Transcript Document
The following lecture has been approved for University Undergraduate Students This lecture may contain information, ideas, concepts and discursive anecdotes that may be thought provoking and challenging It is not intended for the content or delivery to cause offence Any issues raised in the lecture may require the viewer to engage in further thought, insight, reflection or critical evaluation Depressive Illness Dr. Craig Jackson Senior Lecturer in Health Psychology Faculty of Health BCU health.bcu.ac.uk/craigjackson [email protected] “The good physician treats the disease, but the great physician treats the person.” William Osler Traditional model of Disease Development Pathogen Modifiers Lifestyle Individual susceptibility Disease (pathology) Dominance of the biopsychosocial model Mainstream in last 15 years Hazard Illness (well-being) Psychosocial Factors Attitudes Behaviour Quality of Life Rise of the person as a “psychological entity” Depressive Illness Usually treatable Common Marked disability Reduced survival Increased costs Depression may be Coincidental association Complication of physical illness (i.e. “secondary depression”) Cause of / Exacerbation of somatic symptoms Psychiatry in Pictures – Steve Blundell Digital Cry Stapled Red Depressive Illness 2% of population suffer from pure depression (evenly distributed between mild, moderate, and severe) Further 8% suffer from a mixture of anxiety and depression Patients with symptoms not severe enough to qualify for diagnosis of either anxiety or depression..... ??? Impaired working and social lives and many unexplained physical symptoms Greater use of medical services “Walking Well” Spectrum of mood disturbance Mild thru to Severe Transience thru to Persistence Continuous distribution in population Clinically significant when: (1) interferes with normal activities (2) persists for min. 2 weeks Diagnosis of depression / depressive disorder “Persistent & pervasive low mood” “Loss of interest or pleasure in activities” “Ennui” Epidemiology 2nd biggest cause of disability worldwide by 2020 (WHO) (IHD still the biggest) Associated with increased physical illness • 5% during lifetime have MDD • 1 in 20 consultations • 100 patients per GP • MDD & Dysthmia > in females • 20% develop chronic depression • 30% of in-patients have depressive symptoms Suicide Suicide Final clinical pathway 1 million deaths per year, 10-12 million attempts UK Males – most common in older Female – most common in middle age Steady decline since 1990 5,554 suicide deaths in UK 2006 15 per 100,000 deaths males 6 per 100,000 deaths females Almost 50% fail on first attempt Previous attempters 23 times more likely to dies from suicide than those without previous attempts Internal stress Pre-existing psychiatric morbidity Demographics Opportunities Stack 2001 Behavioural Indicators - recent bereavement or other life-altering loss - recent break-up of a close relationship - major disappointment (failed exams or missed job promotion) - change in circumstances (retire, redundant or children leaving home) - physical illness - mental illness - substance misuse / addiction - deliberate self-harm, (particularly in women) - previous suicide attempts - loss of close friend / relative by suicidal means - loss of status - feelings of hopelessness, powerlessness and worthlessness - declining performance in work / activities (sometimes this can be reversed) - declining interest in friends, sex, or previous activities - neglect of personal welfare and hygiene - alterations in sleeping habits (either direction) or eating habits Case Summary of a Depressed Patient #1 Date Symptoms Referral 1985 (16) Anorexia Secure unit teenagers 1986 (17) Suicide attempt Secure unit teenagers 1986 (17) Self-harm (A levels) Secure unit CAMHS Psychiatry - ECT unsubstantiated 1987-9 (18-20) Self-harm. Anorexia (university) UMC 1990 (21) Working as au pair (left university) GP monitoring & anti-depressants 1993 Self-harm Secure unit admission (24) (joined commune) Female. Abused by father from 6 to 15. Moved to boarding school, then to grandparents Insomnia - Feeling worthless – Guilt - Recurrent morbid thought - Bleak views - Self harm – Suicide Ideation Scholastically bright. University. Dropped out. Tried own business. Business failed. Admin working. Epidemiology Depression more common in those with: • Life threatened / limited / chronic physical illness • Unpleasant / demanding treatment • Low social support • Adverse social circumstances • Personal / family history of depression / psychological vulnerability • Substance misuse • Anti-hypertensive / Corticosteroid / Chemotherapy use Aetiology Most depressions have triggering life events - Reactive depression Especially in a first episode Many patients present initially with physical symptoms (somatization) Some may show multiple symptoms of depression in the apparent absence of low mood - “Masked Depression” Some depression has no triggering cause - “Endogenous Depression” More persistent and resistant to treatment Clinical Features • Adjustment Disorders mild short-lived reactive episodes • Major Depressive Disorder (MDD) 5 symptoms displayed in 14 days • Dysthymia depressed mood for 2+ years not severe chronic depression unhealthy lifestyle associations • Bipolar Disorder / manic depression major depression & mania Major depression (DSM IV) 5 or more….. • decreased interest / pleasure * • depressed mood * • reduced energy • weight gain / loss • insomnia / hypersomnia • feeling worthless • guilt • recurrent morbid thought • psychomotor changes • fatigue • poor concentration • pessimism / bleak views • self harm ideas / actions • suicide ideation Classification of Depression (ICD-10) Primary Unipolar Mixed anxiety and depressive disorder (prominent anxiety) Depressive episode (single episode) Recurrent depressive disorder (recurrent episodes) Dysthymia - Persistent and mild ("depressive personality") Bipolar Bipolar affective disorder - manic episodes ("manic depression") Cyclothymia - Persistent instability of mood Other primary Seasonal affective disorder Brief recurrent depression Depressive episode may be Moderate or severe With/Without somatic syndrome With/Without psychotic symptoms Somatization Syndrome (DSM IV) 4 or more….. Anhedonia Loss of emotional reactivity Early waking (>2 hours early) Psychomotor retardation or agitation Marked loss of appetite Weight loss >5% of body mass in one month Loss of libido Linking Emotions with Physical Symptoms Case Summary of a Depressed Patient #2 Date Symptoms Referral 1985 (17) Pervasive low mood GP monitors 1986 (18) Suicide attempt Child Psychiatry 1986 (18) Self-harm Psychiatry 1987 (19) Anorexia. Self-harm Psychiatry – CPN 1988 (20) Suicide attempt (failed romance) Psychiatry – CPN 1989 (21) Suicide attempt (failed romance) Psychiatry – CPN 1990 (22) Fertility worries Psychiatry – CPN – fertility counselling 1990 (22) Working in office GP monitoring & anti-depressants 1992 (24) Self-harm MH unit (open door policy) CPN 1996 (26) Chronic Fatigue MH unit (open door policy) CPN 1998 (28) Fibromyalgia MH unit (open door policy) CPN Risk Factors – Existing Health Conditions Depressed Patients and “Positive Symptoms” Rosemary Carson Sensations of maggots moving within her body Depressed, attempted suicide at the age of 15 Spent long periods of early adult life in psychiatric hospitals Treated with medication and electro convulsive therapy 17-year remission in affective symptoms and sensations of maggots By 1996 became ill again - began to hear voices Her art captures memories of fellow patients and situations from earlier admissions Depressed Patients and Positive Symptoms Rosemary Carson - The Hospital Ward at Night Classification • Many patients do not fit neatly into categories of either anxiety or depression • Mixed anxiety and depression is now recognised • Presence of physical symptoms indicates a somatic syndrome • Value of somatic features in predicting response to treatment is not clear • Presence of psychotic features has major implications for treatment • Brief episodes of more severe depression are also recognised (brief recurrent depression) • More prolonged recurrence is now termed recurrent depressive disorder Return to Work 10 20 30 40 50 60 70 80 90 100 % returning to work Longer off work = Less likely to return to work <1 2 4 6 8 10 12 14 16 18 20 22 24 months not working Waddell, 1994 Risk Factors Anxiety + Sadness + Somatic discomfort Normal psychological response to life stress Clinical depression is a “final common pathway” Resulting from interaction of biological, psychological, and social factors Likelihood of this outcome depends on many factors: • genetic and family predisposition • clinical course of concurrent medical illness • nature of any treatment • functional disability • individual coping style • social and other support Risk Factors - Causality Certain illnesses such (stroke, Parkinson's disease, multiple sclerosis, and pancreatic cancer) may cause depression via direct bio mechanisms. Stroke received most attention, but studies fail to show convincing direct aetiology Psychological Consequences of Chronic Illness e.g. Cancer • Distress • Reduced QoL • Delay seeking help Fear Denial • Depressed / Anxious • Increased somatic complaints (Pain Fatigue Breathlessness) Adjustment Disorder – commonest psychiatric diagnosis Neuropsychiatric complications Increased risk of suicide in early stages Depression in Cancer Patients • Response to perceived loss • Awareness of losses to come = bereavement • Loss of body, family, friends, role, life • Severe depression X4 likely in cancer patients • 10-20% of cancer patients Behavioural Responses to Diagnoses Hedonism Put life in order Premature grieving ADAPTIVE COPING Talk about it Planning Changes Sick Role Illness Behaviour Over-sensitivity to symptoms Premature death MALADAPTIVE COPING Drink Eat Substance use Neuropsychiatric Complications Brain metastases: Delirium Dementia Depression Produce psych. symptoms before discovery • Paraneoplastic Syndromes Neuropsychiatric problems in absence of metastases Orig. lung, ovary, breast, stomach, or Hodgkin’s Neuropsychiatric syndromes • 61 yr old female • Frontal headaches for 3 months • Lethargic and weak • Difficulty walking • Diffuse areas of nodular destructive lesions • Consistent with multiple myeloma or metastatic disease • Skeleton is common site for mets from carcinomas and occasionally sarcomas • Lesions may be “silent” or symptomatic, such as pain, swelling, deformity, compression of the spinal cord, nerve roots, or pathologic fractures. Recognition & Diagnosis Often missed in diagnoses 1. Distinguish depressed behaviour (sadness and loss of interest), from realistic expected response to stress / physical illness 2. Confusion of whether physical symptoms of depression are due to underlying medical condition 3. Negative attitudes to diagnosis of depression 4. Unsuitability of clinical setting for discussing personal & emotional matters 5. Patients' unwilling to report symptoms of depression Recognition & Diagnosis Depressive illness is often under-diagnosed and under-treated Especially