Depression: A primary care approach - Gerald W. Smetana, M.D

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Association of depression with mood disorder is common in psychiatry. Can occur at all ages but is most common age 18-45. Invite you read the reference Sermon depression: the approach of primary care to learn about basic questions and Epidemiology of depression.

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Nội dung Text: Depression: A primary care approach - Gerald W. Smetana, M.D

Depression: A Primary Care Approach Gerald W. Smetana, M.D. Division of General Medicine Beth Israel Deaconess Medical Center Associate Professor of Medicine Harvard Medical School
Key Questions • Does screening for depression work? • How long to treat? • Are newer antidepressants more effective than SSRIs? • How do side effect profiles differ between drugs? • Which is better: switching or augmenting?
Epidemiology of Depression • Twice as common in women as in men • 2-3 fold increase in risk if family history in parent or sibling • 2-5% incidence of suicide among depressed patients • 3-fold increase in number of sick days from work • Leading cause of disability among people aged 18-44 years CMAJ 2002;167:1253
Question #1 • Does screening for depression work? • How do I follow up on a positive screening survey?
Does Screening for Depression Work? • US Preventive Health Services Task Force • December 2009 Update • Recommends screening for depression (Grade B recommendation - fair evidence) when resources for Rx and follow up are available • Good evidence that screening improves the accurate identification of depression in primary care settings and • Treatment in the primary care setting decreases clinical morbidity Ann Intern Med 2009;151:784
Screen for Depression If • Sadness, low energy, apathy, irritability or anxiety • Sexual complaints • Unexplained physical symptoms or unexpectedly frequent use of medical services • Frequent symptoms with unrevealing workups • Concurrent general medical illness • Recent stressful life events and lack of social supports
Which Screening Tools to Use? • Multiple available questionnaires • Administration times range from 1-5 minutes • In a systematic review of screening tools: • Positive likelihood ratio (LR+) – 3.3 (range 2.3-12.2) • Negative likelihood ratio (LR-) – 0.19 (range 0.14-0.35) • High sensitivity (80-90%) but only fair specificity (57-85%) The Rational Clinical Examination. Is this patient clinically depressed? JAMA 2002;287:1160
Simple Screening Tool: Ask Two Questions 1. ‘During the past month, have you often been bothered by feeling down, depressed or hopeless?’ 2. ‘During the past month, have you often been bothered by having little interest or pleasure in doing things?’ • 96% sensitive but only 57% specific for at least one positive response • Recommended by USPSTF J Gen Intern Med 1997;12:439
Phan Vietnamese Psychiatric Scale • Culturally sensitive mental health questionnaire derived from Vietnamese individuals • Four domains – Depression - affective – Depression - psycho-vegetative – Anxiety – Somatic symptoms Tuong Phan et al. Transcultural Psych 2004;41:200 9
Phan Scale: Sample Questions Affective • Did you feel lonely or empty? • Did you become pale or have dark rings under your eyes? • Did you feel your life had become meaningless? • Did you feel disgraceful or ashamed of yourself without any reason? Psycho-vegetative • Did you feel confused or in a daze? • Did you cry without any reason? • Did you feel like not getting out of bed? 10
Prevalence of Symptoms Among 2000 Adult Vietnamese Refugees to U.S. West J Med 1995;163:341 Symptom Prevalence (%) Physical symptoms Headaches 21 Anxiety about symptoms 25 Loss of appetite 20 Psychological symptoms Sad 31 Difficulty concentrating 30 Hopeless 7 Culture-specific symptoms Bothered 10 Shameful and dishonored 7 11 Desperate 6
Suicide Screening Questions • Three simple questions – Do you ever think of hurting yourself or taking your own life? – Do you currently have a plan? – What is your plan? • Do not fear that asking questions will suggest the idea of suicide to a patient • Emergency mental health evaluation if patient can’t contract for safety N Engl J Med 2000;343:1942
Ms. Tran • Ms. Tran is a 24 year old woman who sees you for sadness • It has been present for 2 months • She is sleeping poorly and has lost 5 kg. in weight • She is distracted and has a hard time concentrating while at work • You are contemplating antidepressant mediations
Question #2 • What are response rates to initial Rx? • How long should one continue antidepressant medication?
STAR*D Trial of Citalopram: Time to Response Among Responders • Mean dose 40 mg qd • Results at 14 weeks • Response – 47% • Remission – 28% • Most responders do so by 8 weeks • Consistent with previous reports Am J Psychiatri 2006;163:28
Systematic Review: SSRIs More Alike than Different Ann Intern Med 2008;149:734-750
Three Treatment Phases • Acute Treatment 6-12 Weeks • Continuation Treatment 3-12 Months • Prevents relapse • Maintenance Treatment Long term • Prevents Recurrence
Approach to Relapse After Initial Rx • Initial Rx may have been too brief – Continuation Rx for at least 6-9 months • Relapse after adequate duration of Rx – Suggests need for maintenance Rx – At least 2-3 years • First strategy is to resume the same med that led to initial remission • Consider psychotherapy in addition to meds
Special Considerations in the Elderly • Depression increases risk of mortality post MI, post stroke, and after nursing home admit • Higher rates of completed suicides • SSRI’s preferred 1st line due to favorable side effect profile • SNRI’s second line • Observational data suggest increased morbidity and mortality with drug therapy* Coupland C, et al. BMJ 2011 epub ahead of print
Important Considerations • Initial med Rx response rates 50% • Rx for at least 6-9 months • Withdrawal symptoms if abrupt d/c of SSRIs • Risk of serotonin syndrome for SSRIs increases with certain drug interactions • Increased suicidal behavior for SSRIs for patients aged 18-29 years • Increased risk of GI bleeding for SSRIs in older patients • Medication probably not beneficial for minor depression