Mood Disorders:

Identification and Management

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Copyright 2004 Trustees of Dartmouth College May be utilized for non-commercial purposes only

Sponsored by
The John D. and Catherine T. MacArthur Foundation Initiative on Depression and Primary Care

Lecture Outline
Background Epidemiology, impact Risk factors Types of mood disorders Presentation and symptoms Treatment
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Depression is Common
Major Depression (lifetime)-10% of men; 20% of women Most common mental disorder in primary care Three times more primary care visits Higher rates of depressed patients in primary care offices
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Depression is Significant
Impact on quality of life greater than most chronic medical diseases Increases morbidity/mortality from co-existing medical conditions Decreased work productivity Suicide-7th leading cause of death in US; 70% have mood disorder Costs over $44 billion yearly 5 (1990)

Recognition and Treatment Problems

30%-70% of depression is not recognized or treated 50% of treated patients stop medication within first 3 months Medication often not used at dosage sufficient to give full remission
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Barriers to Recognition
Somatization-present with physical symptoms Competing demands Comorbidity-multiple problems Stigma Insurance Reimbursement; carve-outs
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Diagnostic and Monitoring Tools

Depression diagnostic tools may aid in initial diagnosis and tracking response PHQ-9 recommended by many organizations Important for practices to have some sort of system in place for monitoring
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Risk Factors For Mood Disorders

First degree relatives with mood disorders (at least 3 times higher) Women twice as likely as men Care taking responsibilities Current or history of abuse, trauma Stressful events, loss
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Major Types of Mood Disorders

Major depression Dysthymia Bipolar affective disorder Minor depression

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DSM-IV Criteria For Major Depression

Four hallmarks, nine symptoms:
depressed mood anhedonia (loss of interest/pleasure) four physical symptoms three psychological symptoms

For diagnosis-depressed mood or anhedonia & at least 5 of the 9 symptoms Symptoms most of time for 2 weeks

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Depressed Mood
Hallmark 1
Neither necessary nor sufficient for the diagnosis Can be misleading Dont hang everything on the question Are you depressed?
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Anhedonia
Hallmark 2
Loss of interest or pleasure in things that you normally enjoy May be the most important and useful hallmark

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Physical Symptoms
Hallmark 3
Sleep disturbance Appetite or weight change Low energy or fatigue Psychomotor retardation or agitation
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Psychological Symptoms
Hallmark 4
Low self-esteem or guilt Poor concentration Suicidal ideation or persistent thoughts of death

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Dysthymia
Long term problem with moderate symptoms Depressed mood most of time for 2 years Plus 2 other symptoms of depression High level of chronic impairment Increased risk for major depression

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Bipolar Disorder
Episodes of mania or hypomania along with depressive episodes Mania may be overlooked; patient may hide symptoms or not see as problem Often misdiagnosed and managed as unipolar depression
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Misdiagnosis of Bipolar Patients

Potential risks from antidepressants
May induce mania or hypomania Can cause rapid cycling

Requires mood stabilizer (e.g. lithium or valproic acid) before brief use of antidepressant Generally need psychiatry consultation or referral
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Minor Depression
Fewer symptoms than major depression Shorter duration than chronic depression Significant disability Best management probably watchful waiting with regular follow-up Proceed with pharmacologic treatment or psychotherapy if

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Depression Treatment
Psychotherapy
Alone or as adjunctive therapy

Pharmacotherapy
Effective for major depression and dysthymia Questionable effectiveness in minor depression

Primary care supportive counseling

Important part of treatment
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Antidepressants
Tricyclics MAO Inhibitors-rarely used by primary care physicians SSRIs: citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft)
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Antidepressants
Other new agents (multiple actions)
bupropion (Wellbutrin) mirtazapine (Remeron) venlafaxine (Effexor)

Dual action agents More coming

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Tricyclic Antidepressants
As effective as newer agents Side effects potentially more dangerous Cheaper-especially generic forms May be good for selected patients Start with low dose, titrate q 3-7 days
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Advantages of SSRIs and Other New Agents

