RCPsych AGM10 - Diagnosing depression in primary care and hospital settings new evidence (v3)

Alex Mitchell [email protected]

Consultant in Liaison Psychiatry & Psycho-oncology

Diagnosing Depression in Primary Care and Hospital

Settings - Towards a change in clinical practice

RCPsych Workshop 2010 – 9.45 – 11am

Loss of confidenceLow motivation / driveWithdrawalAvoidanceSocial isolationWorryFeelings of dreadHelplessnessHopelessnessPsychic anxietySomatic anxietyAngerLack of reactive moodCognitive Change (=> memory complaints)Perceptual distortion

Which Are Recognized Symptoms of MDD?

=> plan

ALL

SOME

NONE

UNSURE

DSMVICD11

Symptoms

Under-served

Distress

Monitoring

Scales

Screening

Qualityof care

Older people

PhysicalIllness

DepressionDetection

Prescribing

Follow-up

Culturaleffects

Se Change

PhysiciansSpecialSymptoms

PrimaryCare

Impairment

Help Seeking

Introduction – What’s Going Wrong?

BackgroundContents

% Receiving Any treatment for Depression (CIDI)

10.911.3

8.18.8

4.3

5.6

10.9

13.8

6.8

17.9

3.4

5.5

15.4

7.2

0

2

4

6

8

10

12

14

16

18

20

High Inc

omeBelg

ium

France

German

y

Israe

l

Italy

Japa

nNeth

erlan

dsNew

Zeala

nd

Spain USALow

Inco

me

ChinaColom

biaSouth

Afri

caUkra

ine

Wang P et al (2007) Lancet 2007; 370: 841–50

n=84,850 face-to-face interviews

=> USA

77.7

17.7 20.515.6

29.9

14.8

25.3

84.3

12.8

21.717.5 20.3

10.8

23.2

84.5

28.3

40.9

30.3

43

28.9

46

0

10

20

30

40

50

60

70

80

90

Any

prim

ary

care

pra

ctiti

oner

vis

it (1

-yr)

Any

men

tal h

ealth

spe

cial

ist v

isit

(1-y

r)

Any

antid

epre

ssan

t or a

ntia

nxie

ty m

edic

a...

Appr

opria

te m

edic

atio

n us

e*

Any

coun

selin

g us

e

Appr

opria

te c

ouns

elin

g us

e*

App

ropr

iate

trea

tmen

t use

*

Depression Alone (=883)

Anixety Alone (n=314)

Depression and Anxiety (n = 439)

Young et al (2001) The Quality of Care for Depressive and Anxiety Disorders in the United States. Arch Gen Psychiatry. 2001;58:55-61

462 (42%)Meetable Needs

1093 (100%)Population

388 (84%)Aware of Need

172 (44%)Requested Help

80 (47%)Needs Met

462 needs

17.3%

322 DSMIV

25%

Patient & provider factors=> DUD

94.2%

37.4%

8 yrs N= 9282 NCS‐R

N=23 studies; 50% some treatment 33% minimal treatment N=19 studies; 30% 1 in 1/12; 10% 3 in 3 months

5 Steps to Improve QoC….and change clinical practice

1. Re-look at concept / criteria /symptoms

2. Understand Detection Problems

3. Understand special populations

4. Consider Enhanced Detection

5. Tie Detection to Clear Action

Depression Care: Who Provides it?

2/3rds 1/3rd

25%Psychiatry

10%Medical

Primary Care

cg90cg42

Percentage of U.S. retail psychotropic prescriptions written from August 2006 to jul07

Mark et al. PSYCHIATRIC SERVICES September 2009 Vol. 60 No. 9

1.00

0.64

0.26

0.10

0.00

0.20

0.40

0.60

0.80

1.00

1.20

All visits (N =14,372) Primary care (N =3,605) Psychiatrists (N =293) Medical specialists (N=10,474)

Comment: Slide illustrates added proportion of all depression treated in each setting. Most depression is treated in primary care

J Gen Intern Med. 2006 September; 21(9): 926–930.

