rcpsych workshop - depression in medical settings (mar11)

Alex Mitchell [email protected]

Consultant in Liaison Psychiatry & Psycho-oncology

Diagnosing Depression in Medical Settings:

Symptoms and screening….60min workshop

RCPsych Workshop 2011

DSMVICD11

Symptoms

Under-served

Distress

Monitoring

Scales

Screening

Qualityof care

Older people

PhysicalIllness

DepressionDetection

Prescribing

Follow-up

Culturaleffects

Se Change

PhysiciansSpecialSymptoms

PrimaryCare

Impairment

Help Seeking

DSMVICD11

Symptoms

DistressScales

Screening

Qualityof care

Older people

PhysicalIllness

DepressionDetection

SpecialSymptoms

PrimaryCare

ContentsOverview Depression in medical settingsComorbidity | impairment | mortality

Prevalence of depression in medical settingsCancer | IHD | Stroke

Symptoms of Depression in medical settingsSame or different?.....older people?

Conventional screeningAccuracy | acceptability | Does it work?

New Screening innovationsWhy?

1.Overview: Depression in medical settings

Comorbidity | impairment | mortality

34.4

42.9 42.7

33.8

39.3

41.239.8

30.6

36.6

9

14.315.2

3.9

7.3

17.3

7.7

1.92.5

5.1

2.6 2.2 1.8 1.7 1.4 10.3 0.1

0

5

10

15

20

25

30

35

40

45

50

Depression Panic disorder PTSD Specific phobia Social phobia Bipolar disorder GAD Alcohol abuse Drug abuse

Yearly DOR

Unique

PAR%

Impairment: Days totally out of role per year

Quality of life: Moussavi et al (2007) Lancet 2007; 370: 851–58

n=245 404 participants from 60 countries

Psychosomatic Med (2004) Barth et al

Mortality and IHD+depression

77.7

17.7 20.515.6

29.9

14.8

25.3

84.3

12.8

21.717.5 20.3

10.8

23.2

84.5

28.3

40.9

30.3

43

28.9

46

0

10

20

30

40

50

60

70

80

90

Any

prim

ary

care

pra

ctiti

oner

vis

it (1

-yr)

Any

men

tal h

ealth

spe

cial

ist v

isit

(1-y

r)

Any

antid

epre

ssan

t or a

ntia

nxie

ty m

edic

a...

Appr

opria

te m

edic

atio

n us

e*

Any

coun

selin

g us

e

Appr

opria

te c

ouns

elin

g us

e*

App

ropr

iate

trea

tmen

t use

*

Depression Alone (=883)

Anixety Alone (n=314)

Depression and Anxiety (n = 439)

Young et al (2001) The Quality of Care for Depressive and Anxiety Disorders in the United States. Arch Gen Psychiatry. 2001;58:55-61

% Receiving Any treatment for Depression (CIDI)

10.9 11.3

8.18.8

4.3

5.6

10.9

13.8

6.8

17.9

3.4

5.5

15.4

7.2

0

2

4

6

8

10

12

14

16

18

20

High Inc

omeBelg

ium

France

German

y

Israe

l

Italy

Japa

nNeth

erlan

dsNew

Zeala

nd

Spain USALow

Inco

me

ChinaColom

biaSouth

Afri

caUkra

ine

Wang P et al (2007) Lancet 2007; 370: 841–50

n=84,850 face-to-face interviews

=> In physical

% Receiving Any treatment for Mental Health% Receiving Any treatment for Mental Health

7.2

34.6

5.7 6.3 6.4

11.7

19.1

14

8.9

3.9 3.25.7

32.7

5 57.7

11

16.1

6.5 6.2

2.3 1.8

0

5

10

15

20

25

30

35

40

All P

atie

nts

Men

tal Il

l Hea

lth

No

Men

tal Il

l Hea

lthN

o ch

ronic

med

ical

cond

itions

1 ch

ronic

med

ical c

ondi

tion

2 ch

roni

c m

edica

l con

ditio

ns3

chro

nic

med

ical c

ondi

tions

18-4

4 ye

ars

45-6

4 ye

ars

65-7

4 ye

ars

75+

Cancer n=4878

No Cancer n=90,737

Maria Hewitt, Julia H. Rowland Mental Health Service Use Among Adult Cancer Survivors: Analyses of the National Health Interview Survey Journal of Clinical Oncology, Vol 20, Issue 23 (December), 2002: 4581-4590

12mo Service Use 12mo Service Use (NIH, 2002)(NIH, 2002)

Two explanations=>

Audience:

How common are medical co-morbidities in depression?

Comorbid Physical Diagnoses in Elderly Depressed Patients

0

10

20

30

40

50

60

70

80

One Tw o Three+ None

Proctor EK, et al (2003) American Journal of Geriatric Psychiatry;11:329‐38.

