Depression: Definition, Incidence, Treatment and Followup

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DepressionDefinition, Incidence, Treatment and
Follow-up

• Amanda Ingram, M3
• 9/8/05

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Major Depression DSM IV Definition

• A patient with major depression will experience
  at least one of the symptoms from Category 1 and
  three or more symptoms from Category 2 for a
  total of at least 5 out of 9 symptoms. These
  symptoms must be present for most of the day,
  nearly every day for at least TWO weeks.
• Category 1
• Persistent depressed mood
• Pervasive anhedonia (loss of interest/pleasure)
• Category 2
• Sleep disorder
• Change in weight or appetite
• Fatigue/loss of energy
• Psychomotor retardation/agitation
• Difficulty concentrating/indecisiveness
• Guilt/low self-esteem
• Recurrent thoughts of death or suicide

Feldman MD and Christensen JF. Behavioral
Medicine in Primary Care. 2nd Ed, New York Lange
Medical Books/McGraw-Hill, 2003. Fadem, Barbara.
Behavioral Science. 4th ed, Philadelphia
Lippincott Williams and Wilkins, 2005.
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Incidence of Depression

• At any one point in time the incidence of major
  depression is 2.3-3.2 for men and 4.5-9.3 for
  women
• Lifetime prevalence is 7-12 men and 20-25 for
  women
• Women age 25-44 are at greatest risk (and most
  likely to use an OB/GYN physician for primary
  source of health care)
• The USPSTF gives depression screening in adults a
  rating of B or recommends, because screening
  has been found to help identify and treat
  patients with depression.

Dietrich, AJ. Depression care attitudes and
practices of newer obstetrician-gynecologists A
national survey. Am J Obstet Gynecol
2003189267-73 Feldman MD and Christensen JF.
Behavioral Medicine in Primary Care. 2nd Ed, New
York Lange Medical Books/McGraw-Hill, 2003. U.S.
Preventive Services Task Force, Guidelines from
Guide to Clinical Preventive Services, 2002.
lthttp//www.ahrq.gov/clinic/uspstf/uspsdepr.htmgt
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Incidence in Cancer Patients

• 20-40 of patients with a coexisting medical
  problem will develop major depression
• 15-25 of cancer patients are comorbidly effected
  by major depression
• Several anti-cancer drugs can also cause
  depressive symptoms
• corticosteroids, procarbazine, asparaginase,
  interferon, vinblastine, vincristine, tamoxifen,
  and cyproterone
• It is important to identify these organic causes
  when assessing a patient for depression

Feldman MD and Christensen JF. Behavioral
Medicine in Primary Care. 2nd Ed, New York Lange
Medical Books/McGraw-Hill, 2003. Chochinov, HM.
Depression in cancer patients. Lancet Onc 2001,
Aug vol 2, num 8.
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Treatment Options

• Supportive Care
• Tricyclic Antidepressants
• Selective Serotonin Reuptake Inhibitors (SSRIs)
• Serotonin Antagonists
• NE and Dopamine reuptake inhibitors
• Serotinin antagonists and reuptake inhibitors
• Electroconvulsive Therapy

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Treatment In Depth

• Supportive Care
• SPEAK approach Schedule, Pleasurable activities,
  Exercise, Assertiveness, Kind thoughts about
  oneself
• Areas the physician can encourage the patient to
  develop in order to combat depression
• Single drug therapy only effective in 50-60 of
  patients
• Drug therapy should be combined with supportive
  psychotherapy, whether with the identifying
  physician, a referred mental health specialist,
  or group therapy
• Patient should be followed even if referred
  somewhere else for supportive psychotherapy

Feldman MD and Christensen JF. Behavioral
Medicine in Primary Care. 2nd Ed, New York Lange
Medical Books/McGraw-Hill, 2003. Whooley, MA and
Simon, GE. Managing Depression in Medical
Outpatients. NEJM 2000 3431942-1950
7
Treatment In Depth

