Major Depressive Disorder

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Major Depressive Disorder

• A clinical review
• Barry J. Fenton, M.D.

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(No Transcript)
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Depressionan Overview

• Prevalence
• Comorbidity
• Impact on society
• Diagnosis
• Treatment options
• Treatment guidelines
• Treatment compliance

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Lifetime Prevalence of Common Psychiatric
Disorders
In menstruating women.
Kessler 1994 Kessler 1995 DSM-IV-TR 2000.
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DepressionPrevalence

• In any given year, about 21 million American
  adults suffer a major depressive episode
• Nearly 1 out of 6 American adults experience
  depression at some time in their lives
• 21 of women
• 13 of men

Kessler 1994 US Bureau of the Census 2000
Depression in Primary Care, 1 (AHCPR) 1993
DSM-IV-TR 2000.
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DepressionMedical Comorbidities
Kessler 1999 Carney 1987 Frasure-Smith 1993
AHCPR Guidelines 1993 Anderson 2001 Bing 2001
Reifler 1986 Rovner 1989 Breslau 1991 Minden
1987 Joffe 1987.
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Medical ConditionsImplications of Comorbid
Depression

• Increased somatic symptoms, eg, multiple pain
  complaints
• Excess functional disability
• Increased morbidity/mortality
• Increased healthcare utilization and costs
• Poor self-care
• Decreased adherence to treatment regimens
• Higher drug interaction potential due to
  polypharmacy

Katon 1990 Gregor 1997.
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DepressionAnxiety Comorbidities
Many patients with anxiety disorders have
depression at some time during their lives
Figures for panic disorder and depression not
specified as lifetime in DSM-IV-TR.
Kessler 1995 DSM-IV-TR 2000 Brawman-Mintzer
1993 Rasmussen 1992 Stein 2000 Van Ameringen
1991 Wittchen 1999.
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Anxiety Is a Common Symptom of Depression
Sadock and Sadock 2003.
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DepressionImplications of Anxiety Comorbidities

• Increased severity of symptoms
• Increased impairment of mental and physical
  functioning
• Delayed recovery
• In patients with comorbid panic disorder and
  depression,
• Increased prevalence of suicide attempts
• Decreased work productivity and attendance
• Increased service use (medical, mental health,
  social services)

Brown 1996 Coryell 1988 Roy-Byrne 2000.
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DepressionEconomic Impact
Cost of depression in the US estimated at 43.7
billion (1990 dollars)
Prevalence-based analysis of direct and indirect
costs of depression, including direct costs of
medical, psychiatric, and pharmacologic care
mortality costs from depression-related suicides
and morbidity costs (reduced productivity and
absenteeism) associated with depression in the
workplace.
Greenberg 1993.
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DepressionImpact on the Healthcare System

• Compared with those without depression, depressed
  individuals may
• Utilize all types of healthcare services more
  often
• Incur 1½ to 2 times greater healthcare costs
• Have an increased length of hospital stay
• Report significant worsening of physical, social,
  and role functioning

Simon 1995 Luber 2000 Verbosky 1993 Wells 1989.
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Major Depressive DisorderDiagnostic Criteria
Five or more of the following symptoms are
present most of the day, nearly every day, during
a period of at least 2 consecutive weeks
At least 1 of these2 symptoms

• Symptoms must cause clinically significant
  distress or impairment in social, occupational,
  or other important areas of functioning

DSM-IV-TR 2000.
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DepressionUnderdiagnosis

• Prevalence
• About 1/3 of people experiencing depression do
  not seek treatment
• Approximately 1/3 to 1/2 of patients with
  depression who present in primary care do not
  receive a diagnosis of depression
• Implications
• Increased time spent on history taking and
  physical examination
• Unnecessary diagnostic procedures, particularly
  in response to patients vague somatic complaints

Hirschfeld 1997 US Dept of Health and Human
Services 1999 Simon 1999 Simon and VonKorff
1995 Callahan 1996.
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DepressionSomatic Presentation

• Overall, 69 of depressed patients (range
  45-95 P.002) present with somatic complaints
  that can complicate diagnosis, such as
• Headaches
• Weakness
• Constipation

• Back pain
• Joint pain
• Abdominal pain

Simon 1999 Depression in Primary Care 1 (AHCPR),
1993.
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Patient Health Questionnaire-9 (PHQ-9)
Diagnostic Tool for Primary Care

• Validated self-administered questionnaire
• Scores interpreted by clinician
• Quick and easy to administer
• Yields accurate, validated depression diagnoses
• Patient rates each of the 9 DSM-IV-TR criteria
  for depression on a scale of 0 (not at all) to 3
  (nearly every day)
• Brevity and ease of use make it a valuable
  resource
• Tear-off sheets may be used as a diagnostic
  screener or to monitor disease severity over time

Kroenke 2001.
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PHQ-9 Symptom Checklist
Kroenke 2001.
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Translating PHQ-9 Depression Scores into Practice
Kroenke 2001.
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DepressionCommon Treatment Options
IMS America February 2003 Sadock and Sadock
2003 Depression in Primary Care 2 (AHCPR), 1993.
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DepressionAHCPR Treatment Guidelines
Agency for Health Care Policy and Research
currently known as the Agency for Healthcare
Research and Quality (AHRQ), an agency within
the US Department of Health and Human Services.
Kupfer 1991 Depression in Primary Care, 2
(AHCPR) 1993.
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DepressionUndertreatment
In a 12-month period, one study showed, A
majority of patients with depressive disorder did
not receive adequate treatment
Young 2001.
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DepressionPredictors of Appropriate Care
In a 12-month period, one study showed, Receipt
of minimally adequate treatment varied by gender,
ethnicity, and age
Young 2001.
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DepressionAdherence to Treatment
In a study examining adherence, 28 of patients
discontinued antidepressant treatment within the
first month

• According to AHCPR, patients who discontinue
  medication early have a relapse rate of about 25
  within 2 months

Lin 1995 Depression in Primary Care, 2 (AHCPR)
1993.
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Depressiona Highly Recurrent Disorder
DSM-IV-TR 2000 Kupfer 1991.
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DepressionSummary

• Depression will affect nearly 1 in 6 American
  adults at some time in their lives
• Depression has been associated with both chronic
  medical and psychiatric conditions
• Depression is often underdiagnosed and
  undertreated
• Depression can
• Be costly to society
• Decrease patient quality of life
• Effective treatments are available
• Treatment guidelines recommend that
  antidepressant treatment be continued for a
  minimum of 4 to 9 months after remission

Kessler 1994 Bureau of the Census 2000
Depression in Primary Care, 1 (AHCPR), 1993
Kessler 1999 Carney 1987 Frasure-Smith 1993
Anderson 2001 Bing 2001 Reifler 1986 Rovner
1989 Breslau 1991 Minden 1987 Joffe 1987
Kessler 1995 Brawman-Mintzer 1993 Rasmussen
1992 Stein 2000 Van Ameringen 1991 Hirschfeld
1997 US Department of Health and Human Services
1999 Simon 1999 Simon and VonKorff 1995
Callahan 1996 Greenberg 1993 Simon 1995 Luber
2000 Verbosky 1993 Wells 1989 Hirschfeld 2000
Kroenke 2001 Kupfer 1991. Depression in Primary
Care, 2 (AHCPR) 1993.
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Life Explained
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