Depression in Primary Care

Magnitude of the problem

120 million people worldwide Lifetime prevalence 5-20% One of the leading causes of disability worldwide 70% of suicides due to depression

Change in Rank Order of Global Burden of Disease or Injury 19902020

Disease or Injury : 1990 1) Lower Respiratory Infections 2) Diarrheal Diseases 3) Conditions Arising During the Perinatal Period 4) Major Depression 5) Ischemic Heart Disease 6) Cerebrovascular Disease 7) Tuberculosis Disease or Injury : 2020 1) Ischemic Heart Disease 2) Major Depression 3) Road Traffic Accidents 4) Cerebrovascular Disease 5) Chronic Obstructive 6) Pulmonary Disease 7) Lower Respiratory Infections

Murray CJL, Lopez AD, eds: The Global Burden of Disease: Harvard University Press on behalf of WHO and the World Bank; 1996

Psychiatric disorders in primary care

Psychiatric disorder ~ 25% of patients Depression ~ 5-10 % Depression ~ 15-40 % of patients with chronic medical illnesses

 Depression is often undiagnosed at Primary Care level ! Diagnostic success : 10-30%

Depression usually untreated or undertreated in Primary Care

Treated Appropriately (only 1/6)

Untreated

Undertreated

Hirschfeld et al. JAMA. 1997;277:333-340.

Common presentations
Physical complaints Poor school/work performance Suicidal attempt Substance abuse Depressed mood

Primary Care Patients With Depression Usually Present With Physical Symptoms

Psychological Symptoms 30% Physical Symptoms 70%

Simon GE, et al. N Engl J Med. 2002;341(18):1329-1335.

Presentation influences psychiatric diagnosis in primary care

Presenting Complaint
100

Correct Diagnosis
100

83% Patients with Psychiatric Disorders (%) Correct Diagnosis (%)

80

94%
80

60

60

50%
40

40

20

17%

20

0
Somatic complaints Psychological complaints

0
Somatic complaints Psychological complaints

N=500
Bridges KW, Goldberg DP. J Psychosom Res. 1998;29:563-569.

Physical complaints are rarely organic

10

3-Year Incidence (%)

No organic cause identified Organic cause

0
Chest Pain Fatigue Dizziness Headache Edema Back Insomnia Pain Dyspnea Abdominal Pain Numbness

Kroenke K, Mangelsdorff AD. Am J Med. 1989;86:262-266.

Recognizing Depression in Primary Care

Depression - normal emotion commonly experienced by healthy people in response to misfortunes. Depression - symptom of many other psychiatric and medical disorders such as schizophrenia, dementia, hypothyroidism. Depression illness

Criteria for major depressive disorder

Depressed mood plus 4 or more of the following for at least 2 weeks:
Sleep:
Interest: Guilt: Energy:

Insomnia or hypersomnia nearly every day

Markedly diminished interest or pleasure in nearly all activities most of the time Excessive feelings of guilt or worthlessness most of the time Loss of energy or fatigue most of the time

Concentration: Diminished ability to think or concentrate indecisiveness most of the time Appetite: Increase or decrease in appetite Psychomotor: Observed psychomotor agitation/retardation Suicide: Recurrent thoughts of death/suicidal ideation

Common clinical errors

Insufficient questioning use SIGECAPS Failure to consult a family member Acceptance of diagnosis of mood disorder without adequate criteria depressed mood is not enough Explaining rather than treating: Of course youre depressed; who wouldnt be in your situation?

Differential diagnosis of depression

Rule out underlying medical conditions (eg, CNS disease, hypothyroidism)

Rule out medications causing depression

Screen for substance abuse

Suicide
Evaluate risk factors: substance abuse, hopelessness, lack of supports, past attempts, family history Ask directly Hospitalize if strong impulses or high risk Frequent visits/small prescriptions Mobilize support

Types of treatment
Medication Psychotherapy Electroconvulsive therapy Light therapy

Antidepressant Medication
Tricyclics
Nortriptyline, Imipramine, Amitriptyline

SSRIs
Fluoxetine, Sertraline, Paroxetine, Citalopram

SNRIs
Venlafaxine, Duloxetine

MAOIs
Phenylzine, Tranylcypromine

Miscellaneous
Bupropion, Mirtazapine, Tianeptine

Medication guidelines
All equally efficacious Different side effects Onset of effect 3-6 wk Adequate dose
Fluoxetine 20 mg/day Sertraline 50-200 mg/day Imipramine 75-225 mg/day

Duration of treatment: 9-12 months

When to refer
Diagnosis in doubt Severe episode High suicide risk Poor treatment response (?12 weeks) Psychotic symptoms

Summary
Depression- a common problem Have high index of suspicion Always ask about suicide- its one of the diagnostic criteria! History and Physical examination can identify contributing medical/substance issues Medication/psychotherapy both work

Conclusion
Depression treatment isnt rocket science It is worth the effort Effective depression treatment saves lives and allows people to be more productive

THANK YOU

PHQ-9 Prime MD questionnaire

Over the past 2 weeks, how often have you been bothered any of the following problems?
Little interest or pleasure in doing things Feeling down, depressed, or hopeless Trouble falling/staying asleep, sleeping too much Feeling tired or having little energy Poor appetite or overeating Feeling bad about yourself or that you are a failure or have let yourself or your family down Trouble concentrating on things, such as reading the newspaper or watching television Moving or speaking so slowly that other people could have noticed. Or the opposite being so fidgety or restless that you havebeen moving around a lot more than usual. Thoughts that you would be better off dead or of hurting yourself in some way