Recognizing and Treating Depression: An Imperative for ObstetricianGynecologists

1
Recognizing and Treating Depression An
Imperative for Obstetrician/Gynecologists
Lee A. Learman, MD, PhD, Ronald A. Chez, MD,
Martha Gerrity, MD,PhD, Lisa Bernard, MD, and
Nada L. Stotland, MD Supported by the Initiative
on Depression and Primary Care of the John D. and
Catherine T. MacArthur Foundation Adapted, in
part, from Cole S, Raju M, Barrett J, et al The
MacArthur Foundation Depression Education Program
for Primary Care General Hospital Psychiatry ( in
press)
2
Lecture Objectives

• Impact epidemiology and consequences
• Barriers to diagnosis
• Forms of depression in women
• Diagnostic criteria and assessment
• Management options
• Follow-up strategy

3
A Common Disease

• 10 of primary care adult patients
• 3x visits as non-depressed patients
• Occurs in all demographic groups
• Occurs in women 2x men
• 20 lifetime incidence
• 50 age 25-44 years

4
A Morbid Disease

• Disruptive and burdensome
• major risk factor for suicide
• increased morbidity and mortality from
• medical conditions
• increased disability, days in bed, impaired
• function
• disruptive of family, job, social functioning
• recurrent and chronic in 50 of patients

5
Depression In Perspective

• More disability days than any other chronic
  condition except advanced CAD
• More chronic pain than any other chronic disease
  except arthritis
• WHO the 2nd most important cause worldwide
• of life years lost to disability (2020)
• 31.3 billion/year in the United States (1990)

6
Rarely Recognized Or Treated

• Under-recognized
• 80 of patients are undiagnosed
• only 20 of patients receive treatment
• 80 of patients respond to treatment
• Thus, universal screening is necessary

7
Barriers To Making A Diagnosis

• Patients
• resistance to diagnosis of a mental disorder
• belief it is natural to be depressed sometimes
• belief they can will themselves well

8
Barriers To Making A Diagnosis

• Physician
• difficulty distinguishing normal sadness from
  depression
• failure to recognize somatization
• discomfort with emotional issues
• label etiology as organic or hormone related
• concern that assessment is time-consuming
• difficulties in obtaining a referral

9
Suspect The Diagnosis

• Clinical presentations
• multiple visits for vague complaints
• voice, facial expression, posture suggesting
• sadness
• pain syndromes vulva, pelvic, vagina,
• menses, coitus, urinary tract
• clinician's sense of sadness during/after visit

10
Cultural Differences

• Under treatment of depression is more
• pronounced among African-Americans,
• Latinas and Asian-Americans
• Whites may have more mood and anxiety
• symptoms, African-Americans more diurnal
• variation in symptoms, and Latinas more
• physical symptoms
• Screening tools appear to work equally well

11
Forms Of Depression In Women

• Unipolar forms
• major depressive disorder
• chronic depression (dysthymia)
• Bipolar mood disorder (manic-depression)
• Other distinct syndromes in women
• eating disorders
• premenstrual dysphoric disorder (PMDD)
• postpartum mood disorders
• Grief/adjustment reactions (minor depression)

12
Premenstrual Dysphoric Disorder

• 5 of women, typical age 18-30 years
• Symptoms last 5-14 days, luteal pattern
• Must abate at onset of menses
• Symptoms depression, anxiety, emotional
• lability, tension, irritability, anger,
  sleep
• and appetite disturbances
• Lifetime morbidity totals to 3-8 years
• Rx with SSRIs

13
Postpartum Mood Disorders
14
Grief Reactions

• May last up to 2 years after loss or event
• Usually falls short of criteria for major
  depression
• Rarely causes prolonged impairment in work
• and other activities
• Cyclicity is common in days, weeks, months
• If functional impairment, SSRI Rx for 30 days

15
Focus On Unipolar Depression

• Major depressive disorder
• mild
• moderate
• severe
• Chronic depression dysthymia

16
Criteria For Major Depression

• Symptoms should be present
• most days
• most of the day
• for at least 2 weeks

17
Screening With 2 Questions

• Depression is present if 1 or both present
• In the past month have you been often bothered
  by. . .
• . . . depressed mood?
• . . . lack of interest or
  pleasure?

