Disability of depressed workers – how to recognize, treat and prevent depression

in OHS

Teija Honkonen

MD, Psychiatrist, FIOH

14.1.2004

The term 'Depression' may refer to

• Affect

• Symptom

• Syndrome (disorder)

Essential in the recognition of depressive disorders in OHS

• Syndromatic approach

• Longitudinal information and follow-up

• Differential diagnostic reassessments

• Assessment of co-morbidity

Depressive disorders / syndromes

• Major depression– unipolar depression– bipolar disorder

• Dysthymic disorder• Recurrent non-major depressive syndromes

– seasonal affective disorder– premenstrual dysphoric disorder

• Cyclothymic disorder• Adjustment disorder with depressed mood• Organic mood disorders

Diagnostic criteria for Major Depressive Disorder (ICD 10: F32-33)

• The following symptoms have been present during the same 2-week period:

• A) at least two of the following

– depressed mood most of the day, nearly every day

– markedly diminished interest or pleasure in almost all activities

– fatigue or loss of energy nearly every day

Diagnostic criteria for Major Depressive Episode (ICD 10: F32-33)

• B) in addition, some of the following symptoms (altogether at least 4/10 symptoms)

– feelings of worthlessness or diminished self-esteem

– feelings of excessive or inappropriate guilt

– diminished ability to think or concentrate, or indeciveness

– recurrent thought of death or suicidal ideation

– insomnia or hypersomnia

– decrease/increase in appetite

– psychomotor agitation or retardation

Severity of depression

• Mild depression: at least 4 symptoms

• Moderate depression: at least 6 symptoms

• Severe depression: at least 8 symptoms

• Psychotic depression

• Diminished functional capacity correlates usually with the severity of depression

Psychotic major depression (ICD 10- F32-33.3)

• About 10-15% of depressive episodes are psychotic

• Often boundary between non-psychotic and psychotic depression is not clear

• Symptoms:

– delusions (including deep hopelessness)

– hallucinations

– often major changes in psychomotoric functioning

Diagnostic Criteria for Dysthymic Disorder (ICD 10: F34.1)

• Depressive or irritabile mood for at least 2 years

• In addition, at least 3/11 of the following symptoms

– diminished energy, insomnia, diminished self-esteem, poor concentration, tearfulness, diminished interest on pleasure, hopelessness, feelings of incapacity, pessimism, social withdrawal or diminished talkativeness

Diagnostic criteria for Adjustment Disorder with depressed mood

(ICD-10: F43.2)

• Symptoms in response to an identifiable stressor occurring within a month of the onset of the stressor

• The disturbance does not meet the criteria for another specific mental disorder

• Once the stressor has terminated, the symptoms do not persist for more than an additional 6 months

Important symptoms associated with depressive disorders

• Anxiety

• Physical symptoms

• Fear of illness, hypochondriasis

Co-morbidity

• Psychiatric co-morbidity– concurrent mental disorders / syndromes

• Somatopsychiatric co-morbidity– concurrent mental disorder and somatic illness

Co-morbidity of depression

• Psychiatric co-morbidity– anxiety disorders 40-60%– personality disorders 40-50%– substance abuse 20-40%

• Somatopsychiatric co-morbidity– among elderly patients up to 90%

Depression and functional disability

• WHO's Global Burden of Disease study:

– Unipolar major depression is the fourth most important illness in terms of functional disability

– The role of depression is expected to become even more important by the year 2020

Murray & Lopez 1997

Quality of life and functioning of depressed primary care patients

• Primary care patients with depressive conditions have poorer mental, role-emotional, and social functioning than patients with common chronic medical conditions

• Depressed patients have worse physical functioning than patients with asthma, hypertension, gastrointestinal tract

problems, or migraines

Wells et al. 1999

Disability pensions due to depression in Finland

• In Finland, about 40 % of the disability pensions are granted due to mental disorders

• Depression is now among the most common causes of disability pensions

Causes of increase in disability pensions due to depression

• Changes in illness behaviour in population ?

• Increase in incidence of depression ?

• Changes in diagnostics ?

• Changes in treatment methods ?

• Increased demands of work ?

Health 2000 Survey:The prevalence of major depression

• In Finland, within the last 12 months– a diagnosis of major depressive disorder was

found among 4.9 % of the subjects – major depression was more common among

females than males• The prevalence of depression has not increased

during the last 20 yearsPirkola et al. 2002

Depression and cognitive symptoms

• Depression causes – diminished ability to think or concentrate – diminished ability to learn or remember – decreased motivation to undertake new tasks– difficulty in finishing tasks – reduced energy– indecisiveness– slowness of psychomotor performances

Need for sick-leave in depression

• Individual case-specific assessment

• Even in case of a severely depressed patient work may have positive impact in preventing patient from social withdrawal

Early recognition and treatment of depression is important, because

• 75-80% (90%) of depressed patients will benefit from adequate treatment

• Effective and early treatment may prevent unnecessary suffering, disability and suicides

Treatment of depression includes

• Comprehensive evaluation of the patient– diagnosis– comorbidity– suicidality– psychosocial functioning– current life events– social support– socio-economic situation

• Well-planned treatment• Prevention of the recurrences

Why is it not always easy to diagnose depression ?

• Patient

– may not talk about it, because he/she is not able to recognize his/her own state of mood

– may be unwilling to discuss it due to fear of potential negative consequences

Why is it not always easy to diagnose depression ?

