ࡱ>  ` Kbjbj 3P1 4 8dX\4 %H(000g> $םh?ʛ YE"gYYʛ00 ߛ***Yv 0 0*Y**pr 0 "ǯH'~DN0%^CM)CC  *SʛʛS*j%YYYY4 4 4 Ćc4 4 4 4 4 4  Web Based Education Module 4: Doc, Im Tired and Have Little Energy FINAL DRAFT - CORE CONTENT OUTLINECONTENTI. Case Based IntroductionMr. George is a 44 year old male with a past medical history of hypertension for 4 years. He comes to this visit requesting his serology results from his last visit. At that time, he complained of feeling tired and having little energy especially in the morning hours. Mr. George denied shortness of breath, chest pains, palpitations, fevers, or anxiety. No GI complaints, no melena, no hematochezia. He read on the internet about thyroid disease, anemia, and Lyme disease which all could explain his symptoms. He has not been traveling outside of Manhattan and did not visit a wooded area recently. Those laboratory tests from his last visit one month ago are completely negative today. He also had a recent annual physical examination two months ago and everything was normal. Past Medical History Hypertension Medication Hydrochlorothiazide 25mg once a day Past Social History Works as an office manager. Heavy stressors under a new boss. Married to his wife of 14 years, monogamous, and has one 10 year old daughter. Denies alcohol, drug, and tobacco use. Sexually active with his wife about once a year only as we just dont have time or energy anymore. No interpersonal conflicts at home with family, although she laments that they dont go out much anymore. Family History Father is alive and suffers from gout, hypertension, and cholesterol. Mother is alive and has been diagnosed with diabetes last year. ROS He has trouble falling asleep almost every night and he wanted to ask you about safe sleeping pills that he heard about on television commercials. This has been going on for 8 weeks. PE BP 135/80 P70 R21 Wgt 210 lbs (was 195 lbs 5 months ago) General In no acute distress HEENT WNL, No JVD, No thyromegaly or nodules Lungs CTA B Cor RRR No M Abd S / NT Pos BS Ext No C / C / E Neuro No tremors; reflexes 2+ upper and lower extremities; normal hand to nose coordination, normal gait essentially a normal neurological exam Psych Admits to less pleasure in doing things he used to like to do, and feels down occasionally but does not feel he is depressed. He has increased appetite having gained 15 pounds since his visit 5 months ago. He attributed the weight gain to stress at work. Denies suicidal ideation or homicidal ideation. He also notices trouble concentrating at work and cant get into television shows or movies in the same way he did prior. Labs: Guaiacs Neg x 3 TSH 1.44 (WNL 0.34 4.25) Chem 7 WNL Hct 40 Lyme Titers Neg Question 1) Mr. George feels tired and has little energy. His physical examination and lab work are negative. He completely denies being depressed. Upon further questioning he does describe losing interest in activities he used to like to do, increased appetite and weight gain, problems with concentration, and insomnia. At this point, Mr. George wants to know the next appropriate step in his assessment and management. Of the following, which one is the most appropriate recommendation? Perform a whole body CT or MRI scan to look for an occult source Recommend that Mr. George and his family go on a vacation Consider testing for underlying neurological disease Refer him to a gastroenterologist for a colonoscopy screen Have Mr. George complete a standardized screening questionnaire for depression Write him a prescription for sleeping medications The correct answer is e. Mr. George has many classic signs and symptoms of depression (e.g., anhedonia, insomnia, weight gain, etc.), and performing a standardized screening questionnaire for major depression is appropriate to assist in making the diagnosis. Many people who suffer from depression do not report a depressed mood. Although some neurological diseases can have depressive symptoms, major depression is much more common in the primary care setting and should be evaluated first. He also has no neurological findings. A colonoscopy would not seem appropriate in a 44 year old man at this point without gastrointestinal complaints, no findings of anemia, and weight gain. A whole body CT or MRI scan is not cost effective, and may cause more physical and emotional harm than benefit. Insomnia may be a sentinel symptom of depression, and prescribing sleeping medications without assessing the patient for depression would not be best practice. Although a vacation may be in order for Mr. George and his family, it will not effectively treat an underlying depressive disorder.II. Facts About Depression Web Based Education Module 4: The Diagnosis and Management of Depression in The Primary Care Setting Facts About Depression Depression is one of the most common conditions seen by primary care physicians second only to hypertension. The point prevalence in the outpatient primary care setting is between 4.8 8.6%, and the point prevalence in the inpatient setting is 14.6% Large scale studies have suggested that 7 12% of men will suffer an episode of major depression at one point in their lives, while the percentage for women is more on the order of 20 25%. Bipolar disorder is less common than depression (0.4% in men and 1.6% in women over their lifetimes) but has no gender difference. Depression can begin in early adulthood, with a peak onset between ages 20 30. Over half the people who experience an episode of major depression are at risk for a relapse and recurrence (Cutler, J. Charon, R. 1999). Depression costs the United States economy more than 43 million dollars every year in medical treatments and lost work productivity (Kahn, 1999). Globally, depression accounts for 4.4% of the disease burden, which is similar to that of diarrheal diseases and ischemic heart disease (Mann, 2003). 300 million people in the world suffer from depression with 18 million of them in the United States (Harvard Press, 1996). Depression has a high rate of morbidity and mortality when left untreated. Most patients do not necessarily complain of feeling depressed, but rather that they have a lack of interest or pleasure in activities, may have somatic complaints, or vague unexplained complaints. In one study, 69% of diagnosed depressed patients reported unexplained physical symptoms as their chief complaint (NYCDOH, 2006). Unlike patients with depression in psychiatric inpatient or outpatient care settings, persons suffering from depression in primary care settings often present as undifferentiated patients. Depression is often undiagnosed and untreated, and even when it is diagnosed it is often under treated. Primary care physicians must remain alert to effectively screen for depression in their patients. Barriers to effective screening include inadequate education and training, limited coordination with mental health resources, time constraints, poor systematic follow up, and inadequate reimbursement (NYCDOH, 2006). It is sometimes difficult for primary care providers to determine if a patient is depressed as opposed to experiencing a normal response to the challenges of everyday life. Gender, age, culture, and language of the patient and the physician may create further barriers. Furthermore, persons with mood disorders also may have enormous stigma associated with being mentally ill and may see it as a sign of weakness, fear the criticism of other people, or be concerned that they will be institutionalized. Patients who suffer from diabetes, ischemic heart disease, stroke, or lung disorders that have concurrent depression have poorer outcomes than those without depression. Depressed patients have a higher risk of death from heart disease, respiratory disorders, stroke, accidents, and suicide (Mann, 2005). Fifteen percent of patients with severe mood disorders die from suicide. In one study among older patients who committed suicide, 20% visited their primary care physician on the same day as their suicide (NYCDOH, 2006). III. Goals and ObjectivesEducational Goal: Students will be able to demonstrate competencies in knowledge, skills, and attitudes of an effective clinician in evaluating and caring for patients with depression and mood disorders in the primary care setting. Medical Knowledge The students will: Apply the nationally recognized guidelines for screening and diagnosing depression and other mood disorders in patient care. Apply the practice guidelines for the treatment of patients with major depressive disorders. Identify appropriate elements of a suicide risk assessment and action plan. Patient Care The students will: Recognize the importance of effective detection and treatment of depression in adults. Review the depressed mood algorithm and the DSM-IV to guide the differential diagnosis in the primary care setting. Identify manic and hypomanic symptoms associated with bipolar disorder in depressed patients. Formulate management plans for the longitudinal care of patients with depression. Develop prevention plans, including health education and behavioral change strategies, for patients with depression. Interpersonal and Communication Skills The student will: Explore relevant psychosocial and cultural issues that impact on care. Provide effective education and counseling to patients with mood disorders and their families. Demonstrate awareness of improved health care outcomes through effective communication and forming therapeutic alliances with patients. Discuss behaviors with patients, in an empathic, respectful and non judgmental manner. Practice Based Learning The student will: Use information technology to access medical information and support self-education and clinical decision making. Critically review the medical literature regarding new evidence based clinical trials and its implication on current treatment guidelines of depression and mood disorders. Use information technology to access patient and family education resources on depression. Professionalism The student will: Demonstrate professionalism by completing this web module during the assigned period. Systems Based Practice The student will: Identify which cases can be managed by the primary care physician and which should be referred for co-management with a specialist. Improve patient care outcomes through effective communication with other health care professionals, partnerships through community resources, and government agencies.IV. The Etiology of Mood DisordersThe Etiology of Mood Disorders Neurotransmitters, genetics, and psychosocial stressors all seem to play a part in mood disorders. The same depressed patient may have variable clinical symptoms from one major depressive episode to another. Despite this variability, major depression may have the same underlying cause. The variable presentations may be due to differing patterns in neurotransmitter abnormalities. Deficiencies in serotonin, norepinephrine, dopamine, GABA, and peptide neurotransmitters (somastatin, thyroid-related hormones, and brain derived neurotrophic factors) have all been hypothesized as contributing to depression. Over activity in other neurotransmitters including substance P, and acetylcholine, and elevated serum cortisol (with lack of diurnal variation) has also been proposed to contribute to depression. Although no specific genes that affect neurotransmitters or hormones have been identified, both depression and bipolar disorder are clearly inheritable. The first degree relatives of a patient with recurrent major depression have a 1.5 3 times higher risk of depression themselves as compared to the general population. 27% of children with one parent with a mood disorder will develop a mood disorder themselves, and that increases to 50 75% if both parents are affected. First degree relatives of patients with bipolar disorder have an estimated 12% lifetime prevalence of bipolar disorder, which is 10 times higher than the general population (Cutler, J. Charon, R. 1999). Genetic predisposition is not enough to result in a patient with a mood disorder, however. Identical twins have incomplete concordance in regards to depression. Depression also occurs in patients with no family history of mood disorders, which may infer that they have another acquired biological deficiency such as a viral insult, genetic or perinatal insult, or vascular brain disease. Psychosocial stressors in combination with a genetic predisposition have been postulated to alter the size of neurons, neuronal function, repair capabilities, and production of new neurons. Elevated cortisol in some depressed patients may reduce hippocampus volume, especially if their depression has not been treated in some time. Brain imagery has also noted some altered structures, which suggest some changes in neurocircuitry. Psychosocial theories suggest that experiences of loss in certain vulnerable individuals may cause depression, either through trauma, parental loss, loss of love from others, or loss of self-esteem.  