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The Diagnosis and Treatment of Depress gela Heithaus, MD attle Healing Arts nuary 3, 2007
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Page 1: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,

The Diagnosis and Treatment of Depression

Angela Heithaus, MDSeattle Healing ArtsJanuary 3, 2007

Page 2: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,

Depressive DisorderDepressive Disorder Illness that involves the body, mood and Illness that involves the body, mood and

thoughtthought Can affect eating, sleeping, thoughts about self Can affect eating, sleeping, thoughts about self

and thoughts about other thingsand thoughts about other things Without treatment, symptoms can last for Without treatment, symptoms can last for

weeks, months, or yearsweeks, months, or years 3 most common types3 most common types

Major depressionMajor depression DysthymiaDysthymia Bipolar disorderBipolar disorder

? inheritance? inheritance

Page 3: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,

EpidemiologyEpidemiology 4th leading cause of worldwide disese in 1990, 4th leading cause of worldwide disese in 1990,

causing more disability than either ischemic causing more disability than either ischemic heart disease or cerebrovascular disease heart disease or cerebrovascular disease

Prevalence of Major Depressive Disorder (MDD) Prevalence of Major Depressive Disorder (MDD) in Western industrialized nations isin Western industrialized nations is 2.3-3.2 % males2.3-3.2 % males 4.5-9.3 % females4.5-9.3 % females

Lifetime riskLifetime risk 7-12 % males7-12 % males 20-25 % females20-25 % females

Page 4: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,

Major Depression US Major Depression US Impact on EconomyImpact on Economy

Lost productivity cost employers Lost productivity cost employers > $ 31 billion > $ 31 billion Most loss due to reduced performance Most loss due to reduced performance

while at workwhile at work

Page 5: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,

Risk FactorsRisk Factors

Increased riskIncreased risk female, native american, middle-aged, female, native american, middle-aged,

widowed, separated or divorced, low widowed, separated or divorced, low incomeincome

Decreased riskDecreased risk asian, hispanic or blackasian, hispanic or black

Page 6: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,

Other Risk FactorsOther Risk Factors

History of depressive illness in first History of depressive illness in first degree relativesdegree relatives

Prior episodes of major depressionPrior episodes of major depression Significant association with other Significant association with other

specific psychiatric d/o such as: specific psychiatric d/o such as: substance dependence, panic and substance dependence, panic and generalized anxiety d/o and generalized anxiety d/o and personality d/opersonality d/o

Page 7: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,

PrecipitantsPrecipitants

Psychosocial stressorsPsychosocial stressors Adverse living conditions, war, environmental Adverse living conditions, war, environmental

changeschanges

BereavementBereavement Loss of a loved oneLoss of a loved one

LossLoss Housing, relationships, healthHousing, relationships, health

Page 8: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,

Meds/SupplementsMeds/Supplements

CorticosteroidsCorticosteroids Many patients experience a sense of well-Many patients experience a sense of well-

beingbeing Larger doses can cause hypomanic and/or Larger doses can cause hypomanic and/or

depressive symptomsdepressive symptoms

Omega 3 fatty acidsOmega 3 fatty acids Low levels correlate with depressive Low levels correlate with depressive

symptomssymptoms

Page 9: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,
Page 10: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,

Medical Conditions Associated Medical Conditions Associated with Depressionwith Depression

HypothyroidismHypothyroidism FibromyalgiaFibromyalgia Systemic lupus erythematosusSystemic lupus erythematosus Diabetes mellitusDiabetes mellitus Cardiovascular diseaseCardiovascular disease Chronic painChronic pain OthersOthers

Hypercalcemia, sjogren’s syndrome, seizure d/oHypercalcemia, sjogren’s syndrome, seizure d/o

Page 11: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,

Depression vs Other Medical Depression vs Other Medical ConditionsConditions

Ask closed-ended questions about the nine Ask closed-ended questions about the nine diagnostic criteria for depressiondiagnostic criteria for depression

Ask about alcohol and substance abuse and the Ask about alcohol and substance abuse and the use of other medicationsuse of other medications

Conduct a medical review of systems that may Conduct a medical review of systems that may elicit the presence of medical disorders (TSH, elicit the presence of medical disorders (TSH, electrolytes, folate, vitamin B12, ECG)electrolytes, folate, vitamin B12, ECG)

Ask about other psychiatric conditions such as Ask about other psychiatric conditions such as anxiety disorderanxiety disorder