1a. Re-examination of Depression

Is depression a disease; disorder (syndrome) or normally distributed

Graphical – two diseases

Healthy

Stroke# ofIndividualsWith symptom

Severity of Infarct

Point of Rarity

Comment: Slide illustrates the concept of discrimination using one symptom severity of “low mood”

Graphical – two disorders

Healthy

Diabetes

# ofIndividualsWith symptom

HBA1c

?Point of Rarity

Optimal cut

Graphical - Dimension

Non-Depressed

Depressed# ofIndividualsWith symptom

Severity of Low Mood

Comment: Slide illustrates added hypothetical distribution of mood scores in a population with hidden depression

Do We Have Good Data in Psychiatry?

0

500

1000

1500

2000

2500

3000

Zero One

TwoThree Fo

urFiv

e

SixSeve

neig

htNine Ten

Eleven

Twelv

eTh

irtee

nFour

teen

Fiftee

nSixt

eenSeve

nteen

Eighteen

HADS-D N=18,414

Comment: Slide illustrates added actual distribution of mood scores on the HADS in a cancer population with hidden depression from the Edinburgh cancer centre

Distress Ratings (n=2,200) clinical significance criterion

Proportion

18 .4 %

12 .9 %

11.2 %12 .3 %

8 .1%

11.9 %

5.0 %

2 .8 % 2 .6 %

7.7% 7.2 %

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

20.0%

Zero One Two Three Four Five Six Seven Eight Nine Ten

Insignificant SevereModerateMildMinimal

p124

50%

Depression is on a continuum using current scales……..There will always be a trade-off of sensitivity vs specificty

Back to Basics Lessons

=> Categorial

1b. Re-examination of Criteria of Depression

=> ICD10

YesYesGuilt or self-blame

DSMIVICD10Core Symptoms

YesNoSignificant change in weight

YesYesAgitation or slowing of movements

YesYesSuicidal thoughts or acts

NoYesPoor or increased appetite

NoYesLow self-confidence

YesYesPoor concentration or indecisiveness

YesYesDisturbed sleep

YesYes (core)‏Fatigue or low energy

Yes (core)‏Yes (core)‏Loss of interests or pleasure

Yes (core)‏Yes (core)‏Persistent sadness or low mood

Symptom Significance in Depression

(7 or) 8 symptoms ‏(3+4)

(5 or )6 symptoms

4 symptoms ‏(2+2)

