Diagnosis and Classification of Depression

1
Diagnosis and Classification of Depression
POST IT Write down 7 characteristics of
depression?

• Aim
• Can I outline the clinical characteristics of
  depression?
• Can I discuss issues relating to the reliability
  and validity of diagnosis and/or classification
  of depression?

2

• http//www.healthtalkonline.org/mental_health/Depr
  ession/Topic/1495/Interview/875/Clip/3322/

3
Outline

• What is depression
• Symptoms
• Causes
• Types
• Risk Factors
• Women
• Elderly
• Young Adults

4
Outline

• Racial/Ethnic Disparities
• Psychosocial/Environmental Factors
• Burden
• Detailing Messages

5
What Is Depression?

• A very common, highly treatable, medical illness.
• Affects physical, mental and emotional
  well-being.
• Affects basic, everyday activities like eating
  and sleeping.
• Affects how people think about things and feel
  about themselves.

6
What is Depression?

• In contrast to the normal emotional experiences
  of sadness, loss, or passing mood states,
  clinical depression is persistent and can
  interfere significantly with an individual's
  ability to function.
• People with depressive illness cannot just pull
  themselves together and get over it.
• Depression often takes on a life of its own
  without treatment, symptoms can last months or
  even years.

7
Symptoms of Depression

• Feeling sad, blue, or down in the dumps
• Loss of interest in things you usually enjoy
• Feeling slowed down or restless
• Having trouble sleeping or sleeping too much

8
Symptoms of Depression

• Loss of energy or feeling tired all the time
• Having an increase or decrease in appetite or
  weight
• Having problems concentrating, thinking,
  remembering or making decisions
• Feeling worthless or guilty
• Having thoughts of death or suicide

9
Symptoms of Depression

• People with Major Depression experience at least
  five of these symptoms all day, nearly every day,
  for at least 2 weeks.
• The symptoms cause clinically significant
  distress or impairment in social, occupational,
  or other important areas of functioning.

10
Causes of Depression

• Causes not known, but current theories include
• Genetic
• Runs in families
• However, depression can also occur in people who
  have no family history.
• Environmental
• A serious loss, difficult relationship, financial
  problem, or any stressful (unwelcome or even
  desired) change in life patterns can trigger a
  depressive episode.

11
Causes of Depression

• Personality Characteristics
• low self-esteem, pessimistic world view, low
  stress tolerance
• Whether this represents a psychological
  predisposition or an early form of the illness is
  not clear.
• Biological
• Continues to be studied extensively
• Current thinking explores problems in brain
  functioning in the following areas Limbic
  system, neurotransmitters and neurons, hormones
  and the endocrine system

12
Causes of Depression

• Combination
• a combination of genetic, psychological,
  environmental, and/ or biological factors may
  contribute to the onset of a depressive disorder.
  

13
Forms of Depression

• Major Depression
• At least 5 of the 9 symptoms of depression
  present including either loss of
  interest/pleasure or depressed mood symptoms
  interfere with daily functioning
• Minor Depression
• Fewer symptoms than major depression with
  significant disability shorter duration than
  chronic depression

14
Forms of Depression

• Bipolar Disorder
• Cycling mood changes with severe highs (mania)
  and severe lows (depression)
• Dysthymia
• Low grade chronic symptoms of depression that
  last for a minimum of 2 years

15
Depression and Suicide

• Of those with MDD, close to 50 report feelings
  of wanting to die, 33 consider suicide and 8.8
  report a suicide attempt.
• More than 90 of those who commit suicide have a
  diagnosable psychiatric illness at the time of
  death, usually depression, alcohol abuse or both

16
Who is at risk for Depression?

• Anyone is potentially at risk for a depressive
• illness. Yet, these groups are believed to be at
• higher risk
• Older adults
• Young adults
• Women, pregnant and post partum women
• Note women report depression about twice as
  often as men. This may result from a greater
  likelihood to discuss depression or to seek help.

17
Depression in Women

• Depression is the second leading cause of
  disease-related disability among women
• 1 in 4 women will suffer from a Major Depressive
  Episode during the course of their lives as
  compared to 1 in 10 men.
• Women may be more likely to discuss depression or
  to seek help.
• Women of childbearing age are at increased risk
  for major depression
• Pregnancy and new motherhood may increase the
  risk of depressive episodes

18
Depression in Older Adults

• Of the nearly 35 million Americans age 65 and
  older, an estimated 2 million have a depressive
  illness (major depressive disorder, dysthymic
  disorder, or bipolar disorder).
• Symptoms of clinical depression can be triggered
  by other chronic illnesses common in later life,
  such as Alzheimers disease, Parkinsons disease,
  heart disease, cancer and arthritis.
• Depression is one of the most common conditions
  associated with suicide in older adults.
• Individuals age 65 and older have highest rates
  of suicide
• High suicide rate among older people (85 and
  older) is largely accounted for by White men.

