Diagnosing depression in primary care

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Diagnosing depression in primary care

• LTC Michael J. Roy, MD MPH
• Associate Professor of Medicine
• Uniformed Services University

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Learning Objectives

• Prevalence of depression in primary care
• Consequences of undiagnosed and untreated
  depression
• Presentations of depression in primary care
• Diagnostic criteria for depression
• Depression, diabetes other comorbidities
• Tools for screening, diagnosis of mental
  disorders in primary care

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Mental disorders in primary care

• 25 of patients have a mental disorder
• 88 of patients with mental disorder seek primary
  care first
• Diagnosis missed half the time for depression,
  more for eating disorders and alcoholism

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Depression usually untreated or undertreated in
Primary Care
Treated Appropriately (only 1/6)
Untreated
Undertreated
Hirschfeld et al. JAMA. 1997277333-340.
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Obstacles to diagnosis

• Insufficient training
• Insufficient time
• Presentation with
• somatic symptoms
• Competing
• problems
• Stigmatization
• Minimization

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Presentation influences psychiatric diagnosis in
primary care
Presenting Complaint
Correct Diagnosis
94
83
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Patients with Psychiatric Disorders ()
Correct Diagnosis ()
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N500
Bridges KW, Goldberg DP. J Psychosom Res.
198529563-569.
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Physical complaints are rarely organic
3-Year Incidence ()
Back Pain
Dizziness
Chest Pain
Fatigue
Head- ache
Edema
Insomnia
Abdom- inal Pain
Numb- ness
Dyspnea
Kroenke K, Mangelsdorff AD. Am J Med.
198986262-266.
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Mental disorders diagnosed treated in primary
care
100 80 60 40 20 0
60.1
56.7
47.5
Regier 1978
Schurman 1985
Borus 1985
Regier et al. Arch Gen Psychiatry.
197835685-693. Schurman et al. Arch Gen
Psychiatry. 19854289-94. Borus et al. Gen
Hosp Psychiatry. 198810317-321.
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The Burden of Depression
Total costs 44 billion per year in 1990
dollars Direct costs 12.4 billion per year in
1990 dollars
Direct Costs
Absenteeism
25
27
3
Pharmaceuticals
17
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Reduced Productivity
Mortality
Greenberg et al. J Clin Psychiatry.
199354405-418.
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The Personal Price of Depression

• Mental anguish
• Poor physical functioning
• Poor social andoccupational functioning
• Pain, somatic symptoms
• Family frustration
• Suicide and other mortality risks

Wells et al. JAMA. 1989262914-919.
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The Personal Price of Depression

• To most of us who have experienced it, the
  horror of depression is so overwhelming as to be
  quite beyond expression. . . it kills in many
  instances because its anguish can no longer be
  borne.

Styron. Darkness Visible A Memoir of Madness.
1990.
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The Medical Model of Depression
Hollister LE. Antidepressant agents. In Katzung
BG, ed. Basic Clinical Pharmacology. New York,
NY McGraw-Hill 1997.
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Depression in the Human Brain
Major Depression and Brain Glucose Metabolism
Before treatment
After treatment
Baxter et al, UCLA School of Medicine.
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Differentiating the Types of Depression

• Major depressive disorder (single episode,
  recurrent, chronic)
• Dysthymia (low-grade chronic depression, for at
  least 2 years)
• Bipolar disorder (manic depression)
• Depressive disorder due to a general medical
  condition, medication, or other drug

(DSM-IV). 1994. Depression Guideline Panel.
Depression in Primary Care. Agency for Health
Care Policy and Research 1993.
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Diagnostic Criteria for Major Depressive Disorder

• Five or more of the following for at least 2
  weeks
• Depressed mood
• Loss of interest or pleasure
• Appetite/weight change
• Sleep disturbance
• Psychomotor disturbance
• Fatigue or low energy
• Feelings of worthlessness or inappropriate guilt
• Impaired ability to think or concentrate
• Recurrent thoughts of death or suicide

