Ghania Masri, MD

Division of General Internal Medicine

Prevalence.

Health care costs.

Screening.

Diagnosis.

Association with Chronic medical disease.

Management.

A 62 year old white female: history of multiple sclerosis present to PCP office for follow up.

The patient has been complaining of fatigue for the last few months with excessive day time sleepiness. She was seen by her neurologist last month who started her on Provigil.

ROS positive for decreased appetite, mood swings, decrease concentration and interrupted sleep.

Prevalence of depression is estimated to be between 5.4% - 8.9% in US.

It is estimated that depression affects 1 out of 10 patients.

Depression accounts for more than 4% on the world disease burden and represents the third leading cause of disability according to WHO.

Douglas M-Primary Care Clinic in Office Practice-DEC-2006

Depression affects more than 16% of U.S. adults during their lifetime.

In 2000 the economic burden of depression was estimated to be as high as 83.1 billion dollars.

The high cost of depression disorder is mostly attributed to direct and indirect medical cost and social loss.

Gartlehner G- Annals of Internal Madicine-18- NOV-2008

Depression is very commonly encountered in a primary care setting. It affects between 5-10% of their patients.

More than 50% of patients with depression are undiagnosed by their PCP and more than 50% of those who have been diagnosed are not adequately treated.

David Goldmann- Annals of Internal Medicine-1-May-2007

In 2002 U.S. Preventive Services task Force recommended primary care physicians to screen high risk patients for depression.

Important note: positive screening tests for depression does not diagnose depression.

Screening interval is not well defined.

Older age.

Recent childbirth.

Recent stressful events.

Personal or family history of depression.

Patients with several unexplained somatic symptoms.

Patients with chronic medical conditions.

Patients with comorbid psychological conditions.

Goldmann D- Annals of Internal Medicine-1-May-2007

There are multiple depression screening tools used for adults.

Most commonly used:◦ The Beck Depression Inventory Scales II.

◦ Hamilton Rating Scale for depression.

◦ Geriatric Depression Scale.

◦ Patient Health Questionnaire.

Over the past 2 weeks have you felt down, depressed, hopeless?

Over the past 2 weeks have you felt little interest or pleasure in doing things?

These 2 questions have a high sensitivity of 96% and a specificity of 57%.

David Goldmann- Annals of Internal Medicine-1-May-2007

Criteria:Depressed mood.Anhedonia.Significant weight change.Psychomotor agitation or retardation.Fatigue.Feeling of worthlessness .Diminished ability to concentrate.Recurrent thoughts of death.Insomnia or hypersomnia.

Diagnosis of Major Depressed Episode

Patients with depressed mood and two of the following four symptoms daily for 2 weeks will meet the criteria for diagnosis of MD disorder.

1. Sleep disturbance.

2. Anhedonia.

3. Low self-esteem.

4. Appetite disturbance.

SALSA Inventory has 97% sensitivity and 96 % specificity.

Goldmann D- Annals of Internal Medicine-1-May-2007

PCP should consider that other conditions can exhibit similar behaviors as the one indicative of major depression such as:

Hypothyroidism

Cushing disease

Substance Abuse

Medication : OCP, Steroids, Interferon, Propanolol.

50% to 80% of patients with depression will exhibit somatic complaints to their PCP.

Fatigue and pain are the most common complaints.

Other typical complaints are weakness, headache, abdominal pain, and constipation.

Seelig- M-J of Occupational and Environmental Med-APR-2008

Depression is more prevalent in patients with chronic medical conditions especially DM, CAD, stroke, and chronic pain syndrome.

Presence of depression contributes to poor medical outcome which could be related to decreased compliance with medication and non-adherence to healthy lifestyle.

There is strong association with the presence of depression and DM.

Patients with diabetes have increased incidence of depression from 1.3 - 3 times higher than non diabetic patients.

Diabetic patients with depression have an increased risk of disability, diabetic complication, and mortality.

Brown-LC-Canadian Medical Association J-1-July-2006

There are conflicting evidences whether diabetes is a risk factor for depression.

A Recent Longitudinal cohort study of US adults aged 45-84 years showed a positive association with treated diabetic patients and depression, relative hazard of 1.37.

While IFG and untreated diabetes were inversely associated with depression.

Sherita H Golden- JAMA- 18- June-2008

Patients with depression have higher incidence of diabetes with estimated RH 1.21.

Decreased physical activities and increased caloric intake is the most contributing factor.

Other factors: activation of neuroendocrine and inflammatory response causing increase insulin resistance.

Golden S - JAMA- 18- June-2008

There is no evidence that aggressive depression management will improve diabetic control as decrease HgA1c or improve adherence to medication.

Treating depression will improve depression symptoms and further studies are needed to assess long term outcome on diabetes control.

Lin E– Annals of Family Medicine – 1- JAN- 2006.

Depression is more prevalent in patients with CAD. It affects more than 20% of such patients.

Patients with coexisting CAD and depression have higher incidence of morbidity and mortality.

Depression is likely an independent risk factor for CAD.

AHA recommends screening and treating of depression in patients with CAD.

