Diagnosing Depression

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Diagnosing Depression

• Public Health Detailers Training
• NYC Department of Health and Mental Hygiene
• Ann M. Sullivan, M.D.
• Regional Director of Psychiatry for the Queens
  Health Network
• New York City Health and Hospitals Corporation

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Outline

• Diagnosis
• Risk Factors
• DSM-IV Criteria
• MDD
• Dysthymia
• Bipolar
• Minor Depression
• Depression-Anxiety Continuum

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Outline

• Other Causes
• Assessment Elements
• Suicide Assessment
• Epidemiology
• Risk Factors
• Myths
• Care Management

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Diagnosis of Mood Disorders

• DSM-IV Diagnostic Manual
• Dysthymic Disorder
• Major Depressive Disorder
• Cyclothymic Disorder
• Bipolar Disorder
• Mood Disorder due to medical disorder, or
  substance induced
• Other Minor Depression/Depressive Symptoms

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What Differentiates The Various Diagnoses?

• Severity
• Time present
• High or low mood
• Specific symptoms and the number of symptoms
  present
• Clearly definable external direct cause e.g.
  substance induced mood disorder
• History

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How Diagnosis Made?
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RISK FACTORS/RED FLAGS TO SCREEN FOR DEPRESSION

• HISTORY
• Personal History Depression/Bipolar Disorder
• Family History Depression/Bipolar
  Disorder/Alcoholism
• History of abuse, physical, sexual, emotional
• History of Anxiety Disorder
• History of Substance Abuse/Alcoholism
• CURRENT
• Significant stressors loss of job, family loss,
  family conflict, etc.
• Substance abuse drugs or alcohol
• Weight loss, sleep disturbance, multiple somatic
  complaints with no clear diagnosis
• Anxiety moderate to severe
• Poor job or social functioning change in
  functioning
• Self-Destructive behavior
• Mood changes I cant cope Im overwhelmed
• Self-Destructive Behavior/wish to die
• Medical Illness

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DSM-IV Criteria For Major Depression

• Four hallmarks, nine symptoms
• depressed mood
• anhedonia (loss of interest/pleasure)
• four physical symptoms
• three psychological symptoms
• For diagnosis-depressed mood or anhedonia at
  least 5 of the 9 symptoms
• Symptoms most of time for 2 weeks
• MacArthur Foundation Tool Kit

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Depressed Mood

• Hallmark 1
• Neither necessary nor sufficient for the
  diagnosis
• Can be misleading
• Dont hang everything on the question Are you
  depressed?
• MacArthur Foundation Tool Kit

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Anhedonia

• Hallmark 2
• Loss of interest or pleasure in things that you
  normally enjoy
• May be the most important and useful hallmark
• MacArthur Foundation Tool Kit

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Physical Symptoms

• Hallmark 3
• Sleep disturbance
• Appetite or weight change
• Low energy or fatigue
• Psychomotor retardation or agitation
• MacArthur Foundation Tool Kit

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Psychological Symptoms

• Hallmark 4
• Low self-esteem or guilt
• Poor concentration
• Suicidal ideation or persistent thoughts of death
• MacArthur Foundation Tool Kit

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Dysthymia

• Long term problem with moderate symptoms
• Depressed mood most of time for 2 years
• Plus 2 other symptoms of depression
• High level of chronic impairment
• Increased risk for major depression
• MacArthur Foundation Tool Kit

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Bipolar Disorder

• Episodes of mania or hypomania along with
  depressive episodes
• Mania may be overlooked patient may hide
  symptoms or not see as problem
• Often misdiagnosed and managed as unipolar
  depression
• MacArthur Foundation Tool Kit

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Misdiagnosis of Bipolar Patients

• Potential risks from antidepressants
• May induce mania or hypomania
• Can cause rapid cycling
• Requires mood stabilizer (e.g. lithium or
  valproic acid) before brief use of antidepressant
• Generally need psychiatry consultation or
  referral
• MacArthur Foundation Tool Kit

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Minor Depression

• Fewer symptoms than major depression
• Shorter duration than chronic depression
• Best management probably watchful waiting with
  regular follow-up
• May Proceed with pharmacologic treatment or
  psychotherapy if symptoms persistent or worsening
  or significant disability/poor functioning
• MacArthur Foundation Tool Kit

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Depression Anxiety Continuum

