Depression in Primary Care: Mourning and Melancholia Descartes Li, - PDF document

Depression in Primary Care: Mourning and Melancholia Descartes Li, M.D. Clinical Professor University of California, San Francisco descartes.li@ucsf.edu By Max Halberstadt - http://politiken.dk/kultur/boger/faglitteratur_boger/ECE1851485/psykoanalysen-har-stadig-noget- at-sige-i-noejagtigt-betitlet-bog/, Public Domain, https://commons.wikimedia.org/w/index.php?curid=5234443 Disclosure I have no relevant financial relationships with any companies related to the content of this course. Descartes Li, MD 1

Outline • Introduction and Epidemiology • “Normal sadness” • Trap of Meaning • Antidepressant controversy and Placebos • Stepped pharmacotherapy of depression (STAR*D) • Exercise, Light Therapy, Bibliotherapy Outline • Introduction and Epidemiology • “Normal sadness” • Trap of Meaning • Antidepressant controversy and Placebos • Stepped pharmacotherapy of depression (STAR*D) • Exercise 2

Prevalence in U.S.: 1 year = 6.6% (13.1-14.2 million) Lifetime = 16.2% (32.6 – 35.1 million) Face-to-face household survey, n = 9090 Kessler, RC et al. The Epidemiology of Major Depressive Disorder: Results From the National Comorbidity Survey Replication (NCS-R). JAMA. 2003;289:3095-3105. Prevalence of Psychiatric Disorders* Disorder Lifetime prevalence(%) Any mood disorder 19.54 Major depression 16.54 Dysthymia 4.30 Bipolar I 3.31 Bipolar II 2.33 Any anxiety disorder 16.16 Social anxiety 4.97 Any drug use disorder 10.33 *Conway KP et al. Lifetime Comorbidity of DSM-IV Mood and Anxiety Disorders and Specific Drug Use Disorders: Results of the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry 2006;67:247-257. 3

The prevalence of MDD: 4.4% in both 1990 (4.2 – 4.7%) and 2010 (4.1 – 4.7%). Challenging the myth of an "epidemic" of common mental disorders: trends in the global prevalence of anxiety and depression between 1990 and 2010. https://www.ncbi.nlm.nih.gov/pubmed/24448889 4

Outline • Introduction and Epidemiology • “Normal sadness” • Trap of Meaning • Antidepressant controversy and Placebos • Stepped pharmacotherapy of depression (STAR*D) • Exercise Case Vignette A: 72yo man is depressed in the context of the death of his wife. How long would you wait before diagnosing Major Depressive Disorder? Assume he meets DSM-5 criteria for a Major Depressive Episode a) Two weeks b) One month c) Two months d) Six months e) One year or more 5

Case Vignette A: 72yo man is depressed in the context of the death of his wife. How long would you wait before diagnosing Major Depressive Disorder? Assume he meets DSM-5 criteria for a Major Depressive Episode a) Two weeks b) One month c) Two months d) Six months e) One year or more Mourning and Melancholia Outwardly can look the same Melancholia: • No conscious object loss • Loss of self-regard, but not ashamed • Difficulty with nourishment, digesting • Difficulty with sleeping 6

“Normal Sadness” Per Horvitz and Wakefield, 3 criteria: 1. Has an environmental trigger 2. Roughly proportionate in intensity to loss 3. Ends when loss situation ends Horwitz AV, Wakefield JC. The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder. New York, NY:Oxford University Press; 2007. (p.16) Problems with “normal sadness” 1. What constitutes a trigger? 2. When is the response proportionate to the loss? 3. Does the presence of a recent major loss somehow make it more likely that depression will spontaneously resolve? 7

Resilience to Spousal Loss New York Times online Accessed October 8, 2016 http://nyti.ms/2cPiePQ “…resilience in the face of spousal bereavement is less common than previously thought” -Only 8% showed resilience across all five indicators of life satisfaction and general health functioning Infurna FJ and Luthar SS. Resilience to Major Life Stressors Is Not as Common as Thought. Persp Psychol Sci. 2016 Mar;11(2):175-94. doi: 10.1177/1745691615621271. Depression vs. Grief Individuals who fulfill MDD criteria after loss of significant other have NOT been shown to recover at a greater rate than MDD alone 8

What the DSM-5 says about bereavement Grief is still exists, but depressive episodes must be diagnosed independently of loss Grief and MDD are different and therefore they should be distinguished separately http://www.dsm5.org/Documents/Bereavement%20Exclusion %20Fact%20Sheet.pdf Depression vs. Grief 9