Exclude alternative causes for depressive Exclude alternative causes for depressive symptoms or syndromes to diagnose a primary symptoms or syndromes to diagnose a primary mood disordermood disorder

Page 12: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,

Primary Care SettingPrimary Care Setting

10-40% of patients have significant depressive 10-40% of patients have significant depressive symptomssymptoms

5-10 % of patients meet criteria for DSM-IV MDD5-10 % of patients meet criteria for DSM-IV MDD 10% of patients meet criteria for minor 10% of patients meet criteria for minor

depressiondepression 3-5 % of patients meet criteria for dysthymic 3-5 % of patients meet criteria for dysthymic

disorderdisorder

Approximately 50% of depressed patients Approximately 50% of depressed patients present with somatic complaintspresent with somatic complaints

Page 13: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,

Male vs FemaleMale vs Female

MenMen Less likely to admit depressive symptomsLess likely to admit depressive symptoms Practitioners less likely to suspectPractitioners less likely to suspect Rate of suicide four times that of womenRate of suicide four times that of women Depression often masked by alcohol, drugs, long Depression often masked by alcohol, drugs, long

work hourswork hours Symptoms more likely to involve irritability, anger, Symptoms more likely to involve irritability, anger,

discouragement discouragement women women

More attempts at suicideMore attempts at suicide Symptoms more likely to involve hopelessness, Symptoms more likely to involve hopelessness,

helplessnesshelplessness

Page 14: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,
Page 15: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,

ScreeningScreening

The U.S. Preventive Services Task Force The U.S. Preventive Services Task Force (USPSTF) recommends screening adults (USPSTF) recommends screening adults for depression in clinical practices that for depression in clinical practices that have systems in place to assure accurate have systems in place to assure accurate diagnosis, effective treatment, and follow diagnosis, effective treatment, and follow upup

Page 16: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,

Clinical ConsiderationsClinical Considerations

Screening toolsScreening tools Zung self assessment depression scale, Beck Zung self assessment depression scale, Beck

depression inventory, General Health depression inventory, General Health QuestionnaireQuestionnaire

Or 2 simple questionsOr 2 simple questions

over the past two weeks have you felt down, over the past two weeks have you felt down, depressed or hopeless?depressed or hopeless?

over the past two weeks have you felt little over the past two weeks have you felt little pleasure and interest in doing things?pleasure and interest in doing things?

Page 17: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,

PHQ-9 QuestionnairePHQ-9 Questionnaire

Page 18: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,

DSM-IV Criteria (SIG E CAPS)DSM-IV Criteria (SIG E CAPS) Major depression-5 or more symptoms present Major depression-5 or more symptoms present

during same 2 week periodduring same 2 week period Depressed mood most of the dayDepressed mood most of the day Diminished interest and pleasure in all or almost all Diminished interest and pleasure in all or almost all

activitiesactivities Decrease or increase in weight and/or appetiteDecrease or increase in weight and/or appetite Diminished ability to think, indecisivenessDiminished ability to think, indecisiveness Insomnia or hypersomniaInsomnia or hypersomnia Psychomotor agitation or retardationPsychomotor agitation or retardation Fatigue or loss of energy nearly dailyFatigue or loss of energy nearly daily Feelings of worthlessness or excessive or inappropriate Feelings of worthlessness or excessive or inappropriate

guiltguilt Recurrent thoughts of death (not just fear of Recurrent thoughts of death (not just fear of

dying),recurrent suicidal ideation without specific plandying),recurrent suicidal ideation without specific plan

Page 19: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,

Dysthymic Disorder-CriteriaDysthymic Disorder-Criteria

Depressed modd for most of the day, for more Depressed modd for most of the day, for more days than not, for at least 2 yearsdays than not, for at least 2 years

Presence, while depressed, of two (or more)Presence, while depressed, of two (or more) Poor appetite or overeatingPoor appetite or overeating Insomnia or hypersomniaInsomnia or hypersomnia Low energy or fatigueLow energy or fatigue Low self-esteemLow self-esteem Poor concentration or indecisivenessPoor concentration or indecisiveness Feelings of hopelessnessFeelings of hopelessness

During 2 year period, never been without the first During 2 year period, never been without the first two criteria for more than 2 months at a timetwo criteria for more than 2 months at a time

Page 20: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,
Page 21: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,

Assessing Suicidal RiskAssessing Suicidal Risk

Suicide is 11Suicide is 11thth leading cause of death in US leading cause of death in US (2000)(2000)

Depression is one of most common psychiatric Depression is one of most common psychiatric disorders associated with suicidedisorders associated with suicide

