Transcript The Diagnosis and Management of Depression

THE DIAGNOSIS AND
MANAGEMENT OF
DEPRESSION
Louis T. Joseph, M.D.
Hospital Psychiatry and Consultation Service
Brain Stimulation Service
Addiction Psychiatry Service
Henry Ford Health System
Consult Question:
Please evaluate for depression.
WHAT DEPRESSION ISN’T
AN ALL TO COMMON
CONSULT…
42 year old female with past history of HTN
and no past psychiatric history admitted to the
hospital with several weeks of fatigue. Found
to have a leukocytosis on CBC with
predominance of blasts. Patient diagnosed
earlier today with AML and has been crying for
2 hours. Mood euthymic on admission. Please
evaluate for depression medications.
MAJOR DEPRESSIVE
EPISODE
 5 or more symptoms of depression for a 2 week period. At least
one symptom is depressed mood or anhedonia.
SIG E CAPS
DEPRESSED MOOD
 How are you feeling?
 Up to 50% of patients will report they feel fine when in fact they
meet all the other criteria for depression.
-How can you diagnose depression in a patient who says
they feel “fine”?
 50% of patients will report a diurnal variation in their mood
SLEEP
 Hypersomnia or Insomnia can occur
 80% of depressed patients report insomnia
 How does one define insomnia?
-1. difficulty initiating or maintaining sleep, or suffering from
non-restorative sleep.
-2. sleep disturbance (or associated daytime fatigue) causes clinically
significant distress or impairment in social, occupational, or other
important areas of functioning.
INTEREST (ANHEDONIA)
 Key Point: Diminished interest and pleasure needs to occur with
almost all activities every day for all day!
 Ask about favorite foods and sex drive
 Palpate the Limbic System during the interview
GUILT
 Needs to be excessive or inappropriate
 Can also be feelings of worthlessness
ENERGY
 95% of depressed patients report decreased energy
 Do you feel fatigued?
CONCENTRATION
 85% of depressed patients report difficulty concentrating
 Can also count Indecisiveness or Trouble thinking
APPETITE
 Can also ask about weight change which also counts.
 5% change in body weight over past month
PSYCHOMOTOR
 Can be agitation or retardation
 How do we ask about this?
SUICIDAL IDEATION
 Incredibly common in depression, ~66%
 10-15% complete suicide
OTHER SYMPTOMS
 Anxiety- 90%
 Pain- 60-70%
 Delusions and Hallucinations
-Mood congruent symptoms in MDD
-Hospitalize patient ASAP
ADDITIONAL QUESTIONS
ABOUT DEPRESSION
 Past mood episodes?
 Symptoms first noticed by patient and family?
NECESSARY RULE OUTS
 Bipolar Disorder
 Substance Use
 Demoralization
 Bereavement
BIPOLAR DISORDER
 Need to rule our a history of mania or hypomania
 Can be difficult because only 50% of the time, patients recall
mania
O T H E R F E AT U R E S S U G G E S T I V E O F
BIPOLAR DISORDER
Early age of onset
Psychotic Depression before age 25yo
Co-morbid substance use disorder
Postpartum Depression or Postpartum Psychosis
Rapid onset and offset of depressive episodes of short
duration (<3 months)
O T H E R F E AT U R E S S U G G E S T I V E O F
BIPOLAR DISORDER
 Family History of Bipolar Disorder
 High density, three generation pedigrees
 Hypomania associated with antidepressants
 Repeated loss of efficacy of antidepressants after initial response (at least 3
times)
 Depressive mixed state (with psychomotor agitation, irritable hostility, racing
thoughts, and sexual arousal during depressive episode)
SUBSTANCE USE
 Timeline, timeline, timeline!
DEMORALIZATION
 Various degrees of despair, helplessness, hopelessness, confusion,
and subjective incompetence that people feel when they are failing to
cope with life’s adversities.
 Can have the same symptoms of MDD
BEREAVEMENT
 Realm of ‘normal’ human
 Marked Psychomotor
experience
Retardation
 When to consider depression
versus bereavement?
 -Suicidal Ideation
 -Severe loss of functioning
 -Severe worthlessness
 -Severe guilt
 -Hallucinations
 Mummification
BEREAVEMENT: TO TREAT
OR NOT TO TREAT
 Counseling or Psychotherapy is always helpful
 What about antidepressants?
-Sparse evidence suggesting that they can be effective if patient meets
criteria for MDD
WHEN TO CONSIDER
PSYCHIATRY REFERRAL
 1. Non-response to medications you are trying
 2. Any case of bipolar disorder
 3. Practicing outside your scope of expertise
PROGNOSIS OF
DEPRESSION
Untreated
 Depressive episodes last 6-13 months
 50% reoccurrence rate within the next 2 years
 After first episode- 50-60% chance of having a second episode.
 After second episode-70% chance of having a third episode
 After third episode-90% chance of having a fourth episode
PROGNOSIS OF
DEPRESSION
Untreated
 Episodes typically occur more frequently, become longer, and are
more severe the more untreated episodes one has
 Psychological stress typically plays a role in triggering the first 1-2
episodes but not subsequent ones
PROGNOSIS OF
DEPRESSION
Treated
1. Treated episodes last 3 months in length
2. Cessation of antidepressant treatment
within the first 3-6 months almost always
leads to a relapse
TREATMENT EFFICACY
 1. Medications
35% for initial trial
75% after 4 treatment trials
 2. ECT
90% remission
70% remission for medication refractory patients
 3. Psychotherapy
Equivalent efficacy to medications for mild-moderate depression
N U M B E R O F S U I C I D E S I N H E N RY
F O R D H E A LT H S Y S T E M H M O P E R
YEAR
13
REFERENCES
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REFERENCES CONT.
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