When Will I Get Better? Prognostic Factors

Related to Mood Disorders

Todd Finnerty, Psy.D.

PsychContinuingEd.com

OPA 2010

“It may be a matter of weeks,

or a matter of years”

My main goals

• To encourage researchers to look at this question

• To encourage practitioners to focus on these issues

Why assess for severity and prognosis?

?

• Select Interventions

• Identify potential roadblocks

• Predict the course of treatment

Expectations

• The clinical course of depression is “highly variable”

• Depressive episodes may often improve relatively quickly.

• Two people who are diagnosed with depression may not appear the same

A Tale of Two Clients

• Client #1 (fewer factors)

• Client #2 (more factors )

Client Number One

• 20 something male

• In the psych unit overnight

• Resistant to discussing feelings

• Had made a suicide-related statement in an e-mail

• Denied suicidal ideation, denied psychosis, denied a history of depression or anxiety

Client Number One (cont.)

• The psychiatrist felt there was “no serious intent when he made the suicidal statement. It appears to be more an act of frustration. He was counseled about the need to act responsibly…”

• There was no diagnosis at discharge, no medications prescribed.

Client Number Two

• 20 something male

• In the psych unit overnight

• Resistant to discussing feelings

• Based on the client and collateral contacts:

Client Number Two (cont.)

• Very early onset of psych difficulties (childhood)

• Also diagnosed w/ depression and selective mutism in the 8th grade

• Comorbidity: History of depression, anxiety, learning and speech difficulties

Client Number Two (still cont.)

• Hx of failed treatments/recurrent problems

• Hx of interpersonal problems and a perception of poor social support

• Potentially negative and angry view towards others and the world.

We’re still on Client #2

• Suicidal and homicidal ideation (planning/intent?)

• He owns knives and firearms

• Possible hx of psychotic symptoms/ paranoid delusions

Does Client #1 have less

severity and a better prognosis

than #2?

Less severity or…

…did we just have less

information?

Client 1 & Client 2 are the same person

and I quote…

“no serious intent when he made the suicidal statement. It appears to be more an act of frustration. He was counseled about the need to act responsibly…”

What happened?

Would we have thought the same thing?

An Imperfect Science

Can the science and practice be improved

upon?

Good

Fair

Guarded

Poor

Specific Factors:

Physiological

Cognitive

Clinical

“Physiological” factors

• Ex: potential “biomarkers;” lab tests- factors linked to vascular disease; genetic testing; sleep EEG/brain waves

• Most “physiological” research studies are generally designed to predict medication response

• Hx of conflicting findings

• Currently have limited utility in your office

Still waiting for the flying car

• Don’t ignore co-occurrence with physical concerns

(ex: pain)

which will significantly impact prognosis.

“Cognitive” Factors

• Psychomotor slowing- vegetative sxs

• Executive Functioning– Controlling yourself– Managing emotions– Sustaining attention and effort

Predictive of worse clinical, social and occupational outcomes in mood

disorders.

What does this mean for someone with a

comorbid ADHD, LD or language disorder?

(+ mood dysregulation?)

Some specific “Clinical” factors

• Overall Severity and comorbidity

• The nature of onset

• A chronic or recurrent course

• Prior failed and intensive treatments

• Suicidal intent

• Interpersonal concerns

• Stable “trait” factors

Determining Overall Severity

• Clinical impressions

• Screeners such as the Beck scales, PHQs

• As easy as Mild, Moderate and Severe?

The “middle ground” may have the best prognosis- both in terms of severity

and age of onset***

The nature of onset

• Age of first episode

• Quick vs more gradual

• Patterns of decompensation/deterioration– Ex: “the downward spiral”

Chronicity

We want to know where the client has been to help determine where they are going.

Those who do not learn from history…

DSM-5 ETA 5/2013

Is a diagnosis of “Dysthymic Disorder” necessarily less severe than a diagnosis of “Major Depressive Disorder?”

-A dx may not always communicate px

-Potentially longer tx and more long-term impairment when chronic

regardless of the dx.

A proposed new Chronic Depression diagnosis

• Chronic Depressive Disorder?

• Dysthymic disorder and chronic MDD combined for DSM-5?

• See dysthymic disorder at dsm5.org

Caution:

• Client #1 had no chronic history

• Relying on self report alone can lead to dichotomies like Client #1 & Client #2 being the same person

• You are counseled to use self report “responsibly”

•What can we do?

Focus on the Fundamentals

• The “devil” is in the details (follow up)

– Frequency, Intensity, Duration

• Ex: A one minute, one-time panic attack vs regular, prolonged attacks.

Symptoms do not equal Severity

(focus on functioning)

Focus on Functioning

• All symptoms are not created equally

• The same symptoms do not effect different people in the same ways

• We all live in “different worlds”

• What type of assistance/ accommodations allows them to function the way they do?

• Can someone’s environment swing their prognosis one way or the other?

• Social support (!)

No Man is an Island

Case Example

The apparent functioning of an anxious and depressed person with a supportive significant other vs one without that support.

How would they appear if they were both thrown in

an environment without those supports?

Involve others

• Is it “taboo” to get collateral information from family/significant others in treatment?

• Can involving others in an individual’s treatment help them perceive social support?

• Did collateral reports make a difference in our client #1 vs client #2 scenario?