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Card

iova

scul

ar d

iseas

eFu

nctio

nal s

omat

ic sy

ndro

mes

Osteoa

rticu

lar di

sord

ers

Neu

rolo

gical

dise

ases

Derm

atol

ogica

l dise

ases

Endo

crin

e dis

orde

rsRe

spira

tory

dise

ases

Dige

stive

dise

ases

: Ulce

r

Urin

ary

tract

dise

ase:

Ren

al lit

hias

is

Any m

edic

al di

sord

er

First Episode MDD (n=6090)

Recurrent Episode MDD (n=4167)

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

Hype

rtens

ion

Osteoa

rthrit

is H

eada

che

Hype

rlipi

dem

ia

Chro

nic fa

tigue

synd

rom

e Ch

ronic

pain

Irr

itabl

e bow

el

Sebo

rrhoe

ic de

rmat

itis

Migra

ine

Disc

her

niat

ion

Diab

etes

Fi

brom

yalg

ia Ec

zem

a Di

gest

ive U

lcer

Asth

ma

Thyr

oid d

iseas

e

COPD

Ps

oria

sis

Rena

l lith

iasis

Acut

e inf

arct

ion

Epile

psy

Park

inso

n

First Episode MDD (n=6090)

Recurrent Episode MDD (n=4167)

Physical Comorbidity in Schizophrenia and Depression

0

5

10

15

20

25

30

35

40H

yper

tens

ion

Chr

onic

bro

nchi

tis

Ast

hma

Dia

bete

s

Ulc

er

Rhe

umat

oid

arth

ritis

Hea

rt c

ondi

tion

Ost

eoar

thrit

is

Any

can

cer

Stro

ke

Emph

ysem

a

Live

r pro

blem

s

Wea

k/fa

iling

kid

neys

Con

gest

ive

hear

tfa

ilure

Myo

card

ial i

nfar

ctio

n

Ang

ina

Cor

onar

y he

art

dise

ase

SchizophreniaDepressionNHANES

Sokal 2004

J Nerv Ment Dis 192: 421–427

NHANES ‐ US Department of Health National Health and Nutrition Examination Survey , 1988 –1994

Prevalence Depression in medical settings

Methodological | Scale vs interview | Current vs 12mo vs lifetime

Cancer | IHD | Stroke

0

1

2

3

4

5

6

7

8

9

10

Isch

emic

hea

rt d

isea

seR

heum

atoi

d ar

thrit

isD

iabe

tes

mel

litus

Pros

tate

can

cer

Hyp

erac

idity

syn

drom

esB

reas

t can

cer

Park

inso

n di

seas

eC

hron

ic lu

ng d

isea

seC

onge

stiv

e he

art f

ailu

reM

oder

ate

pain

Urin

ary

inco

ntin

ence

Seiz

ure

diso

rder

Anx

iety

and

sle

ep d

isor

ders

Psyc

hose

s an

d ag

itatio

nD

epre

ssio

nSe

vere

pai

nB

ipol

ar d

isor

der

Suicide odds ratio

Juurlink (2004) 1354 older individuals who died of suicide in Ontario, CA

0

2

4

6

8

10

12

14

16

18

No disord

er

Conges

tive H

eart Fa

ilure

(n=39

1)Hyp

erten

sion (

n=737

1)Diab

etes (

n=17

94)

Corona

ry Arte

ry Dis (n

=3491

)

CVA (n=7

10)

COPD (n=16

81)

End-Stag

e Ren

al Failu

re (n

=431)

Egede (2007) 12mo prevalence rates from the Data on 30,801 adults from the US 1999 National Health

National Health Interview Survey (NHIS) – CIDI‐SF

Prevalence of depression in Oncology settings

70 studies involving 10,071 individuals;14 countries.16.3% (95% CI = 13.9% to 19.5%)

Mj 15% Mn 19% Adj 20% Anx 10% Dysthymia 3%

Proportion meta-analysis plot [random effects]

0.0 0.3 0.6 0.9

combined 0.1730 (0.1375, 0.2116)

Colon et al (1991) 0.0100 (0.0003, 0.0545)

Massie and Holland (1987) 0.0147 (0.0063, 0.0287)

Hardman et al (1989) 0.0317 (0.0087, 0.0793)

Derogatis et al (1983) 0.0372 (0.0162, 0.0720)

Lansky et al (1985) 0.0455 (0.0291, 0.0676)

Mehnert et al (2007) 0.0472 (0.0175, 0.1000)

Katz et al (2004) 0.0500 (0.0104, 0.1392)

Singer et al (2008) 0.0519 (0.0300, 0.0830)

Sneeuw et al (1994) 0.0540 (0.0367, 0.0761)

Pasacreta et al (1997) 0.0633 (0.0209, 0.1416)

Lee et al (1992) 0.0660 (0.0356, 0.1102)

Reuter and Hart (2001) 0.0761 (0.0422, 0.1244)

Grassi et al (2009) 0.0826 (0.0385, 0.1510)

Grassi et al (1993) 0.0828 (0.0448, 0.1374)

Walker et al (2007) 0.0831 (0.0568, 0.1165)

Kawase et al (2006) 0.0851 (0.0553, 0.1240)

Coyne et al (2004) 0.0885 (0.0433, 0.1567)

Alexander et al (2010) 0.0900 (0.0542, 0.1385)

Love et al (2002) 0.0957 (0.0650, 0.1346)

