The Depressed The Depressed PatientPatient

A Patient-Centered, Evidence-Based A Patient-Centered, Evidence-Based Diagnostic and Treatment ProcessDiagnostic and Treatment Process1,21,2

A Presentation for A Presentation for SOMC Medical Education

Kendall L. Stewart, MD, MBA, DFAPAKendall L. Stewart, MD, MBA, DFAPADecember 17, 2010December 17, 2010

1My aim is to offer practical insights you can put to use in your professional life.2Please let me know whether I have succeeded on your evaluation forms.

Why is this important?

• After listening to this presentation, you will be able to answer the following questions:– Why is this important?– How do these patients

present?– What are the

diagnostic criteria?– What is the

differential diagnosis?– What is the

treatment?– What are some of the

treatment challenges?1

• This is a common, serious disorder.1,2

• The lifetime prevalence is between 15 and 20-percent.

• About 10-percent of patients who present to primary care physicians are depressed.

• About 15-percent of medical inpatients are depressed.

• Women are depressed about twice as often as men.

• It is as disabling as coronary artery disease or arthritis.

• It is among the most common reasons for seeing a physician.

1This disorder is frequently missed and often inadequately treated.2What is the most effective screening tool?

How do these patients present?

• “I’m just down all the time.”

• “I just can’t seem to get myself going.”

• “Life doesn’t seem to mean much anymore.”

• “I don’t get along with my husband like I used to.”

• “I can’t sleep.”1

• “I have a lot of headaches.”• “I have this hurting in my

chest now and then.”• “I’ve been depressed on

and off throughout my life.”2

• “It usually didn’t last very long, but now I’m depressed for weeks at a time.”

• “I’ve seriously considered suicide, but I wouldn’t want to do that to my children.”

• “I can’t seem to fall to sleep, but then I wake up early and can’t get back to sleep.”

• “I feel helpless, hopeless and worthless.”

• “I can’t concentrate.”• “I don’t enjoy anything

anymore.”• “I’m tired all the time.”• “I don’t enjoy sex at all.”• “I have a pretty good life;

I can’t figure out why I would feel this way.”

• You can listen to a depressed man talk about his struggle here.

1Treating your older patients’ unrealistic expectations that they will sleep through the night will challenge you.2Major depressive episodes are often superimposed on Dysthymic Disorder.

What are the diagnostic criteria for Major Depression?

• A change from a previous level of functioning• One of the following

– Depressed mood– Inability to experience pleasure

• Five or more of the following symptoms during a continuous two-week period

– Depressed mood– Markedly diminished interest– Significant weight loss or gain without

explanation– Insomnia or hypersomnia– Psychomotor agitation or retardation– Feelings of worthlessness or guilt– Inability to concentrate– Recurrent thoughts of death

• No evidence of a mixed episode• Significant distress or impairment• Not due to drugs• Not caused by bereavement1

1Here are the keys to your success as a physician: Listen attentively. Accept the patient’s feelings. Ask clarifying questions. Ask if they believe you understand. Ask permission to tell them your opinion. Go over all the options. State the ultimate goal. Recommend the best option. Admit how much you don’t know.

What are the different diagnoses of depression?

• Mood Disorders– Depressive Disorders

• Major Depressive Disorder1

• Dysthymic Disorder• Depressive Disorder Not Otherwise

Specified (NOS)

– Bipolar Disorders2,3

• Bipolar I Disorder• Bipolar II Disorder• Cyclothymic Disorder• Bipolar Disorder NOS

– Mood Disorder due to General Medical Condition (GMC)

– Substance-Induced Mood Disorder– Mood Disorder NOS

1With the older antidepressant medications, I used to know how to diagnose major depression.2These disorders are easily missed—and mistreated.3Ask the patient and her family key screening questions.

-10

-8

-6

-4

-2

0

2

4

6

8

10

Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10 Week 11 Week 12

Symptom Intensity Scale

What is the course of Major Depression?

Normal Life

What is the course of Dysthymic Disorder?

Normal Life

-10

-8

-6

-4

-2

0

2

4

6

8

10

Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10 Week 11 Week 12

Symptom Intensity Scale

What is the course of Bipolar I Disorder?

Normal Life

-10

-8

-6

-4

-2

0

2

4

6

8

10

Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10 Week 11 Week 12

Symptom Intensity Scale

What is the course of Bipolar II Disorder?