On the Threshold of Eternity / At Eternitys Gate / Old Man in Sorrow - Vincent van Gogh LINK: Vincent van Gogh (Wikipedia:  HYPERLINK "http://en.wikipedia.org/wiki/Vincent_van_Gogh" http://en.wikipedia.org/wiki/Vincent_van_Gogh)V. Diagnosing Mood Disorders Screening for Depression Major Depressive Episode Approaches To The Clinical Interview Depressive Spectrum Disorders: The Depressed Mood Algorithm Mood disorder due to a general medical condition Substance-induced depression Dysthymic Disorder Bereavement Adjustment disorder with depressed mood Seasonal affective disorders Postpartum depression Pseudodementia Manic and Hypomanic Symptoms and Bipolar Disorders Suicidal Patients students to identifyScreening for Depression The primary care physicians most powerful screening tool for depression is patient observation and active listening skills. Most depressed patients do not realize they are depressed and this is especially true in elderly patients. A physician should consider that a patient may have depression in the setting of unexplained physical symptoms or complaints. The higher the number of somatic complaints that a patient has, the higher the risk that they may have a mood disorder. Other clues may be a patient with persistent worries or concerns about medical illness, complaints that do not respond to typical interventions, or complaints outright of anxiety or panic attacks. Patients with substance abuse issues may also suffer from a mood disorder. A careful history of present illness, past medical history, social and family history, and review of systems may yield more important information for making the diagnosis. The primary care physician should ask open-ended questions of the patient about normal patterns as well as variations to determine baseline function and mood. Mood is a range of emotions that a person feels over a period of time, while affect is how a person displays his or her mood. The presence of a mood disorder may affect a persons concentration, attention, motivation, interest, and sleep, as well as energy level, hunger and satiety levels, sexual pleasure, and pain sensation. These patients also frequently lose interest and lose pleasure (anhedonia) in things, people, or activities that they used to enjoy. Interruption in personal relationships with others can be a side effect due to increasing anger and conflicts, lower frustration tolerance, or from apathy and lack of enthusiastic feelings towards other people. Patients with depression may become emotionally constricted and lose their emotional flexibility. Depression can impair cognitive function. Cognitive dysfunction is common and patients may state that when they watch television they lose the point of the story; they read the same page of a book over and over again without comprehension; or lose the point of conversations with other people. A depressed patients memories may amount to more of selective recall, and normal perceptions may become distorted. Severe cognitive impairment due to depression is known as pseudodementia, and may be seen in elder populations or patients with central nervous disorders. Psychomotor activity is usually decreased in depressed patients. Psychomotor retardation is present when thoughts, motor movements, or speech are slowed down. Psychomotor agitation can also occur and is present when patients experience unintentional and purposeless movements such as unstoppable crying, pacing around a room, or hand-wringing. Frequently patients may complain of insomnia. In addition to having difficulty falling asleep, depressed patients typically wake up in the middle of the night or early in the morning with feelings of sadness, anxiety, or thoughts of dread or doom. They may also sleep excessively or stay most of the day in bed. Depressed patients may also have self-worth that goes through turbulent fluctuations. For depressed patients, past events may be viewed with extreme guilt and self criticism, and feelings of worthlessness. Patients may view themselves and their world as hopeless. Suicidal ideation or a history of suicidal attempts from the patient should be assessed. Asking depressed patients about recent bereavement is also important to note. A past medical history of prior episodes of depression is a very important question because you may be observing a relapsing episode. In addition, the physician should inquire about a previous history of bipolar disorder because inappropriate treatment with an antidepressant-therapy alone in these patients may precipitate a manic episode. It is also important to inquire about a family history of depression or bipolar disorder. When to think about screening adults for depression Personal previous history of depression or bipolar disorder First-degree biologic relative with history of depression or bipolar disorders Patients with chronic diseases Obesity Chronic pain (e.g., backache, headache) Impoverished home environment Financial strain Experiencing major life changes Pregnant or postpartum Socially isolated Multiple vague and unexplained symptoms (e.g., gastrointestinal, cardiovascular, neurological) Fatigue or sleep disturbance Substance abuse (e.g., alcohol or drugs) Loss of interest in sexual activity Elderly age Adapted from Sharp, LK, Lipsky MS. Screening for depression across the lifespan: a review of measures for use in primary care settings. American Family Physician. 2002; 66: 1001-1008 Question 2) Which are the current recommendations of United States Preventive Screening Task Force for screening adults for depression in primary care settings? No recommendation for or against routine screening for depression in primary care settings Screen only adults with positive risk factors for major depression, such as those with a positive family history or chronic pain Screen in all primary care practices because it is highly effective Screen only when the primary care practice has a psychiatrist on staff Screen only when systems are in place to ensure adequate treatment and follow up The correct answer is e. The United States Preventive Screening Task Force recommends screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow up (USPSTF, 2006). The system in place to assure follow up and monitoring can be the primary care physician, their primary care colleagues, or properly trained staff such as nurses. Access to mental health services, outside the practice, is important should referrals be necessary for complicated cases (e.g., psychiatrists, therapists, emergency departments, etc.). The USPSTF recommends that clinicians provide depression screening to eligible patients because of fair evidence that screening improves important health outcomes and concludes that benefits outweigh harms. The existing literature suggests that screening tests perform reasonably well in adolescents and that treatments are effective, but the clinical impact of routine depression screening has not been studied in pediatric populations in primary care settings. (Source: United States Preventive Screening Task Force. Screening for depression: Recommendations and rationale. November 2006 Recommendations. http://epss.ahrq.gov/PDA/index.jsp) There are many formal screening tools available such as the Zung Self-Assessment Depression Scale, Beck Depression Inventory, General Health Questionnaire (GHQ), Center for Epidemiologic Study Depression Scale (CES-D), and the Patient Health Questionaire-2 (PHQ-2). The USPSTF does not recommend one screening test over another and the interval for screening that is considered optimal is unknown. Recurrent screening in patients with a history of depression, unexplained somatic symptoms, substance abuse, chronic pain, or co-morbid psychological conditions may be the most useful. Any screening test that is positive requires a full diagnostic interview that uses standard diagnostic criteria, Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition (DSM-IV) to determine the presence of major depressive disorder and/or dysthymia. The Patient Health Questionnaire - 2 (PHQ-2) is a validated primary care tool for depression screening, and is favored because of the relative ease of using a two question tool and because the USPSTF believes that with current available evidence it is as effective as longer screening tools. Patient Health Questionnaire 2 (PHQ-2) Screen for depression by asking the following 2 questions: Over the past 2 weeks, have you been bothered by: little interest or pleasure in doing things? feeling down, depressed, or hopeless? A no response to both questions is a negative screen. A yes response to either question OR if the physician is still concerned about depression, then the physician should ask more thorough assessment questions using the Patient Health Questionnaire 9 (PHQ-9). The Patient Health Questionnaire 9 (PHQ-9) is a nine item questionnaire that can be completed by the patient before or during a primary care office visit. It is available in several languages. The PHQ-9 can reliably detect and quantify the severity of depression using the DSM-IV criteria for major depressive episode. The PHQ 9 was created by Dr. Robert Spitzer, et al. at Columbia University and is copyright protected by Pfizer Inc. The PHQ 9 is also useful for patient follow up visits to assess symptom management. Instructions on the use of the PHQ 9 is available on the PDF files below: LINK: PDF of PHQ 9 (English) LINK: PDF of PHQ 9 (Spanish) Major Depressive Disorder Summary of DSM-IV Criteria for Major Depressive Episode If depressed mood or loss of interest or pleasure persists for more than at least a two-week period, consider the diagnosis of major depressive episode. The diagnostic criteria are summarized below: At least five of the following symptoms have been present during the same two-week period, nearly every day, and represent a change from previous functioning. At least one of the symptoms must be either (1) depressed mood or (2) loss of interest or pleasure: Depressed mood (or alternatively can be irritable mood in children and adolescents) Marked diminished interest or pleasure in all, or almost all, activities Significant weight loss or weight gain when not dieting Insomnia or hypersomnia Psychomotor retardation or agitation Fatigue or loss of energy Feelings of worthlessness or excessive or inappropriate guilt Diminished ability to think or concentrate Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or specific plan for committing suicide Symptoms are not accounted for by a mood disorder due to a general medical condition, a substance-induced mood disorder, or bereavement (normal reaction to the death of a loved one). Symptoms are not better accounted for by a psychotic disorder (e.g. schizoaffective disorder). A well-known mnemonic that is commonly used to remember the DSM-IV criteria is SIGECAPS: Sleep Interest (anhedonia) Guilt Energy Concentration Appetite Psychomotor Suicidality A major depressive episode can be associated with special features: melancholic, psychotic, or atypical. Patients with melancholic features will report nearly total anhedonia. Depressed patients with melancholia must have three of the following symptoms: diurnal variation (depression worse in the morning); pervasive and irremediable depressed mood; marked psychomotor retardation or agitation; significant weight loss or anorexia; excessive or inappropriate guilt; and early morning awakening. Depressed patients with melancholic features have the best response to pharmacotherapy. Depressed patients that have psychotic features such as hallucinations and delusions are at very high risk for suicide even if they deny suicidal ideation. These patients should be sent for hospitalization immediately and should be under the care of a psychiatrist. Patients with atypical features have milder depressed symptoms. Depressed patients with atypical features must experience mood reactivity as well as two of the following: leaden paralysis (enormous effort to walk or exert); hypersomnia; rejection hypersensitivity (even when the patient is not acutely depressed); overeating or weight gain. These patients respond less to tricyclic antidepressants. Approaches to Interviewing Patients with Suspected Depression Depressed patients may feel so helpless, hopeless, indecisive, or lacking in energy that physicians may need to take a more active role to engage the patient or to show their interest or concern. Again in major depression, the more common complaint is anhedonia and not depressed mood. Quiet listening and empathy are important approaches physicians can use with patients. A caring and nonjudgmental tone is critical to allay patient fears of the stigma of depression. Introducing the topic of depression with an educational statement first and then asking the patient for their response may help the patient not feel judged (example Patients who have had a heart attack sometimes get depressed or down after the event. Has this been happening to you recently?). Making a statement instead of a question may allow the patient to have permission to be depressed and to know that you are willing and open to discussing the issue without judgment (example It sounds like you have been pretty down recently.). Physicians may want to excuse depression symptoms in patients by attributing them to stressors or complications of life. Patients with increasing financial stress, work difficulties, and relationship problems should raise further possibility of major depression. These patients may be unduly critical of themselves but may also be critical of others including their doctors. It is important to recognize when they evoke frustration or anger in you so that you can avoid negative countertransference and avoid directing anger back at the patient. Depressive Spectrum Disorders: The Depressed Mood Algorithm Major depressive episode is just one of several depressive spectrum disorders. In addition, depression may be associated with chronic medical illnesses. The following depressed