2 or 3 symptoms

0 or 1 symptom

ICD10

16 - 21UnspecifiedSevere

12 - 155 symptoms (Mj)‏

Moderate

8 -112-4 symptoms (minor) ‏

Mild

4 - 71 or No core symptoms

Sub-syndromal

0 - 30 symptomHealthy

HADs D ScoreDSMIVDepression Severity

Change in practice – ICD10 2/4/6/8 + CS

“Common” Symptoms of Depression

0.120.56Thoughts of death

0.330.59Psychic anxiety

0.120.61Worthlessness

0.420.69Anxiety

0.270.70Insomnia

0.120.81Diminished interest/pleasure

0.240.82Diminished concentration

0.320.83Sleep disturbance

0.270.87Concentration/indecision

0.320.87Loss of energy

0.300.88Diminished drive

0.180.93Depressed mood

Non-Depressed FrqDepressed FrqItem

Mitchell, Zimmerman et al n=2300

“Uncommon” Symptoms

0.060.16Increased weight

0.060.19Hypersomnia

0.070.19Increased appetite

0.060.22Lack of reactive mood

0.060.23Decreased weight

0.040.28Psychomotor retardation

0.090.34Psychomotor agitation

0.260.44Anger

0.110.45Decreased appetite

0.250.46Somatic anxiety

Non-Depressed ProportionDepressed ProportionItem

Mitchell, Zimmerman et al MIDAS Database. Psychol Med 2009

-0.10

0.00

0.10

0.20

0.30

0.40

0.50A

nger

Anx

iety

Dec

reas

ed a

ppet

ite

Dec

reas

ed w

eigh

t

Dep

ress

ed m

ood

Dim

inis

hed

conc

entr

atio

n

Dim

inis

hed

driv

eD

imin

ishe

d in

tere

st/p

leas

ure

Exce

ssiv

e gu

ilt

Hel

ple

ssne

ss

Hop

eles

snes

s

Hyp

erso

mni

a

Incr

ease

d ap

peti

te

Incr

ease

d w

eigh

t

Inde

cisi

vene

ss

Inso

mni

aLa

ck o

f re

acti

ve m

ood

Loss

of

ener

gy

Psyc

hic

anxi

ety

Psyc

hom

otor

agi

tati

on

Psyc

hom

otor

cha

nge

Psyc

hom

otor

ret

arda

tion

Slee

p di

stur

banc

e

Som

atic

anx

iety

Thou

ghts

of

deat

h

Wor

thle

ssne

ss

Rule-In Added Value (PPV-Prev)Rule-Out Added Value (NPV-Prev)

Comment: Slide illustrates added value of each symptom when diagnosing depression and when identifying non-depressed

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

Depressed Mood

Diminished drive

Diminished interest/pleasure

Loss of energy

Sleep disturbanceDiminished concentration

Sensitivity

1 - Specificity

n=1523

Comment: Slide illustrates summary ROC curve sensitivity/1-specficity plot for each mood symptom

Symptoms of depression are not necessarily optimalFurther research is required against course and burden


2. Recognition in Routine Care

Is “diagnosis as usual” sufficient?

1,2 or 3 Simple QQ15%

Clinical Skills Alone73%

ICD10/DSMIV0%

Short QQ3%

Other/Uncertain9% Other/Uncertain

2%

Use a QQ15%

ICD10/DSMIV13%



Cancer StaffCurrent Method (n=226)

Psychiatrists

=> Psychiatrists



ICD10/DSMIV0%

Short QQ3%

Other/Uncertain9% Other/Uncertain

2%

Use a QQ15%

ICD10/DSMIV13%



Cancer Staff Psychiatrists

Current MethodComment: Slide illustrates preferences of cancer clinicians vs psychiatrists for detecting depression

86.8

55.6 54.4

43.3

36

29.826.2 25.6 25.2 23.8 24

21.4 21.2

13.9 12.89.5

7.2 7 7 5.9 4.8 4.1 2.6 1.8 1.8 1.3 0.9 0.4 0.40

10

20

30

40

50

60

70

80

90

100

Slee

p di

stur

banc

es; i

nsom

nia;

ear

ly w

aken

ing

Loss

of a

ppet

ite; o

vere

atin

g; w

eigh

t cha

nges

Dep

ress

ed m

ood;

hop

eles

snes

s; s

ad; g

loom

y

Apat

hy; l

etha

rgy;

tire

dnes

s; la

ssitu

de

Loss

of i

nter

est;

with

draw

al; i

ndiff

eren

ce; l

onel

ines

s

Loss

of e

nerg

y; lo

ss o

f driv

e; b

urnt

out

Loss

of l

ibido

; los

s of

sex

driv

e; im

pote

nce

Tear

s; w

eepi

ng; c

ryin

g

Anxi

ous;

agi

tate

d; ir

ritab

le; r

estle

ss, t

ense

; stre

ssed

Feeli

ng w

orth

less

; gui

lty; l

ack

of s

elf e

stee

m

Som

atic

; veg

etat

ive

sym

ptom

s; m

alai

se; m

ultip

le c

onsu

ltatio

ns

Suici

de th

ough

ts; t

houg

ht o

f sel

f inj

ury

Loss

of c

once

ntra

tion;

poo

r mem

ory,

poo

r thi

nkin

g

Dim

inis

hed

perfo

rman

ce; i

nabi

lity to

cop

e

Emot

iona

l labi

lity;

moo

d sw

ings

Loss

of a

ffect

; fla

t affe

ct; l

oss o

f em

otio

n

Loss

of e

njoy

men

t or p

leas

ure;

lack

of h

umor

Beha

viou

ral p

robl

ems;

agg

ress

iven

ess;

beh

avio

ural

cha

nges

Pess

imis

m; n

egat

ive

attit

udes

, wor

ryin

g

Psyc

hom

otor

reta

rdat

ion;

slow

ness

Hea

dach

es; d

izzi

ness

Appe

aran

ce; s

peec

h; e

xces

sive

sm

iling

; vag

uene

ss, e

tc.