Pozuelo L- CCJM-JAN- 2009

International case control study, enrolled 24,767 people.

11,119 patients with first MI matched with 13,648 people according to their age and sex.

Traditional CAD risk factors were obtained and the presence of depression and psychosocial stresses as well as the financial stresses were assessed at work, and at home.

Psychological stress and depression were independent risk factors for CAD with estimated 32.5 % of contributed risk.

Rosengren A – Lancet – 11-SEP -2004

1996 Epidemiologic Catchment Area Study found that people with depression have four times higher risk for MI than average people.

Meta- analysis for 28 epidemiologic studies included 80,000 people. The study confirms that MD as independent risk factor for MI.

People with depression have a relative risk of 1.64 to develop CAD compared to smoking which has RR of 2.5.

Pozuelo L- CCJM-JAN- 2009

Patients with heart diseases have higher risk of developing depression compared to other medical conditions.

Patients with heart disease and depression have higher morbidity and may be doubling their mortality risk secondary to poor compliance with medication, smoking cessation, cardiac-rehab, and life style changes.

Pozuelo L- CCJM-JAN- 2009

Sympathetic activation: higher level of catecholamine.

Hypothalamic pituitary adrenal gland activation: Increased cortisol level contributes to increase BP and atherosclerosis.

Increased platelets activation and inflammatory response.

Pozuelo L- CCJM-JAN- 2009

Many studies like SADHART, MIND-IT, and ENRICHD failed to prove that an effective treatment of depression has a positive outcome on survival.

SSRIs, especially Sertraline and Citalopram seem to be safe in treating depression post MI, keep in mind SSRIs can interact with anticoagulant and increase bleeding time.

TCAs are more likely to cause significant cardiovascular events in patients with CAD.

Sub- analyses of the Nurses’ Health Study to examine the association of depression and new incident of colon cancer revealed positive results.

Women with higher Mental Health Index score have increased risks of developing colon cancer with estimated hazard ratio of 1.43.

Kroenke CH – Am J Epidemiol – 1- NOV - 2005

Pharmacotherapy is the main and first line approach in treating depression.

Second generation antidepressant medication almost replaced tricyclic antidepressant and MAOI because of their safer profile, decreased toxicity, and maintained efficacy.

Almost 170 million prescriptions of anti-depressant medication were purchased in 2005.

SSRIs: Citalopram, Sertraline, Fluoxetine, Escitalopram, Paroxetine.

SSNRI: Duloxetine.

SNRI: Venlafaxine, Mirtazapine.

Others: Trazodone, Bupropion, Nefazodone.

There is no evidence to support choosing one second generation antidepressant over another, on the basis of differences in efficacy.

Primary care Physicians should choose their treatment on the basis of adverse effect profile, cost, and patient preferences.

Primary care physicians should assess patient’s status and therapeutic response within 1-2 weeks of therapy initiation.

Qaseem A – Annals Internal Medicine- 18- NOV - 2008

Primary care physician should modify the treatment if the patient does not have an adequate response within 6-8 weeks .

Primary care physicians should monitor their patients for adverse effects.

Recommend to continue treatment for 4-9 months after adequate response to treatment.

SSRIs are the most prescribed treatment for depression in U.S.

Indicated to treat MDD, GAD, OCD.

Common adverse effects: WT gain insomnia, diarrhea and sexual dysfunction.

Inhibit cytochrome P450 system drug-drug interaction.

SSRIs have increased nonfatal suicidal risk.

Venalafaxine: may have greater and faster response rate in patients with depression and anxiety but, it can increase diastolic BP and has a high rate of discontinuation.

Bupropion: They have fewer adverse effects than SSRIs and may promote weight loss but, they have higher incidences of insomnia and headaches.

Prospective randomized study randomized 202

adults with MD to four groups:

1- Sertraline.

2- Home base exercise.

3- supervised exercise in group settings.

4- Placebo.

Blumenthal JA-Psychosom Med-1-SEP-2007

P Value 0.057

Patients Factors:

Stigma of depression as mental health disorder.

Patients focus on their physical symptoms which delay their diagnosis.

Patients may perceive antidepressant medication as drugs with physical dependency; it is estimated that more than 40% of depressed patients discontinue their medication within 6 weeks.

Seelig- M-J of Occupational and Environmental Med-APR-2008

Physician Factors:

Focus on physical complains and not considering depression in their differential diagnosis.

Prescribe inadequate dose.

Lack of time and reimbursement.

Lack of referral systems for mental health provider.

System factors:

Health care system tends to differentiate between medical and mental health coverage.

Lack of funding to develop case management program and to implement collaborative care model.

Depression is very common in primary care practice.

Primary care physicians should sharpen their skills for screening and treating depression.

Depression is associated with multiple chronic medical problems and it can have a negative impact on disease outcome.

Second generation antidepressant may have a similar efficacy but they have a different adverse profile.

Exercise could be an alternative treatment for depression in selected group.

Primary Care Provider should be familiar with local mental health resources.

Depression is a major public health concern since it is associated with high medical cost and indirect cost.