mood algorithm can be used in primary care settings to assist in making the differential diagnosis. Depressed Mood Algorithm  SHAPE \* MERGEFORMAT  Adapted with permission from Depression Janis Cutler MD and Rita Charon, MD. Primary Care Psychiatry and Behavioral Medicine: Brief Office Treatment and Management Pathways. Edited by RE Feinstein, AA Brewer. Springer Publishing Co., New York, NY. 1999 Depression Due To General Medical Conditions Alterations in mood may be related to underlying medical conditions. Depression may be associated with other chronic medical diseases such as cancer, stroke, heart disease, endocrine disorders, neurological diseases, epilepsy, gastrointestinal diseases, rheumatologic diseases, and severe anemia. This depression is independent of the psychological impact of the stress of the illness, and is patho-physiologically related to the underlying condition. Medical Conditions Associated With Increased Incidence of Depression Cardiac disease Ischemic disease, Myocardial infarction Heart failure Cancer Brain cancer Pancreatic cancer Endocrine disorders Hyperthyroidism Hypothyroidism Diabetes Parathyroid dysfunction Cushings disease Gastrointestinal disorders Inflammatory bowel disease Irritable bowel syndrome Hepatic encephalopathy Cirrhosis Neurologic disease Stroke Chronic headache Dementias Traumatic brain injury Multiple sclerosis Parkinsons disease Epilepsy Pulmonary disease Sleep apnea Reactive airway disease Rheumatologic disease Lupus Rheumatoid arthritis Chronic fatigue syndrome Fibromyalgia Metabolic disease Renal failure Electrolyte disturbances Infectious disease HIV disease Syphilis Hepatitis Lyme disease Hematologic disorder Severe anemia Identification of co-morbid disease or conditions is important in patients with depression. Primary care physicians should consider initial lab testing such as thyroid-stimulating hormone, complete blood count, and chemistry panel. The findings of the complete history and physical examination may clarify the need for further testing for other diseases or syndromes. Depression Impacting Existing Medical Illness Patients who suffer from diabetes, ischemic heart disease, stroke, or lung disorders and who have concurrent depression have poorer outcomes than those without depression. Depressed patients, in general, have a higher risk of death from heart disease, respiratory disorders, stroke, accidents, and suicide. Question 3) Depression may affect the management of general medical illness. Which of the following statement is false? Patients with depression may exhibit maladaptive interpersonal behaviors which can make collaboration with physicians more challenging Patients with depression have higher rates of adverse health-risk behaviors when compared to non-depressed patients Patients with aversive symptoms such as pain are at an increased risk for developing depressive disorders The presence of a chronic medical illness is the most prevalent risk factor for the development of depression The importance of screening, diagnosing, and treating depression after a myocardial infarction has been well documented The correct answer is d. The presence of a chronic medical illness alone is not the most prevalent risk factor for developing depression. Depressed patients have higher rates of adverse health risk behaviors which may lead to higher risk of death from heart disease, respiratory disorders, stroke, accidents, and suicide. Chronic pain is known to be a risk factor for developing depression. Depressed patients may express maladaptive interpersonal behaviors such as anger or non-adherence which may cause some conflict with their medical providers. Screening, diagnosing, and treating depression after a myocardial infarction has been found to be of benefit in these patients. Substance-induced depression Depression may be induced by substances ingested for recreation or mood alteration or from their withdrawal. These substances include alcohol, hypnotics, sedatives, opiates, marijuana, amphetamines, cocaine, and other designer drugs (e.g., ketamine, ecstasy). Prescription drugs used for medical treatment can also cause mood disturbances such as blood pressure medication (e.g., reserpine, propanolol), anticholinergics, steroids, oral contraceptives, psychotropic medications, and antineoplastic drugs. Dysthymic disorder Dysthymic disorder is a chronic form of depression. The signs and symptoms are milder but can cause much distress and dysfunction. The patient must have at least a two year history of complaints occurring on over half the days to make the diagnosis. It is important to distinguish dysthymic disorder from major depression because dysthymic disorder is more chronic and unremitting, and less responsive to pharmacotherapy. Family and friends may experience people with dysthymic disorders to be chronic complainers or pessimists. Summary of DSM-IV Criteria for Dysthymic Disorder Depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least two years. Note: In children and adolescents, mood can be irritable and duration must be at least one year. Presence, while depressed, of two (or more) of the following: Poor appetite or overeating Insomnia or hypersomnia Low energy or fatigue Low self-esteem Poor concentration or difficulty making decisions Feelings of hopelessness During the two year period (one year for children and adolescents) of the disturbance, the person has never been without the symptoms in criteria A or B for more than two-months at a time. No major depressive episode has been present during the first two years of the disturbance (one year for children and adolescents); i.e, the disturbance is not better accounted for by chronic major depressive disorder, or major depressive disorder in patial remission. There has never been a manic episode, a mixed episode, or a hypomanic episode, and criteria have never been met for cyclothymic disorder. The disturbance does not occur exclusively during the course of a chronic psychotic disorder, such as schizophrenia, or delusional disorder. The symptoms are not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or general medical condition (e.g., hypothyroidism). The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Bereavement Bereavement is a normal reaction to the loss of a loved one. It is accompanied by insomnia, sadness, weight loss, decreased appetite. Symptoms resolve normally within 2 months and do not require psychotherapy or pharmacotherapy. When symptoms persist beyond 2 months, the possibility of a diagnosis of major depression exists. Pathologic symptoms include thoughts of death beyond the wish to be with the lost loved one, excessive guilt, an overwhelming new sense of worthlessness, severe psychomotor retardation, hallucinations (other than transiently hearing the voice or seeing the image of the loved one), or the inability to perform usual tasks and obligations. Adjustment disorder with depressed mood Adjustment disorder with depressed mood is diagnosed when the patient has depressive symptoms or complaints within 3 months of an identifiable psychosocial stressor. Stressors may include academic failure, job loss, or divorce. The stressor causes depressed symptoms that do not meet the criteria for major depression or dysthymic disorder. The treatment of choice is psychotherapy over pharmacologic therapy. Seasonal affective disorders Major depressive episodes that have a seasonal pattern, particularly with the start of fall or winter, or when natural daylight decreases, are considered seasonal affective disorders. The diagnosis can not be made if there is a clear psychosocial stressor related to the change in season. These patients respond to standard antidepressants and psychotherapy, in addition to light therapy. Depression in pregnancy and postpartum depression Question 4) You have a 28 year old woman who is in her third trimester of pregnancy. She has been diagnosed with severe depression and is under the care of a psychiatrist. She wants to discuss with you the risk of taking antidepressants during the rest of her pregnancy. Which of one of the following statements is true? If she takes an SSRI (selective serotonin reuptake inhibitor), her newborn has a small risk of developing a transient withdrawal syndrome that may consist of inconsolable crying, irritability, tachypnea, thermal instability, and poor muscle tone. If she takes an SSRI (selective serotonin reuptake inhibitor), her newborn has a small risk of developing a permanent serotonin syndrome that may consist of inconsolable crying, irritability, tachypnea, thermal instability, and poor muscle tone. If she takes an SSRI, her newborn will likely be larger than a newborn delivered by a mother not taking antidepressants. Tricyclic antidepressants have teratogenic effects. She should stop any antidepressant a few weeks prior to her due date to prevent neonatal withdrawal syndrome. The correct answer is a. Selective serotonin reuptake inhibitors are the agents of choice. Selective serotonin reuptake inhibitors and tricyclic antidepressants appear to have no teratogenic effects. There is also a small but significant risk of withdrawal syndrome in the newborn if serotonergic antidepressants are taken during the third trimester. This withdrawal syndrome consists of irritability, inconsolable crying, tachypnea, thermal instability, and poor muscle tone but is usually mild and transient. More recently, a case-control study reported a possible association between SSRI use in late pregnancy and persistent pulmonary hypertension in the offspring. Although depression in pregnancy and postpartum depression is beyond the scope of this web module, it is important for primary care physicians to be aware of screening these patients for timely intervention. Medical management of depressed patients during pregnancy usually stirs discomfort in physicians because of fear of teratogenic effects in the fetus. Adverse effects of not treating this population are well documented, as well as the safety profiles of commonly prescribed psychiatric medications. Selective serotonin reuptake inhibitors are the agents of choice. Fluoxetine and tricyclic antidepressants appear to have no teratogenic effects, and new data shows similar safety profiles for other selective serotonin reuptake inhibitors. The mood stabilizers (e.g., dilantin, valproic acid, carbamazepine) appear to be teratogenic. The decisions regarding the use of psychiatric medications should be individualized. The most important factor is usually the patients level of functioning in the past when she was not taking medications. There is a small but significant risk of withdrawal syndrome in the newborn if serotonergic antidepressants are taken during the third trimester. This withdrawal syndrome consists of irritability, inconsolable crying, tachypnea, thermal instability, and poor muscle tone but is usually mild and transient. Overall, pregnant patients, once identified with depression, should be under the care of a psychiatrist and an obstetrician or family physician with experience in high risk obstetrics. Psychotherapy has also been found to be useful in these women. Postpartum depression typically occurs within one month of delivering a baby. Normal baby blues can begin 24 hours after delivery and last up to 10 days. Postpartum depression is not different from a major depressive episode, but the primary care physician or obstetrician should recognize the symptoms as immediate interventions can have positive outcomes for the mother and baby. One important challenge is that the onset of postpartum depression frequently occurs before the patient is seen for a routine six-week postpartum visit. The risk-benefit decision about whether to start antidepressants in a breastfeeding woman is based on the severity of the depression and the need for pharmacotherapy, rather than any known risks to the infant. More information on treatment of depression in pregnancy, postpartum women, and breastfeeding woman can be found in this web modules library. LINK: Ward, R. Zamorski, M. Benefits and Risks of Psychiatric Medications in Pregnancy Am Fam Physician. 