Normal Life

-10

-8

-6

-4

-2

0

2

4

6

8

10

Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10 Week 11 Week 12

Symptom Intensity Scale

What is the course of Cyclothymic Disorder?

Normal Life

-10

-8

-6

-4

-2

0

2

4

6

8

10

Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9 Week 10 Week 11 Week 12

Symptom Intensity Scale

What is the differential diagnosis?

• Normal depression– Grief

• Other depressive disorders– Bipolar disorders

• Depression secondary to a general medical condition– Cancer

• Substance-induced depression– Recent use of steroids1

• Depression secondary to other psychiatric disorders– Panic Disorder

1I have often seen steroids cause both depression and mania.

What is the treatment?

• Depression– Provide reassurance.– Consider paroxetine 20

mg/day and increase to maximum dose of 60 mg/day.

– Follow an evidence-based algorithm for treatment resistant depression.1,2

– Consider referral to a psychiatrist.

• Suicidal risk– Conduct a

careful risk assessment.– Document your assessment.– Take appropriate

precautions.• Insomnia

– Consider the short-term use of your favorite sleeper.

• Other comorbid disorders– Diagnose and treat these

conditions vigorously.• Maladaptive attitudes and

behaviors– Consider

cognitive behavioral psychotherapy (CBT)

• Education and self help– Provide educational

resources.– Recommend a daily

exercise regimen.– Recommend a healthy diet.– Suggest healthy

distractions.– Recommend meditation.– Recommend online

resources with caution.– Recommend self help

groups with caution.1We all go through life trying to do as much of what we want to do and as little of what we don’t want todo as possible. The key is to learn to want to do more of the right things.2The values-based life is the most satisfying.

What are some of the treatment challenges?

• Only 30 to 40-percent of patients achieve a complete remission with the first adequate trial of antidepressant medication.

• The treatment of the rest of these folk is tough and complicated.– Failure to comply is often an issue.– Accompanying personality disorders are

very tough to treat.1

– Partial remission is often the best result you can realistically achieve.

– Depression usually recurs, and is best managed as a chronic illness.

– Chronically-suicidal patients are particularly challenging.

1I once treated a beautiful young woman who was a rock band groupie.

Where can you learn more?

• American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000

• Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, 20081

• Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 20072

• Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship, Second Edition, March 2005

• Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition, March 20093

• Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007

• Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, January 2008

• Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, February 2008

• Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients,” 2000

Where can you find evidence-based information about mental disorders?

• Explore the site maintained by the organization where evidence-based medicine began at McMaster University here.

• Sign up for the Medscape Best Evidence Newsletters in the specialties of your choice here.

• Subscribe to Evidence-Based Mental Health and search a database at the National Registry of Evidence-Based Programs and Practices maintained by the Substance Abuse and Mental Health Services Administration here.

• Explore a limited but useful database of mental health practices that have been "blessed" as evidence-based by various academic, administrative and advocacy groups collected by the Iowa Consortium for Mental Health here.

• Download this presentation and related presentations and white papers at www.KendallLStewartMD.com.

• Learn more about Southern Ohio Medical Center and the job opportunities there at www.SOMC.org.

• Review the exceptional medical education training opportunities at Southern Ohio Medical Center here.

How can you contact me?1

Kendall L. Stewart, M.D.Kendall L. Stewart, M.D.VPMA and Chief Medical OfficerVPMA and Chief Medical OfficerSouthern Ohio Medical CenterSouthern Ohio Medical Center

Chairman & CEOChairman & CEOThe SOMC Medical Care Foundation, Inc.The SOMC Medical Care Foundation, Inc.

1805 27th Street1805 27th StreetWaller BuildingWaller Building

Suite B01Suite B01Portsmouth, Ohio 45662Portsmouth, Ohio 45662

740.356.8153740.356.8153

StewartK@somc.org StewartK@somc.org KendallLStewartMD@yahoo.comKendallLStewartMD@yahoo.com

www.somc.orgwww.somc.orgwww.KendallLStewartMD.comwww.KendallLStewartMD.com

1Speaking and consultation fees benefit the SOMC Endowment Fund.

SafetySafety QualityQuality ServiceService RelationshipsRelationships Performance Performance

Are there other questions?

www.somc.orgwww.somc.org

Sarah Porter, DOSarah Porter, DOSOMC FP 2007SOMC FP 2007

Ryan Foor, DORyan Foor, DOOUCOM 2005OUCOM 2005