Ozalp et al (2008) 0.0971 (0.0576, 0.1510)

Morasso et al (2001) 0.0985 (0.0535, 0.1625)

Costantini et al (1999) 0.0985 (0.0535, 0.1625)

Silberfarb et al (1980) 0.1027 (0.0587, 0.1638)

Desai et al (1999) [early] 0.1111 (0.0371, 0.2405)

Morasso et al (1996) 0.1121 (0.0593, 0.1877)

Prieto et al (2002) 0.1227 (0.0825, 0.1735)

Ibbotson et al (1994) 0.1242 (0.0776, 0.1853)

Payne et al (1999) 0.1290 (0.0363, 0.2983)

Kugaya et al (1998) 0.1328 (0.0793, 0.2041)

Alexander et al (1993) 0.1333 (0.0594, 0.2459)

Gandubert et al (2009) 0.1597 (0.1040, 0.2300)

Razavi et al (1990) 0.1667 (0.1189, 0.2241)

Akizuki et al (2005) 0.1797 (0.1376, 0.2283)

Leopold et al (1998) 0.1887 (0.0944, 0.3197)

Devlen et al (1987) 0.1889 (0.1141, 0.2851)

Berard et al (1998) 0.1900 (0.1184, 0.2807)

Joffe et al (1986) 0.1905 (0.0545, 0.4191)

Berard et al (1998) 0.2100 (0.1349, 0.3029)

Maunsell et al (1992) 0.2146 (0.1605, 0.2772)

Grandi et al (1987) 0.2222 (0.0641, 0.4764)

Evans et al (1986) 0.2289 (0.1438, 0.3342)

Spiegel et al (1984) 0.2292 (0.1495, 0.3261)

Golden et al (1991) 0.2308 (0.1353, 0.3519)

Fallowfield et al (1990) 0.2565 (0.2054, 0.3131)

Hosaka and Aoki (1996) 0.2800 (0.1623, 0.4249)

Kathol et al (1990) 0.2961 (0.2248, 0.3754)

Green et al (1998) 0.3125 (0.2417, 0.3904)

Jenkins et al (1991) 0.3182 (0.1386, 0.5487)

Burgess et al (2005) 0.3317 (0.2672, 0.4012)

Hall et al (1999) 0.3722 (0.3139, 0.4333)

Morton et al (1984) 0.3958 (0.2577, 0.5473)

Baile et al (1992) 0.4000 (0.2570, 0.5567)

Passik et al (2001) 0.4167 (0.2907, 0.5512)

Bukberg et al (1984) 0.4194 (0.2951, 0.5515)

Massie et al (1979) 0.4850 (0.4303, 0.5401)

Ciaramella and Poli (2001) 0.4900 (0.3886, 0.5920)

Levine et al (1978) 0.5600 (0.4572, 0.6592)

Plumb & Holland (1981) 0.7750 (0.6679, 0.8609)

proportion (95% confidence interval)

0 20 40 60 80 100

0.0

0.1

0.2

0.3

0.4

Time (months)

Pro

porti

on

Meta regression using the random effects model on raw porportions Estimated slope = - 0.02 % per month (p=0.0016). Circles proportional to study size.

1a. Routine Recognition of Depression

Is depression a disease; disorder (syndrome) or normally distributed

Audience:

Is depression categorical or dimensional?

Graphical – two diseases

Healthy

Stroke# ofIndividualsWith symptom

Ischaemic change on mri

Point of Rarity

Comment: Slide illustrates the concept of discrimination using one symptom severity of “low mood”

Graphical – two disorders

Healthy

Diabetes

# ofIndividualsWith symptom

HBA1c

?Point of Rarity

Optimal cut

Graphical - Dimension

Non-Depressed

Depressed# ofIndividualsWith symptom

Severity of Low Mood

Comment: Slide illustrates added hypothetical distribution of mood scores in a population with hidden depression

0

500

1000

1500

2000

2500

3000

Zero One

TwoThree

Four

Five SixSev

eneig

htNine

TenElevenTwelv

eTh

irtee

nFourte

enFif

teen

SixteenSeve

nteen

Eighteen

HADS-D

1.00

0.64

0.26

0.10

0.00

0.20

0.40

0.60

0.80

1.00

1.20

All visits (N =14,372) Primary care (N =3,605) Psychiatrists (N =293) Medical specialists (N=10,474)

Comment: Slide illustrates added proportion of all depression treated in each setting. Most depression is treated in primary care

J Gen Intern Med. 2006 September; 21(9): 926–930.

Comment: Slide illustrates added actual distribution of mood scores on the HADS in a cancer population with hidden depression from the Edinburgh cancer centre

0

0.05

0.1

0.15

0.2

0.25

0.3

Eight

Nine Ten

Eleven

Twelv

eTh

irtee

nFo

urtee

n

Fiftee

nSixt

een

Seven

teen

Eighteen

Ninetee

n

Twen

tyTw

enty-

one

Proportion MissedProportion Recognized

HADS-D

Recognition from WHO PPGHC Study (Ustun, Goldberg et al)

7470 69.6

61.5 59.656.7 56.7 55.6 54.2

45.7 43.939.7

28.4

22.2 21 19.3

0

10

20

30

40

50

60

70

80

Santia

go

Verona

Manch

ester

Paris

Groningen

Berlin

Seattle

Mainz

TOTALBangalo

reRio de J

aneir

o

Ibadan

Ankara

Athen

sShan

ghaiNagas

aki

Audience:

What are the predictors of improved recognition?