2002;66:629-36,639. LINK TO RESOURCE FOR PATIENTS AND DOCTORS ON PREGNANCY AND DEPRESSION:  HYPERLINK "http://www.womensmentalhealth.org" www.womensmentalhealth.org Depression in the Elderly and Pseudodementia QUESTION 5) Which one of the following statements is true about depression in the elderly? Physicians are more likely to diagnose depression correctly in the elderly than in younger people. Depression in the elderly is less important than in younger patients because depression is a normal part of the aging process. Patients who are elderly when their first depressive episode occurs have a relatively high likelihood of developing recurring chronic depression. Risk factors for depression in elderly persons include a history of depression, chronic medical illness, male sex, being single or divorced, brain disease, alcohol abuse, use of certain medications, and stressful life events. The long term prognosis for the elderly suffering from depression is poor even with treatment. The correct answer is c. As in younger populations, depression in the elderly is often not diagnosed and not treated by physicians. A popular misconception by patients, families, and physicians is that depression is a normal part of the aging process. Risk factors for depression in elderly persons include a history of depression, chronic medical illness, female sex, being single or divorced, brain disease, alcohol abuse, use of certain medications, and stressful life events. Patients who are elderly when their first depressive episode occurs have a relatively high likelihood of developing recurring chronic depression. With proper diagnosis and management, depression in the elderly is treatable and has a good prognosis. (Source: Birrer, RB, Vemuri SP. Depression in later life: A diagnostic and therapeutic challenge. Am Fam Physician 2004; 69 (10): 2375-2382) Depression in the elderly is not part of the normal aging process. This common misconception may lead elderly patients, or their families, not to seek appropriate help. It can also lead physicians to miss the diagnosis of depression in the elderly and leave it untreated. A common complaint in elderly patients is not depression but insomnia, anorexia, and fatigue. Treatment with antidepressants, especially selective serotonin reuptake inhibitors can be useful. Patients who are elderly when they have their first episode of depression have a relatively higher likelihood of developing chronic and recurring depression. The prognosis for recovery is equal in young and old patients, although remission may take longer to achieve in older patients. Pseudodementia, associated with severe depression, can be easily mistaken for dementia, especially in the elderly or persons with underlying neurological disease (e.g., strokes, etc). The symptoms of pseudodementia include marked psychological distress, inability to concentrate or complete daily tasks, and marked cognitive dysfunction. Differentiating between dementia and pseudodementia is important. Typically, patients suffering from pseudodementia will exhibit profound concern about their impaired cognitive function, in contrast with patients with a diagnosis of dementia, who may tend to minimize their disability. In addition to pharmacotherapy, electroconvulsive therapy may be warranted in patients with pseudodementia. All patients with depression of all ages, including the elderly, should have a mini-mental status examination at baseline. Patients successfully treated of their major depression will see their pseudodementia and cognitive dysfunction improve. Reproduced with permission from Birrer, R., Vemuri, S. Depression in Later Life: A Diagnostic and Therapeutic Challenge. American Family Physician. 2004;69:2375-82. More information on depression in the elderly is available in this web modules library. LINK TO: Birrer, RB, Vemuri SP. Depression in later life: A diagnostic and therapeutic challenge. Am Fam Physician 2004; 69 (10): 2375-2382 Manic and Hypomanic Symptoms: Bipolar Disorder Question 6) You are evaluating a 35 year old male in your primary care practice. He has a history of depression and occasional panic attacks. His previous physicians treated his panic symptoms with selective serotonin reuptake inhibitors (SSRIs) approved for panic disorders but the medications made him more restless, agitated, and unable to sleep. Upon further questioning, you discover he has been having symptoms with impairing depressive episodes and anxiety since late childhood. His father was hospitalized with a manic episode on one occasion. Upon further exploration, which one of the following would be most specific for confirming the diagnosis of bipolar disorder? His brother has a confirmed diagnosis of bipolar I disorder His sister has a confirmed diagnosis of bipolar II disorder The patient has symptomatic improvement on lithium His mothers mania improved with lithium The patient has had a hypomanic episode The correct answer is e. The risk of having bipolar disorder is higher in persons with first degree relatives with bipolar disorder. Incidental improvement of symptoms with lithium may also provide clues. Of all these findings, the most specific to the diagnosis is the patient having a hypomanic episode himself. (Source: American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, ed 4 text revision, American Association, 2000. Washington DC) A major depressive episode can appear as a unipolar disorder, but all primary care physicians should be aware that this presentation may be part of an underlying bipolar disorder. Primary care physicians who diagnose and treat patients with depression should carefully assess patients for a history or current complaint of manic and hypomanic symptoms. Misdiagnosis of a bipolar disorder patient presenting with major depressive symptoms can lead to mistreatment with antidepressants alone, which may precipitate a manic episode. A manic mood is characterized by irritability or abnormal euphoria. Hypomania can be seen as a lesser degree of mania that lasts for a shorter duration. Hypomanic patients usually can continue with their normal life routines and dont require hospitalization. A patient with a mixed state has to technically satisfy all the criteria of a major depressive disorder and mania at the same time. DSM-IV criteria for mania and hypomania can be found on the next table. Patients with bipolar disorder should be referred for collaborative care with a psychiatrist. Summary of DSM-IV Criteria for Manic Episode A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting 1 week (or any duration if hospitalization is necessary). During the period of the mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree: Inflated self-esteem or grandiosity Decreased need for sleep (e.g., feels rested after only 3 hours of sleep) More talkative than usual or pressure to keep talking Flight of ideas or subjective experience that thoughts are racing Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli) Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments) The symptoms do not meet the criteria for a Mixed Episode. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g. hyperthyroidism). Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g. medication, electroconvulsive therapy, light therapy) should not count toward the diagnosis of Bipolar I Disorder. Summary of DSM-IV Criteria for Hypomanic Episode A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual non-depressed mood. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree: Inflated self-esteem or grandiosity Decreased need for sleep (e.g., feels rested after only 3 hours of sleep) More talkative than usual or pressure to keep talking Flight of ideas or subjective experience that thoughts are racing Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli) Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments) The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic. The disturbance in mood and the change in functioning are observable by others. The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g. hyperthyroidism). Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g. medication, electroconvulsive therapy, light therapy) should not count toward the diagnosis of Bipolar II Disorder. Assessing The Risk of Suicide  The Scream Edvard Munch LINK: Edvard Munch (Wikipedia:  HYPERLINK "http://en.wikipedia.org/wiki/Edvard_Munch" http://en.wikipedia.org/wiki/Edvard_Munch) Patients with depression may be at increased risk for suicide (Kahn, 1999. NYCDOH, 2006, Mann, 2005). Any patient that has a positive screening for depression should be evaluated for suicide risk. Asking about suicidal thoughts can save the patients life. Contrary to many physicians fear, asking about suicidal plans or ideation does not make patients more prone to commit suicide. Patients are usually relieved that they have been asked about their feelings and thoughts. Asking about suicidal ideation or plans conveys your interest in their well-being. Questions in Assessing Suicidal Risk Current thoughts of harming or killing self Current plans to harming or killing self Prior suicide attempts (critical indicator of future suicide risk) Family history of mood disorder, alcoholism, or suicide Actions or threats of violence to others Access to firearms Male Elderly Significant comorbid anxiety or psychotic symptoms and active substance abuse Poor social support system or living alone Recent loss or separation Hopelessness Preparatory acts (e.g., putting affairs in order, suicide notes, giving away personal belongings) Physicians can initiate the topic of suicidal ideation with questions about the patients feelings about life. Did you ever wish you could go to sleep and never wake up? Have you ever felt life was not worth living? Depending on the response, more specific questions about suicidal ideation can be asked. Do you ever feel others would be better off without you? Are you having thoughts about killing yourself? Have you thought about killing or hurting others? If suicidal ideation is elicited, physicians should ask patients if they have a suicidal plan (e.g., how, when, where). A patient that is actively thinking about suicide and has a plan for suicide constitutes a medical emergency. This is especially true in patients with previous suicide attempts. 911 should be called for safe transport to the nearest emergency room for psychiatric care. Prediction of which patients with suicidal ideation will attempt or commit suicide is very poor. The Institute of Mental Health has made recommendations for physicians who are assisting potentially suicidal patients. It is important to monitor your own reactions to a suicidal patient. Stay calm and dont appear threatened so that the patient feels secure and maintains the doctor-patient dialogue. Listen attentively so that the patient feels validated about their distress and is not ignored. Avoid judgmental statements. Emphasize that suicidal feelings worsen with stress, but is a treatable condition. Also highlight that suicide causes family members and friends great pain that lasts for years. Make it clear to the patient that he or she will have input into their treatment along with you and the psychiatric team as part of a partnership. Question 7) Outpatients at risk for suicide should not receive large supplies of antidepressants in case of overdose. Which one of the following statements is true about antidepressants and suicide? Fluoxetine has been shown to lead to more suicide attempts in adolescents than use of placebo. Norepinephrine reuptake inhibitors (NRIs) are less like than selective serotonin reuptake inhibitors (SSRIs) to be associated with suicidal thoughts in adolescents. Tricyclic antidepressants (TCAs) are more lethal in overdose than SSRIs. Suicide rates are higher with TCAs than with SSRIs. The correct answer is c. Tricyclic antidepressants are more lethal in overdose over selective serotonin reuptake inhibitors. The risk of suicide in all patients who are recovering from major depression may transiently increase during initial treatment, but whether antidepressants possibly cause increased suicide risk is extremely controversial. Increased energy to act on suicidal ideation is only one of the possible explanations currently under consideration. Monitoring patients closely during treatment is paramount and is part of psychiatric treatment. Fluoxetine is the only antidepressant found to be effective in children and adolescents, but close surveillance for suicidal ideation or plans is again warranted. The average risk of suicide in general was 4% with antidepressants and 2% on placebo. (Sources: Jick SS, Dean AD, Jick H. Antidepressants and suicide. BMJ 1995; 310 (6974): 215-218; Simon GE. How can we know whether antidepressants increase suicide risk? Am J Psychiatry 163:1861-1863, 2006.) A link to a recent article on whether antidepressants increase suicide risk and the advent of black box warnings is available in the library. LINK: Simon GE: How can we know whether antidepressants increase suicide risk? Am J Psychiatry 163:1861-1863, 2006.VI. Treatment Recommendations for Major Depressive DisorderTreatment Recommendations for Major Depressive Disorder Successful treatment of major depressive disorder starts with a thorough assessment of the patient. As discussed previously and based on recommendations of the American Psychiatric Association, healing begins with psychiatric management of the patient, followed by three phases of treatment. This may be done by the primary care physician, and / or psychotherapist, and / or psychiatrist depending on the history, complexity, and degree of severity of the depression. The following recommendations are for Major Depressive Disorder, and although no existing scientific literature has been established it may apply to other syndromes such as dysthymic disorder. Psychiatric Management Perform a diagnostic evaluation to determine if the diagnosis of depression is warranted or if other psychiatric or medical conditions exist. History of present illness and current symptoms Psychiatric history (e.g., symptoms of mania, previous history of psychiatric treatment, response to previous psychiatric treatments) General medical history History of substance abuse disorders Personal history (e.g. psychological development, response to major life events and transitions) Social history Occupational history Family history Medication review A review of systems A physical examination A mental status examination Diagnostic studies as indicated (e.g., TSH, CBC, Basic Chemistry Profile) Evaluate for the safety of the patient and of others. This evaluation is crucial. Presence of suicidal or homicidal ideation or plans Access to a means for suicide and the lethality of the means (e.g. access to