Financial Disclosures none Descartes Li, M.D. Clinical Professor - PDF document

Depression in Prim ary Care Mourning or Melancholia? Financial Disclosures none 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 Outline Outline • Introduction and Epidemiology • I ntroduction and Epidem iology • “Normal sadness” • “Normal sadness” • Trap of Meaning • Trap of Meaning • Bipolar Depression • Bipolar Depression • Depression with Apathy, r/ o dementia • Depression with Apathy, r/ o dementia • Perspectives Approach • Perspectives Approach • Treatment implications • Treatment implications 1

Case Vignette Diagnosis of Depression Key issues 72yo man is depressed in the context of the death of 1) Rule out Medical conditions his wife one month ago. causing psychiatric symptoms 2) Rule out Substance abuse or iatrogenic medications Which of the following is the best diagnosis? a) Normal bereavement 3) Rule out Bipolar disorder (ie, b) Major depressive disorder screen for mania or c) Bipolar depression d) Neurocognitive disorder with apathy hypomania) Prevalence of Psychiatric The Three S’s of the Psychiatric Disorders* Interview Disorder Lifetime prevalence(%) Any mood disorder 19.54 Major depression 16.54 1) S – Stressors/ triggers Dysthymia 4.30 Bipolar I 3.31 2) S – Suicidality Bipolar II 2.33 Any anxiety disorder 16.16 Social anxiety 4.97 3) S – Substance Abuse 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. 2

Prevalence of Psychiatric Disorders Disorder Lifetime prevalence(%) Post-traumatic stress disorder in women (1) 10.1 Post-traumatic stress disorder in men (1) 4.9 Why shouldn’t I be depressed? Suicidal ideation (2) 13.5 Suicidal plan (2) 3.9 Suicide attempt (2) 4.6 1. Bromet E et al. Risk Factors for DSM-III-R Posttraumatic Stress Disorder: Findings from the National Comorbidity Survey. Am J Epidemiol 1998; 147:353-61. 2. Kessler RC et al. Prevalence of and Risk Factors for Lifetime Suicide Attempts in the National Comorbidity Survey. Arch Gen Psychiatry. 1999;56:617-626. Life means suffering 3

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/ The Crazy State of Psychiatry, by Marcia Angell Turner E et al. Selective Publication of Antidepressant Trials and I ts I nfluence on Apparent Efficacy. NEJM 2008 358(3): 252 4

I n Defense of Antidepressants American Psychiatric Association Practice Guidelines for Depression Agency for Health Care Policy and Research, Clinical Practice Guidelines Cochrane Review http: / / www2.cochrane.org/ reviews/ en/ ab0079 54.html “In Defense of Antidepressants” , by Peter Kramer (The New York Times, July 9, 2011) Bottom Line: For mild depression, watchful waiting is a reasonable option Case Vignette Outline 72yo man is depressed in the context of the death • Epidemiology of his wife. • “Norm al sadness” • Trap of Meaning Pair discussion: How long would you wait before diagnosing MDD? • Bipolar Depression • Depression with Apathy, r/ o dementia a) One month • Perspectives Approach b) Two months c) Six months • Treatment implications d) One year or more 5

Major Depressive Episode Mourning and Melancholia —Diagnostic Criteria Criterion A. Five or more of the following… MDE = ≥ 2wks of • signif wt ∆ ( ↓ or ↑ ) • ↓ ’d mood • insomnia or hypersomnia • Ψ motor agitation/retardation Sleep • anhedonia (PMA/PMR) Interest Guilt • fatigue or anergia • guilt/worthlessness ( G/W) Energy • ↓ ’d concentration Concentration • recurrent thoughts of death or Appetite Psychomotor SI Suicide 5 symptoms (with ≥ 1 sx in blue) Major Depressive Episode Major Depressive Disorder —Diagnostic Criteria ( cont.) —Diagnostic Criteria ( cont.) Criterion B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of Criterion D. The occurrence of the MDE functioning. is not better explained by schizoaffective Criterion C. The episode is not attributable disorder, schizophrenia, etc. to the physiological effects of a substance or to another medical condition. Criterion E. There has never been a manic episode or a hypomanic episode. Criteria A-C represent a major depressive episode *note: deletion of Bereavement exclusion in DSM 5 6

No Bereavement in DSM-5 “Norm al Sadness” Per Horvitz and Wakefield, 3 criteria: No Bereavement exclusion in DSM-5 • Has an environmental trigger Grief is still exists • Roughly proportionate in intensity to Mild depressive episodes can be loss treated with psychotherapy alone • Ends when loss situation ends http: / / www.dsm5.org/ Documents/ Bereavement% 20Exclusion Horwitz AV, Wakefield JC. The Loss of Sadness: How Psychiatry Transformed % 20Fact% 20Sheet.pdf Normal Sorrow into Depressive Disorder. New York, NY: Oxford University Press; 2007. (p.16) Depression vs. Grief Problem s w ith “norm al sadness” • What constitutes a trigger? • When is the response proportionate to the loss? • Does the presence of a recent major loss somehow make it more likely that depression will spontaneously resolve? 7

Case Vignette Depression vs. Grief 72yo man is depressed in the context of the death of his wife. • Beware the Trap of Meaning! He has had 6 prior episodes of depression in the past. Each episode lasted 2-9 months and he met • Individuals who fulfill MDD criteria DSM criteria for depression in each of them. after loss of significant other have Pair discussion: Which of the following is the best NOT been shown to recover at a diagnosis? greater rate than MDD alone a) Normal bereavement b) Major depressive disorder c) Bipolar depression d) Neurocognitive disorder with apathy W hat is m elancholic Specifiers for Major Depressive depression? Episodes Melancholic depression is characterized by significant psychomotor symptoms, • Atypical insomnia, • Catatonia early morning awakening, • Melancholic worsening of mood in the morning (called diurnal variation in mood), • Mixed features significant anorexia, and a lack of • Postpartum onset reactivity to pleasurable stimuli. • Psychotic features 8

Outline Case vignette 28yo man, recently married 6m ago, • Epidemiology appears well, but quickly breaks down: He says he’s made a terrible mistake • “Normal sadness” for imposing himself on his wife. “I’m a terrible person who cheated on my • Trap of Meaning wife and on my taxes.” He reports two months of depressed mood, crying • Bipolar Depression spells, as well as oversleeping and not being able to get out of bed. In • Depression with Apathy, r/ o dementia addition, his energy has been low, he has no appetite, and he can’t focus at • Perspectives Approach work. http://commons.wikimedia.org/wiki/File:Portrait-as-an-artist-as-a-young-man.jpg • Treatment implications Would you diagnose him with Major Depressive Disorder? Would you prescribe an antidepressant? Case vignette The Trap of Meaning “I cheated on my wife and on my taxes.” “Finding an explanation that appears Do we accept his reasons as meaningful and adopting it as causal.” 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 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. 9