if it coexists with physical illness This often causes great distress for patients: mistakenly assumed that symptoms (weakness or fatigue) are due to an underlying medical condition. Practitioners must be able to diagnose and manage depressive illness • Alertness to clues in interviews • Patients' manner Use of screening questions can detect up to 95% of patients with major depression. Screening Questionnaires “How have you been feeling recently?” “Have you been low in spirits?” “Have you been able to enjoy the things you usually enjoy?” “Have you had your usual level of energy, or have you been feeling tired?” “How has your sleep been?” “Have you been able to concentrate on your favourite tv shows?” Self-report screening instruments Beck Depression Inventory (BDI) General Health Questionnaire (GHQ) Hospital Anxiety Depression Scale (HAD) Can’t replace systematic clinical assessment – LISTENING Persistent low mood and lack of interest and pleasure in life cannot be accounted for by severe physical illness alone Non-Specific Symptoms Often missed in assessment Prevalence of Non-Specific Symptoms Symptom Prevalence % Stuffy nose 46.2 Headaches Tiredness Cough Itchy eyes Sore throat Skin rash Wheezing Respiratory Nausea Diarrhoea Vomiting 33.0 29.8 25.9 24.7 22.4 12.0 10.1 10.0 9.0 5.7 4.0 Heyworth & McCaul, 2001 Modern day complaints Multiple Chemical Sensitivity Chronic Fatigue Syndrome Sick Building Syndrome Gulf War Syndrome Low-level Chemical Exposure Electrical Sensitivity Fibromyalgia Historical complaints Railway Spine Neurasthenia Combat Syndrome Drug Treatment Tricyclics since the 1950s effective and cheap limit compliance variable degrees of sedation fatal in overdose (except Lofepramine) dose-related anticholinergic side effects postural hypotension Monoamine Oxidise Inhibitors (MAOI’s) rare fatalities tyramine-free diet Selective Serotonin Re-uptake Inhibitors (SSRI’s) fluoxetine lack sedation no anticholinergic effects improved compliance less immediate benefit for disturbed sleep safe in overdose single or narrow range of doses works Placebo & Nocebo In approx. 30% of pop. Subjected to more clinical trials than any other medicament Nearly always does better than anticipated The range of susceptible conditions seems limitless Does not always occur Present in subjective and objective outcomes Negative outcomes can occur (Nocebo effect) Placebo Big pills better than smaller pills Red pills better than blue 4 pills better than 2 30% of pop. Long Term Prognosis Identifying Unhelpful Patient Beliefs Discuss potential unhelpful beliefs Counter any simple aetiological beliefs Outline biopsychosocial perspective Can highlight potential perpetual factors that inhibit recovery Agree on positive open minded approach Do not argue over best name for condition! Treatment Much depressive illness of all types is successfully treated in primary care Four main reasons for referral to specialist psychiatric services: 1) Condition is severe 2) Failing to respond to treatment (e.g. Psychomotor retardation) 3) Complicated by other factors (e.g. Personality disorder) 4) Presents particular risks (e.g. Agitation and psychotic behaviour) • Principal decision is whether to treat with drugs or a talking therapy • Most patients in primary care settings would prefer a talking therapy • Effectiveness is limited to particular forms of psychotherapy • Mild-Mod. Depression: CBT and antidepressants are equally effective • Severe Depression: antidepressant drugs are more effective Management The main aims of treatment: • improve mood and quality of life • reduce the risk of medical complications • improve compliance with and outcome of physical treatment • facilitate the "appropriate" use of healthcare resources Primary care staff should be familiar with properties and use of: 1) common antidepressant drugs & brief psychological treatments 2) assessment of suicidal thinking and risk Patients with more enduring or severe symptoms will usually require specific treatment - usually drug therapy For patients with suicidal ideation / whose depression has not responded to initial management, specialist referral is the next step Management Low level risk Clinical picture Suicidal ideation but no suicide attempts Supportive environment Physically healthy No history of psychiatric illness Action Consider referral to mental health professional for routine appointment (not always necessary) Management Moderate level risk Clinical picture Low lethality suicide attempt (patient's perception of lethality) Frequent thoughts of suicide Previous suicide attempts Persistent depressive symptoms Serious medical illness Inadequate social support History of psychiatric illness Action Refer to mental health professional to be seen as soon as possible Management High level risk Clinical picture Definite plan for suicide (When? Where? How?) Action Refer to mental health professional for immediate assessment Major depressive disorder High lethality suicide attempt or multiple attempts Advanced medical disease Social isolation History of psychiatric illness Summary • Detection can be hard – symptom overlap and patient unaware • Depression a natural occurrence in population • Whole range of depressive conditions with varying severity • Depression can be present in acute or chronic states • Depression can have physiological, biological or social causes • Depression may have a mixture of causes • Depression co-exists with many other symptoms • Depression is a natural reaction to disease diagnosis and presence • Depression and symptomotology are highly related