handguns) Presence of psychotic symptoms (e.g. command hallucinations or delusions) Severe anxiety Concurrent alcohol or substance use History of previous attempts Family history of suicide Recent exposure to another person who committed suicide Evaluate functional impairment by assessing: Interpersonal relationships Work Living conditions Health and medical related needs Determine a treatment setting. This can vary from ambulatory settings with a primary care provider only, ambulatory settings with a primary care provider in conjunction with a psychiatrist, day programs, to involuntary psychiatric hospitalization. Criteria for involuntary hospitalization are usually set by local jurisdictions. Patients should be treated in the setting that is the safest and is the most effective. The setting should be reassessed at follow up visits. The following situations require referral to psychiatrist: Suicide risk Bipolar disorder or manic episode Psychotic symptoms Severe decrease in level of functioning (e.g., unable to care for self) Recurrent depression Chronic depression Depression that is refractory to treatment Cardiac disease that requires tricyclic antidepressants treatment (contraindication) Need for electroconvulsive therapy (ECT) Lack of available support system Any diagnostic or treatment questions Establish and maintain a therapeutic alliance. Major depression is a chronic disease and it requires that the patient actively engages and adheres to long periods of treatment. Symptoms of major depressive disorder (e.g., poor motivation, cognitive dysfunction, pessimism, etc.), side effects of medications, and misunderstandings between the physician and patient can be major obstacles to adherence. Pay attention to concerns patients and their families. The physician should be aware of any transference or countertransference issues with the patient (e.g., frustration or anger from or toward the patient, etc.). Continue to monitor the patients psychiatric status and safety. With treatment, some symptoms may improve while others emerge. Significant changes in psychiatric status or emergence of new symptoms requires diagnostic and management reassessment. Provide patient education and, if appropriate, to the patients family. Effective education will allow patients to make informed decisions about their treatment and improve adherence. Emphasize that major depression is a real illness and not a moral defect. Effective treatment is available and necessary. Discuss anticipated side effects of treatments. Education of family and friends is important Support groups are available for patients and their families Enhance treatment adherence. It is critical for the physician to monitor the patient closely especially as they begin to feel better as the patient may start to focus on the side effects of treatment rather than the benefits. The patient should be encouraged to verbalize any concerns or issues. Review with the patient when and how often to take their medication. Explain that beneficial effects may take 2 4 weeks to be noticed. Explain the need to continue taking the medication even after the patient feels better. Remind the patient the need to consult with a physician before stopping medication. Explain to the patient how to access you, a colleague, or the health care team in case a question or problem arises. Consider issues of polypharmacy especially in elderly patients. Consider the financial impact of medications on patients. Encourage the family to help in the process of adherence. Work with the patient to address early signs of relapse. Exacerbations and relapse are common in major depressive disorder, and patients and families should be educated on this point. A review of signs and symptoms of relapse with the patient is critical as the next episode may contain different depressive characteristics. Emphasize the need to seek early treatment and intervention if symptoms arise to prevent a full-blown exacerbation. The three phases of treatment of major depression Treatment consists of three phases: Acute Phase Remission is induced (minimum 6 8 weeks in duration). Continuation Phase Remission is preserved and relapse prevented (usually 16 20 weeks in duration). Maintenance Phase Susceptible patients are protected against recurrence or relapse of subsequent major depressive episodes (duration varies with frequency and severity of previous episodes). Remission and relapse have been defined by the American Psychiatric Association. Remission is the return to the patients baseline level of symptom severity and functioning. Remission should not be confused with significant but incomplete improvement. Relapse is the re-emergence of significant depressive symptoms or dysfunction after remission has been achieved. Acute phase treatment The goal of acute phase treatment is to induce remission and typically lasts a minimum 6 8 weeks in duration. For patients with mild to moderate depression, the initial treatment modalities may include pharmacotherapy alone, psychotherapy alone, or the combination of medical management and psychotherapy. As stated prior, psychiatric management must be integrated into treatment regardless of the initial approach. Antidepressant medications Antidepressant medications can be used as initial treatment modality by patients with mild or moderate depression. Clinical features that may suggest that antidepressant medication is preferred over other modalities are a positive response to prior antidepressant treatment, significant sleep and appetite disturbance, severity of symptoms, or anticipation by the physician that maintenance therapy will be needed. Patient preference for antidepressant medication alone should be taken into consideration. Most primary care physicians can medically manage these patients in their practices as long as they continue to monitor the patients symptoms closely. The frequency of monitoring in the acute phase of pharmacotherapy is from once a week to multiple times a week. Psychotherapy Psychotherapy alone may be considered as initial treatment modality for patients with mild to moderate depressive disorder. Clinical features that suggests the use of psychotherapy over other modalities are the presence of psychosocial stressors, interpersonal difficulties, intrapsychic conflict, and any axis II comorbidities (personality disorders as per DSM-IV). In addition, patient preference for psychotherapy alone should be taken into consideration, as well as a womans desire to get pregnant, be pregnant, or to breastfeed. Most primary care physicians will refer these patients to a professional psychotherapist for management. The frequency of monitoring in the acute phase of psychotherapy is from once a week to multiple times a week. Combination antidepressant medication and psychotherapy The combination of antidepressant medication and psychotherapy may be the initial treatment approach for patients with moderate depression in the presence of psychosocial stressors, interpersonal difficulties, intrapsychic conflict, and any axis II comorbidities. Combination therapy may also be appropriate for patients with only partial remission on one type of treatment, or with a history of poor adherence to treatment. Most primary care physicians can medically manage these patients while referring them to a professional psychotherapist for co-management. Initial acute phase treatment approaches for patients with severe depressive symptoms Antidepressant medications alone can be used as initial treatment modality by patients with severe depression. There is insufficient evidence that psychotherapy alone is effective for patients with severe depression. The combination of antidepressant medication and psychotherapy may be the initial treatment approach for patients for patients with severe depression in the presence of psychosocial stressors, interpersonal difficulties, intrapsychic conflict, and any axis II comorbidities. Patients with depression and psychotic symptoms, catatonia, or severe impairment may be considered for combination therapy with antidepressants, antipsychotics, and / or electroconvulsive therapy (ECT). Patient with severe depression are usually referred for care under a psychiatrist. Assessing an adequate response in the acute phase with mild to moderate depression Although the goal of acute phase treatment is to return patients to their functional and symptomatic baseline, it is common for patients to have a substantial but incomplete response to acute phase treatment. Structured tools that measure depression severity and functional status may be used for follow up assessment (e.g., PHQ- 9, Beck Depression Inventory, etc.). It is important to not conclude treatment for these patients at this phase as it may be associated with poor functional outcomes. The degree of an adequate response to treatment of depression has been loosely defined: non-response is the decrease in baseline symptoms of 25% or less; partial response is a 26 49% decrease in baseline symptoms; partial remission is 50% or greater decrease in baseline symptoms with residual symptoms; and remission is the complete absence of symptoms). When patients have not fully responded at this phase, the most important first step is increasing the dose. Overall, if after the initial 4 8 weeks there is not a moderate improvement in baseline symptoms in the acute phase, then a reassessment of the diagnosis, medication regimen and / or psychotherapy, adherence, substance or alcohol use is in order. Increasing the treatment dose is the first step to be considered. If 4 8 weeks after the increase of treatment dose there is not a moderate improvement in symptoms, another review should occur. Other treatment options should then be considered in consultation with a psychiatric specialist. Question 8) From our initial opening clinical case, Mr. George is a 44 year old male who you found to have major depression. Administration of a standard depression questionnaire (such as the PHQ 9) found his depression to be of moderate severity. You started him on antidepressants. You see him 8 weeks later after starting the antidepressant medication and his appetite is back, he is sleeping well, and concentrating better at home and at work. He still feels tired but denies feeling depressed. He still has not assumed his normal social activities. You re-administer the same standard depression questionnaire, and conclude that he has achieved partial remission. Reassessment has found no issues with substance abuse or adherence issues with his medications. After this initial reassessment, which one of the following is the most appropriate first step in treatment options? Maintain the current dosage of medication and see him back in 4 to 8 weeks. Increase the dose of the medication and see him back in 4 to 8 weeks. Change the medication. Recommend adjunct psychotherapy. Consult with a psychiatrist. The correct answer is b. In the acute phase of treatment, if after 4 8 weeks there is not a moderate improvement in baseline symptoms in the acute phase, then a reassessment of the diagnosis, medication regimen and / or psychotherapy, adherence, substance or alcohol use is in order. The first step is increasing the dose of the medication since he achieved only partial remission at the initial dose. If after another 4 8 weeks, Mr. George is not improved, consideration can be given to again increasing the dose of the medication, changing to a different medication, or begin adjunct psychotherapy. If 4 8 weeks after the change in treatment there is not a moderate improvement in symptoms, another review should occur. Other treatment options should then be considered in consultation with a psychiatric specialist or at any time the primary care physician feels improvement is not optimal. (Source: Working Group on Major Depressive Disorders. Practice Guidelines for the Treatment of Patients With Major Depressive Disorder. American Psychiatric Association. 2000. Washington D.C.) Continuation Phase Treatment Patients who have been treated with antidepressant medications in the acute phase should be maintained with this regimen to prevent relapse. This continuation phase should last for 16 20 weeks after remission. Psychiatric management should continue in this phase. The American Psychiatric Association recommends the medication doses used in the acute phase be maintained in the continuation phase. There is increasing data to support the continued use of specific effective psychotherapy in this phase. The use of ECT in this phase has not been well researched. The frequency of visits in the continuation phase may vary. Stable patients may be seen once every 2 3 months. Patients in active psychotherapy may be seen several times a week. Patients who remain stable throughout the continuation phase, and who are not candidates for the maintenance phase (e.g., recurrent relapsing chronic depression, etc.), can be considered candidates for discontinuation of treatment. QUESTION 9) A 35 year old female returns for a follow visit after you have successfully treated her first episode of uncomplicated major depression. After 6 weeks of treatment with an antidepressant, all of her depressive symptoms have resolved. Based on the evidence, the total length of treatment with antidepressants should be at a minimum: 3 months 6 months 9 months 12 months Indefinite The correct answer is b. Based on the treatment recommendations of the American Psychiatric Association, this uncomplicated patient with her first major depressive episode would have had an initial six weeks of antidepressant treatment. This six week period in the acute phase of treatment has apparently induced complete remission of symptoms. The evidence would recommend another 16 20 weeks of continuation phase treatment. The minimum total length of acute and continuation phase treatment for this patient would be about 6 months. (Source: Working Group on Major Depressive Disorders. Practice Guidelines for the Treatment of Patients With Major Depressive Disorder. American Psychiatric Association. 