Transcript Dr David Armentrout

An everyday sequence:
Feeling bad?
We’ll call the doctor
• How bad is it?
So what happens next?
Depression
Toward a working protocol
David P. Armentrout, Ph.D., C.T.S.
Depression?
Everyone has
a bad day, so
what’s the big
deal?
What do these
people have in
common?
Renowned Child Psychologist
Academic
Scientists
Inventor of FM
Inventor of EEG
White House Counsel
…and these people?
Ex-President
South Korea
Roman General
Wife of German
Chancellor
Politics,
Leaders
US Secretary of
Defense
…and ?
Popular
Actress
Nobel author
Popular Syndicated
Author
Actor, SNL
Creative
Artists
Acclaimed
musician
Man
of
Steel
“For godly grief and the pain God is
permitted to direct, produce a repentance
that leads and contributes to salvation and
deliverance from evil, and it never brings
regret; but worldly grief, the hopeless
sorrow that is characteristic of the pagan
world, is deadly – breeding and ending in
death.”
II Corinthians 7: 10
Vince Foster 1993
gunshot
Hemingway 1969
Sleeping pill overdose
…, it kills
Kurt Cobain 1994
Shotgun
Amy Vanderbilt 1974
Jumped from apt.
Roh Moo-hyun 2009
Jumped, 100 ft cliff
Hannelore Kohl 2001
Sleeping pill overdose
James Forrestal
Jumped 16th fl window
Hans Berger 1991
hanging
B Bettelheim 1990
Self suffocation
Steeve Reeves 1959
Luger shot to head
Edwin Armstrong
Jumped 13 floor
John Belushi
Barbiturate overdose
Marilyn Monroe 1962
Sleeping pill overdose
Marc Antony 30 BC
Fell on own sword
Depression also has a morbidity…
• 18.8 mil. Americans a year (9.5%)
• 100 million worldwide at any given time
• Life time prevalence – 15.3% - 17.9% M.D.D.,
35.4% any depression
• Leading cause of disability in US & market
economies
• Suicide = 7th leading cause of death, 3rd in 1524 year olds
Disease Burden (Adjusted Life Years)
• M.D.D. 2nd only to ischemic
heart disease in magnitude
of disease burden
• Costs over 44 billion
dollars per year in US
• By 2020 WHO projects
unipolar depression to be
second only to ischemic
heart disease in disease
burden, and the leading
disease burden for women
and in developing
countries.
An Increasing/Pandemic Problem
– 1982 Hagnell, et al: Sweden, 1/10 mid 60s, 1/6 in mid 70s.
Ten fold increase in young men (20s & 30s)
– 1989 Klerman & Weissman: Incidence and prevalence of
depression increasing and age of onset decreasing for
successive birth cohorts. Increase for all ages from 1960 to
1975.
– 1992 Cross-National Collaborative Group: reported overall
increase in rates of depression over time.
– 1993 Lewinsohn, et. al: Confirmed the increasing rates in
younger cohorts in 1,710 Ss. Robust controls for
current mood, social desirability response bias,
labeling, & time since episode did not reduce the
Age Cohort Effect.
Increasing rates cont.
– 1994, Wittchen, et. al: Successively more recently born
cohorts have greater depression & more depressive sx;
positive affect stable over time, depressive affect
decreases over the adult life span.
– 1996 Prosser & McArdle: Major depression and the
incidence of suicide increasing in US and UK in
adolescents, particularly among males.
– 1999 Sandanger, et. al.: Incidence rates for depression
increased significantly in Norway from 1930 and 1991.
All this in the face of increased resources:
• From 1988 to 1999 # psychiatrists increased to
39k, 1.3k/yr = 43% increase from 1988 to 2007.
• Ratio in 1998 md to non-md, @ 1:3 : addiction
counselors, forensic counselors, grief counselors, marriage
counselors, pastoral counselors, lay ministries, rehab counselors,
social workers, developmental psychologists, neuropsychologists,
geropsychologists, school counselors, psychiatric nurses,
psychologists (clinical, school, counseling, etc), etc. etc. etc.
• California 2007: 1 counselor for every 815.3 students, 1
psychologist for every 1,363.6, 1 social worker for every
18,118 and 1 librarian for every 5,123.8 students.
And Then There’s Medication
• 1950s-1988 tricyclics, MAO inhibitors
• 1988 Fluoxetine (Prozac) released by
FDA
• 103% increase in prescriptions in U.S.
(13.3 to 27million) from 1996 to
2005.