At least one of these symptoms must be present.
Adapted from Diagnostic and Statistical Manual of
Mental Disorders. 4th ed. (DSM-IV). 1994327,
339.
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Risk Factors for depression

• Family History
• Depression
• Bipolar disorder
• Alcohol abuse
• Other psychiatric illness
• Patient History
• Age of onset of depression
• Gender
• Periods of significant depression in the past
• Previous episodes of other psychiatric
  disorder(s)
• Previous treatments

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Differential diagnosis of depression

• Rule out underlying medical conditions (eg, CNS
  disease, hypothyroidism)
• Rule out medications causing depression
• Screen for substance abuse

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Depression and Comorbidity
Prevalence of Depressionas a Concomitant
Condition

• Cancer 25
• Diabetes 32.5
• Postpartum 1020
• Poststroke 32
• Post-myocardial infarction 16

Massie, Holland. J Clin Psychiatry, 1990.
Lustman et al. Diabetes Care, 1988. Dobie and
Walker. J Am Board Fam Pract, 1992. Morris et
al. Int J Psychiatry Med, 1990. Frasure-Smith
et al. Circulation, 1995.
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Diabetes Mellitus
RR2.2
RR2
Major Depression
RR3
Bipolar
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Potential Explanations

• Depression as reaction to DM?
• But, depression often precedes Type II DM
• Depressionmetabolic changesDM?
• Common neuroendocrine pathway?
• Medication or lifestyle induced?

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Metabolic change

• ...a surplus of insulin antagonists are present
  during severe depressions. These include
  epinephrine, growth hormone, and cortisol.
• ... poor metabolic control was demonstrated by
  the psychiatrically ill group, both at index and
  follow-up evaluations."

Lustman et al, 1988
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Neuroendocrine abnormality

• Dysregulation of hypothalamic-pituitary
• -adrenocortical (HPA) axis activity
• seen in both diabetes and depression
• Evidenced by increased urinary-free cortisol
  outputs and dexamethasone test nonsuppression

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Medication Effects

• Antidepressants and antipsychotics can affect
  glycemic control
• Consider both therapeutic and life-threatening
  effects
• May require adjusting dose of insulin or oral
  agents for diabetes
• May influence choice of medication when treating
  mood disorder or neuropathy

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Antidepressants

• Tricyclics increase appetite glucose levels
  while reducing insulin levels in diabetics and
  non-diabetics
• Selective serotonin re-uptake inhibitors (SSRIs)
  tend to improve glycemic control, may lead to
  the need to reduce insulin or oral medication
  doses

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SSRIs

• Sertraline and citalopram
• fewest drug interactions
• preliminary studies show improvement in diabetic
  neuropathic pain
• Fluoxetine
• long half-life
• May precipitate mania in bipolar patients
• Paroxetine may cause weight gain

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Weight Gain
Significantly more weight gain occurred with
paroxetine Than with sertraline or fluoxetine
Faye et al. J Clin Psychiatry 2000
Fluoxetine
Paroxetine
Sertraline
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Antipsychotics

• Phenothiazines can induce hyperglycemia in
  diabetics and nondiabetics
• Butyrophenones (e.g. haloperidol) do not
• Novel or atypical antipsychotics clozapine and
  olanzapine have been associated with new-onset
  diabetes, exacerbation of hyperglycemia in
  diabetics, and extreme weight gain. Quetiapine,
  Ziprasidone, and Risperidone have not

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Screening Instruments

• What are the ideal features?
• Brief, compatible with time constraints
• Easy to administer inexpensive
• Makes accurate diagnoses
• Educates the provider
• Educates the patient/fosters realization
• Overcomes stigmatization
• Associated with improved outcomes

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Early Instruments

• General Health Questionnaire
• Hopkins Symptom Checklist
• Multiple versions, most w/ many questions
• Elicit symptoms of distress, not diagnoses