2000. Washington D.C.) Maintenance Phase Treatment Between 50 85% of patients with a single major depressive episode will have another episode. Maintenance phase treatment is designed to prevent recurrence. Issues to consider in using maintenance phase treatment are severity of episodes (e.g., suicidal ideation or attempts, psychotic symptoms, functional impairment); risk of recurrence (e.g., residual symptoms between episodes, number of recurrent episodes); comorbid conditions; side effects experienced with continuous treatment; or patient preference. The same treatment that was effective in the acute and continuation phase should be continued in the maintenance phase. The doses of medication in the previous phases are usually maintained. The type of psychotherapy employed dictates the frequency of visits in the maintenance phase (e.g., cognitive behavioral therapy and interpersonal therapy decrease to once a month, while psychodynamic psychotherapy maintains the same previous frequency). Combination therapy (psychotherapy and pharmacotherapy) may be beneficial for some patients although it is not well studied. Patients with recurrent moderate or severe depressive episodes who dont respond well to pharmacotherapy may be candidates for periodic ECT. Frequency of visits in the maintenance phase can vary as in the continuation phase. The length of maintenance treatment that is optimal is unknown. Factors that may influence this period may be frequency and severity of recurrent episodes, persistence of symptoms after a period of recovery, tolerability of treatment, and patient preference. Some patients may require indefinite maintenance treatment. Question 10) For which one of the following patients is a trial of discontinuation of antidepressant medication appropriate? A 30 year old male with is his first lifetime episode of major depression who is now asymptomatic after taking his medication for 3 months. A 50 year old female with depression and an anxiety disorder with her fourth episode of major depression, which has taken 6 months of medication and is now asymptomatic. A 40 year old male with is third lifetime episode of major depression who has taken medication for 12 months and is now asymptomatic. A 40 year old female with her first lifetime episode of major depression who is now asymptomatic after taking 12 months of medication The correct answer is d. The 40 year old male and 50 year old female with recurrent episodes of major depression may benefit from longer or indefinite treatment. The 30 year old male with his first episode and who is now asymptomatic after 3 months of medication has not completed the recommended length of continuation phase treatment. The 40 year old female with her first lifetime episode of major depression who is now asymptomatic after taking 12 months of medication is the only possible candidate for a trial of discontinuation but still needs monitoring and education on relapse. (Source: Working Group on Major Depressive Disorders. Practice Guidelines for the Treatment of Patients With Major Depressive Disorder. American Psychiatric Association. 2000. Washington D.C.) Discontinuation of active treatment The factors to discontinue treatment are based on the same considerations in deciding on using maintenance phase therapy: frequency and severity of recurrent episodes, dysthymic symptoms between episodes, the presence of other psychiatric disorders, the presence of chronic general medical disorders, or patient preference. If maintenance pharmacotherapy is discontinued, it is recommended to taper the medication over several weeks. Slow tapering may allow the physician to detect emerging symptoms and restore the medical management to full therapeutic doses. Discontinuation syndromes (e.g., mood disturbances, sleep, energy, and appetite) can appear much like relapses but are in fact due to lack of tapering of medications. Patients on short acting agents are more prone to discontinuation syndromes and should be tapered over longer periods of time. Signs and symptoms of relapse should again be reviewed with the patient once discontinuation of treatment has occurred.VII. Medical Management of DepressionFirst line choices of antidepressant drugs QUESTION 11) Which one of the following statements is true regarding the effectiveness of antidepressants agents for treating major depression? Selective serotonin reuptake inhibitors (SSRIs) are the most effective class of antidepressants. Tricyclic antidepressants (TCAs) are the most effective class of antidepressants. Serotonin-norepinephrine reuptake inhibitors are the most effective class of antidepressants. Monoamine oxidase inhibitors (MAOIs) are the most effective class of antidepressants. All classes of antidepressants are equally as effective. The correct answer is e. Although there may be specific class considerations for use of one medication over another for a particular patient, all classes of antidepressants are equally effective. (Source: Mann, JJ., The Medical Management of Depression New England Journal of Medicine. 2005 Oct 27;353(17):1819-34.; and Working Group on Major Depressive Disorders. Practice Guidelines for the Treatment of Patients With Major Depressive Disorder. American Psychiatric Association. 2000. Washington D.C.) Antidepressant medications effectiveness is generally comparable across classes and within classes of medications. The medications differ in side effect profiles, drug-drug interactions, and cost. The history of a positive response to a particular drug for an individual or a family member, as well as patient preferences, should also be taken into account. Most psychiatrists agree that an SSRI should be the first line choice. The dual action reuptake inhibitors venlafaxine and bupropion are generally regarded as second line agents. Tricyclics and other mixed or dual action inhibitors are third line, and MAOIs (monoamine oxidase inhibitors) are usually medications of last resort for patients who have not responded to other medications, due to their low tolerability, dietary restrictions, and drug-drug interactions. Most primary care physicians would prefer that a psychiatrist manage patients requiring MAOIs. The recommended starting dose of antidepressants is illustrated in the table below from Mann JJ., The Medical Management of Depression New England Journal of Medicine. 2005 Oct 27;353(17):1819-34. Titration of the drug to therapeutic levels is done over the initial weeks of treatment. The rate of titration may depend on the patients age, the development of side effects, and comorbid conditions. In the geriatric population, the starting dose is usually half the recommended starting dose for other adults. Classification, Doses, Safety, Side Effects of Antidepressants   Table reproduced with permission from the Massachusetts Medical Society. Taken from Mann, JJ., The Medical Management of Depression New England Journal of Medicine. 2005 Oct 27;353(17):1819-34. Copyright 2005 Massachusetts Medical Society. All rights reserved. As stated prior, the patient should be monitored over time for improvement, exacerbation of depression, suicidal feelings, side effects, and adherence. All antidepressants may induce a manic episode in patients susceptible to bipolar disorder. The frequency of monitoring can vary from once a week to multiple times a week. Monitoring can be done via face-to-face visits, telephone contact via the physician and patient, or the patient and nursing staff. This can be a challenge in clinical practice, but there are novel approaches for improving systems for monitoring depressed patients in primary care settings (available in the library of this module). LINK: Oxman, T., et al. A Three-Component Model for Reengineering Systems for the Treatment of Depression in Primary Care. Psychosomatics 2002; 43:441-450. Antidepressant Medications Most antidepressant agents amplify norepinephrine or serotonin signaling by inhibiting their reuptake at the synaptic cleft. Selective serotonin reuptake inhibitors (SSRIs) Clinical trials have found little difference in efficacy and tolerability amongst the various SSRIs. SSRIs tend to be well tolerated as compared with other classes of antidepressants. The half life of all of the SSRIs is long enough to allow for once a day dosing, which improves patient adherence. Of note, fluoxetine is the only antidepressant found to be effective in controlled trials treating depressed children and adolescents. SSRIs have fewer cardiovascular effects than tricyclic antidepressants. Tricyclic antidepressants (TCAs) and Norepinephrine reuptake inhibitors (NRIs) TCAs and NRIs are older classes of antidepressants. They may be more effective in severe depression or depression with melancholic features. They may also be more effective than SSRIs for depression that has predominant physical symptoms or pain. TCAs and NRIs tend to have cardiac conduction effects and thus they are not the drug of choice in patients with cardiovascular conditions, particularly conduction defects. They are also contraindicated in people with benign prostatic hypertrophy, urinary retention, and closed angle glaucoma. Dual action antidepressants Venlafaxine, milnacipran, duloxetine are serotonin-norepinephrine reuptake inhibitors. They block monoamine transporters much more selectively than the TCAs and NRIs and thus have less cardiac-conduction effects. Venlafaxine has been shown to be more effective than SSRIs or TCAs through higher rates of remission in severe depression. Duloxetine is as effective as the SSRI paroxetine. Both duloxetine and paroxetine are also effective in treating chronic pain and diabetic neuropathy. Bupropion inhibits norepinephrine and dopamine, but not serotonin, reuptake. It has similar efficacy to TCAs and SSRIs, but has less diarrhea, nausea, somnolescence, and sexual side effects than SSRIs. Bupropion also can be used as an adjunct in smoking cessation (although some health insurance companies will pay for buproprion as an antidepressant but not as a smoking cessation medication). Monoamine oxidase inhibitors (MAOIs) MAOIs nonselectively block Mao A and B isoenzymes, and have similar efficacy to TCAs. Again, MAOIs are not considered first line choice due to the side effect profile, drug-drug interactions, and the need to adhere to a low tyramine diet to prevent a hypertensive crisis. Under the care of a psychiatrist, MAOIs may be more effective than TCAs for atypical depression which is characterized by extreme fatigue, sensitivity to rejection, or troubled relationships. Newer antidepressant therapies Nefazodone blocks 5-HT serotonin receptors thus enhancing serotonin in synaptic clefts. It has an efficacy similar to SSRIs, and tends to be sedating. Mirtazapine blocks alpha 2 adrenergic receptors, specific serotonin receptors, and histamine receptors to enhance norepinephrine in the synaptic cleft. It is as effective as SSRIs and TCAs. Mirtazapine tends to be quite sedating and to cause significant weight gain. Considerations before switching antidepressants As mentioned prior, patients getting the same dose of an antidepressant and not achieving a response should consider having their antidepressant dose increased before changing the medication altogether. Before the medication is switched, the primary care physician should reassess the diagnosis; consider increasing the antidepressant dose; assess the patient for adherence; consider alcoholism or substance-abuse; and re-evaluate for coexisting medical conditions and use of non-psychiatric drugs that may contribute to treatment failure. It is generally recommended that patients who dont have a response to an SSRI should be switched to an antidepressant in another class. Similarly, if a dual action antidepressant has been used first, a switch to an SSRI should be considered. For patients with a partial response to one antidepressant, a second antidepressant from another class can be added for augmentation. Adjunct medications There are other medications that are used in conjunction with antidepressants to augment their effects. Mood stabilizers, such as lithium can prevent manic and depressive episodes in bipolar patients. Lithium can also be an effective augmenting agent in patients who dont have an effective response to antidepressants alone. Antipsychotic medications can be added to antidepressants to treat depression with psychotic features. Anxiety: Antidepressants and Anxiolytics In major depression with comorbid anxiety or panic disorder (15 30% of cases), depression and anxiety symptoms resolve with antidepressant treatment. SSRIs and TCAs may initially worsen the anxiety. This can be avoided by starting at lower doses and titrating up more slowly. Benzodiazepines are used as an adjuvant in 30 - 60% of cases of depression with anxiety or insomnia. Benzodiazepines improve antidepressant response, but