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Learning Objectives Depression and Anhedonia 1/25/2017 Learning Objectives • Importance of screening for depression in the primary care setting. • How to use screening tools for depression in an effective way. • Learn changes in DSM‐5 classification that could help with a more accurate diagnosis of subtypes of depressive disorder. • Review evidence‐based treatment options including AITALA GIRON , M.D. antidepressants vs psychotherapy or both. Case Scenario Depression is among the leading cause of disability in adults in the USA . Ms. G is a 54 year old female, mixed raced. She has been your patient for that last 3 years. Her medical history is positive for Type II Diabetes (diagnosed 6 Is very common for patients to present first to a month ago), obesity and HTN. primary care setting to seek help . Her last laboratory results where remarkable for : AIC% Hb of 7.2 Medication regimen includes :Metformin 500 mg BID, Metoprolol 50 mg per day. Simvastatin 20 mg per day. Her oldest son is leaving for college and is she is having marital Screening with accurate diagnosis and then effective problems. treatment will improve clinical outcome. Presents to follow up complaining of “sleeping difficulties”. Reports being tired all the time and reports anhedonia . She has sad affect and starts crying that she has gained 30 lb. in the last DSM‐5 uses available evidence and data to fine tune 6 months, has no interest in sex, difficulties concentrating and is having hot flashes. the diagnosis of depressive disorders. She think this is why her husband is not interested in her any longer . Depression and Anhedonia Prevalence of Major Depression Major Depression diagnosis is especially difficult when they occur in an individual who also has a general According to the World Health Organization (WHO; medical condition (e.g., cancer, stroke, myocardial 2010), major depression carries the heaviest burden of infarction, diabetes, pregnancy). disability among mental and behavioral disorders Some of the criterion signs and symptoms of a major depressive episode are identical to those of general medical conditions (e.g., weight loss ,weight gain , In 2015, an estimated 16.1 million adults aged 18 or fatigue, hypersomnia, insomnia). older in the United States had at least one major Nonvegetative symptoms of dysphoria, anhedonia, depressive episode in the past year. guilt or worthlessness, impaired concentration and suicidal thoughts should we asses and help with the differential diagnosis . This number represented 6.7% of all U.S. adults. 1 1/25/2017 Prevalence of Major Depression among Major Depression with Severe US Population 2015 Impairment Among Adults in 2015 Rates of Clinical Diagnosis of Depression among USA Workers Depression Among USA Workers Workers with a diagnosis of depression miss an estimated 68 million additional days of work each year Results in an estimated cost of more than $23 billion in lost productivity annually to U.S. employers. Workforce with diagnosis of depression misses average 8.7 missed work days each year due to poor health. Workers with no depression miss an average of 4.6 work days per year. Witters D, Liu D, Agrawal S. Depression costs http://www.gallup.com/poll/163619/depression - costs-workplaces-billion-absenteeism.aspx. Inflammation and Depression Depression and Diabetes Inflammatory Markers elevated in Depression A meta‐analysis of cross‐sectional studies in 2006, depression had a includes :Interleukin 1B ,Tumor Necrosis Factors , prevalence of 17.6% among those with Type II Diabetes and 9.8% among those without Type II Diabetes C‐Reactive protein. Patients with a history of childhood trauma have an Comorbid depression and diabetes are particularly common among elevated risk not only for depression but also for a women, with female preponderance noted in the 2001 findings (28% variety of common chronic medical diseases. for women vs. 18% for men) A relationship exists between childhood maltreatment and elevations in plasma inflammatory markers in In a large study (143,943 primary care patients with major depressive adulthood. disorder), Type II DM was present in 9.3% of the major depressive disorder population, in comparison with 4.3% of those without Depressed male patients with a history of early‐life depression stress demonstrate an increased inflammatory response to acute psychosocial stress. Smith DJ, et al: Depression and multimorbidity:J Clin Psychiatry 2014; 75:1202–1208 2 1/25/2017 Depression and Diabetes DSM‐5 Depressive Disorders There is speculation that the structural and neurochemical changes associated with diabetes induce depressive Disruptive Mood Dysregulation Disorder symptoms Major Depressive Disorder Persistent Depressive Disorder (Dysthymia) The neuroinflammatory changes induced by diabetes and the direct impact of altered insulin metabolism on the Premenstrual Dysphoric Disorder brain are biologically plausible mechanisms by which those Substance/Medication‐Induced Depressive Disorder with diabetes could be predisposed to depression. Depressive Disorder Due to Another Medical Condition Diabetes‐related biochemical changes induce cognitive disturbances and can adversely affect emotional processing and reward circuitry. DSM‐5 Criteria for Major Depression DSM‐5 Criteria for Major Depression Disorder Disorder Five (or more) of the following symptoms have been present during the same Psychomotor agitation or retardation nearly every day (observable by 2‐week period and represent a change from previous functioning; at least one others, not merely subjective feelings of restlessness or being slowed of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. down). Note: Do not include symptoms that are clearly attributable to another medical condition. Fatigue or loss of energy nearly every day. Feelings of worthlessness or excessive or inappropriate guilt (which may be Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by delusional) nearly every day (not merely self‐reproach or guilt about being others (e.g., appears tearful). (Note: In children and adolescents, can be sick). irritable mood.) Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others). Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account Recurrent thoughts of death (not just fear of dying), recurrent suicidal or observation). ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in The symptoms cause clinically significant distress or impairment in social, appetite nearly every day. (Note: In children, consider failure to make occupational, or other important areas of functioning. expected weight gain.) The episode is not attributable to the physiological effects of a substance or to Insomnia or hypersomnia nearly every day. another medical condition. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric American Psychiatric Association. Diagnostic and Statistical Manual Publishing; 2013. of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013. Major Depression Disorder Major Depression Disorder The symptoms have to occur simultaneously during a 2‐week period and to have undergone a change from Anhedonia is the second anchor criteria of depression. previous functioning. Appetite change and unintended weight loss reflect the physical symptoms related to depression Either depressed mood or anhedonia (loss of interest or pleasure) must be one of the symptoms. Sleep disturbances. The individual feels that he or she is not getting enough sleep and experiences fatigue or exhaustion The depressed mood of a major depressive episode is during waking hours. objective, is sustained, and preoccupies most of the Insomnia include initial insomnia ,middle insomnia and time nearly every day. terminal insomnia (early awakening and difficulty falling The patient can describe it as a profound sense of back asleep) hopelessness or internal emptiness. Altered psychomotor activity is expressed in agitation or retardation 3 1/25/2017 Major Depression Disorder Depression and Comorbid Conditions Fatigue and loss of energy may be subjective, Comorbid Conditions in Depression objective, or both. MDD: 72% lifetime prevalence Thoughts and cognitive processes are disrupted. May have feelings of unworthiness or excessive or Anxiety Disorder: 59% inappropriate guilt Substance Use Disorder:24% Diminished ability to think or concentrate. The Impulse Control Disorder :30% capacity to perform at previously documented levels is impaired. Recurrent thoughts of death and suicide are a common feature of the depressive episode Major Depression Disorder Major Depression Disorder Average age of onset: 29 years Risk of relapse after one episode: 50 % Average length of episode 3 month Risk of Relapse after three episodes: >80% 63% of patients full recovery in 6 months Family studies shows 2‐ 3 times more frequent in 80% of patients full recovery in 2 years relatives of those with Major Depression than in the 5‐10 % develop Bipolar Disorder general population . 15% of
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