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15-20 item depression screens

• Beck Depr Inventory
• Zung Self-Assessment Depression Scale (SDS)
• Center for Epidemiologic Studies Depression
  Screen (CES-D)
• MOS-D (8-item)

• Focused on depression
• However, detect hassles, stress, and distress
  more than specific diagnoses
• MOS-D has less items but requires calculator
• Time constraints limit use

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Short instruments for depression

• SDDS five questions
• Original PRIME-MD 2 questions
• During the past month, have you
• Often been bothered by feeling down, depressed,
  or hopeless?
• Had little interest or pleasure in doing things?
• Sensitivity 86-96, specificity 57-75,
  comparable to more cumbersome measures

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More about the PRIME-MD

• Validated in urban rural primary care,
  academic centers
• PQ one-page patient questionnaire
• CEG Clinician Evaluation Guide
• Questions based on DSM criteria for mental
  disorders
• Ask if positive responses on PQ
• MDs ID 2X as many mental disorders
• Time consuming if lots of positives

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Utility of original PRIME-MD

• Widely used in research studies
• Less use in clinical settings
• Average patient visit
• Average time to complete PRIME-MD 8.4 minutes
• Need for a tool that takes less provider time

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PRIME MD TODAY?

• Validated in 3000 primary care 3000 OB/GYN
  patients
• Entirely self-administered by patients
• Provider can scan the document quickly to discern
  which DSM-IV diagnoses are met
• Accuracy (85) comparable to PQ/CEG
• 75 sensitivity 90 specificity
• WRAMC demonstrates same site validity

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Clinician Time Requirements
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PRIME MD TODAY?Questionnaire Categories

• Brief PHQ (2 pages)

• PHQ (4 pages)

• All Brief PHQ categories
• Other anxiety syndrome
• Somatoform disorder
• Bulimia nervosa
• Binge-eating disorder
• Alcohol abuse

• Major depressive syndrome
• Other depressive syndrome
• Panic syndrome
• Functional impairment
• Psychosocial stressors
• Womens reproductive health

PHQ Patient Health Questionnaire
Spitzer et al. PRIME-MD. 19951-14. Spitzer et
al. PRIME MD TODAY. 1999.
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PRIME MD TODAY? Quick Guide

• Interprets the questionnaire
• Explains the FOR OFFICE CODING section
• Aids in making a diagnosis
• Physician verification is recommended
• Additional clinical considerations for the
  physician
• Stressors, duration, current treatment,
• level of impairment, patient/family history

Spitzer et al. PRIME MD TODAY. 1999.
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PRIME MD TODAY? Scoring

• 2. Over the last 4 weeks, how often have you been
  bothered by the following problems?

Not Several More than at all days half the days
a. Feeling nervous, anxious, on edge . .
. b. Feeling restless . . . c. Getting tired very
easily . . . d. Muscle tension, aches, or
soreness . . . e. Trouble falling asleep or
staying asleep . . . f. Trouble concentrating . .
. g. Becoming easily annoyed or irritated . . .
FOR OFFICE CODING Other anxiety syndrome if 2a
and answers to three or more of 2bg are More
than half the days.
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Somatoform disorders

• Reduces stigma by starting with somatic symptoms
• Requires physician judgment regarding medical
  explanation for symptoms
• Makes diagnosis of Multi-somatoform disorder
  rather than undifferentiated somatoform or
  somatization disorders
• Symptom count most critical predictor

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Treatment of somatization?
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Depressive disorders

• 9 questions, based on DSM-IV criteria for major
  depression
• Asks for frequency over past 2 weeks not at all,
  several days, more than half the days, or nearly
  every day
• Makes subthreshold diagnosis with lower symptom
  count
• Physicians missed half the diagnoses

