression  Mental anguish  Poor physical functioning  Poor social and occupational functioning  Pain, somatic symptoms  Family frustration  Suicide and other mortality risks Wells et al. JAMA. 1989;262:914-919.

9. The Personal Price of Depression “To most of us who have experienced it, the horror of depression is so overwhelming as to be quite beyond expression... it kills in many instances because its anguish can no longer be borne.” —Styron. Darkness Visible: A Memoir of Madness. 1990.

10. Adapted from Diagnostic and Statistical Manual of Mental Disorders. 4th ed. (DSM-IV ™ ). 1994:327, 339. Diagnostic Criteria for Major Depressive Disorder Five or more of the following for at least 2 weeks  Depressed mood*  Loss of interest or pleasure*  Appetite/weight change  Sleep disturbance  Psychomotor disturbance  Fatigue or low energy  Feelings of worthlessness or inappropriate guilt  Impaired ability to think or concentrate  Recurrent thoughts of death or suicide *At least one of these symptoms must be present.

11. Adapted from US Dept of Health and Human Services. Depression in Primary Care: Volume 1. Detection and diagnosis. AHCPR Publication No. 93-0550, Agency for Health Care Policy and Research, Rockville, MD 1993, p. 20 Diagnosis Pathway*

12. Screening: Good History a Must!  Suicide Risk  Psychiatric co-morbidities  Family history  Past history  Substance Abuse  Prescription Medications  Occult medical illness

13. Risk Factors for depression  Family History  Depression  Bipolar disorder  Alcohol abuse  Other psychiatric illness  Patient History  Age of onset of depression  Gender  Periods of significant depression in the past  Previous episodes of other psychiatric disorder(s)  Previous treatments

14. Differential diagnosis of depression  Rule out underlying medical conditions (eg, CNS disease, hypothyroidism)  Rule out medications causing depression  Screen for substance abuse

15. Depression and Comorbidity Cancer: 25% Diabetes: 32.5% Postpartum: 10%–20% Post stroke: 32% Post-myocardial infarction: 16% Massie, Holland. J Clin Psychiatry, 1990. Lustman et al. Diabetes Care, 1988. Dobie and Walker. J Am Board Fam Pract, 1992. Morris et al. Int J Psychiatry Med, 1990. Frasure-Smith et al. Circulation, 1995. Prevalence of Depression as a Concomitant Condition

16. Diabetes Mellitus Major Depression RR=2 RR=2.2

17. Potential Explanations  Depression as reaction to DM?  But, depression often precedes Type II DM  Depression>>>metabolic changes>>>DM?  Common neuro endocrine pathway?  Medication or lifestyle induced?

18. Metabolic change  “...a surplus of insulin antagonists are present during severe depressions. These include epinephrine, growth hormone, and cortisol.”  “... poor metabolic control was demonstrated by the psychiatrically ill group, both at index and follow-up evaluations." Lustman et al, 1988

19. Medication Effects  Antidepressants and antipsychotics can affect glycemic control  Consider both therapeutic and life- threatening effects  May require adjusting dose of insulin or oral agents for diabetes  May influence choice of medication when treating mood disorder or neuropathy

20. SSRIs  inhibit reuptake of serotonin at neuronal membrane  Side Effects  Anxiety/agitation, insomnia  Sexual side effects  GI – nausea, vomiting  Can lower seizure threshold  Serotonin syndrome  Rare – hypoglycemia, anemia, visual disturbance, SIADH

21. SSRIs  Advantages  Safety  Less orthostatic hypotension, anticholinergic side effects, adverse cardiac effects  Increased patient satisfaction  Weekly formulation of fluoxetine available  Disadvantages  Cost - $50-150 per month  Potential for interactions with other drugs  Lack of sedation  Development of serotonin syndrome  Some distressing side effects

22. Antidepressants  Selective serotonin re-uptake inhibitors (SSRIs) tend to improve glycemic control, & may lead to the need to reduce insulin or oral medication doses

23. Follow Up  Assess every 2-4 weeks  Titrate dose for total remission  Maintain effective dose for 4-9 months  Consider maintenance therapy

24. What do warnings mean for family docs?  Patients with new prescriptions for antidepressants & their family members should be warned of the risks of suicide  Patients on a new antidepressant medication should have regular (e.g. every 1-2 week) appts. until they are stable

25. Drug Selection – General Considerations  History of previous response  Impact of antidepressant on concurrent medical conditions  Bupropion with epilepsy  Venlafaxine with severe hypertension  Nefazodone with liver disease  Safety in overdose  Potential for drug interactions  Ease of administration  Cost

26. Treatment Guidelines  Titrate agent to achieve therapeutic dose or remission  Full effect may take 4-6 weeks  Treat for 4-9 months after full remission  Continue medication indefinitely for recurrent depression

27. Partial or No Response  Check for adherence  Re-evaluate diagnosis  Adjust dose  Change medication  Add psychotherapy  Obtain psychiatric consultation

28. Screening Instruments What are the ideal features?  Brief, compatible with time constraints  Easy to administer & inexpensive  Makes accurate diagnoses  Educates the provider  Educates the patient/fosters realization  Overcomes stigmatization  Associated with improved outcomes

29. Short instruments for depression  Original PRIME-MD: 2 questions  During the past month, have you 1) Often been bothered by feeling down, depressed, or hopeless? 2) Had little interest or pleasure in doing things?  Sensitivity 86-96%, specificity 57-75%, comparable to more cumbersome measures

30. Clinician Time Requirements

31. Refer when:  Severe depression that is endangering the life of the patient (ie, suicidality or inability to care for self) or others (aggressivity or inability to care for dependent others).  Depression that has failed to respond to initial treatment trials, whether due to patient adherence, perceived side effects, or treatment-refractoriness.  Desire to treat with psychotherapy, light therapy, electroconvulsive therapy, or other modalities requiring specialty expertise.  Psychotic depression.  Depression that is part of the course of bipolar disorder, schizoaffective disorder, or another major psychiatric illness.  Depression whose presentation or management is complicated by significant psychiatric comorbidity.  Patients for whom the diagnosis of depression (or its comorbidities) is uncertain

32. Discussing Results With Patients Review questionnaire results with patient Explain  “You are not alone; this illness affects many people.”  “Depression/anxiety is a medical illness.”  “Physical symptoms—like yours—are common in...”  “… is a medical illness like hypertension or diabetes— not a character defect or weakness.”  “Effective treatment is available.”

33. When you can’t do it alone

34. Assessing Suicidal Ideation  Studies show that more than 70% of suicide victims visit a physician within 2 months preceding their death Spitzer et al. JAMA. 1994;272:1749-1756. “Over the last 2 weeks, how often have you been bothered by thoughts that you would be better off dead, or of hurting yourself in some way?” If the answer is yes: “Tell me about it.”

35. Suicidal Potential  Evaluate suicidal potential if during evaluation patient admits to suicidal ideation by considering:  Degree of hopelessness about situation  Any reason to stay alive (eg, for children)  Thoughts of a specific method of suicide  Personal or family history of suicide attempts  If there is significant suicidal potential: refer to psychiatrist

36. Key Points  Screening can be simple  Diagnoses missed half the time or more  High prevalence and associated disability make strong argument for routine screening

37. Questions?