Whooley MA, Avins AL, Miranda J, Browner WS.
Case-finding instruments for depression Two
questions are as good as many. J Gen Int Med
199712439-445.
18
DSMIV Criteria For Major Depression

• At least five of nine symptoms
• depressed mood and/or anhedonia (required)
• low self-esteem
• sleep disturbance
• change in appetite or weight
• difficulty concentrating
• fatigue, loss of energy
• psychomotor agitation or retardation
• recurrent thoughts of death or suicide

19
Depressive Symptoms How To Ask

• Required symptoms (one or both)
• depressed mood
• patient may not recognize
• may not be present
• "How's your mood been lately?"
• anhedonia
• loss of interest or pleasure
• lack of enjoyment in most daily activities
• "What have you enjoyed doing lately?"
• "Are you getting less pleasure in things you
  
• typically enjoy?"

20
Depressive Symptoms How To Ask

• Other symptoms
• "Have you been feeling down on yourself?"
• "How are you eating sleeping?
• "How's your energy level?"
• "Do you ever feel like life is not worth living?"
• "How's your concentration?"

21
Criteria For Chronic Depression

• Dysthymia
• 2 years of depressed mood present most days
• accompanied with 2 or more symptoms of
• depression
• a major depressive episode has not occurred

22
Rule Out Initiating Factors

• General medical illness
• diabetes, hypothyroidism
• Substance abuse
• Medication side effects
• reserpine, propranolol, alpha-methyldopa
• glucocorticoids
• amphetamine withdrawal
• Acute grief and mourning

23
Suicide Risk Assessment

• Screen every patient suspected of depression
• Asking does not insult patient or initiate
  thought
• Ask direct questions
• "Have you had thoughts of hurting yourself?"
• "Do you sometimes wish your life was over?"
• "Have you had thoughts of ending your life?"

24
Suicide Risk Assessment

• If yes, assess immediate risk
• "Do you feel that way now?
• "Do you have a plan?"
• "Do you have the means to carry out your plan?
• "Do you promise to call me immediately if your
• suicidal thoughts get stronger?

25
? Suicide Risk

• Obtain emergency psychiatric assessment
• when in doubt
• psychosis is present
• presence of substance abuse
• presence of specific plan or strong impulse
• lack of sufficient social support
• unsafe living situation

26
Treatment Of Major Depression

• Components
• psychotherapy
• psychopharmacotherapy
• psychosocial interventions

27
Effective Communication

• Create a productive dialogue by
• listening
• facilitating psychosocial discussion
• responding to emotions
• Educate patient and family about depression
• a common medical illness
• not a character defect or weakness
• successful treatment is available

28
Mental Health Referral

• Indications
• diagnostic consultation
• bipolar disorder
• comorbid psychiatric condition
• need for involuntary commitment
• dangerous to self, suicidal
• unable to care for self
• concern about family safety

29
Mental Health Referral

• Indications
• current substance abuse including alcohol
• current psychiatric medications
• patient request
• need for psychotherapy
• partial or failure to respond to medications
• inconsistent use of medicines
• return of symptoms after positive response

30
Mental Health Referral

• Setting the stage for acceptance
• explain the basis for recommendation
• review signs and symptoms of concern
• identify limitation of clinical expertise
• stress you will remain involved in patient's
• care
• reassure patient depression is an illness
• relatively common
• not crazy or to blame

31
Treatment

• Psychotherapy
• mild depression monotherapy okay
• moderate depression monotherapy okay
• severe depression useful adjunct
• interpersonal conflicts useful
• life transitions useful
• dysthymia possibly effective

32
Treatment

• Pharmacotherapy popular and effective
• major depression
• dysthymia
• postpartum depression
• premenstrual dysphoric disorder
• grief reactions

33
Antidepressants An Abbreviated List

• SSRIs
• fluoxetine ProzacR
• paroxetine PaxilR
• sertraline ZoloftR
• Bupropion WellbutrinR

34
Choosing An Antidepressant

• Patient's previous experience with medication
• Drug characteristics
• half life ProzacR PaxilR ZoloftR
  WellbutrinR
• dosing schedule qd, bid
• side effects
• cost (health plan vs. out-of-pocket)
• physician's previous experience
• Concurrent nonpsychiatric medical illness
• Concomitant use of non-Rx, Rx, herbals

35
Safety Of Drugs In Pregnancy

• Include the patient in decision-making
• overall well-being
• quality of life
• ability to function, attend prenatal visits
• Safety profile of drug
• ProzacR, ZoloftR, PaxilR are category C
• WellbutrinR is category B
• most human data are for Prozac
• no increased risk of anomalies

36
Safety Of Drugs Lactation

• Pregnant and lactating women are excluded from
  controlled trials of new drugs
• SSRIs and WellbutrinR are present in breast milk
• limited data on newborn impact
• Include the patient in decision-making

