Depression in Medicine

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Depression in Medicine

• slides courtesy of Lara J. Cox
• Psychiatry Student Interest Group Network
• October, 2009

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• Profound melancholia is a day-in, day-out,
  night-in, night- out, almost arterial level of
  agony.
• - Kay Redfield Jamison, An Unquiet Mind

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Diagnostic Criteria1

• depressed mood
• anhedonia
• significant weight loss or gain
• insomnia or hypersomnia
• psychomotor agitation or retardation
• fatigue, loss of energy
• feelings of worthlessness, inappropriate guilt
• inability to concentrate or indecisiveness
• recurrent thoughts of death, suicidal ideation,
  or suicide attempt

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Prevalence of Major Depressive Episodes in US
Adults, 2005-20062
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Costs

• 83 billion total cost in US in 20003
• 62 workplace related costs
• 774,256 hospitalizations for mood disorders in
  20074
• national aggregate cost 11,176,511,980
• worldwide, leading cause of disability5
• lt25 receive effective treatment

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• in ways that are totally remote from normal
  experience, the gray drizzle of horror induced by
  depression takes on the quality of physical pain.
  
• - William Styron, Darkness Visible

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Somatic Comorbidities

• cardiovascular disease
• 14 of coronary heart disease patients have
  clinical depression6
• risk factor for adverse cardiac events
• other somatic illness
• increased risk of arthritis, back pain, COPD,
  migraines in patients with depression7
• increased risk of depression in patients with
  chronic disease

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Psychiatric Comorbidities

• suicide
• 33,300 deaths in 20068
• 3rd leading cause of death for people aged 15-24
• 8.3 million adults with serious thoughts of
  suicide in 20082
• substance abuse2
• 27.2 with illicit drug use
• 9.6 with heavy alcohol use
• 20.3 with substance abuse or dependence

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Course

• single episode in 50
• recurrent episodes in 25 in first 18 months9
• 35-40 over 20 years10
• 2.2 commit suicide11
• if ever hospitalized for suicidality, 8.6

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• Most people cannot emerge from really serious
  depression just by fighting a really serious
  depression has to be treated, or it has to pass.
• - Andrew Solomon, The Noonday Demon

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Pharmaceutical Options

• serotonin selective reuptake inhibitors (SSRIS)
• serotonin norepinephrine reuptake inhibitors
  (SNRIs)
• tricyclic antidepressants
• monoamine oxidase inhibitors
• adjunct therapies
• atypical antipsychotics
• mood stabilizers
• anxiolytics

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Psychotherapy

• cognitive behavioral therapy
• interpersonal therapy
• problem-solving therapy
• supportive therapy
• group therapy

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Other Treatments

• electroconvulsive therapy (ECT)
• omega-3 fatty acids
• St. Johns wort
• s-adenosylmethionine (SAM-e)
• acupuncture
• biofeedback
• deep brain stimulation

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• Illness of the mind is real illness. As
  organs go, the brain is quite an important one,
  and its malfunctions should be addressed
  accordingly.
• - Andrew Solomon, The Noonday Demon

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Depression in Medical School

• 38.2-46.5 of medical students screen positive
  for depression12,13
• 25.1 had considered suicide, 11.2 in past
  year13
• only 22 of those with depressive symptoms
  receive treatment14

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Physicians Depression

• 11.3 of physicians report moderate to severe
  depression15
• 250 physicians commit suicide in the US per
  year16
• male physicians 1.4 times as likely as the
  general population to commit suicide17
• female physicians 2.27 times as likely17

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Stigma

• 50.7-52.3 of depressed physicians avoid seeking
  care due to concerns about stigma or
  confidentiality15
• same is true for 30-37 of depressed medical
  students18
• perceived stigma predicts poor medication
  adherence19

18

• you can think of improved empathy, the capacity
  to understand and then accept patients'
  suffering, and a tendency to be more present,
  more "real" in my interaction with patients as
  "side effects" of depression and its treatment.
• - Dr. Raymond Reyes