2012: 125 branded SSRIs, SNRIs, TCA, TeCAs:
• Celexa, Cipramil, Cipram, Dalsan, Recital, Emocal, Sepram, Seropram,
Citox, Cital, Priligy, Lexapro, Cipralex, Seroplex, Esertia, Prozac, Fontex,
Seromex, Seronil, Sarafem, Ladose, Motivest, Flutop, Fluctin (EUR), Fluox
(NZ), Depress (UZB), Lovan (AUS), Prodep (IND), Luvox, Fevarin, Faverin,
Dumyrox, Favoxil, Movox, Upstene, Paxil, Seroxat, Sereupin, Aropax,
Deroxat, Divarius, Rexetin, Xetanor, Paroxat, Loxamine, Deparoc, Zoloft,
Lustral, Serlain, Asentra, Viibryd, Zelmid, Normud, Effexor, Pristiq,
Cymbalta, Yentreve, Dalcipran, Ixel, Savella, Levomilnacipran, Meridia,
Reductil,Bicifadine, SEP-227162, Edivoxetine, Elavil, Tryptizol, Laroxyl,
Amioxid, Ambivalon, Equilibrin, Evadyne, Anafranil, Deparon, Tinoran,
Norpramin, Pertofrane, Noveril, Victoril, Istonil, Istonyl, Miroistonil,
Prothiaden, Adapin, Sinequan, Tofranil, Janimine, Praminil, Imiprex,
Elepsin, Lomont, Gamanil, Deanxit, Dixeran, Melixeran, Trausabun,
Timaxel, Pamelor, Aventyl, Norpress, Agedal, Elronon, Nogedal,
Azafen/Azaphen, Depressin, Vagran, Vivactil, Kevopril, Kinupril, Adeprim,
Quinuprine, Asendin. Deprilept, Ludiomil, Psymion, Mazanor, Sanorex,
Bolvidon, Norval, Tolvon, Remeron, Avanza, Zispin, Tecipul
The Banished Child:
• Nemifitide
–80% effective, no side effect vs.
40% for the SSRIs
–10 IM injections in 6w, then 1 per
year
–UK, FDA approved, then blocked by
gov & big pharma
Not the expected/desired panacea:
• Medication Problems:
– Side effect, discontinuance, improper dosage
– BMJ 2005, adults taking SSRIs have higher than
expected rates of suicide
– 2005 FDA launches a review of antidepressants &
adult suicidality
– 2005, Moncrief & Kirsch – “very poor outcomes in
longitudinal follow-up studies for people treated
for depression, both in hospital & community
– Kirsch & Moore, 2002 – 80% of response to
antidepressant medication (SSRIs) duplicated in
placebo control groups, and the mean difference
between drug and placebo was 2 pts on the HAM-D
Basics for Understanding Depression:
Taxonic (42) or Dimensional
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Neurotic
Psychotic
Reactive
Endogenous
Exogenous
Involutional
e
Unipolar
Cyclothymic
Mourning
Masked
Bipolar
Personal
Severe
Mild
Post Partum
Melancholic
Vital
Symptomatic
Periodic
Somatic
Simple
Normal
Hostile
Dysthymia
Primary
Secondary
Biological
One Dimension
Pure Depressive Diseas
Schizophrenic
Atypical
Seasonal Affective
Physiological S Type
Depressive Spectrum Disease
Physiological J Type
Adjstmnt. Dis with dep mood
Major Depressive Disorder
Physiological Retardation
Bereavement
Schizo-Affective
Exhaustion Depression
Secondary to prob. of living
Our understanding of depression is a mess.
If we don’t
do
something
different -
And, we have ignored the spiritual
nature of our being…
• 1987. Fehring, Brennan & Keller. Spiritual
well being is inversely associated with
depression and negative mood.
• 1990. Brown, et al. Inverse relationship
between religiosity and depression for
both males and females with lower levels
of depression seen in respondents with
higher levels of religiosity.
• 1991. Genia & Shaw. Intrinsic religious
commitment is associated with lower
levels of depression.
A seminal spiritual study..
• 1991. Balk. Religion may play role in
helping youth (14-19) face the death of a
sibling. Religious youth had far more
depressive symptoms than non-religious
youth at the time following the death of
their sibling. By the time of the interview
av. = 24mos) religious youth had only mild
symptoms while non-religious were still
feeling depressed and confused.
Designed by God
Nehemiah
Jesus
“For Godly grief and the pain God is permitted to direct, produce
a repentance that leads to salvation and deliverance from evil,
and it never brings regret; But worldly grief (the hopeless
sorrow that is characteristic of the pagan world) is deadly,
breeding and ending in death.”