• Physician– is not able to recognize depression

– is able to recognize it but he/ she has not enough time for that

– does not want to recognize it because he/ she thinks it is untreatable

Methods of measuring depression

• Semi-structured interviews

– Schedules for Clinical Assessment in Neuropsychiatry (SCAN)

• Fully structured interviews

– Composite International Diagnostic Interview (CIDI)

• Rating scales

– Hamilton Rating Scales for Depression (HAMD)

– Montgomery-Åsberg Depression Rating Scale (MADRS)

• Self-administered questionnares

– Beck Depression Inventory (BDI)

Main treatment methods of depression in OHS

• Psychotherapy

– mild – moderate depression

• Antidepressant medication

– moderate – severe depression

• Psychotherapy and medication have a synergistic effect

Other treatment options of depression

• Bright light treatment– effective in treatment and prevention of seasonal affective disorder

• Physical exercise– effective as additional treatment of mild-moderate depression

• Sleep deprivation– duration of efficiency unknown; not widely used in Finland

• Electroconvulsive treatment (ECT)– most effective treatment for severe depression

• Transcranial magnetic stimulation (TMS)– promising future treatment, efficiency not yet known

Selective serotonin reuptake inhibitors (SSRIs)

• 70-80% of patients respond to treatment if indication of medication is correct

• SSRIs are usually safe in overdose and in terms of interaction

• As a side-effect, in the beginning of treatment SSRIs may cause nausea and sometimes increased anxiety; about 30% may also suffer from sexual dysfunction

Antidepressant medication

• Medication without any psychotherapeutic physician-patient relationship is not adeqaute treatment

• Not prescriping antidepressant medication may also be inadequate treatment

• All patients do not benefit from medication

• Antidepressant medication does not cause addiction

Common problems with medication in OHS

• Lack of systematic follow-up of treatment response and side-effects

– problems with compliance

– no optimal treatment

• Acceptance of partial remission leading into

– recurrent depressions

– difficulties in decreasing disability

• Continuation of inefficient medication

• Lack of sequential medication trials

Depression and disability

• The severity of depression is the most important factor affecting the disability

• Symptoms of depression improve more rapidly than functional disability caused by depression

Psychosocial disability during long-term course of MDD

• Psychosocial functioning during an average of 10 years’ follow-up of 371 patients with MDD was assessed

• Disability is pervasive and chronic but disappears when patients become asymptomatic

• As long as any level of depressive symptoms and disability are present effective and continued treatment is necessary

• Treatment to full recovery should be the goal

Judd et al. 2000

Risk for recurrency of depression

• After one episode 50%

• After two episodes 70%

• After three episodes > 90%

• Long-term prophylactic treatment with antidepressant medication

Psychotherapy in depression

• Supportive treatment

– listening, understanding, offering practical advice and help, psychoeducation, maintaining hope

• Specific short psychotherapies

– cognitive

– interpersonal (IPT)

– problem focused

– psychodynamic

Interpersonal psychotherapy, IPT

• Time-limited – 12-16 sessions– three phases

• Manualized• Active• Demonstrated efficacy

Markowitz 2000

Characteristics of IPT

• 'Here and now' focus• Non-neutral, active therapist• Affective engagement on one of 4 problem areas:

– grief– role dispute– role transition– interpersonal deficits

• Exploration of options• Socialization and activity

Markowitz 2000

Initial sessions (1-3)

• Diagnosing the depression• Eliciting the interpersonal inventory• Establishing the interpersonal problem area• Giving the patient the 'sick role’• Making the interpersonal formulation• Beginning psychoeducation • Instilling hope

Markowitz 2000

Middle sessions (4-12)

• Focus on one or more of the four problem areas– grief (complicated bereavement)– role dispute– role transition– interpersonal deficits

Markowitz 2000

Termination sessions (13-16)

• Assessment of gains• Prevention of relapse• Graduation• Addressing non-response• Continuation / booster sessions ?

Markowitz 2000

Training primary-care physicians to recognize and manage depression

• In Netherlands, a 20- hour training programme was developed, that sought to improve primary care physicians' ability to detect and manage depression

• 17 physicians participated in the study

• Training physicians can improve short-term patient outcomes, especially for patients with a recent onset of depression

Tiemens et al. 1999

Impact of improved depression treatment in primary care on daily functioning

• MDD- patients were randomly assigned to usual care or to a collaborative management programme

• More effective acute-phase depression treatment reduced somatic distress and improved self-rated overall health at 4 and 7 month

• There was no significant intervention effect on other disability measures

Simon et al 1998

Factors predicting chronic outcome of depression

• Duration of depressive episode before beginning of treatment

• Severity of depression

• Some personality traits

• Poor social support

• Negative life events during depression

• Co-morbidity (substance abuse, somatic illness)

• Inadequate treatment

Inadequate treatment and disability pension

• In Finland, patients who were pensioned during 1993-1994 due to depression:

• 87% had used antidepressants– 2/3 had received antidepressants at adequate dose

– about 60% had received only one antidepressant before disability pension was granted

• Weekly psychotherapy was rare (9%)• Electro-convulsive therapy was rare (4%)

Isometsä et al 2001

Primary prevention of depression?

• Crisis interventions

• Prevention of burnout

• Physical exercise

• Social support

• Preventive treatment of seasonal affective disorder

Secondary and tertiary prevention of depression

• Sofar, the majority of subjects with major depression suffer from a chronic illness with either fluctuating or chronic course

• Early recognition and early, active treatment would constitute the best secondary and tertiary prevention of depression