Hea

vy u

se o

f alc

ohol

, tob

acco

or d

rugs

Del

usio

ns; h

alluc

inat

ions

; con

fusi

on

Reac

tion

to p

roba

ble

caus

es o

r life

eve

nts

Fam

ily o

r pas

t his

tory

of d

epre

ssio

n

Obs

essi

ve id

eatio

n; p

hobi

asLa

ck o

f ins

ight

Perio

d of

life

(men

opau

se)

Comment: Slide illustrates which symptoms are asked about by GPS looking for depression

What do GPs Ask about:Sleep

AppetiteLow

Energy

GP Recognizes:Proportion of Individual Symptoms Recognised by GPs

76.1

36.4 34.631.6

21.616.7

13.39.1 8.3 8.3

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

Low m

ood

Insomnia

Hypoc

hondri

asis

Loss

of in

terest

Tearfu

lness

Anxiety

Loss

of en

ergy

Pessim

ism

Anorex

ia

Not Copin

g

O’Conner et al (2001) Depression in primary care.Int Psychogeriatr 13(3) 367-374.

GP Detection of Depression – Meta-analysis

Methods– 140 studies of GP recognition

rate =>

– 90 depression– 40 interview– 19 se sp (+2)– 10 countries

Accuracy 2x2 Table

PrevalenceSpecificitySensitivity

NPVTrue -VeFalse -VeTest -ve

PPVFalse +veTrue +veTest +ve

DepressionABSENT

DepressionPRESENT

Accuracy of GP’s Diagnoses

955927,6406553

667825,1254050GP -ve

501825152503GP +ve

DepressionABSENT

DepressionPRESENT

Sensitivity48%

PPV 42.8%

Specificity80.1%

NPV 85.1%

Prevalence 19%

N=35 studies

100 weekly referrals

GP Assessment

10TP 10FN

20 D

Screen #1+ve

n = 20 80 ND

Sp 80%

Se 50%

n = 80

N = 100

TP = 10

FP = 1664TN 16FP TN =64

FN = 10

PPV 28% NPV 88%

Screen #1-ve

GP Opinion

50% TP and 25% FP Offered Treatment

50‐80% accept initial treatment

100 weekly referrals

GP Assessment

7TP 13FN

20 D

Screen #1+ve

n = 20 80 ND

Sp 90%

Se 30%

n = 80

N = 100

TP = 10

FP = 1672TN 8FP TN =64

FN = 10

PPV 50% NPV 80%

Screen #1-ve

50% TP and 25% FP Offered Treatment

50‐80% accept initial treatment

1/3 of screen positive patients with no treatment well at follow‐up

GP Notation

3/20TP Offered Rx => appropriate treatment rate of 5-20%

2/80FP Offered Rx => inappropriate treatment rate of 1-2%

Weekly Population

GP Assessment

Possible case

Depression

Screen #1+ve

n = 20 No Depression

Sp 80%

Se 50%

n = 80

N = 100

TP = 10

FP = 16Probable Non-Case TN =64

FN = 10

PPV 28%

2nd Assessment Sp 80%

Se 50%

NPV 88%

Probable Depression TP = 56

FP = 72Probable Non-Case TN =288

FN = 84

PPV 44% NPV 77%

Screen #1-ve

Screen #2+ve

Screen #2+ve

Cumulative YieldTP = 56

TN = 728

FN = 144

FP = 72

NPV 83%

PPV 44%

Sp 91%

Se 28%

77%

89%

Single assessment inadequateFalse +ve’s are more of a problem than expected


3. Predictors of Recognition

0.03

0.19

0.210.22

0.20

0.05

0.02 0.020.01 0.01

0.010.01 0.01 0.01

0.00

0.05

0.10

0.15

0.20

0.25

5mins

10mins

15mins

20mins

25mins

30mins

35mins

40mins

45mins

50mins

55mins

60mins

65mins

70mins

65%

Geraghty JGIM 2007

Is 10‐15 minutes enough?