Social Support

=

muy importante

Interpersonal factors

Some people behave in ways which “create” negative interpersonal experiences even when not depressed

“Stress-generating behaviors”

-their interpersonal problem solving difficulties lead to conflict

Interpersonal Factors

• Negative feedback-seeking– People with negative opinions of themselves

may try to convince others of their “worthlessness.”

– People may “look for” and sometimes obtain interpersonal rejection

Excessive Reassurance Seeking

• Significant others may start out comforting, but proceed to annoyed and potentially rejecting

• An eventual negative effect on perceived social support?

Excessive Reassurance Seeking:

By the way, how is my presentation so far?

Are you sure it’s not running a little long?

They probably can’t hear me in the back

I do tend to mumble…

…are you sure you can hear me?

you’re just saying that…

…I drive you crazy don’t I?

I’d like to avoid any interpersonal conflict

• Low assertiveness

• Avoidance and social withdrawal

Interpersonal Problems

• These problems are often found in individuals with chronic and recurrent depression

Comorbidity“Perhaps the most important severity indicator”

What type of disorder is comorbid in as high as 50% of people w/ Major Depressive Disorder?

Anxiety

• Yerkes-Dodson: arousal is only good for performance up to a point.

• Comorbid anxiety usually predicts worse psychosocial outcomes

Psychotic symptoms

• Mood Congruent:

–Do they occur with an elevated mood or depressive mood w/ depressive/ manic themes?

Mania and hypomania

• Bipolar I: possibly briefer but “more severe” episodes of depression than MDD.

• Subthreshold manic/hypomanic sxs may not cause much functional impairment (euphoria, irritability, overactivity)– However, they may predict a longer course

and poor pattern of response to antidepressants if comorbid with MDD.

Substance Use

• Usually significant improvement within approx 30 days w/ abstinence if substance-induced

• Otherwise “just say low” when it comes to prognosis for improvement w/ comorbid substance use and another disorder.

relatively stable tendencies

• Schemas/Automatic thoughts– Irrational, “Bitter Beliefs”

• “Cognitive Vulnerabilities”– Ex: Hopelessness; negative attitudes,

rumination

• Personality Disorder/personality traits– Ex: Neuroticism/Negative Emotionality

Some Overlapping Concepts:

‘cause we’ve got… Personality

• Usual mood dominated by dejection, gloominess, cheerlessness, joylessness…

• Beliefs of inadequacy, worthlessness

• Critical, blaming, derogatory towards self

• Brooding, given to worry

• Negative, critical, judgmental to others

• Pessimistic

• Prone to feeling guilty, remorseful

We can be agnostic as to “why”

Mix of Nature & Nurture; early experiences

They’re often noticeable by the early teenage years in some individuals

Gender differences develop about the same time as in depression.

Personality Impacts Depression

• risk for onset of an episode and recurrence/relapse of future episodes

• risk for treatment resistance and a longer course of treatment

• poor functioning

• Increased comorbidity

Treatment Outcomes

• The more of these factors you have, the more likely you are to have poor treatment outcomes

• Many of these may also potentially relate to a risk for…

Suicide.

These factors may also relate to Suicide

• Plus: Extent of suicidal intent/planning

• identifying with and time spent dwelling on themes of death

disability

The more these factors interfere with daily

functioning and predict a chronic course the more likely they are to lead to

“disability”

Can Secondary Gain create a barrier to

successful treatment?

Do you share the same treatment goals?

Case Example

Younger gentleman in a nursing home with back problems

– Went home every day – Didn’t receive much nursing home assistance– Came back in time to not be discharged

because…

…his Dr. said it would increase his chances of getting benefits if he were still in the nursing home.

…it may not be “malingering”

Secondary gain can potentially impact prognosis

in a negative fashion

File Review Consultant Bias

• DOCUMENTATION

I didn’t sign up for a

“lecture” on documentation!

Bait & Switch?

• Another case example of client #1 vs Client #2

Client #2 has a severe mental illness

Client #1’s progress notes look like this…

“Pt seendoing OK

RTC 3 mo”

We can fit over 4 years of treatment on 3 PowerPoint slides

…As expected

Client #1 and Client #2 are the same person…

…with enough limitations that they would qualify for disability based on their severe mental illness.

(apparently “doing ok” is a relative term)

Brevity = valor?

• Will things you write in your notes “hurt” your client?

• Possibly depending on your definition of “hurt”

• No one says write everything down

• You are not protecting yourself or your client by leaving out important details.

When you are aware of factors related to prognosis and/or severity…

Write them down

Write this down…

• Disability• Medical Necessity• Legal/ethical (“S.O.S.”)• Continuity of care

• Doom

• Gloom

»and…

Factors Related to Prognosis

Resilience

We also have strength

Reminders

• Symptoms do not equal Severity (focus on functioning)

• The “devil” is in the details

(follow up)

• Frequency, Intensity, Duration

• No man is an Island

• History may repeat itself.

Review• Chronicity and recurrence

• # of failed and intensive treatments

• Comorbidity/Co-occurrence

• Suicidal intent & preoccupation w/ death

• The “middle ground” of severity and age of onset may have the best prognosis.

• Stable “personality” characteristics can prolong the course of treatment & create risk of recurrence

Clinical Judgment

• Predictions based solely on the self-report of a single individual will only take us so far– Ex: client #1 vs client #2

• We should continue to improve the process of integrating multiple types of information to increase accuracy.

Thank you!materials @

ToddFinnerty.com