• National Co-Morbidity Screening 1999 8098
  Respondents
• Depression Anxiety
• 14.9 a major depression/non bipolar disorder at
  some time in their life
• 28.7 an anxiety disorder generalized, panic,
  phobia, PTSD, OCD sometime in their life
• Co-morbidity
• 58 of these with lifetime incidence of
  depression had lifetime incidence of an anxiety
  disorder (most often Generalized Anxiety
  Disorder, Panic Disorder PTSD)
• Tendency to co-occur each individually
• Treatment
• Anxiety and Depressive either CBT or medication
• Medication SSRTs effective in both.
  Benzodiazepines treat anxiety, not depression

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Depression Anxiety Continuum

• When do they occur or co-occur
• 2/3 lifetime history MDD Anxiety Disorder
  reported Anxiety Disorder occurred at earlier
  date
• 15.4 reported that MDD started before first
  Anxiety Disorder
• 16 started at the same time

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Depression Anxiety Continuum

• Characteristics of Co-Morbid Anxiety Depression
• Illness is more persistent
• Illness is more likely recurrent over time
• Co-morbid anxiety has a significant increase in
  the persistence of depression
• Co-morbid anxiety often predicts more severe
  depression
• Some variation by type of anxiety disorder, e.g.
  all of the above are less likely with Panic
  Disorder

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OTHER CAUSES OF DEPRESSION

• Medications
• Substance induced
• Medical Disorders

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ELEMENTS OF ASSESSMENT

• Quantify severity of assessment
• Assess and document impairment of function
• Evaluate pertinent history and co-morbid
  conditions
• Past history of depression or other mental health
  problems
• Past history of mental health treatment
• Past history of substance use or substance use
  treatment
• Family history of mental illness (particularly
  bipolar illness or alcoholism)
• History suicide attempt
• History physical or sexual abuse
• Stressful life events
• Social Isolation
• Current substance use
• Bipolar Illness
• Current Medications

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SUICIDE ASSESSMENT
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EPIDEMIOLOGY

• Suicide was the 11th leading cause of death in
  the US in 1999. Preliminary data indicate that
  suicide was 9th leading cause of death in the US
  in 2001.
• Suicide was the 8th leading cause of death for
  males, and 19th leading cause of death for
  females.
• Suicide was the 3rd leading cause of death for
  young people aged 15-24

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EPIDEMIOLOGY

• Suicides in that year accounted for 1.3 of all
  deaths, compared with 30.3 from heart disease,
  23 from cancer, and 7 from stroke (top three
  causes of death in the US).
• Same number of people died by suicide as did from
  homicide. In 1996, there were three suicides in
  the US for every two homicides committed.

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EPIDEMIOLOGY

• Affective Disorder 15 lifetime risk of
  suicide 60 of all suicides.
• Schizophrenia 10 lifetime risk of suicide 10
  of all suicides.
• Alcohol/Substance abuse 3-5 lifetime risk of
  suicide 25 of all suicides.
• Highest suicide rates were for white men over 85,
  who had a rate of 59/100,000.

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Three Tasks of Suicide Assessment

• Gathering information about the patients risk
  factors for suicide
• Gathering information about the patients suicidal
  ideation and plan
• Clinical decision making using the information
  gathered

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MAJOR RISK FACTORS

• ADULTS
• MALES MORE THAN FEMALES
• PEOPLE WHO ARE WIDOWED,DIVORCED,SINGLE.
• LACK OF SOCIAL SUPPORTS
• UNEMPLOYMENT
• DROP IN SOCIAL OR ECONOMIC STATUS

• ADOLESCENTS
• MALES MORE THAN FEMALES
• MARRIED PEOPLE MORE THAN UNMARRIED
• HISTORY OF PERINATAL DISTRESS
• STATUS OF BEING UNWED AND PREGNANT
• PARENTAL ABSENCE, ABUSE
• ACADEMIC PROBLEMS

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MAJOR RISK FACTORS

• ADOLESCENTS
• AFFECTIVE ILLNESS, ESPECIALLY BIPOLAR
• SUBSTANCE ABUSE, ATTENTION DEFICIT HYPERACTIVITY
  DISORDER,EPILEPSY
• CONDUCT DISORDERS, IMPULSIVITY, EXPLOSIVENESS
• FAMILY HISTORY
• DISCIPLINARY CRISIS, HUMILIATION
• PREVIOUS ATTEMPTS
• EXPOSURE TO SUICIDE
• PRESENCE OF FIREARMS AND ALCOHOL