Evaluation of patient includes assessment of Evaluation of patient includes assessment of ideation, plan and intentideation, plan and intent

Risk of suicide imminent in those who have an Risk of suicide imminent in those who have an active plan or intent to harm themselves and active plan or intent to harm themselves and have a lethal means that is readily assessablehave a lethal means that is readily assessable

Page 22: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,

Discussing DiagnosisDiscussing Diagnosis

Depression is commonDepression is common Depression increases perception and Depression increases perception and

impact of physical symptoms such as impact of physical symptoms such as fatigue, headache, and abdominal painfatigue, headache, and abdominal pain

Depression is a physical illness, which is Depression is a physical illness, which is associated with biologic changes in the associated with biologic changes in the brain (depletion of catecholamines)brain (depletion of catecholamines)

Treatment of depression with medication Treatment of depression with medication and/or psychotherapy can shorten durationand/or psychotherapy can shorten duration

Page 23: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,

PharmacotherapyPharmacotherapyvs Psychotherapyvs Psychotherapy

Drug tx alone for severely depressedDrug tx alone for severely depressed Either drug tx or psychotherapy equally Either drug tx or psychotherapy equally

effective for moderate to mild depressioneffective for moderate to mild depression New public health model of telephone New public health model of telephone

psycotherapy and care management + psycotherapy and care management + drug txdrug tx

Page 24: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,

AntidepressantsAntidepressants

Meta-analysis of 28 randomized, Meta-analysis of 28 randomized, controlled trials involving 5940 patients controlled trials involving 5940 patients with major depression, dysthymic, or with major depression, dysthymic, or mixed anxiety depression, newer mixed anxiety depression, newer antidepressants were significantly more antidepressants were significantly more effective than placebo but similar to TCeffective than placebo but similar to TC

Page 25: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,

Bush using drugs to control depression and erratic behaviorBush using drugs to control depression and erratic behavior

Page 26: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,

Classes of AntidepressantsClasses of Antidepressants

MAO inhibitorsMAO inhibitors Tranylcypromine, phenelzine, selegilineTranylcypromine, phenelzine, selegiline

Heterocyclics/TCHeterocyclics/TC Desipramine, nortriptyline, imipramine, amitriptylintDesipramine, nortriptyline, imipramine, amitriptylint

SSRIsSSRIs Fluoxetine, sertraline, paroxetine, citalopram, Fluoxetine, sertraline, paroxetine, citalopram,

escitalopramescitalopram OthersOthers

Bupropion, venlafaxine, duloxetine, trazodone, Bupropion, venlafaxine, duloxetine, trazodone, mirtazapinemirtazapine

Page 27: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,

Mechanisms of ActionMechanisms of Action MAO inhibitorsMAO inhibitors

Irreversibly blocking monoamine oxidase responsible for the Irreversibly blocking monoamine oxidase responsible for the oxidative deamination of serotonin, norepinephrine and dopamineoxidative deamination of serotonin, norepinephrine and dopamine

Heterocyclics/TCsHeterocyclics/TCs Increase concentration of serotonin and/or norepinephrine by Increase concentration of serotonin and/or norepinephrine by

inhibiting reuptakeinhibiting reuptake SSRIsSSRIs

Increase concentration of serotoninIncrease concentration of serotonin OthersOthers

Buproprion enhances dopamine levels especially in ‘reward’ area Buproprion enhances dopamine levels especially in ‘reward’ area of the brainof the brain

Venlafaxine increases serotonin levels, inhibits norepinephrine Venlafaxine increases serotonin levels, inhibits norepinephrine reuptakereuptake

Page 28: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,

ConsiderationsConsiderations

Prior success of an antidepressant Prior success of an antidepressant A positive response to a particular A positive response to a particular

antidepressant by a first degree relativeantidepressant by a first degree relative Practitioner drug familiarity and drug side Practitioner drug familiarity and drug side

effectseffects

Page 29: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,

Major Side EffectsMajor Side Effects MAO inhibitorsMAO inhibitors

Can cause increased sympathic activity and severe hypertension Can cause increased sympathic activity and severe hypertension with concomitant ingestion of tyramine containing foodswith concomitant ingestion of tyramine containing foods Fermented cheeses, imported beer, Chianti, soy sauce, avocados, Fermented cheeses, imported beer, Chianti, soy sauce, avocados,

bananasbananas TCsTCs

Anticholinergic effects such as: dry mouth, blurred vision, Anticholinergic effects such as: dry mouth, blurred vision, constipation, urinary retentionconstipation, urinary retention

