Assessment of DepressionAssessment of Depression

DiagnosisDiagnosis

Risk AssessmentRisk Assessment

Risk ManagementRisk Management

FormulationFormulation

TreatmentTreatment

OutcomeOutcome

Associated symptoms in Associated symptoms in increasing importance: increasing importance:

InsomniaInsomnia Fatigue Fatigue loss of interest/pleasureloss of interest/pleasure Morbid self-opinionMorbid self-opinion Impaired concentrationImpaired concentration Hopelessness ± suicidal thoughts. (Blacker Hopelessness ± suicidal thoughts. (Blacker

and Clare ‘88)and Clare ‘88)

Diagnostic domainsDiagnostic domains

Affective symptomsAffective symptoms Physical symptomsPhysical symptoms Cognitive symptomsCognitive symptoms

Affective Diagnostic Criteria.Affective Diagnostic Criteria.Must haves!Must haves!

Depressed mood (irritable in children or Depressed mood (irritable in children or adolescents).adolescents).

Or markedly diminished interest or pleasureOr markedly diminished interest or pleasure Must be most of the time over at least 2 Must be most of the time over at least 2

weeks.weeks. Change from normal functioningChange from normal functioning

Physical symptomsPhysical symptoms

Weight change when not dietingWeight change when not dieting Sleep disturbance –insomnia (particularly Sleep disturbance –insomnia (particularly

middle insomnia and EMW), hypersomnia.middle insomnia and EMW), hypersomnia. Agitation or retardationAgitation or retardation Fatigue/loss of energyFatigue/loss of energy

Cognitive symptomsCognitive symptoms

Worthlessness, xs/inappropriate guiltWorthlessness, xs/inappropriate guilt Diminished ability to think and concentrateDiminished ability to think and concentrate Recurrent thoughts of death and suicideRecurrent thoughts of death and suicide

DiagnosisDiagnosis

Eye contact - observe body language.Eye contact - observe body language. Open questions.Open questions. Attend to “distinct quality of mood” Attend to “distinct quality of mood”

eg.Coldness/deadness/emptiness.  eg.Coldness/deadness/emptiness. 

Paykel ’85Paykel ’85

Comorbidity and missed Comorbidity and missed diagnosisdiagnosis

Presentation affected by-Presentation affected by- Gender (Women 2:1 Men)Gender (Women 2:1 Men) AgeAge InsightInsight Comorbid physical illnessComorbid physical illness

Gotland survey. Pop 56,000Gotland survey. Pop 56,000

60% GPs trained in depression diagnosis 60% GPs trained in depression diagnosis 1981/21981/2

By 1985 - ↓ referrals 50%, inpatient by 75% By 1985 - ↓ referrals 50%, inpatient by 75% and sick leave by 50%and sick leave by 50%

Suicide rates dropped from 20 to 7/100,000Suicide rates dropped from 20 to 7/100,000 Antidepressant prescribing increased 60%Antidepressant prescribing increased 60% Anxiolytic prescribing decreased 25%Anxiolytic prescribing decreased 25%

SuicidesSuicides

♀♀:♂:♂ ratio 2:3 before the programme 1:7 ratio 2:3 before the programme 1:7 after.after.

Of increased px 1/3 ♂, 2/3 ♀Of increased px 1/3 ♂, 2/3 ♀ Of increased ♂ px most were for elderly!Of increased ♂ px most were for elderly! Improved ability in Primary Care benefits Improved ability in Primary Care benefits

those in contact with Primary Care i.e. those in contact with Primary Care i.e. Women!Women!

Male Depressive SyndromeMale Depressive Syndrome

Lowered stress toleranceLowered stress tolerance Acting out/aggression/low impulse control/ Acting out/aggression/low impulse control/

Transitional sociopathyTransitional sociopathy Burnt out feeling/emptinessBurnt out feeling/emptiness Chronic fatigueChronic fatigue Irritability/restlessness/dissatisfactionIrritability/restlessness/dissatisfaction IndecisionIndecision Sleep disturbance/morning anxietySleep disturbance/morning anxiety

Missed depression Missed depression Depressed mood may be absentDepressed mood may be absent Watch for “inner emptiness or deadness”Watch for “inner emptiness or deadness” Prominent anhedoniaProminent anhedonia Somatic complaints in patients with poor verbal Somatic complaints in patients with poor verbal

skills or the elderlyskills or the elderly Pseudo dementia- behavioural withdrawal, Pseudo dementia- behavioural withdrawal,

memory problemsmemory problems Unexplained physical symptoms associated with Unexplained physical symptoms associated with

depression e.g. pain . Impt to rule out organic depression e.g. pain . Impt to rule out organic causecause

Reference:1. Simon GE, et al. N Engl J Med. 1999;341(18):1329-1335.

Depression – the physical Depression – the physical presentationpresentation

In primary care, physical symptoms are often the chief complaint in depressed patients

N = 1146 Primary care patients with major depression

In a New England Journal of Medicine study, 69% of diagnosed depressed patients reported unexplained physical symptoms as their chief complaint1

Is your depressed patient Is your depressed patient bipolar?bipolar?

