Post on 31-Jan-2016
description
Diagnosis and Classification 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?
POST IT …Write down 7 characteristics of depression?
POST IT …Write down 7 characteristics of depression?
http://www.healthtalkonline.org/mental_health/Depression/Topic/1495/Interview/875/Clip/3322/
Outline
What is depression Symptoms Causes Types Risk Factors
Women Elderly Young Adults
Outline
Racial/Ethnic Disparities Psychosocial/Environmental Factors Burden Detailing Messages
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.
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.
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
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
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.
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.
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
Causes of Depression
Combination a combination of genetic, psychological,
environmental, and/ or biological factors may contribute to the onset of a depressive disorder.
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
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
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
Who is at risk for Depression?
Anyone is potentially at risk for a depressiveillness. Yet, these groups are believed to be athigher 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.
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
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 Alzheimer’s disease, Parkinson’s 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.
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
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
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.
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
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
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
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.
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.
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.
Detailing Messages
Primary care physicians can effectively detect and manage depression.
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 don’t 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
Detailing Messages
Routinely screen for depression using a simple 2-question tool (PHQ2)
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 botheredby:
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.
Detailing Messages
Depression can be treated! Medication and psychotherapy, alone or in combination, can help most patients.
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.
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 researchon evaluation of medical treatments, but little on quality of diagnosis
Kraemer et al (2012) – much researchon evaluation of medical treatments, but little on quality of diagnosis
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
Why are reliability and validity important?
• Faulty diagnosis• Incorrect treatment
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
DSM
Used in AmericaRequires 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 bereavementEndogenous depression = hormonesReactive depression = triggered by external events
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
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
Research into reliability
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)
Beck Depression Inventory (BDI)21-item self-report questionnairedesigned to measure severity thus helping to distinguish between e.g. major depression and dysthemia
The BDI is also high in content validity ( as the criteria based on consensus among clinicians and basedon psychiatric patients) ANDconcurrent validity ( as it concurs with other measures such as the Hamilton DepressionScale)
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.
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’.