37
Herbals

• St John's wort (hypericum perforatum)
• mild antidepressant, sedation, anxiolysis
• active ingredient hyperforin
• inactive ingredient hypericin
• more effective than placebo for mild to
  moderate depression
• photosensitization at excessive dosing
• cytochrome P450 metabolism

38
Drug Interactions

• PaxilR ProzacR ZoloftR in P450 inhibition
• Common interactions
• codeine, dextromethorphan 4sibutramine
• anticonvulsants 4alprazolam
• tricyclic antidepressants 4digoxin
• beta-blockers 4ketoconazole
• calcium channel blockers 4erythromycin
• type1C anti-arrhythmic agents4coumadin

39
Daily Dosing Of SSRIs

• Start Elderly Increments Maximum
• ProzacR 20 mg 10 mg 2-4 weeks 80 mg
• PaxilR 20 mg 10 mg 2-4 weeks 50
  mg
• ZoloftR 50 mg 25 mg 2-4 weeks 200
  mg

40
Wellbutrin SRR

• Dosing
• start at 75 mg bid for 1 week
• increase dose every 2-4 weeks prn
• do not exceed 150 mg in one dose
• maximum dosing 150 mg tid
• avoid use if risk of seizures

41
Pharmacotherapy

• Guidelines
• optimal effect may take 4-6 weeks
• titrate agent to achieve therapeutic dose
• if no response by 6 weeks, switch agents
• if partial response at maximum dose,
• obtain consultation
• treat for 6-12 months

42
Promoting Adherence

• Identify patient's experience with prior
  medications
• Explain
• 4-6 weeks for medication effect
• most adverse side effects abate in 2-4 weeks
• need to take daily
• need to take even when feeling better
• need to keep follow up appointments
• do not stop without calling physician
• Provide written educational materials

43
SSRIs Side Effects

• Agitation/insomnia ProzacR ZoloftR PaxilR
• add sedative or hypnotic
• Gastrointestinal distress
• take medication after meals
• Sedation
• take medication at bedtime

44
SSRIs Side Effects

• Anticholinergic effects
• hydration
• add bulk to diet, hard candy
• Postural hypotension
• hydration
• change positions slowly
• support hose
• Sexual dysfunction
• switch to WellbutrinR

45
NEW AGENTS

• SNaRIs, NaSSAs, NaRIs
• more rapid onset of action
• greater specificity decreased side effects
• sexual dysfunction
• weight gain
• sleep disturbances
• anergia and fatigue
• drug-drug interactions
• broaden choice and increase individualization
• Kent Lancet 2000

46
NEW AGENTS

• SNaRIs serotonin noradrenergic reuptake
• inhibitor
• venlafaxine (Effexor)
• nefazodone (Sexone, Dutonin, Defador)
• NaSSAs increase noradrenergic, serotonergic
• transmission
• mirtazapine (Remeron)
• NaRIs selective noradrenaline reuptake
  inhibitor
• reboxetine (Edronax, Vestra, Prolift)
• Kent Lancet 2000

47
Adjunctive Interventions

• Behavioral S-P-E-A-K
• Schedule regular weekly activities
• engage in Pleasant activities
• Exercise
• practice Assertive direct communication
• and behavior
• think Kind thoughts about yourself

48
Adjunctive Interventions

• Psychosocial
• assess for adverse personal relationships
• assess family and community support
• consider self-help groups
• pursue watchful waiting with periodic follow up

49
Follow Up

• Phone call in 3 days to assess side effects
• 1,2 or 4 weeks according to severity
• phone can be used to titrate dose
• use flow sheet to score symptoms
• Remission normal psychosocial functioning
• Maintain effective dose for 6-12 months
• Consider role of prophylactic maintenance Rx
• if current episode is a relapse

50
Partial Or No Response

• Effect should be present by 6 weeks
• Assess for adherence to daily dosing
• Re-evaluate diagnosis
• other psychiatric disorders
• substance abuse
• organic disorder
• Adjust dosage or change medication
• Refer to a psychiatrist

51
System Requirements

• Psychiatric emergency services
• Specific names and phone numbers
• psychiatrist
• psychologist
• psychiatric social worker
• List of reimbursed medications and cost to the
  patient
• Appropriate health education materials

52
Conclusions

• Depression is a chronic, recurrent disease
• Depression is common in women
• Many women suffer needlessly because their
  depression is not diagnosed and treated
• Diagnosing depression is straightforward
• Antidepressant treatment is effective and
  practical
• Ob/Gyns should take the lead in recognizing and
  treating depression in women