19
Depression in Young Adults

• 10 of college students have been diagnosed with
  depression, including 13 of college women.
• Lifetime prevalence for MDE highest among young
  adults age 18-25 (10)
• Suicide is the third leading cause of death for
  those aged 15-24

20
Additional Risk Factors for Depression

• Family or personal history of depression
• Current substance abuse problem
• A major life stressor or change in life events
  i.e. loss of a loved one or a job
• Chronic disease

21
Depression in Racial/Ethnic Minorities

• Mental health needs of minority racial/ ethnic
  groups remain largely unmet .
• Certain groups have higher rates of major
  depression
• Native Americans
• Women (middle aged, separated or divorced,
  low-income)
• Mexican- American and white individuals
• Have significantly earlier onset of major
  depressive disorder compared with African
  Americans.

22
Depression in Racial/Ethnic Minorities

• Latinos with self reported depression are less
  likely to
• receive any treatment for depression
• fill an antidepressant prescription
• receive adequate course of psychotherapy
• African American and Latinos are more likely than
  Whites to be under-diagnosed and under-treated
• Minorities are less likely than Whites to receive
  treatments that adhere to treatment guidelines

23
Explanatory Factors

• Lack of insurance coverage
• Poor access to appropriate screening and early
  detection
• Tendency to attribute mental health problems to
  religious and other cultural belief systems
• Lack of access to receptive and culturally
  compatible providers

24
Psychosocial/Environmental Factors

• Psychosocial health has been associated with
  mental health in general and with depression in
  particular
• Neighborhood social disorganization is associated
  with depressive symptoms,
• Living in socio-economically deprived areas is
  associated with depression. A recent study found
• 29 - 58 were more likely to report part 6
  month depression
• 36 - 64 were more likely to report lifetime
  depression

25
Depression Burden

• Untreated depression causes distress, disability,
  and, most tragically suicide.
• Depressive disorders are associated with
  increased prevalence of chronic diseases (e.g.
  asthma, diabetes)
• Increased use of general medical services as well
  as costlier health services, such as Emergency
  Room and Inpatient.

26
Depression Burden

• Patients who are depressed are more likely to
  engage in behaviors that contribute to poor
  health, such as smoking, limited or no exercise,
  poor eating habits and are likely to have greater
  difficulty managing their co-morbid conditions.
• ? Depressive disorders are projected to become
  the leading cause of disability and the second
  leading contributor to the global burden of
  disease by 2020
• US workers with depression cost employers an
  estimated 44 billion per year.

27
Detailing Messages

• Primary care physicians can effectively detect
  and manage depression.
• Routinely screen for depression using a simple
  2-question tool (PHQ2)
• Depression can be treated! Medication and
  psychotherapy, alone or in combination, can help
  most patients.

28
Detailing Messages

• Primary care physicians can effectively detect
  and manage depression.

29
Detection of Depression Why Screen and Manage in
primary care?

• Primary care is the 1st line of defense To
  find people who may be depressed or at risk for
  depression who dont know it
• Screening for depression in the primary care
  setting improves detection rates
• US Preventative Service Task Force (USPSTF)
  recommends screening adults for depression in
  clinical practices that have systems in place for
  accurate diagnosis, effective treatment, and
  follow-up.
• Only 50 of those referred to specialty mental
  health practitioners complete more than one visit

30
Detailing Messages

• Routinely screen for depression using a simple
  2-question tool (PHQ2)

31
Depression Screening PHQ2

• A physician can simply and quickly screen for
  depression by asking 2 questions (PHQ2)
• During the past 2 weeks, have you been bothered
• by
• 1. little interest or pleasure in doing things?
• 2. feeling down, depressed, or hopeless?
• The PHQ-2 is a valid and practical tool for
  depression screening in busy medical settings.

32
Detailing Messages

• Depression can be treated! Medication and
  psychotherapy, alone or in combination, can help
  most patients.