Severity

0

500

1000

1500

2000

2500

3000

Zero One

TwoThree Fo

urFiv

e

SixSeve

neig

htNine Ten

Eleven

Twelv

eTh

irtee

nFour

teen

Fiftee

nSixt

eenSeve

nteen

Eighteen

HADS-D

0

0.05

0.1

0.15

0.2

0.25

0.3

Eight

Nine Ten

Eleven

Twelv

eTh

irtee

nFo

urtee

n

Fiftee

nSixt

een

Seven

teen

Eighteen

Ninetee

n

Twen

tyTw

enty-

one

Proportion MissedProportion Recognized

HADS-D

Comment: Slide illustrates diagnostic accuracy according to score on DT

11.815.4

30.4 28.9

41.9 42.9 40.7

57.1

82.4

66.771.4

15.8

25.0

26.124.4

19.4 19.0

33.3

21.4

11.8

22.2 14.3

72.4

59.6

43.546.7

38.7 38.1

25.921.4

5.911.1

14.3

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

Zero One Two Three Four Five Six Seven Eight Nine Ten

Judgement = Non-distressedJudgement = UnclearJudgement = Distressed

CNS in Oncology N=401

Recognition from WHO PPGHC Study (Ustun, Goldberg et al)

7470 69.6

61.5 59.656.7 56.7 55.6 54.2

45.7 43.939.7

28.4

22.2 21 19.3

0

10

20

30

40

50

60

70

80

Santia

go

Verona

Manch

ester

Paris

Groningen

Berlin

Seattle

Mainz

TOTALBangalo

reRio de J

aneir

o

Ibadan

Ankara

Athen

sShan

ghaiNagas

aki

Clinician traits eg confidence

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

Pre-test Probability

Post

-test

Pro

babi

lity

Ave Confidence+

Ave Confidence-

Baseline Probability

Above Ave Confidence+

Above Ave Confidence-

High Confidence+

High Confidence-

Low confidence = more cautious, fewer false positives, more false negatives

High confidence = less cautious, more false positives, low false negatives

p180

Predictors of Recognition

Prevalence10% rural 15% mean 20% urban 20% (oncology 25%)

Severity70% mild 20% moderate 10% severe

InternationalLow in developing but in Western:Italy > Netherlands >Australia > UK > US

ContactCummulative: 77% single 89% 3-6 monthsAppointment Duration

Confidence &trust

4. Comorbid Depression

Back to Basics

Approaches to Somatic Symptoms of DepressionInclusiveUses all of the symptoms of depression, regardless of whether they may or may not be secondary to a physical illness. This approach is used in the Schedule for Affective Disorders and Schizophrenia (SADS) and the Research Diagnostic Criteria.

ExclusiveEliminates somatic symptoms but without substitution. There is concern that this might lower sensitivity. with an increased likelihood of missed cases (false negatives)‏

EtiologicAssesses the origin of each symptom and only counts a symptom ofdepression if it is clearly not the result of the physical illness. This is proposed by the Structured Clinical Interview for DSM and Diagnostic Interview Schedule (DIS), as well as the DSM-III-R/IV).

SubstitutiveAssumes somatic symptoms are a contaminant and replaces these additional cognitive symptoms. However it is not clear what specific symptoms should be substituted

Who Uses Specific Non-Somatic scales?

Medically Unwell Alone

Primary Depression Alone

Secondary Depression

Comment: Slide illustrates concept of phenomenology of depressions in medical disease

FatigueAnorexiaInsomnia

Concentration

Study: Coyne Thombs Mitchell

N= 4500; Pooled database study; All comparative studies

Physical illness+comorbid depressionVsPhysical illness aloneVs

Primary depression alone

Co-morbid Depression vs Primary Depression

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Agitatio

n (Com

orbid)

Agitatio

n (Prim

ary)

Anxiety

(Com

orbid)

Anxiety

(Prim

ary)

Appetite

(Comorb

id)

Appetite

(Prim

ary)

Concen

tratio

n (Comorb

id)

Concen

tratio

n (Prim

ary)

Fatigu

e (Comorb

id)

Fatigu

e (Prim

ary)

Guilt (

Comorbid)