• ADULTS
• PRESENCE OF PSYCHIATRIC DIAGNOSIS, ESPECIALLY
  MAJOR AFFECTIVE DISORDERS
• COMORBIDITY
• PHYSICAL ILLNESS
• FAMILY HISTORY
• PSYCHOLOGICAL TURMOIL
• HUMILIATION
• EMBARASSMENT
• PREVIOUS ATTEMPTS
• ALCOHOL USE OR ABUSE
• PRESENCE OF FIREARMS

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Lethal Triad of Risk Factors

• Lethal triad of risk factors
• The patient presents immediately after attempting
  a serious suicidal act.
• The patient presents with a dangerous display of
  the psychotic processes suggestive of lethality.
• The patient shares suicidal planning or intent in
  the interview, suggesting that he or she is
  seriously planning imminent suicide ( or
  corroborative sources supply information
  suggestive of such planning).

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 MYTHS that become traps for the clinician in
assessing suicide potential

• Asking about suicidal plans will somehow give
  the patient ideas.
• No known case where discussion of suicide gives
  patient ideas.
• Reports of suicide are common in society films,
  media, TV, games, lyrics

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MYTHS that become traps for the clinician in
assessing suicide potential

• False belief that in the interview, the patient
  will give off clues or hints that they are at
  risk. (Leakage myth).
• An ambivalent person may give some hint or
  frankly discuss this. Suicide is a topic that is
  seen as shame-producing or conversationally
  taboo. People more frequently keep thoughts of
  suicide private unless used for dramatic
  manipulation.

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Common resistances to sharing suicidal thoughts

• The client feels that suicide is a sign of
  weakness and is ashamed.
• The client feels that suicide is immoral or a
  sin.
• The client feels that discussion of suicide is
  literally a taboo subject.
• The client is worried that the interviewer will
  perceive the client as crazy.
• The client fears that he or she will be locked
  up if suicidal ideation is admitted.
• The client truly wants to die and does not want
  anyone to know.
• The client does not think that anyone can help.

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What to look for in an assessment

• Direct Verbal Warnings
• Depressed Behavior
• Changes in Social Behavior
• Making final plans
• Suicidal History
• Use of drugs and or alcohol
• Intuition of a person close to the patient

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 DECREASING CLIENT RELUCTANCE TO DISCUSS
SUICIDE

• Use specific Wording
• Listen for Hesitancy in Patients response
• The no not really answer
• Body Language
• Dont take notes
• Take your time and try to appear at ease and
  unhurried

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Direct Verbal Warning

• Inability to keep going
• Feelings of hopelessness and despair
• Bids for Reaction from another person
• Hints as to specific Plans

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HOPELESS/HELPLESS

• NO MOTIVATION NO INCENTIVE TO DO SOMETHING
  POSITIVE
• BREEDS A FEELING THAT THIS IS AS GOOD AS IT IS
  GOING TO GET
• IT IS A SENSE OF NOTHINGNESS- TOTAL EXISTENTIAL
  EMPTINESS
• NO CONNECTION, NO FUTURE, NO LOVE
• NO WISH, NO DESIRE TO GET BETTER

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WORTHLESS

• I AM NO GOOD
• I AM USELESS
• THERE IS NO REASON FOR THE PATIENT TO BE IN THE
  WORLD
• IT IS ALL ABOUT HOW BAD THEY ARE

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HELPLESSNESS

• No Ability To Change Anything
• No Different From Day To Day
• The Practitioner Cant Help Either
• No Power/ Feeling Like They Are Not Able To Do
  Anything For Themselves

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Assessment of Suicide Risk
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PHQ-9

• 0-5 Not depressed
• 5-10 watchful waiting Needs Follow up
• 10 Diagnosable/treatable Diagnosis Major
  Depression/Dysthymic Disorder
• 10-20 referred to Primary Care M.D. if no serious
  risk factors Suicide
• Homicide
• Severe Psychosis
• Severe Substance Abuse
• If 20 or serious risk factors may refer to
  Psychiatry for consultation and treatment

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PHQ-9 Compared to Clinician Assessment of MDD