Case Vignette A: 72yo man is depressed in the context of the death of his wife. How long would you wait before diagnosing Major Depressive Disorder? Assume he meets DSM-5 criteria for a Major Depressive Episode a) Two weeks b) One month c) Two months d) Six months e) One year or more Case Vignette A: 72yo man is depressed in the context of the death of his wife. How long would you wait before diagnosing Major Depressive Disorder? Assume he meets DSM-5 criteria for a Major Depressive Episode a) Two weeks b) One month c) Two months d) Six months e) One year or more 10

Outline • Introduction and Epidemiology • “Normal sadness” • Trap of Meaning • Antidepressant controversy and Placebos • Stepped pharmacotherapy of depression (STAR*D) • Exercise Case vignette B 28yo man, recently married 6m ago, appears well, but quickly breaks down: He says he’s made a terrible mistake for imposing himself on his wife. “I’m a terrible person who cheated on my wife and on my taxes.” He reports two months of depressed mood, crying spells, as well as oversleeping and not being able to get out of bed. In addition, his energy has been low, he has no appetite, and he can’t focus at work. http://commons.wikimedia.org/wiki/File:Portrait-as-an-artist-as-a-young-man.jpg Would you diagnose him with Major Depressive Disorder? Would you prescribe an antidepressant? 11

Case vignette “I cheated on my wife and on my taxes.” Do we accept his reasons as the causes of his depression? Even when confronted with an intuitively plausible set of reasons, we must look for objective causes. http://commons.wikimedia.org/wiki/File:Portrait-as-an-artist-as-a-young-man.jpg Reason vs. Cause What the difference? Reason : (noun) Cause : (noun) ( 1 ) Motive or justification for ( 1 ) That which produces an something effect, thing, event, person, etc …make something happen “Give me the reason for your going.” What was the cause of the fire? “He has adequate reason for Smoking is one of the causes of doing so.” heart disease. 12

The Trap of Meaning “Finding an explanation that appears meaningful and adopting it as causal.” Lyketsos CG, Chisolm MS. The trap of meaning: a public health tragedy. JAMA. 2009 Jul 22;302(4):432-3. doi: 10.1001/jama.2009.1059. The Trap of Meaning Related to the Chanticleer fallacy Post hoc ergo propter hoc “After this, therefore because of this.” The reason doesn't lead to the conclusion 13

"...humans are incredibly good at linking cause and effect — sometimes too good..." "... it means that when you see something occur in a complex adaptive system, your mind is going to create a narrative to explain what happened — even though cause and effect are not comprehensible in that kind of system." Embracing Complexity, An interview with Michael https://hbr.org/2011/09/embracing-complexity/ Mauboussin by Tim Sullivan Harvard Business Review 2011 Life Events have NOT been associated with MDD "in general, Major Depression can be diagnosed independently of the psychosocial context in which it arises." Kendler KS, Gardner CO. Dependent Stressful Life Events and Prior Depressive Episodes in the Prediction of Major Depression: The Problem of Causal Inference in Psychiatric Epidemiology. Arch Gen Psychiatry. 2010;67(11):1120-1127. Kendler KS, Myers J, and Halberstadt LJ. Do reasons for major depression act as causes? Molecular Psychiatry (2011) 16, 626 – 633; doi:10.1038/mp.2011.22; published online 8 March 2011. Kendler KS, Myers J, and Halberstadt LJ. Should the Diagnosis of Major Depression made Independent of or Dependent upon the Psychosocial Context? Psychol Med. 2010 May ; 40(5): 771 – 780. doi:10.1017/S0033291709990845. Lyketsos CG, Chisolm MS. The trap of meaning: a public health tragedy. JAMA. 2009 Jul 22;302(4):432-3. doi: 10.1001/jama.2009.1059. 14

What are the Validated Risk Factors for Depression? Take Home Message Be aware of "explaining away" mood episodes. Anticipate patient’s explanatory model and adherence implications Lyketsos CG, Chisolm MS. The trap of meaning: a public health tragedy. JAMA. 2009 Jul http://jama.jamanetwork.com/article.aspx?articleid=184281 22;302(4):432-3. doi: 10.1001/jama.2009.1059 . 15

Outline • Introduction and Epidemiology • “Normal sadness” • Trap of Meaning • Antidepressant controversy and Placebos • Stepped pharmacotherapy of depression (STAR*D) • Exercise The Crazy State of Psychiatry, by Marcia Angell 16

Prevalence of antidepressant usage http://well.blogs.nytimes.com/2013/08/12/a -glut-of-antidepressants/?_r=0 Is there a glut of coffee, alcohol? http://psychcentral.com/blog/archives/2013/08/19/is-a- How about insulin, Lipitor? glut-of-antidepressants-really-so-bad/ 17