• 2. Tricyclic Antidepressants
• Tertiary amine
• Amitriptyline 100mg at bedtime (initial dose
  25mg)
• Less expensive (9/mon) and proven effectiveness
• More side effects sedation, anti-colinergic
  effects, postural hypotension, weight gain
• Also Includes Doxepin, Imipramine
• Secondary amine
• Desipramine 100mg at bedtime (initial dose 25mg)
• Relatively inexpensive (33/mon) and proven
  effective
• SE less problems than tertiary amines, but still
  causes sedation, anti-cholinergic effects, weight
  gain and postural hypotension
• Also includes Nortriptyline
• 2b. Bicyclic
• Venlafaxine
• Expensive (70-80/mon)
• Less problems with sedation, anti-cholinergic
  effects and no postural hypotension, but
  increased GI and sexual dysfunction problems and
  dose related elevation of diastolic blood pressure

Whooley, MA and Simon, GE. Managing Depression in
Medical Outpatients. NEJM 2000 3431942-1950
8
Treatment In Depth

• SSRIsthe class of choice for initial therapy due
  to effectiveness and lower risk of side effects
• Citalopram 20mg daily (no building dose needed)
• Moderately expensive (60/mon)
• Very low risk of side effectslowest in its
  class,
• Also includes Fluoxetine, Paroxetine, Sertaline
• No risk of postural hypotension

Whooley, MA and Simon, GE. Managing Depression in
Medical Outpatients. NEJM 2000 3431942-1950
9
Treatment In Depth

• Serotonin antagonists
• Mirtazapine 30mg at bedtime (initial dose 15mg)
• Expensive (72/mon)
• Some problems with sedation, low risk of side
  effects in other areas
• NE and Dopamine reuptake inhibitors
• Bupropion 150mg 2x daily (initial dose 75mg 2x
  daily)
• Expensive (90-100/mon)
• Low risk of side effects and no risk of postural
  hypotension
• Serotonin antagonists and reuptake inhibitors
• Nefazodone 150mg 2x daily (initial dose 100mg 2x
  daily)
• Expensive (75/mon), but low risk of side effects
• Trazodone 200mg at bedtime (initial dose 50mg at
  bedtime)
• Less expensive (22/mon), but high frequency of
  sedation
• Electroconvulsive Therapy
• Treatment of choice for psychotic depression,
  depression refractory to pharmacotherapy, and for
  the acutely suicidal
• Very effective and can be safer than medication
  in some patient populations
• Patients with recurrent depression will need
  either prophylactic medication or maintenance ECT
  
• Side effects include temporary short term memory
  loss

Feldman MD and Christensen JF. Behavioral
Medicine in Primary Care. 2nd Ed, New York Lange
Medical Books/McGraw-Hill, 2003. Whooley, MA and
Simon, GE. Managing Depression in Medical
Outpatients. NEJM 2000 3431942-1950
10
Follow-up

• Patient should have a minimum of 3 follow-up
  visits in the first 12 weeks of treatment
• Cancer patients should also be followed by their
  oncologist even if psychotherapy has been
  referredthis improves outcome and decreases
  patients feelings of abandonment
• Remember for many women their OB/GYN physician is
  their primary care provider
• Patient should be aware that it takes at least
  4-6 weeks for antidepressants to start taking
  effect
• If one drug proves unsuccessful after 6 weeks or
  side effects are unbearable, try switching to a
  different class
• Once symptoms are controlled, medication should
  be continued for at least 6 months to prevent
  relapse
• Follow up appointments should be every 3-6 months
• If depression reoccurs, medication should be
  restarted for 3-6 months
• Psychotherapy should also be continued,
  preferably as long as the patient is taking
  medication

Whooley, MA and Simon, GE. Managing Depression in
Medical Outpatients. NEJM 2000
3431942-1950 Chochinov, HM. Depression in cancer
patients. Lancet Onc 2001, Aug vol 2, num 8.