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Resources

• NAMI
• http//www.nami.org/
• Mental Health America
• www.mentalhealthamerica.net
• Depression and Bipolar Support Alliance
• www.ndmda.org
• HopeLine
• www.hopeline.com, 1-800-784-2433
• National Suicide Prevention Hotline
• 1-800-273-8255

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Citations

• 1. American Psychiatric Association. Diagnostic
  and Statistical Manual of Mental Disorders, 4th
  ed., Text Revision (DSM-IV-TR). Washington, DC
  American Psychiatric Association 2000.
• 2. Substance Abuse and Mental Health Services
  Administration. (2007). Results from the 2006
  National Survey on Drug Use and Health National
  Findings http//www.oas.samhsa.gov/NSDUH/2k6NSDUH/
  2k6results.cfmCh8 Accessed 9/30/09.
• 3. Donohoe JM Pincus HA. Reducing the societal
  burden of depression A review of economic costs,
  quality of care, and effectiveness of treatment.
  Pharmacoeconomics. 2007 25(1) 7-24.
• 4. US Agency for Healthcare Research and Quality.
  HCUPnet.
• http//hcupnet.ahrq.gov/HCUPnet.jsp Accessed
  9/30/09.
• 5. World Health Organization. Depression.
  http//www.who.int/mental_health/management/depres
  sion/definition/en/ Accessed 9/30/09.
• 6. Blumenthal JA. Depression and coronary heart
  disease Association and implications for
  treatment. Cleveland Clinic Journal of Medicine.
  2008 75(2) S48-S53.
• 7. Patten SB, Williams JVA, Lavorato DH, Modgill
  G, Jette N, Eliasziw M. Major depression as a
  risk factor for chronic disease incidence
  Longitudinal analyses in a general population
  cohort. General Hospital Psychiatry. 2008 30
  407-413.
• 8. National Institutes of Mental Health. Suicide
  in the U.S. Statistics and Prevention.
  http//www.nimh.nih.gov/health/publications/suicid
  e-in-the-us-statistics-and-prevention/index.shtml
  Accessed 9/30/09.
• 9. OLeary D, Costello F, Gormley N, Webb M.
  Remission onset and relapse in depression An
  18-month prospective study of course for 100
  first-admission patients. Journal of Affective
  Disorders. 2000 57 159-171.
• 10. Eaton WW, Shao H, Nestadt G, Lee BH,
  Bienvenu J, Zandi P. Population-based study of
  first onset and chronicity in major depressive
  disorder. Archives of General Psychiatry. 2008
  65(5) 513-520.
• 11. Bostwick JM, Pankratz VS. Affective
  disorders and suicide risk A re-examination. Am
  J Psychiatry. 2000 157 1925-1932.
• 12. Baldassin S, Alves TCTF, de Andrade AG,
  Martins LAN. The characteristics of depressive
  symptoms in medical students during medical
  education and training. BMC Medical Education.
  2008 8 1-8.
• 13. Dyrbye LN et al. Burnout and suicidal
  ideation among US medical students. Annals of
  Internal Medicine. 2008 149 334-341.
• 14. Rosenthal JM, Okie S. White coat, mood
  indigo Depression in medical school. NEJM.
  2005 353(11) 1-85-1088.
• 15. Schwenk TL, Gorenflo DW, Leja LM. A survey
  of the impact of being depressed on the
  professional status and mental health care among
  physicians. J Clin Psychiatry. 2008 69(4)
  617-620.
• 16. Middleton JL. Today Im grieving a
  physician suicide. Annals of Family Medicine.
  2008 6 267-269.
• 17. Schernhammer ES, Colditz GA. Suicide rates
  among physicians A quantitative and gender
  assessment (Meta-analysis). Am J Psychiatry.
  2004 161 2295-2302.
• 18. Givens JL, Tija J. Depressed medical
  students use of mental health services and
  barriers to use. Acad Med. 2002 77 918-921.