Co morbid substance abuseCo morbid substance abuse Bipolar family history *Bipolar family history * SeasonalitySeasonality Early onset <25 yrs *Early onset <25 yrs * Postpartum onset *Postpartum onset * Psychotic features <35 yrs */ Atypical features Psychotic features <35 yrs */ Atypical features Rapid on/off pattern, frequent recurrence, < Rapid on/off pattern, frequent recurrence, <

3mth duration * /Mixed affective state **3mth duration * /Mixed affective state ** Antidepressant mania/hypomania **Antidepressant mania/hypomania ** Ask about symptoms of hypomania just Ask about symptoms of hypomania just

preceding or following depression either 1preceding or following depression either 1stst episode or early-onset depressionepisode or early-onset depression

Prevalence of Bipolar Spectrum Prevalence of Bipolar Spectrum subtypesubtype

26-39% depressed patients in Primary 26-39% depressed patients in Primary CareCare

45% depressed outpatients 45% depressed outpatients

Allilaire et al “EPIDEP Trial”. Encephale 2001;27:149-158Allilaire et al “EPIDEP Trial”. Encephale 2001;27:149-158

Risk AssessmentRisk Assessment

Risk - aggression to self , others & propertyRisk - aggression to self , others & property

- substance misuse- substance misuse

- vulnerability/ exploitation- vulnerability/ exploitation Ask direct questions about suicide – “have you Ask direct questions about suicide – “have you

thought about or are you thinking about hurting or thought about or are you thinking about hurting or killing yourself”killing yourself”

If yes or unsure, enquire about plan.If yes or unsure, enquire about plan. If yes but wouldn't do it then “What is stopping you If yes but wouldn't do it then “What is stopping you

from doing something?" (protective factors)from doing something?" (protective factors)

Predictors of RiskPredictors of Risk

S – lack of significant others, stress events.S – lack of significant others, stress events. U – unsuccessful attempts, unemployment, U – unsuccessful attempts, unemployment,

unexplained improvement.unexplained improvement. I – identification with family history/peer group I – identification with family history/peer group

suicide.suicide. CI – chronic illness or severe illness of recent CI – chronic illness or severe illness of recent

onsetonset

Predictors of Risk 2Predictors of Risk 2

D – depression + hostility/hopelessness or D – depression + hostility/hopelessness or frustration, decision that suicide is an optionfrustration, decision that suicide is an option

A – age, alcohol, availability.A – age, alcohol, availability. L – lethality of previous attempts e.g. guns, L – lethality of previous attempts e.g. guns,

hanging, jumpinghanging, jumping

BEHAVIOURAL THEORYBEHAVIOURAL THEORY

Stimulus-Response-Reward-RepetitionStimulus-Response-Reward-Repetition Risk AssessmentRisk Assessment Risk Management – current and FUTURERisk Management – current and FUTURE Therapeutic Risk/ ResponsiblityTherapeutic Risk/ Responsiblity

PRESCRIPTIVE DISASTERPRESCRIPTIVE DISASTER

DISclosureDISclosure Anxiety.Anxiety. narrowed choiceSnarrowed choiceS Taking responsibility.Taking responsibility. PatiEnt out of control.PatiEnt out of control. Referral to other.Referral to other.

Interview StyleInterview Style

Be Perceptive- listen and understand, take distress Be Perceptive- listen and understand, take distress seriously do not dismiss, minimise or ignore- build seriously do not dismiss, minimise or ignore- build rapport.rapport.

Be Peaceful and calm. Do not appear threatened.Be Peaceful and calm. Do not appear threatened. Partnership approach- they share responsibility for Partnership approach- they share responsibility for

choosing the treatment approach. Empowerment choosing the treatment approach. Empowerment reduces helplessness reduces risk!reduces helplessness reduces risk!

Interview Style 2Interview Style 2

Be Persuasive- discuss the thoughts/plans in a Be Persuasive- discuss the thoughts/plans in a reasoned manner- “these are symptoms of a reasoned manner- “these are symptoms of a treatable condition, they are very common and treatable condition, they are very common and are often temporary.are often temporary.

Be Positive – instillation of HOPE is the most Be Positive – instillation of HOPE is the most protective thing you can do. protective thing you can do.

Collaborative risk managementCollaborative risk management

Disclosure.Disclosure. Further enquiry.Further enquiry. NormalisationNormalisation Informed choices.Informed choices. Agreed plan. Agreed plan.

Consequences of risk Consequences of risk managementmanagement

Patient retains responsibilityPatient retains responsibility Patient understood and in control.Patient understood and in control. Self image stronger.Self image stronger. Risk lower in subsequent stressRisk lower in subsequent stress

What is Case Formulation?What is Case Formulation?

“ “Case formulation aims to describe a Case formulation aims to describe a person’s presenting problems and use person’s presenting problems and use theory to make explanatory inferences about theory to make explanatory inferences about causes and maintaining factors that can causes and maintaining factors that can inform interventions” inform interventions” Kuyken 2006Kuyken 2006

Case formulation 2Case formulation 2

Predisposing factorsPredisposing factors Precipitating factorsPrecipitating factors Protective factorsProtective factors Perpetuating factorsPerpetuating factors Hypothesis –Inferred mechanisms- goalsHypothesis –Inferred mechanisms- goals

ExerciseExercise ExamplesExamples

TREATMENTTREATMENT

Keep taking the tablets!!Keep taking the tablets!!– Effective drug & doseEffective drug & dose

Psychological – counselling, CBT, Psychological – counselling, CBT, psychodynamic psychotherapypsychodynamic psychotherapy

Social- don’t forget these interventions; Social- don’t forget these interventions; common sense and can make a lot of common sense and can make a lot of difference!difference!

Outcome – response v remissionOutcome – response v remission

Aim for remission “are you back to your Aim for remission “are you back to your normal self?”normal self?”

Use outcome measure GAF/HonosUse outcome measure GAF/Honos