33
Detailing Messages

• More than 80 of people with clinical depression
  can be successfully treated.
• Antidepressants are the 1st line treatment for
  moderate to severe depression
• About half of the moderate to severe episodes of
  depression will improve with antidepressant
  treatment
• A combination of pharmacotherapy and
  psychotherapy may improve treatment response ,
  reduce risk of relapse, enhance quality of life,
  and increase adherence to pharmacotherapy.

34
How RELIABLE are current methods of diagnosing
depression?

• Are the measuring instruments used such as
  questionnaires or scales CONSISTENT?
• I will know if
• Two independent assessors give the similar
  diagnosis INTER-RATER RELIABILITY or
• Test used to deliver the diagnosis are the same
  over time TEST RETEST RELIABILITY

Kraemer et al (2012) much research on
evaluation of medical treatments, but little on
quality of diagnosis
35
How VALID are diagnostic measures/classification
systems?

• Does it measure something that is real and
  distinct from other disorders?
• Does it measure what it claims to measure?
• Comorbidity extent that 2 or more condition
  co-occur
• Content validity does it measure what is sets
  out to measure?
• Concurrent validity extent to which it
  agrees/corresponds with (concurs) with other
  existing standards

36
Why are reliability and validity important?

• Faulty diagnosis
• Incorrect treatment

37
How is depression diagnosed and measured?

• Structured Clinical Interview for the assessment
  of major depressive disorder
• Beck Depression Inventory (BDI)
• International Classification of Diseases (ICD)
• Diagnostic and Statistical Manual of Mental
  Disorders (DSM)
• GP diagnosis/primary care diagnosis

38
DSM

• Used in America
• Requires that 5 of the clinical characteristics
  occur every day for 2 weeks
• depressed mood or disinterest in pleasure
• impair functioning/cause significant distress
• not simply be attributed to bereavement
• Endogenous depression hormones
• Reactive depression triggered by external
  events

39
Evaluation

• Equally valid to ICD
• Keller (1995) fair to good inter-rater
  reliability but
• fair at best
  test-retest reliability
• This is supported by Zanarini (2000)
• Keller suggested that this may be because
• sometimes 1 item disagreement makes a crucial
  difference for diagnosis on the threshold (5/9
  must be present)
• Zimmerman (2010) deems the DSM-IV too lengthy
  
• Krupski and Tiller (2001) found only 1/4 Aus
  and NZ doctors could list 5 symptoms which could
  lead to unreliable diagnosis
• Zimmerman created a brief version based on DSM
  based only on the mood and cognitive symptoms and
  found 95 agreement with full DSM IV

40
ICD-10

• Used in the UK and Europe
• Very similar to DSM but requires that TWO of
  three key symptoms must be present
• (sad, depressed mood loss of interest and/or
  lack of energy)
• Andrews (1999) found this difference not to
  produce a significant number of discrepant
  responses equal validity

41
Research into reliability
Beck Depression Inventory (BDI) 21-item
self-report questionnaire designed to measure
severity thus helping to distinguish between
e.g. major depression and dysthemia

• Lobbesteal et al (2011) inter-reliability
• tested the Structured Clinical Interview
• mixed sample of patients and non-patient
• controls found moderate agreement
  (coefficient of .66)
• Beck et al (1996) test-retest reliability
• tested responses of 26 outpatients at 2
  therapy
• sessions one week apart using the BDI
• found significant reliability
  (coefficient.93)

The BDI is also high in content validity ( as
the criteria based on consensus among
clinicians and based on psychiatric patients)
AND concurrent validity ( as it concurs with
other measures such as the Hamilton
Depression Scale)
42
Research into validity

• McCullough (2003) found few differences on a
  range of clinical, psychosocial and treatment
  response variables when comparing outpatients
  with different types of depression invalid
  distinctions between
• different sub-types of depression
• Weel-Baumgarten (2006) suggests that GP
• diagnoses may be biased based on previous
  patient knowledge invalid
• Comorbidity often two or more condition
  co-occur. Specifically, anxiety disorders and
  major depression. Goodwin (2001) found suicidal
  thoughts with just depression vs no psychiatric
  disorder to be 5x more likely and tripple that if
  depression was combined with an panic disorder.

43
Cultural Differences

• Karanz (2005) NY (36 South Asian and
• 37 European
  American)
• Tested cultural differences and found that
• Ethnic minorities identified the problem
• in terms of social and moral terms with
  suggested treatments self-management and referral
  to non-professional help.
• European Americans emphasised biological
  explanations for the symptoms, including hormonal
  imbalance and neurological problems.