As effective Safety better Increased patient satisfaction Improved adherence to therapy Adherence issues especially important in long term maintenance therapy
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Suggested Medication Algorithm

If decision to use medication usually start with SSRI If patient elderly or has comorbid panic or anxiety-start low, titrate slowly Assess every few weeks Titrate dose for total remission
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Possible Increased Risk of Suicide

FDA Public Health Advisory March, 2004: possible risk of worsening depression and suicidality in patients taking antidepressants Done in reaction to reports of suicidal ideation and attempts in treatment of major depression in pediatric patients. Black box warning for children / 26 adolescents September, 2004

FDA Public Health Advisory

Points out the need to closely monitor patients receiving antidepressants for worsening and suicidality especially at beginning of treatment and with changes in dosage Also need to instruct patients and families to be alert for worsening or suicidal thoughts and to 27

Severity Tools
Depression diagnostic tools may be useful for tracking response to treatment Depression module of PHQ-9 recommended by many organizations Use before treatment, then each visit
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Partial or No Response
At adequate dose, should see response by 4 weeks Check for adherence Re-evaluate diagnosis Adjust dosage if some response or if started low Change medication if no response Add psychotherapy Psychiatric consultation 29

Promoting Adherence
Shared decision making Inquire into prior use of antidepressants Explain that it may take 2 to 4 weeks for therapeutic response, longer for full effect Discuss most common side effects Advise patients to continue medication even if they feel better30 Explain risk of stopping too soon

Follow Up
Close follow up by telephone and or visits until stable Severity tool (PHQ-9) to assess progress Titrate dose for total remission Maintain effective dose for 4 to 9 months (continuation phase) Monitor for early signs of recurrence Consider maintenance therapy

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Managing SSRI Side Effects

Agitation/Insomnia
Rule out bipolar Use adjunctive sedating agent Switch to mirtazapine

Sexual dysfunction
Switch to bupropion, mirtazapine, Add sildenafil in men
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Managing SSRI Side Effects (cont)

Sedation
Give medication at bedtime or switch to bupropion

GI distress
Give medication after meals Antacid, H2 blocker

Dry mouth-hard candy, liquids

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Side Effects-Other New Agents

Bupropion-agitation, headache, lowered seizure threshold Mirtazapine-sedation, weight gain Venlafaxine-GI distress, elevated BP

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Psychiatric Referral
May be needed when:
bipolar disorder suicidality questions about diagnosis Co-morbid psychiatric conditions lack of response to treatment

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Non-Pharmacologic Interventions by PCP

Watchful waiting for mild episode Physician support and office counseling
Active listening Advice, giving perspective Focus on solutions Focus on coping strategies (exercise, pleasurable activities, and other aspects of self management) 36

RESPECT-Depression
The Re-Engineering Systems for the Primary Care Treatment of Depression Project tested an available system of support and tools to implement these evidencebased depression management practices.
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RESPECT-Depression

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RESPECT-Depression
In an RCT (n=400) at 6 months: 60% improved vs 47% in Usual Care (UC) 37% remission vs 27% UC 90% rated care good/excellent vs 75% UC

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RESPECT-D Response Rate (50% Drop in HSCL)

0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0 % 0 Months 0 Months
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TCM Usual Care

RESPECT-D Remission (HSCL <0.5)

0% 0 0% 0 0% 0 0% 0 0% 0 0% 0 0 % 0 Months 0 Months
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TCM Usual Care

RESPECT-Depression Quality of Depression Care

00 0%
Excellent/ Very good

0% 0 0% 0 0% 0 0% 0 0% 0
0 Months 0 Months TCM Usual care

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RESPECT-Depression
Relevant articles, tools and manuals are available at the RESPECTDepression website:

www.depression-primarycare.org

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Summary of Main Points

Mood disorders very common, have major impact Important to be able to distinguish specific mood disorder-affects treatment, prognosis, course Many patients not diagnosed or, if diagnosed, not treated at adequate dosage or long enough
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Summary of Main Points

Psychotherapy, various medications can be effective SSRI common first line therapy Partnership among physician, patient, family, office staff, mental health professionals important (RESPECT-Depression)
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