0.03

0.19

0.210.22

0.20

0.05

0.02 0.020.01 0.01

0.010.01 0.01 0.01

0.00

0.05

0.10

0.15

0.20

0.25

5mins

10mins

15mins

20mins

25mins

30mins

35mins

40mins

45mins

50mins

55mins

60mins

65mins

70mins

65%

Geraghty JGIM 2007

Comment: Slide illustrates diagnostic accuracy according to score on DT

11.815.4

30.4 28.9

41.9 42.9 40.7

57.1

82.4

66.771.4

15.8

25.0

26.124.4

19.4 19.0

33.3

21.4

11.8

22.2 14.3

72.4

59.6

43.546.7

38.7 38.1

25.921.4

5.911.1

14.3

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

Zero One Two Three Four Five Six Seven Eight Nine Ten

Judgement = Non-distressedJudgement = UnclearJudgement = Distressed

CNS in Oncology N=401

86.8

55.6 54.4

43.3

36

29.826.2 25.6 25.2 23.8 24

21.4 21.2

13.9 12.89.5

7.2 7 7 5.9 4.8 4.1 2.6 1.8 1.8 1.3 0.9 0.4 0.40

10

20

30

40

50

60

70

80

90

100

Slee

p di

stur

banc

es; in

som

nia;

ear

ly w

aken

ing

Loss

of a

ppet

ite; o

vere

atin

g; w

eigh

t cha

nges

Dep

ress

ed m

ood;

hop

eles

snes

s; s

ad; g

loom

y

Apat

hy; l

etha

rgy;

tire

dnes

s; la

ssitu

de

Loss

of i

nter

est;

with

draw

al; i

ndiff

eren

ce; l

onel

ines

s

Loss

of e

nerg

y; lo

ss o

f driv

e; b

urnt

out

Loss

of l

ibid

o; lo

ss o

f sex

driv

e; im

pote

nce

Tear

s; w

eepi

ng; c

ryin

g

Anxi

ous;

agi

tate

d; ir

ritab

le; r

estle

ss, t

ense

; stre

ssed

Feel

ing

wor

thle

ss; g

uilty

; lac

k of

sel

f est

eem

Som

atic

; veg

etat

ive

sym

ptom

s; m

alai

se; m

ultip

le c

onsu

ltatio

ns

Suic

ide

thou

ghts;

thou

ght o

f sel

f inj

ury

Loss

of c

once

ntra

tion;

poo

r mem

ory,

poo

r thi

nkin

g

Dim

inis

hed

perfo

rman

ce; i

nabi

lity

to c

ope

Emot

iona

l labi

lity;

moo

d sw

ings

Loss

of a

ffect

; fla

t affe

ct; l

oss

of e

mot

ion

Loss

of e

njoy

men

t or p

leas

ure;

lack

of h

umor

Beha

viou

ral p

robl

ems;

agg

ress

iven

ess;

beha

viou

ral c

hang

es

Pess

imis

m; n

egat

ive

attit

udes

, wor

ryin

g

Psyc

hom

otor

reta

rdat

ion;

slow

ness

Hea

dach

es; d

izzi

ness

Appe

aran

ce; s

peec

h; e

xces

sive

sm

iling

; vag

uene

ss, e

tc.

Heav

y us

e of

alc

ohol

, tob

acco

or d

rugs

Del

usio

ns; h

allu

cina

tions

; con

fusi

on

Rea

ctio

n to

pro

babl

e ca

uses

or l

ife e

vent

s

Fam

ily o

r pas

t his

tory

of d

epre

ssio

n

Obs

essi

ve id

eatio

n; p

hobi

asLa

ck o

f ins

ight

Perio

d of

life

(men

opau

se)

Comment: Slide illustrates which symptoms are asked about by GPS looking for depression

What do GPs Ask about:SleepAppetite

LowEnergy

GP Recognizes:Proportion of Individual Symptoms Recognised by GPs

76.1

36.4 34.631.6

21.616.7

13.39.1 8.3 8.3

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

Low m

ood

Insomnia

Hypoc

hondri

asis

Loss

of in

terest

Tearfu

lness

Anxiety

Loss

of en

ergy

Pessim

ism

Anorex

ia

Not Copin

g

O’Conner et al (2001) Depression in primary care.Int Psychogeriatr 13(3) 367-374.

1,2 or 3 Simple QQ15%

Clinical Skills Alone73%

ICD10/DSMIV0%

Short QQ3%

Other/Uncertain9% Other/Uncertain

2%

Use a QQ15%

ICD10/DSMIV13%



Cancer Staff Psychiatrists

Current MethodComment: Slide illustrates preferences of cancer clinicians vs psychiatrists for detecting depression

3. Symptoms of Comorbid Depression

Same or different?Older People?