Guilt (

Primar

y)

Hopeles

snes

s (Comorb

id)

Hopeles

snes

s (Prim

ary)

Insomnia

(Comor

bid)

Insomnia

(Prim

ary)

Loss In

teres

t (Comorb

id)

Loss In

teres

t (Prim

ary)

Low Mood (C

omorbid)

Low Mood (P

rimary

)

Retard

ation (

Comorbid)

Retard

ation (

Primary)

Suicide (

Comorbid)

Suicide (

Primar

y)

Weight L

oss (C

omorbid)

Weight L

oss (P

rimary

)

*

*

*

*

*

**

*

*

Comorbid Depression

Primary Depression

n=4069 vs 4982Comment: Slide illustrates similar symptoms profile in comorbid vsprimary depression






Concentration

BEFORE




AgitationRetardation

Co-morbid Depression vs Medical Illness Alone

n= 4069 vs 1217

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Anxiety

(Com

orbid)

Anxiety

(Med

ical)

Concen

tratio

n (Comorb

id)

Concen

tratio

n (Med

ical)

Fatigu

e (Comorb

id)Fati

gue (

Medica

l)

Hopeles

snes

s (Comorb

id)

Hopeles

snes

s (Med

ical)

Insomnia

(any t

ype)

(Comorb

id)

Insomnia

(any t

ype)

(Med

ical)

Loss In

teres

t (Comorb

id)

Loss In

teres

t (Med

ical)

Low Mood (C

omorbid)

Low Mood (M

edical)

Retard

ation (

Comorbid)

Retard

ation (

Medica

l)

Suicide (

Comorbid)

Suicide (

Medica

l)

Weight L

oss (C

omorbid)

Weight L

oss (M

edical)

Worthles

snes

s (Comor

bid)

Worthles

snes

s (Med

ical)

Medical Illness Alone

Comorbid Depression

**

*

*

*

*

*

*

*

Comment: Slide illustrates distinct symptoms profile in comorbid depression vs medical illness alone






Concentration

Medically Unwell

Primary Depression


Comment: Slide illustrates actual phenomenology of depressions in medical disease

Weight loss

AgitationRetardation

Comorbid depression scales need to be reexaminedAgainst alternatives


5. Enhanced Detection Strategies

Does Screening Work?



ICD10/DSMIV0%

Short QQ3%

Other/Uncertain9%

Methods to Evaluate Depression

Unassisted Clinician Conventional Scales

Verbal Questions Visual-Analogue Test

PHQ2

WHO-5

Whooley/NICE

Distress Thermometer

Depression Thermometer

Ultra-Short (<5)‏Short (5-10)‏ Long (10+)‏Untrained Trained



ICD10/DSMIV0%

Short QQ3%

Other/Uncertain9%



ICD10/DSMIV0%

Short QQ3%

Other/Uncertain9%

0.00

0.10

0.20

0.30

0.40

0.50

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Post

-test

Pro

babi

lity

Clinician Positive (Fallowfield et al, 2001)

Clinician Negative (Fallowfield et al, 2001)


HADS-D Positive (Mata-analysis)

HADS-D Negative (Meta-analysis)

Comment: Slide illustrates Bayesian curve comparison from indirect studies of clinician and HADS

This illustrates POTENTIAL gain from screening

Gain?

Benefit

All scales side-by-side

Meader et alNational Collaborative Centre for Mental Health

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Post

-test

Pro

babi

lity HADS+

HADS-


GDS30+

GDS30-

GDS15+

GHQ28+

HDRS+

ZUNG+

GDS15-

GHQ28-

HDRS-

ZUNG-

PHQ9+

PHQ9-

WHOOLEY2Q+

WHOOLEY2Q-

BDI+

BDI-

BDI-SF+

BDI-SF-

CESD+

CESD-

1Q+

1Q-

GHQ12+

GHQ12-

PHQ2 = HIGH NPV

What is the actual added value?

Is there a circularity?