Similar to Class 1A antiarrhythmics, which can prolong QT interval Similar to Class 1A antiarrhythmics, which can prolong QT interval and increase risk of sudden cardiac deathand increase risk of sudden cardiac death

Weight gain Weight gain SSRIsSSRIs

Jitteriness, restlessness, agitation, headache, diarrhea, nausea, Jitteriness, restlessness, agitation, headache, diarrhea, nausea, insomnia, sexual dysfunction, weight gaininsomnia, sexual dysfunction, weight gain

OthersOthers Mirtazapine: sedation, weight gainMirtazapine: sedation, weight gain Bupropion: fewer adverse effects related to sexual dysfunction Bupropion: fewer adverse effects related to sexual dysfunction

and weightand weight

Page 30: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,
Page 31: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,
Page 32: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,
Page 33: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,

Timing of Response Timing of Response and Follow-upand Follow-up

Initial response usually within 2-6 weeksInitial response usually within 2-6 weeks Treatment time to maximal response Treatment time to maximal response

may be longermay be longer If no response by 8-12 weeks at a If no response by 8-12 weeks at a

maximum therapeutic dose, consider maximum therapeutic dose, consider another antidepressant from same or another antidepressant from same or different class or referdifferent class or refer

Follow-up at least q 1-2 weeks during Follow-up at least q 1-2 weeks during initial phaseinitial phase

Page 34: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,

Duration of TreatmentDuration of Treatment

6-9 months after first episode6-9 months after first episode If there is an unresolved known precipitant such If there is an unresolved known precipitant such

as: psychosocial stress, bereavement, or loss as: psychosocial stress, bereavement, or loss consider further treatmentconsider further treatment

When tx discontinued, taper over 2-4 weeksWhen tx discontinued, taper over 2-4 weeks AHCPR Guideline Panel recommendation of AHCPR Guideline Panel recommendation of

maintenance therapy for patients withmaintenance therapy for patients with 3 or more depressive episodes3 or more depressive episodes 2 previous episodes plus risk factors2 previous episodes plus risk factors Double depression (dysthymia and major depression)Double depression (dysthymia and major depression)

Page 35: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,

Response to MedicationResponse to Medication

50% of patients respond to the first choice50% of patients respond to the first choice

20% stop due to side effects20% stop due to side effects

30% have no response30% have no response

Page 36: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,
Page 37: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,

Hypericum PerforatumHypericum Perforatum

St John’s WortSt John’s Wort European studies suggest more effective than European studies suggest more effective than

placebo and equal to TC and SSRIs in short-placebo and equal to TC and SSRIs in short-term txterm tx

US studies do not support efficacy in tx of US studies do not support efficacy in tx of severe depressionsevere depression

Consider for mild acute depressionConsider for mild acute depression Avoid concomitnt use with SSRIAvoid concomitnt use with SSRI

Page 38: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,
Page 39: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,
Page 40: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,

National Library of Medicine       (National Library of Medicine       (www.nlm.nih.gov/medlineplus/healthtopics.htmlwww.nlm.nih.gov/medlineplus/healthtopics.html)) National Institute of Mental Health      (National Institute of Mental Health      (www.nimh.nih.govwww.nimh.nih.gov ) )

American Psychiatric Association      (American Psychiatric Association      (www.psych.orgwww.psych.org ) )

American Psychological Association      (American Psychological Association      (www.apa.orgwww.apa.org)) American Academy of Child and Adolescent Psychiatry      (American Academy of Child and Adolescent Psychiatry      (www.aacap.orgwww.aacap.org)) Depression and Related Affective Disorders Association      (Depression and Related Affective Disorders Association      (www.drada.orgwww.drada.org ) )

Depression and Bipolar Support Alliance (DBSA)      (Depression and Bipolar Support Alliance (DBSA)      (www.DBSAlliance.orgwww.DBSAlliance.org ) )

National Foundation For Depressive Illness      (National Foundation For Depressive Illness      (www.depression.orgwww.depression.org)) National Mental Health Association      (National Mental Health Association      (www.nmha.orgwww.nmha.org ) )

National Alliance for the Mentally Ill      (National Alliance for the Mentally Ill      (www.nami.orgwww.nami.org) )

ResourcesResources

Page 41: The Diagnosis and Treatment of Depression Angela Heithaus, MD Seattle Healing Arts January 3, 2007 Angela Heithaus, MD Seattle Healing Arts January 3,

THANK-YOU FOR YOUR ATTENTION!


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