II Cor 7: 10
A Biblical Model of Depression
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Universality of depression
Both Taxonic and Dimensional
Process is important
Etiology is important
Two
Pathways(taxons):
God’s
Path &
The Deadly Spiral
Assessment: What should a dog do when
he catches the car?
• Emotion-driven: Myth of the black hole
• If there’s muck I’m stuck
• I have to fix it right now
• Assessment-Driven:
• Course of action determined by wisdom/discernment
• The data can be made objective
A 4-Level Approach to Screening
1. Incidence (categorical)
2. Severity (Dimensional)
3. Etiology
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Psychosocial Spiritual Etiologies (Dimensional)
Biological Etiologies (Dimensional)
4. Process (Dimensional &Taxonic)
Level 1: Incidence
• The One Question Assessment (90% sensitive)
• The Two Question Assessment (Arroll, et al.,
2003)
• During the past month have you often been bothered
by feeling down, depressed or hopeless?
• And, during the past month have you often been
bothered by little interest or pleasure in doing things?
Level 2: Subjective Severity
• SIGECAPS
– Sleep: increase or decrease in sleep pattern
– Interest: anhedonia – loss of normal interest
– Guilt: feelings of guilt or worthlessness
– Energy: low energy or fatigue
– Concentration: difficulty focusing attention
– Appetite: wt. increase or decrease, 5%/month
– Psychomotor: agitation/restless or slowing
– Suicide: life worth living? Active ideation?
(Criteria: MDD: 5+/2w/mood,Dysthymia: 2+/2y/MOOD?)
Level 2: Objective Severity
• HDI (Hamilton Depression Inventory, CRS & BDI (Beck
Depression Inventory)
– Most frequently used in research (Ham-D), r = .95. r = .93
with BDI. HAM-D includes anxiety & somatic component,
BDI severity, subjective distress- commercially available
• SDS (Zung Self-Rating Depression Scale)
– Quick, 1 transformation to index, scoring easy, readily
available from Eli Lily Pharmaceutical
– For severity estimates, tracks progress
• PHQ-9 (from PRIME-MD)
– Quick, most easily scored, readily available from Pfizer
Pharmaceutical
– Severity estimate, tracks progress
– Sensitivity for MDD,78%; specificity 85%
• CES-D (Cntr Epidem.Study-Depression)
– Frequency may be measured
Lack of Intimacy
Level 3: Etiology
Purposelessness
Busyness
Anger/Self-Indulgence
Guilt
Loss
Exhaustion
Separation from God
Self Worth
Level 3 Biological Etiologies
• One resident’s patient’s reported that God
had told her she was depressed secondary to
a chemical brain imbalance.
• True biological etiology
– Disease
– Medications
– Sleep loss
Level Four: Process, Dimensional
Screening For The Spiral
– Least responsive to simple
intervention
– Higher risk patients
– >somatic sx = delayed
response to fluoxetine
• Elements
– Overwhlemed
– Feeling Control
– Worthlessness/Helplessness/Hopelessness
– Behavioral Involvement
– Cognitive Distortion
– Multiplying, interactive
factors
A useful initial
workup covers all
four levels:
Incidence
Severity
Etiology
Process
Depression Assessment Inventory
• Symptoms (Incidence & Severity)
– DSM frequency & intensity, patterns (including familial)
– Morbid thinking
• Etiology
– Depressogenic illnesses and/or drugs
– Distance from God, Anger, Guilt, Lack of Purpose,
Exhaustion, Loss, Overwhelmed, Busyness, Worth/value,
Intimacy/connection, Self-indulgence
• Spiral (Process)
– Emotion Dominance, Distortion Triad, Behavioral
Elements, Cognitive Distortions
Final Thoughts
• “Keep your heart with all vigilance and
above all you guard, for out of it flow the
springs of life.”
Proverbs 4: 23
Be Blessed !
Criteria
• Major Depression
– 5 or more of the sx present
for two weeks
– mood change or
anhedonia present
– significant distress or
impaired function
– not due to substance
abuse or med illness
– not due to bereavement
– no manic episode
• Dysthymia
– Depressed mood most
of the day, most days x
2y
– never w/o sx for more
than 2 months
– not recurrent MD
– no manic history
– not due to substance
abuse or med illness
– significant distress or
impaired function
Criteria
• Recurrent Major
Depression
– Multiple episodes
separated by periods of
reduced sx
• Adjustment Disorder w/
Depressed Mood
– onset w/in three months
or identifiable stressor
– does not continue more
than 6 months
– significant distress or
impaired function