can cause sedation, memory loss, and dependence and withdrawal syndromes. Benzodiazepines should be used on a limited basis to avoid dependency; avoided in those with a history of alcohol or drug abuse; and be used with extreme caution in geriatric populations who dont metabolize the drugs well and can cause increased cognitive dysfunction, falls, and death. In general, benzodiazepines should not be used as the primary pharmacologic agent in any patient with major depression and anxiety disorders.VIII. Psychotherapeutic Management of DepressionPsychotherapeutic Management of Depression Psychotherapy may be a first line therapy choice for mild depression particularly when associated with psychosocial stress, interpersonal problems, or with concurrent developmental or personality disorders. Psychotherapy in mild to moderate depression is most effective in the acute phase, and in preventing relapse during continuation phase treatment. Psychotherapy is not appropriate alone for severe depression, psychosis, and bipolar disorder. For more severe depression, psychotherapy may be appropriate in combination with the use of medications. The most effective forms of psychotherapy are those with structured and brief approaches such as cognitive behavioral therapy, interpersonal therapy, and certain problem solving therapies. Regardless of the psychotherapy initiated, psychiatric management must be integrated at the same time. Primary care physicians should be aware of the different psychotherapy approaches so that they can understand what their patients are undergoing and what goals they are trying to achieve. Studies indicate that the use of cognitive therapy modalities is most effective (Rupke, 2006); Cognitive behavioral therapy (CBT) is most frequently cited in studies as highly effective in treating depression. However, interpersonal psychotherapy and problem oriented psychotherapy have also been considered as desirable and cost effective when compared to more traditional models of psychotherapy. Cognitive Behavioral Therapy (CBT) CBT targets thoughts and behaviors that need to be changed. Based on the premise that behaviors have their roots in thoughts, this approach assumes that depression is rooted in pessimistic thoughts and excessive self-criticism. The goal of the therapy is to recognize what triggers certain thoughts and behaviors and to alter your routines through direction and action. Learning to substitute healthy thoughts for negative thoughts will improve a persons mood, self-concept, behavior and physical state. Behavior change is the primary goal with internal change as a byproduct. Initially, in treating depression, behavioral principles are used to overcome a patients inertia and to reinforce positive activities. An important part of CBT for depression is scheduling pleasurable activities, especially with others, that usually give positive reinforcement. Other CBT techniques include graded tasks and homework assignments as well as acting out difficult behavioral situations. Emphasis is on the present rather than on the past. The combination of CBT and antidepressants has been shown to effectively manage severe or chronic depression and for adolescents with depression. CBT has been shown to reduce relapse rates and effectively manage residual symptoms. LINK TO LIBRARY ARTICLE: Cognitive Therapy AAFP Interpersonal Therapy (IPT) Based on the belief that depression is caused by problems in important interpersonal relationships, this approach focuses on teaching about the connection between interpersonal problems and depression. Depression is viewed as arising out of conflict or loss in interpersonal relationships. A key feature is the compiling of an interpersonal inventory that lists and examines all the patients relationships. In this approach the number of sessions is generally limited over a period of several months. Treatment is divided into three stages: assessment, practice and termination, with emphasis on relapse prevention skills and techniques. Focus is on present events rather than past history and on learning ways to improve important relationships in the present and to have more positive interactions. Patients are taught not only to identify but to deliberately tolerate feelings. According to this model, as relationships improve, so should the patients mood. The model incorporates psychoeducation; is medication friendly; and agrees with a medical model of depression. Unlike CBT, IPT does not involve formal homework or rely on extensive paperwork, although patients are encouraged to develop skills and experiment between sessions. IPT is particularly useful for patients who find psychodynamic approaches mystifying, and has been modified for use with adolescents. Problem Solving Therapy (PST) Problem solving therapy is a brief, focused form of cognitive therapy that focuses on the problems a person is currently facing and on helping to find solutions to these problems. Based on studies that have demonstrated links between poor problem solving abilities and the etiology and maintenance of psychological disorders, this approach is often used in the treatment of depression. Problem focused methods involve changing the situation itself, whereas emotion-focused strategies involve changing ones reaction to the situation. Problem solving strategies work well in addressing and solving problems encountered in everyday situations where a change in behavior can have positive results. Individuals are taught to identify, discover and invent effective responses for specific problematic situations. The goal is to provide clients with a set of tools on how to effectively manage lifes stress in order to decrease distress, enhance sense of control, and improve quality of life. Interventions include didactic explanations, training exercises, practice opportunities, and homework to practice between sessions. PST sessions are often conducted in groups as well as individual sessions. It is often less expensive than other forms of treatment and can easily be performed by health care professionals. PST has been shown to be effective in treating depression in adults of all ages and is thought to be particularly effective in treatment of older adults.IX. Other TherapiesOther Therapeutic Options Combination of medications and psychotherapy There are very few clinical trials to guide with a specific selection of the optimal combination of antidepressants and psychotherapy. The same considerations in selecting monotherapy of antidepressants or psychotherapy apply. Monitoring with the same frequency for side effects, efficacy, adherence, and safety are the same in combination as when either therapy is given alone. If after 4 8 weeks there is not a moderate improvement in baseline symptoms, then a reassessment of the diagnosis, medication regimen, adherence, substance or alcohol use is in order. Change in treatment can be considered. If 4 8 weeks after the change in treatment there is not a moderate improvement in symptoms, another review should occur. Other treatment options should be considered in consultation with a psychiatric specialist if the patient fails to respond. Electroconvulsive therapy (ECT) ECT is exclusively available through an experienced psychiatric specialist. Remission rates with ECT are around 60 80 percent in severe major depressive disorder (UK ECT Review Group, Lancet 2003), and the maximum response is usually 3 weeks after treatment. ECT is the first line treatment when there is severe depression with psychotic features, psychomotor retardation, or resistance to medications. Suicidal patients and pregnant patients may also have rapid benefits from ECT. ECT consists of 6 12 treatments (2 to 3 times a week). Because the relapse rate after ECT is more than 50 percent, most psychiatrist start prophylactic treatment with antidepressants and adjuvant medications such as lithium. Postictal confusion, retrograde and anterograde memory impairment usually improves in a few days. St. Johns wort  QUESTION 12) A 35 year old male who is HIV positive, takes antiretroviral medications, and lives with severe major depression has achieved remission of his depression on his SSRI but complains of lack of sexual libido. He read some information about St. Johns wort and asks if it would be appropriate to treat his depression. Which one of the following statements is appropriate advice to this patient: St. Johns wort is more effective than placebo in patients with severe major depression. St. Johns wort is not effective for treatment of major depression. St. Johns wort is safe for use in people taking HIV antiretroviral medications. St. Johns wort is safe and effective in combination with SSRIs and TCAs. St. Johns wort is safe and effective in combination with MAOIs. The correct answer is b. St. Johns wort is a plant product commonly used to treat depression. Although two dozen trials have been conducted on the use of St. Johns wort in depression, most have had significant flaws in design and do not enable meaningful interpretation. The results of a randomized, double-blind, placebo-controlled clinical trial conducted between November 1998 and January 2000 in 11 academic medical centers in the United States with 200 participants found that St. Johns wort was not effective in the treatment of major depression (Sources: Shelton RC, Keller M, Gelenberg A, et al. Effectiveness of St. Johns wort in major depression: a randomized controlled trial. JAMA. 2001 (15); 285: 1978-1986). Information on combination of St. Johns wort and SSRIs and TCAs is unknown. St. Johns wort and combination of MAOIs is contraindicated. (Working Group on Major Depressive Disorders. Practice Guidelines for the Treatment of Patients With Major Depressive Disorder. American Psychiatric Association. 2000. Washington D.C.) St. Johns wort is not a drug and thus is not regulated by the FDA, thus there is a lack of standardized preparations. Patients living with HIV / AIDS and on antiretroviral treatment should be made aware that St. Johns wort is contraindicated because it lowers the serum levels of their antiretroviral cocktail. ST JOHNS WORT LINK PDF: National Center for Complementary and Alternative Medicine. Herbs At A Glance: St. Johns Wort. National Center for Complementary and Alternative Medicine Web site. National Institutes of Health. Accessed at  HYPERLINK "http://nccam.nih.gov/health/stjohnswort" http://nccam.nih.gov/health/stjohnswort LINK: : Shelton RC, Keller M, Gelenberg A, et al. Effectiveness of St. Johns wort in major depression: a randomized controlled trial. JAMA. 2001 (15);285: 1978-1986X. Living With DepressionLiving With Depression The Personal Experience  Self Portrait Frida Kahlo LINK: Frida Kahlo (Wikipedia:  HYPERLINK "http://en.wikipedia.org/wiki/Frida_Kahlo" http://en.wikipedia.org/wiki/Frida_Kahlo) Patients living with depression have enormous obstacles to overcome. Recognizing in oneself the symptoms and signs of depression can be difficult. People who suffer from depression describe the experience as a feeling of isolation, a feeling of being cut off from the people around them, almost of being emotionally underwater, of losing interest in physical contact and in sexual relationships, and of excessive worry. They may lack any energy in getting out of bed or to leave home. They may become emotionally distant and not talk to others. They may blame themselves for a moral defect for persistently feeling down. Although some may become aware their feelings are not normal, they may not want to seek help due to fear of stigma or fear of institutionalization. Cultural and social factors may make it even more difficult to seek help. In some cultures, it is not appropriate to discuss feeling depressed or may be seen as an imaginary disease. Men may feel that being depressed is a sign of weakness, and because discussing feelings is not masculine may make males feel even more isolated. Depression is an agonizing experience. HANDOUTS for SPECIAL POPULATIONS Mens Guide Womens Guide Latino Americans Asian Americans African Americans Native Americans VIDEO CLIP OF CBS CORRESPONDANT FROM BACKPACK FULL OF BRICKS With treatment and education, persons with depression can have functional and meaningful lives. It requires ongoing personal acknowledgement of the illness, and surveillance and recognition of signs. It requires the support of family and friends. A compassionate and vigilant primary care physician should also be part of depression monitoring and support. The Effect On Families The effect and impact on family, friends, and coworkers of a person who suffers from depression can be tremendous. Their families and friends may not recognize depressive symptoms, or dismiss the signs as either a normal reaction to life events, or ascribe the symptoms as the person being difficult or moody. Some friends and families may stop socializing with a depressed loved one because the experience can be difficult or frustrating. They may begin to resent the depressed person. Even when depression is evident, families and friends may believe that a person can just stop being depressed, or that the person with depression is acting out at them. Others may think that they may be the sole solution to solving their loved ones depression (e.g., Maybe if I do things differently? Maybe if I can kid them out of their depression? Maybe if we went on vacations more often?), or may suffer tremendous guilt about the situation. It can be difficult for