YesYesGuilt or self-blame

DSMIVICD10Core Symptoms

YesNoSignificant change in weight

YesYesAgitation or slowing of movements

YesYesSuicidal thoughts or acts

NoYesPoor or increased appetite

NoYesLow self-confidence

YesYesPoor concentration or indecisiveness

YesYesDisturbed sleep

YesYes (core) Fatigue or low energy

Yes (core) Yes (core) Loss of interests or pleasure

Yes (core) Yes (core) Persistent sadness or low mood

Symptom Significance in Depression

(7 or) 8 symptoms (3+4)

(5 or )6 symptoms

4 symptoms (2+2)

2 or 3 symptoms

0 or 1 symptom

ICD10

16 - 21UnspecifiedSevere

12 - 155 symptoms (Mj)

Moderate

8 -112-4 symptoms (minor)

Mild

4 - 71 or No core symptoms

Sub-syndromal

0 - 30 symptomHealthy

HADs D ScoreDSMIVDepression Severity

Change in practice – ICD10 2/4/6/8 + CS | DSMIV‐TR Mn => NOS

Symptoms Clinical Significance Duration

ICD-10 Depressive Episode Requires two of the first three symptoms (depressed mood, loss of interest in everyday activities, reduction in energy) plus at least two of the remaining seven symptoms (minimum of four symptoms)

At least some difficulty in continuing with ordinary work and social activities

2 weeks unless symptoms are unusually severe or of rapid onset).

DSM-IV Major Depressive Disorder Requires five or more out of nine symptoms with at least at least one from the first two (depressed mood and loss of interest).

These symptoms cause clinically important distress OR impair work, social or personal functioning.

2 weeks

DSM-IV Minor Depressive Disorder Requires two to four out of nine symptoms with at least at least one from the first two (depressed mood and loss of interest).

These symptoms cause clinically important distress OR impair work, social or personal functioning.

2 weeks

DSM-IV Adjustment disorder Requires the development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s). Once the stressor has terminated, the symptoms do not persist for more than an additional 6 months.

These symptoms cause marked distress that is in excess of what would be expected from exposure to the stressor OR significant impairment in social or occupational (academic) functioning

Acute: if the disturbance lasts less than 6 months Chronic: if the disturbance lasts for 6 months

DSM-IV Dysthymic disorder Requires persistently low mood two (or more) of the following six symptoms:

(1) poor appetite or overeating (2) Insomnia or hypersomnia(3) low energy or fatigue (4) low self-esteem (5) poor concentration or difficulty

making decisions (6) feelings of hopelessness

The symptoms cause clinically significant distress OR impairment in social, occupational, or other important areas of functioning.

Requires depressed mood for most of the day, for most days (by subjective account or observation) for at least 2 years

Audience:

Which of the following are recognized symptoms of MDD

Loss of confidenceLow motivation / driveWithdrawalAvoidanceSocial isolationWorryFeelings of dreadHelplessnessHopelessnessPsychic anxietySomatic anxietyAngerLack of reactive moodCognitive Change (=> memory complaints)Perceptual distortion

Which Are Recognized Symptoms of MDD?

=> plan

ALL

SOME

NONE

UNSURE

“Common” Symptoms of Depression

0.120.56Thoughts of death

0.330.59Psychic anxiety

0.120.61Worthlessness

0.420.69Anxiety

0.270.70Insomnia

0.120.81Diminished interest/pleasure

0.240.82Diminished concentration

0.320.83Sleep disturbance

0.270.87Concentration/indecision

0.320.87Loss of energy

0.300.88Diminished drive

0.180.93Depressed mood

Non-Depressed FrqDepressed FrqItem

Mitchell, Zimmerman et al n=2300

“Uncommon” Symptoms

0.060.16Increased weight

0.060.19Hypersomnia

0.070.19Increased appetite

0.060.22Lack of reactive mood

0.060.23Decreased weight

0.040.28Psychomotor retardation

0.090.34Psychomotor agitation

0.260.44Anger

0.110.45Decreased appetite

0.250.46Somatic anxiety

Non-Depressed ProportionDepressed ProportionItem

Mitchell, Zimmerman et al MIDAS Database. Psychol Med 2009

-0.10

0.00

0.10

0.20

0.30

0.40

0.50A

nger

Anx

iety

Dec

reas

ed a

ppet

ite

Dec

reas

ed w

eigh

t

Dep

ress

ed m

ood

Dim

inis

hed

conc

entr

atio

n

Dim

inis

hed

driv

eD

imin

ishe

d in

tere

st/p

leas

ure

Exce

ssiv

e gu

ilt

Hel

ple

ssne

ss

Hop

eles

snes

s

Hyp

erso

mni

a

Incr

ease

d ap

peti

te

Incr

ease

d w

eigh

t

Inde

cisi

vene

ss

Inso

mni

aLa

ck o

f re

acti

ve m

ood

Loss

of

ener

gy

Psyc

hic

anxi

ety

Psyc

hom

otor

agi

tati

on

Psyc

hom

otor

cha

nge

Psyc

hom

otor

ret

arda

tion

Slee

p di

stur

banc

e

Som

atic

anx

iety

Thou

ghts

of

deat

h

Wor

thle

ssne

ss

Rule-In Added Value (PPV-Prev)Rule-Out Added Value (NPV-Prev)

Comment: Slide illustrates added value of each symptom when diagnosing depression and when identifying non-depressed

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

Depressed Mood

Diminished drive

Diminished interest/pleasure

Loss of energy

Sleep disturbance

Diminished concentration

Sensitivity

1 - Specificity

n=1523

Comment: Slide illustrates summary ROC curve sensitivity/1-specficity plot for each mood symptom

3a. Depression in Older People

Does it go unrecognized?