8 RCTs of screening vs no-screening in PC

Comment: Slide illustrates actual gain in meta-analysis of screening implementation in primary care

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t-tes

t Pro

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lity

Clinical+Clinical-Baseline ProbabilityScreen+Screen-

Comment: Slide illustrates Bayesian curve comparison from RCT studies of clinician with and without screening

This illustrates ACTUAL gain from screening in Study from Christensen

Depression screening can work……..Under favourable conditions


5. Depression in Older People

Does it go unrecognized?

Are Somatic Symptoms Common in Older People?

QuestionsMore or less difficult to detect late-life depression?

More or less

Low moodAgitation InsomniaPoor concentration

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Routine Case-Finding Late-LifeRoutine Exclusion Late-lifeBaseline ProbabilityRoutine Case-Finding MixedRoutine Exclusion MixedRoutine Case-Finding YoungerRoutine Exclusion Younger

Comment: Slide illustrates detection of late life vs mid-life depression in primary care – GPs are least successful with late-life depression

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-0.15

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0

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0.1

Hel

ples

snes

s

Hop

eles

snes

s

Wor

thle

ssne

ss

Anx

iety

(Som

atic

anx

iety

)

Ang

er

Inde

cisi

vene

ss

Thou

ghts

of D

eath

Dim

inis

hed

Con

cent

ratio

n

Anx

iety

(Com

bine

d)

Incr

ease

d A

ppet

ite

Slee

p D

istu

rban

ce (H

yper

som

nia)

Slee

p D

istu

rban

ce (C

ombi

ned)

Incr

ease

d W

eigh

t

Loss

of E

nerg

y

Psyc

hom

otor

Agi

tatio

n

Anx

iety

(Psy

chic

anx

iety

)

Exce

ssiv

e G

uilt

Dim

inis

hed

Inte

rest

Slee

p D

istu

rban

ce (I

nsom

nia)

Dec

reas

ed A

ppet

ite

Dep

ress

ed M

ood

Psyc

hom

otor

Ret

arda

tion

Dec

reas

ed W

eigh

t

More common in late-life depression

More common in early-life depression

Comment: Slide illustrates simple frequency of symptoms in late life vsmid-life depression

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Anger

Anxiety

(Com

bined)

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(Psy

chic

anxie

ty)

Anxiety

(Somatic

anxiet

y)

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ased

App

etite

Decre

ased

Weig

ht

Depres

sed M

ood

Diminish

ed C

oncentra

tion

Diminish

ed In

teres

tExc

essiv

e Guilt

Helples

snes

sHope

lessn

ess

Increas

ed A

ppetite

Increas

ed W

eight

Indecisi

venes

sLoss

of Ene

rgy

Psych

omotor Agita

tion

Psych

omotor Retar

datio

n

Sleep D

isturban

ce (C

ombined)

Sleep D

isturban

ce (H

ypers

omnia)

Sleep D

isturban

ce (In

somnia)

Thoughts

of Dea

thWorth

lessn

ess

<55>54>59>64

*

*

*

*

*

**

*

Comment: Slide illustrates diagnostic value of symptoms in late life vs mid-life depression – few have special significance

Mid-life Depression

Late-life Depression

Comment: Slide illustrates actual phenomenology of late life depression

Poor concworthlessness

Tools and criteria for late-life dep……..May need to be re-examined


=> Future?

=86.4% =82.2%

=57.6%Beals AGP 2004

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Help-Seeking Any+

Help-Seeking Any-


Help-Seeking Medical+

Help-Seeking Medical-

Impairment+

Impairment-

Distress+

Distress-

Beals - Challenges in Operationalizing the DSM-IV - Clinical Significance Criterion Arch Gen Psychiatry. 2004;61:1197-1207

SummaryQuestions

Quick Summary

Depression is modestly common & easily missed5% have depression as their main reason for presentation

Most depression is comorbid50% adults 80% elderly have physical illness

All health professionals struggle with diagnosisSymptom approach

Routine screening modestly effectiveHigh risk, targeted and algorithm approaches

Dimensional approach developingTrials in cardiac care and oncology and neurology of ET

RCPsych AGM10 - Diagnosing depression in primary care and hospital settings new evidence (v3)

Health & Medicine

Transcript of RCPsych AGM10 - Diagnosing depression in primary care and hospital settings new evidence (v3)