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Anxiety Disorders

• Panic syndrome based on anxiety attacks, with
  symptom list from DSM-IV, but frequency not
  obtained
• Other anxiety syndrome based on DSM-IV criteria
  for Generalized Anxiety Disorder, though focused
  on past 4 weeks rather than 6 months

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Eating disorders

• Enables diagnosis of bulimia nervosa and binge
  eating disorder, starting with
• Often cant control what or how much eaten
• Often eat unusually large amount in 2-hr period
• Physician rarely makes diagnosis (10)
• PRIME MD TODAY? has high sensitivity
• Binge eating six times more common

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Alcoholism

• CAGE on original replaced by
• Drank even after MD suggested health problem
• Drinking or hung over for work or school
• Missed or late for work/school/other activities
• Problems with others while drinking
• Drove after several drinks
• Lower sensitivity vs. CAGE (62 vs 81)
• 78 missed by physicians

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Global self-assessment
Percentage with diagnosis

• How difficult have these problems made it for
  you to do your work, take care of things at home,
  or get along with other people?

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PRIME MD TODAY? Discussing Results With
Patients

• Review questionnaire results with patient
• Explain
• You are not alone this illness affects many
  people.
• Depression/anxiety is a medical illness.
• Physical symptomslike yoursare common in ...
• is a medical illness like hypertension or
  diabetesnot a character defect or weakness.
• Effective treatment is available.

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Physicians Impressions of PRIME MD TODAY?

• 87 call it very or somewhat useful in management
  and treatment process
• 80 report it would like it given
• To all new patients
• To all patients who hadnt done it in 1 year
• To any patient for whom it seemed indicated
• Half admitted they only occasionally asked
  patients about such diagnostic symptoms

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Patients impressions of PRIME MD TODAY?

• 89 believed questions were very or somewhat
  helpful in getting their physicians to better
  understand or treat their problems

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PRIME MD TODAY? limitations

• Not perfectif high index of suspicion, ask more
• Easier to do, easier to ignore
• Less impact on MD behavior than original
• Asking questions may increase physician
  involvement, attention, and effectivenesshowever
  this is in comparison to physicians involved in
  study, not in routine practice where PHQ is
  easier to use

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Personal impressions

• Frequent use of any instrument can lead to
  incorporation of changes in practice
• Still great utility in demonstrating to patient
  significance of symptoms/diagnoses
• Inclusion of subthreshold diagnoses is critical
  in primary care
• Even greater attention could be played to
  overlap syndromes

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When you cant do it alone
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Referral Criteria

• Bipolar disorders
• Psychotic features
• Suicidality
• Good therapy candidates
• High level of insight
• Issues uncovered but insufficient time to address
  adequately

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First-Year Predictors of Suicide

• Anxiety-related symptoms of panic attacks
• Psychic anxiety
• Global insomnia
• Diminished concentration
• Alcohol abuse
• Anhedonia

Fawcett et al. Am J Psychiatry.
19901471189-1194.
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Assessing Suicidal IdeationWith PRIME MD TODAY?

• Studies show that more than 70 of suicide
  victims visit a physician within 2 months
  preceding their death

Over the last 2 weeks, how often have you been
bothered by thoughts that you would be better off
dead, or of hurting yourself in some way? If
the answer is yes Tell me about it.
Spitzer et al. JAMA. 19942721749-1756.
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Suicidal Potential

• Evaluate suicidal potential if during evaluation
  patient admits to suicidal ideation by
  considering
• Degree of hopelessness about situation
• Any reason to stay alive (eg, for children)
• Thoughts of a specific method of suicide
• Personal or family history of suicide attempts
• If there is significant suicidal potential refer
  to psychiatrist

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Key Points

• Screening can be simple
• PRIME MD TODAY? makes confirmation of diagnosis
  easy
• Diagnoses missed half the time or more
• Subthreshold disorders more common, account for
  greater disability in population
• High prevalence and associated disability make
  strong argument for routine screening

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Questions?