Are Somatic Symptoms Common in Older People?

Comorbid Physical Diagnoses in Elderly Depressed Patients

0

10

20

30

40

50

60

70

80

One Tw o Three+ None

Proctor EK, et al (2003) American Journal of Geriatric Psychiatry;11:329‐38.

QuestionsMore or less difficult to detect late-life depression?

More or less

Low moodAgitation InsomniaPoor concentration

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

Pre-test Probability

Post

-test

Pro

babi

lity

Routine Case-Finding Late-LifeRoutine Exclusion Late-lifeBaseline ProbabilityRoutine Case-Finding MixedRoutine Exclusion MixedRoutine Case-Finding YoungerRoutine Exclusion Younger

Comment: Slide illustrates detection of late life vs mid-life depression in primary care – GPs are least successful with late-life depression

-0.25

-0.2

-0.15

-0.1

-0.05

0

0.05

0.1

Hel

ples

snes

s

Hop

eles

snes

s

Wor

thle

ssne

ss

Anx

iety

(Som

atic

anx

iety

)

Ang

er

Inde

cisi

vene

ss

Thou

ghts

of D

eath

Dim

inis

hed

Con

cent

ratio

n

Anx

iety

(Com

bine

d)

Incr

ease

d A

ppet

ite

Slee

p D

istu

rban

ce (H

yper

som

nia)

Slee

p D

istu

rban

ce (C

ombi

ned)

Incr

ease

d W

eigh

t

Loss

of E

nerg

y

Psyc

hom

otor

Agi

tatio

n

Anx

iety

(Psy

chic

anx

iety

)

Exce

ssiv

e G

uilt

Dim

inis

hed

Inte

rest

Slee

p D

istu

rban

ce (I

nsom

nia)

Dec

reas

ed A

ppet

ite

Dep

ress

ed M

ood

Psyc

hom

otor

Ret

arda

tion

Dec

reas

ed W

eigh

t

More common in late-life depression

More common in early-life depression

Comment: Slide illustrates simple frequency of symptoms in late life vs mid-life depression

0.000

0.100

0.200

0.300

0.400

0.500

0.600

0.700

0.800

Anger

Anxiety

(Com

bined)

Anxiety

(Psy

chic

anxie

ty)

Anxiety

(Somatic

anxiet

y)

Decre

ased

App

etite

Decre

ased

Weig

ht

Depres

sed M

ood

Diminish

ed C

oncentra

tion

Diminish

ed In

teres

tExc

essiv

e Guilt

Helples

snes

sHope

lessn

ess

Increas

ed A

ppetite

Increas

ed W

eight

Indecisi

venes

sLoss

of Ene

rgy

Psych

omotor Agita

tion

Psych

omotor Retar

datio

n

Sleep D

isturban

ce (C

ombined)

Sleep D

isturban

ce (H

ypers

omnia)

Sleep D

isturban

ce (In

somnia)

Thoughts

of Dea

thWorth

lessn

ess

<55>54>59>64

*

*

*

*

*

**

*

Comment: Slide illustrates diagnostic value of symptoms in late life vs mid-life depression – few have special significance

Mid-life Depression

Late-life Depression

Comment: Slide illustrates actual phenomenology of late life depression

Poor concworthlessness

3b. Comorbid Depression

Back to Basics

Approaches to Somatic Symptoms of DepressionInclusiveUses all of the symptoms of depression, regardless of whether they may or may not be secondary to a physical illness. This approach is used in the Schedule for Affective Disorders and Schizophrenia (SADS) and the Research Diagnostic Criteria.

ExclusiveEliminates somatic symptoms but without substitution. There is concern that this might lower sensitivity. with an increased likelihood of missed cases (false negatives)

EtiologicAssesses the origin of each symptom and only counts a symptom ofdepression if it is clearly not the result of the physical illness. This is proposed by the Structured Clinical Interview for DSM and Diagnostic Interview Schedule (DIS), as well as the DSM-III-R/IV).

SubstitutiveAssumes somatic symptoms are a contaminant and replaces these additional cognitive symptoms. However it is not clear what specific symptoms should be substituted

Medically Unwell Alone

Primary Depression Alone

Secondary Depression

Comment: Slide illustrates concept of phenomenology of depressions in medical disease

FatigueAnorexiaInsomnia

Concentration

Which are the least somatic scales?