families to accept the illness. Some families become socially isolated over secrecy over their loved ones condition. Families and friends benefit by learning about the illness of depression, and understanding what is not in their control and how they can be supportive. Support groups for friends and families of those living with depression also exist. Family and friends also have to find time to take care of themselves. Primary care physicians can be very effective in education and providing support to family and friends. VIDEO CLIP OF FAMILY EXPERIENCE FROM BACKPACK FULL OF BRICKS Patient and Family Education Resources LINK  HYPERLINK "http://www.familyaware.org/" http://www.familyaware.org/ Wellness Guide for Patients With Depression and Their Friends and Families PDF The Arts and Depression The arts have long explored the experience of living with depression and its effects on others. Film, plays, books, and art can provide us with window into the world of a person coping with chronic depression and associated mental health illnesses. A physician can learn much empathy and compassion for these persons thorough these powerful artistic expressions. Film Ordinary People (1980) Director: Robert Redford LINK:  HYPERLINK "http://www.imdb.com/title/tt0081283/" http://www.imdb.com/title/tt0081283/ Pollock (2000) Director: Ed Harris LINK:  HYPERLINK "http://www.imdb.com/title/tt0183659/" http://www.imdb.com/title/tt0183659/ The Snake Pit (1948) Director: Anatole Litvak LINK:  HYPERLINK "http://www.imdb.com/title/tt0040806/" http://www.imdb.com/title/tt0040806/ Sophie's Choice (1982) Director: Alan Pakula LINK:  HYPERLINK "http://www.imdb.com/title/tt0084707/" http://www.imdb.com/title/tt0084707/ Reality Bites (1994) Director: Ben Stiler LINK:  HYPERLINK "http://www.imdb.com/title/tt0110950/" http://www.imdb.com/title/tt0110950/ Wild Strawberries (1957) Director: Ingmar Bergman LINK:  HYPERLINK "http://www.imdb.com/title/tt0050986/" http://www.imdb.com/title/tt0050986/ Plays Monster in A Box (1992) LINK TO VIDEO CLIP FROM BACKPACK FULL OF BRICKS Grays Anatomy (1994) Playwright: Spalding Gray Proof (2001) Playwright:  HYPERLINK "http://en.wikipedia.org/wiki/David_Auburn" \o "David Auburn" David Auburn 4.48 Psychosis (1999) Playwright: Sarah Kane Books The Bell Jar (1963) Author:  HYPERLINK "http://en.wikipedia.org/wiki/Sylvia_Plath" \o "Sylvia Plath" Sylvia Plath The Sorrows of Young Werther (1774) Author:  HYPERLINK "http://en.wikipedia.org/wiki/Johann_Wolfgang_von_Goethe" \o "Johann Wolfgang von Goethe" Johann Wolfgang von Goethe Unholy Ghost: Writers on Depression (2002) Edited by:  HYPERLINK "http://www.harpercollins.com/authors/19447/Nell_Casey/index.aspx" Nell Casey Girl Interrupted (1994) Author: Susanna Kaysen One True Thing (2006) Author: Anna Quindlen Arts On the Threshold of Eternity / At Eternitys Gate / Old Man in Sorrow - Vincent Van Gogh The Scream Edvard Munch Self Portrait Frida KahloXI. ConclusionSummary Depression is one of the most common conditions in primary care, but is often unrecognized, undiagnosed, and untreated. Depression has a high rate of morbidity and mortality when left untreated. Most patients suffering from depression do not complain of feeling depressed, but rather anhedonia or vague unexplained symptoms. All physicians should remain alert to effectively screen for depression in their patients. There are several screening tools for depression that are effective and feasible in primary care settings. An appropriate history, physical, initial basic lab evaluation, and mental status examination can assist the physician in diagnosing the patient with the correct depressive spectrum disorder (including bipolar disorder). Primary care physicians should carefully assess depressed patients for suicide. Depression in the elderly is not part of the normal aging process. Patients who are elderly when they have their first episode of depression have a relatively higher likelihood of developing chronic and recurring depression. The prognosis for recovery is equal in young and old patients, although remission may take longer to achieve in older patients. Elderly patients usually start antidepressants at lower doses than their younger counterparts. Most primary care physician can successfully treat uncomplicated mild or moderate forms of major depression in their settings with careful psychiatric management (e.g., close monitoring of symptoms, side effects, etc.); maintaining a therapeutic alliance with their patient; pharmacotherapy (acute, continuation, and maintenance phases); and / or referral for psychotherapy. The following situations require referral to psychiatrist: suicide risk, bipolar disorder or a manic episode, psychotic symptoms, severe decrease in level of functioning, recurrent depression and chronic depression, depression that is refractory to treatment, cardiac disease that requires tricyclic antidepressants treatment, need for electroconvulsive therapy (ECT), lack of available support system, and any diagnostic or treatment questions. Antidepressant medications effectiveness is generally comparable across classes and within classes of medications. The medications differ in side effect profiles, drug-drug interactions, and cost. The history of a positive response to a particular drug for an individual or a family member, as well as patient preferences, should also be taken into account. Most psychiatrists agree that an SSRI should be the first line choice. The dual action reuptake inhibitors venlafaxine and bupropion are generally regarded as second line agents. Tricyclics and other mixed or dual action inhibitors are third line, and MAOIs (monoamine oxidase inhibitors) are usually medications of last resort for patients who have not responded to other medications, due to their low tolerability, dietary restrictions, and drug-drug interactions. Most primary care physicians would prefer that a psychiatrist manage patients requiring MAOIs. Psychotherapy may be a first line therapy choice for mild depression particularly when associated with psychosocial stress, interpersonal problems, or with concurrent developmental or personality disorders. Psychotherapy in mild to moderate depression is most effective in the acute phase, and in preventing relapse during continuation phase treatment. Psychotherapy is not appropriate alone for severe depression, psychosis, and bipolar disorders. For more severe depression, psychotherapy may be appropriate in combination with the use of medications. The most effective forms of psychotherapy are those with structured and brief approaches such as cognitive behavioral therapy, interpersonal therapy, and certain problem solving therapies. Regardless of the psychotherapy initiated, psychiatric management must be integrated at the same time. Patients, who live with depression, and their family and friends, have enormous challenges to overcome. Primary care physicians can provide compassionate care, important education, psychiatric monitoring, social support, reassurance, and advocacy for these patients and their loved ones. Link To Survey Monkey Feedback and Content QuestionsXII. BibliographyBibliography Ables, A. et al. Antidepressants: Updates on New Agents and Indications Am Fam Physician. 2003; 67:547-54. American Broadcasting Company. Depression: A Backpack Full of Bricks. March 9, 2004. Films For Humanities and Sciences. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, ed 4 text revision, American Association, 2000. Washington DC Birrer, RB, Vemuri SP. Depression in later life: A diagnostic and therapeutic challenge. Am Fam Physician 2004; 69 (10): 2375-2382 Cutler, J. Charon, R. Depression from Primary Care Psychiatry and Behavioral Medicine: Brief Office Treatment and Management Pathways. Edited by RE Feinstein, AA Brewer. Springer Publishing Co., New York, NY. 1999 Dietrich, A., et al. Re-engineering systems for the treatment of depression in primary care: cluster randomized controlled trial. BMJ 2004;329 Gaynes, B., et al. Screening for Suicide Risk in Adults: A Summary of the Evidence for the U.S. Preventive Services Task Force Ann Intern Med. 2004; 140:822-835. Jick SS, Dean AD, Jick H. Antidepressants and suicide. BMJ 1995; 310 (6974): 215-218.) Kahn, David. Mood Disorders. Psychiatry, edited by JL Cutler, ER Marcus. WB Saunders, Philadelphia, PA. 1999 Lewis-Fernandez, R. et al., Depression in US Hispanics: Diagnostic and Management Considerations in Family Practice J Am Board Fam Pract 2005;18: 28296. Mann, JJ., The Medical Management of Depression New England Journal of Medicine. 2005 Oct 27;353(17):1819-34 Morris, Jane, Interpersonal psychotherapy a trainees ABC? in Psychiatric Bulleting (2002), 26, 26-28. National Center for Complementary and Alternative Medicine. St. Johns Wort and the Treatment of Depression. National Center for Complementary and Alternative Medicine Web site. Accessed at http://nccam.nih.gov/health/stjohnswort on June 30, 2005. New York City Department of Health and Mental Hygiene. Detecting and Treating Depression in Adults. City Health Information. 25 (1): 1-8. Nezu, Arthur, et al., Managing Stress through Problem Solving in STRESS NEWS, Vol. 13 No.3, July Oxman, T., et al. A Three-Component Model for Reengineering Systems for the Treatment of Depression in Primary Care. Psychosomatics 2002; 43:441-450. Reid, Cary M., Ph.D., M.D., Determining the Feasibility of a Cognitive-Behavioral Therapy for the Treatment of Co-Occurring Chronic Back Pain and Depression Among Persons Ages 60 Years and Above Aetna INteliHealth: Depression July 12, 2005 (www.intelihealth.com) Remick, R. Diagnosis and management of depression in primary care: a clinical update and review. CMAJ 2002;167(11):1253-60 Rost. K., et al. Managing Depression as a Chronic Disease; a randomized trial of ongoing treatment in primary care. BMJ October 2002; 325 Rupke, Stuart, et al., Cognitive Therapy for Depression Am Fam Physician, 2006: 73, 83-86 Sharp, LK, Lipsky MS. Screening for depression across the lifespan: a review of measures for use in primary care settings. American Family Physician. 2002; 66: 1001-1008 Shearer, S., et al. Excessive Worry. Am Fam Physician 2006;73:1049-56, 1057-8. Shelton RC, Keller M, Gelenberg A, et al. Effectiveness of St. Johns wort in major depression: a randomized controlled trial. JAMA. 2001 (15);285: 1978-1986 Simon GE., How can we know whether antidepressants increase suicide risk? Am J Psychiatry 163:1861-1863, 2006. The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Vol. 1 Cambridge, Mass.: Harvard University Press, 1996. Thimbault, J., et al. Efficient Identification of Adults with Depression and Dementia. Am Fam Physician 2004;70:1101-10. UK ECT Review Group, Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. Lancet 2003; 361: 799-808. United States Preventive Screening Task Force. Screening for depression: Recommendations and rationale. November 2006 Recommendations.  HYPERLINK "http://epss.ahrq.gov/PDA/index.jsp" http://epss.ahrq.gov/PDA/index.jsp Ward, R. Zamorski, M. Benefits and Risks of Psychiatric Medications in Pregnancy Am Fam Physician. 2002;66:629-36,639. Working Group on Major Depressive Disorders. Practice Guidelines for the Treatment of Patients With Major Depressive Disorder. American Psychiatric Association. 2000. Washington D.C.Credits Written and Created by Pablo Joo MD Center for Family Medicine New York Presbyterian / Columbia University College of Physicians and Surgeons Director of Predoctoral Education Contributing Writer: Psychotherapeutic Management of Depression segment Cathie Vourkas, ACSW Behavioral Scientist, Center for Family Medicine New York Presbyterian / Family Medicine Residency Program Contributing Writer: First line choices of antidepressant drugs segment Janis Cutler, MD, Dept. of Psychiatry New York Presbyterian / Columbia University College of Physicians and Surgeons Creative Direction and Production Michelle V. Hall Columbia Center for New Media, Teaching and Learning Columbia University Medical Education Curriculum and Research Contributor Sharon K. Krackov, Ed.D Center for Education Research and Evaluation Columbia University Medical Center Contributing Editors Janis Cutler, MD, Dept. of Psychiatry New York Presbyterian / Columbia University College of Physicians and Surgeons Edgar Figueroa MD, MPH, Family Medicine Director of Student Health Services Weill Medical College of Cornell University Columbia P&S Primary Care Clerkship Co-Directors Primary Care Clerkship Co-directors Rebecca Kurth MD Department of Medicine Pablo Joo MD Center for Family Medicine New York Presbyterian / Columbia University College of Physicians and Surgeons This Columbia P&S Primary Care Clerkship Web Education Module was made possible by a generous grant the Columbia University Primary Care Education and Research Gift Fund.     Page  PAGE 1 of  NUMPAGES 50 YES Dysthymic disorder If NO, Has the depressed mood or anhedonia and milder associated symptoms been present for at least 2 years? NO Depressive disorder not otherwise specified or no disorder YES Adjustment disorder with depressed mood If NO, Are the symptoms due to a stressor? NO Major depressive disorder YES Bereavement If YES, Are they best explained by bereavement? If YES, Are associated symptoms present? Is the depressed mood or anhedonia present for at least 2 weeks? NO YES Substance-induced disorder Is a substance directly responsible for the symptoms? 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