Study: Coyne Thombs Mitchell

N= 4500; Pooled database study; All comparative studies

Physical illness+comorbid depressionVsPhysical illness aloneVs

Primary depression alone

Co-morbid Depression vs Primary Depression

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Agitatio

n (Com

orbid)

Agitatio

n (Prim

ary)

Anxiety

(Com

orbid)

Anxiety

(Prim

ary)

Appetite

(Comorb

id)

Appetite

(Prim

ary)

Concen

tratio

n (Comorb

id)

Concen

tratio

n (Prim

ary)

Fatigu

e (Comorb

id)

Fatigu

e (Prim

ary)

Guilt (

Comorbid)

Guilt (

Primar

y)

Hopeles

snes

s (Comorb

id)

Hopeles

snes

s (Prim

ary)

Insomnia

(Comor

bid)

Insomnia

(Prim

ary)

Loss In

teres

t (Comorb

id)

Loss In

teres

t (Prim

ary)

Low Mood (C

omorbid)

Low Mood (P

rimary

)

Retard

ation (

Comorbid)

Retard

ation (

Primary)

Suicide (

Comorbid)

Suicide (

Primar

y)

Weight L

oss (C

omorbid)

Weight L

oss (P

rimary

)

*

*

*

*

*

**

*

*

Comorbid Depression

Primary Depression

n=4069 vs 4982Comment: Slide illustrates similar symptoms profile in comorbid vs primary depression




AgitationRetardation

Co-morbid Depression vs Medical Illness Alone

n= 4069 vs 1217

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Anxiety

(Com

orbid)

Anxiety

(Med

ical)

Concen

tratio

n (Comorb

id)

Concen

tratio

n (Med

ical)

Fatigu

e (Comorb

id)Fati

gue (

Medica

l)

Hopeles

snes

s (Comorb

id)

Hopeles

snes

s (Med

ical)

Insomnia

(any t

ype)

(Comorb

id)

Insomnia

(any t

ype)

(Med

ical)

Loss In

teres

t (Comorb

id)

Loss In

teres

t (Med

ical)

Low Mood (C

omorbid)

Low Mood (M

edical)

Retard

ation (

Comorbid)

Retard

ation (

Medica

l)

Suicide (

Comorbid)

Suicide (

Medica

l)

Weight L

oss (C

omorbid)

Weight L

oss (M

edical)

Worthles

snes

s (Comor

bid)

Worthles

snes

s (Med

ical)

Medical Illness Alone

Comorbid Depression

**

*

*

*

*

*

*

*

Comment: Slide illustrates distinct symptoms profile in comorbid depression vs medical illness alone

Medically Unwell Alone




FatigueAnorexiaInsomnia

Concentration

Medically Unwell

Primary Depression


Comment: Slide illustrates actual phenomenology of depressions in medical disease

Weight loss

AgitationRetardation

-0.2

0

0.2

0.4

0.6

0.8

1

Anhedo

nia

Appetite

decre

ase

Appetite

incre

ase

Decre

ased

activ

ity in

volve

ment

Decre

ased

sexu

al inter

est

Distinct

mood quali

tyFati

gue

Gastro

intes

tinal

symptoms

Hypers

omnia

Impair

ed co

ncentra

tion/at

tention

Insomnia

(Early

morn

ing)

Insomnia

(Middle)

Insomnia

(Ons

et)

Interpers

onal se

nsitivi

ty

Leaden

paral

ysis

Mood (an

xious)

Mood (irr

itable

)Mood (

sad)

Mood rea

ctivit

y impair

ed

Mood vari

ation b

y tim

e of d

ay

Negati

ve outlo

ok (futu

re)

Negati

ve outlo

ok (se

lf)

Panic

or phobic

symptoms

Psych

omotor agit

ation

Psych

omotor slow

ing

Somatic c

omplaint

s

Suicidal

ideatio

n

Sympath

etic ar

ousal

Weight d

ecrea

se

Weight in

creas

e

Rate in Depressed+MedicalRate in Depression AloneDifferential

-10

-5

0

5

10

15

Lead

en p

aral

ysis

Gas

troi

ntes

tinal

sym

ptom

sSy

mpa

thet

ic a

rous

alSo

mat

ic c

ompl

aint

sIn

som

nia

(Mid

dle)

Moo

d (ir

rita

ble)

Inso

mni

a (E

arly

mor

ning

)Ps

ycho

mot

or a

gita

tion

Psyc

hom

otor

slo

win

gIn

som

nia

(Ons

et)

Fatig

ueW

eigh

t dec

reas

eA

ppet

ite d

ecre

ase

Pani

c or

pho

bic

sym

ptom

sA

ppet

ite in

crea

seW

eigh

t inc

reas

eN

egat

ive

outlo

ok (f

utur

e)D

ecre

ased

act

ivity

invo

lvem

ent

Anh

edon

iaSu

icid

al id

eatio

nD

ecre

ased

sex

ual i

nter

est

Moo

d (a

nxio

us)

Dis

tinct

moo

d qu

ality

Moo

d re

activ

ity im

pair

edM

ood

(sad

)Im

paire

d co

ncen

trat

ion/

atte

ntio

nM

ood

varia

tion

by ti

me

of d

ayN

egat

ive

outlo

ok (s

elf)

Inte

rper

sona

l sen

sitiv

ityH

yper

som

nia

More common inComorbid Depressions

Less common in Comorbid Depressions

4. Conventional Screening (in medical settings)

MethodsAccuracy

Observation

Interview

Visual

Self-Report

MoodScreening

DISCS

VA-SES

ET/DT

HAMD-D17

PhysicalGeneral

Signs ofDS

6

CDSS#10

MADRAS10

Trained

ConfidentSkilledClinician

Alone

YALE

SMILEY

=> Is it accurate?



ICD10/DSMIV0%

Short QQ3%

Other/Uncertain9%

Methods to Evaluate Depression

Unassisted Clinician Conventional Scales

Verbal Questions Visual-Analogue Test

PHQ2

WHO-5

Whooley/NICE

Distress Thermometer

Depression Thermometer

Ultra-Short (<5) Short (5-10) Long (10+) Untrained Trained


Clinical Skills Alone

73%

ICD10/DSMIV0%

Short QQ3%

Other/Uncertain9%


Clinical Skills Alone

73%

ICD10/DSMIV0%

Short QQ3%

Other/Uncertain9%

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1


Pos

t-tes

t Pro

babi

lity

Clinician Positive (Fallowfield et al, 2001)

Clinician Negative (Fallowfield et al, 2001)

Baseline Probability

HADS-D Positive (Mata-analysis)

HADS-D Negative (Meta-analysis)

Comment: Slide illustrates Bayesian curve comparison from indirect studies of clinician and HADS

This illustrates POTENTIAL gain from screening

Gain?

Benefit

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1


Pos

t-tes

t Pro

babi

lity HADS+

HADS-


GDS30+

GDS30-

GDS15+

GHQ28+

HDRS+

ZUNG+

GDS15-

GHQ28-

HDRS-

ZUNG-

PHQ9+

PHQ9-

WHOOLEY2Q+

WHOOLEY2Q-

BDI+

BDI-

BDI-SF+

BDI-SF-

CESD+

CESD-

1Q+

1Q-

GHQ12+

GHQ12-

PHQ2 = HIGH NPV

Comment: Slide illustrates actual gain in meta-analysis of screening implementation in primary care

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1


Post

-test

Pro

babi

lity

Clinical+Clinical-Baseline ProbabilityScreen+Screen-

Comment: Slide illustrates Bayesian curve comparison from RCT studies of clinician with and without screening

This illustrates ACTUAL gain from screening in Study from Christensen

5. Enhanced Detection Strategies

Acceptability

Algorithm

Not just depression

Distress Thermometer

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1


Post

-test

Pro

babi

lity

DT+ [N=4]DT+ [N=4]Baseline Probability1Q+ [N=4]1Q- [N=4]2Q+2Q-DT/IT+DT/IT-HADST+ [N=13]HADST+ [N=13]PDI+PDI-

Mitchell AJ. Short Screening Tools for Cancer Related Distress A Review and Diagnostic Validity Meta-analysis JNCI (2010) in press

Distress

Proportion

18 .4 %

12 .9 %

11.2 %12 .3 %

8 .1%

11.9 %

5.0 %

2 .8 % 2 .6 %

7.7% 7.2 %

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

20.0%

Zero One Two Three Four Five Six Seven Eight Nine Ten

Insignificant SevereModerateMildMinimal

50%

8%

DT37%

DepT23%

AngT18%

AnxT47%

4%

7%

1%

1%

9%

3%

0%

2%

4%

15%

3%

2%

Nil41%

Non-Nil59%

DT

AnxT AngT

DepT

=86.4% =82.2%

=57.6%Beals AGP 2004

18%

DepT23%

Distress69%

Dysfunction76%

0.3%

3% 2%

26%28% 22%

Of the 293 Non-Nil

DysfunctionDistress

DepT

0.80

0.69

0.62

0.50

0.410.43

0.32

0.25

0.33

0.27

0.20

0.18

0.31

0.31

0.47

0.48

0.40

0.40 0.53

0.50

0.45

0.40

0.01

0.00

0.08

0.03

0.07

0.11

0.280.19

0.17

0.18

0.20

0.020.00 0.00 0.00

0.040.06

0.000.03

0.00

0.09

0.20

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Zero One Tw o Three Four Five Six Seven Eight Nine Ten

3=Extremely Difficult”

2=Very Difficult

1=Somewhat Difficult

Unimpaired

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1


Pos

t-tes

t Pro

babi

lity


HADSd+

HADSd-

HADS-T+

HADS-T-

HADS-A+

HASD-A-

Depression_HADS

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1


Post

-test

Pro

babi

lity

1Q+1Q-Baseline ProbabilityDT+DT-2Q+2Q-HADSd+HADSd-HADS-T+HADS-T-BDI+BDI-EPDS+EPDS-HADS-A+HASD-A-

Depression_all

SummaryQuestions

rcpsych workshop - depression in medical settings (mar11)

Health & Medicine

noneproctor

clinically

slide illustrates

recurrent

comorbid physical

slide illustrates

episode mdd

geriatric