Michael Sean Stanley, MD Common Presentations in Primary Care: OHSU Department of Psychiatry [email protected] Depression Anxiety OHSU Objectives 1) Understand the clinical presentation and approach to treatment of OHSUcommon psychiatric disorders. *Caveats Psychiatric Diagnostics Which treatments are OHSUcan be frustrating. approved can be frustrating. Focus on big picture today, try FDA approved medications may not not to dwell on details. represent all medications with evidence for the treatment of psychiatric disorders. Common Presentations in Primary Care: Depression OHSU Test Yourself Which symptoms are most critical to the diagnosis of a major depressive episode? OHSULow Motivation Insomnia Suicidal Ideation Depressed Mood Test Yourself Which symptoms are most critical to the diagnosis of a major depressive episode? OHSULow Motivation Insomnia Suicidal Ideation Depressed Mood Case – Devon - Part 1 Major Depressive Disorder OHSU Case – Devon - Part 1 Major Depressive Disorder 25 yo female from Portland, in relationship with supportive partner, enjoys writing, running, going to new restaurants, currently in graduate school for MFA in creative writing. Family history notable for father with depression and hospitalizations, father attempted suicide when she was 17, but survived and has done well in treatment, and they are quite close. During period of heavy deadlines and crisis about whether to complete the MFA or try something “more practical” like law school, Devon experiences significant stress. After a number of weeks of feeling stressed, Devon experiences onset of more consistent sad mood, early morning waking, fatigue, and ruminative thoughts of being incapable. Over a few weeks, her symptoms begin to include more persistent decreased motivation for school or exercise, feeling slowed physically, decreased interest in OHSUeating although she is not malnourished, and fleeting thoughts that she would be better off not living, although she knows she could never do that to her family. Devon’s partner and father notice she is not her usual self, as they can’t seem to perk her up as they usually might, and begin to worry. Major Depressive Episode 2+ weeks of nearly every day… 5/9 of DSIGECAPS (must include one of *) Depressed Mood* Sleep Problems Interest Loss* Guilt/Worthlessness Energy Loss Concentration Problems Appetite/Weight changes Psychomotor retardation/agitation OHSUSuicidal Ideation Causing functional impairment and not due to medical/substance cause. Appetite Change / Wt Change Sleep Change Psychomotor State Change Fatigue/Energy Loss Concentration Problems (Illness Behavior) Depressed Mood (sad, empty, hopeless) Decreased Interest/Pleasure OHSUSigns of limited drive resilience Guilt/Worthlessness Thoughts of Death / Suicide Turning on oneself Case – Devon – Part 2 Major Depressive Disorder Devon, at the behest of her father and partner, see her father’s PCP, who asks Devon and her family what they’ve noticed recently, and gets a sense of Devon’s medical and mental health history. The PCP has Devon complete a PHQ9 depression rating form (score 17 – mod-severe). Devon’s father also offers what has worked for his depression. Devon has never had a period of low mood so severe or persistent as this, although she has had some “disappointed times” in the past. She does not regularly drink or use drugs, and has generally been pretty healthy. She has not had hypo/manic episodes. She is a bit of a perfectionist, and can be self- critical, although it has not caused her problems in the past. The PCP orders labs to rule out medical contributors, discusses the diagnosis OHSUof Major Depressive Disorder, and discusses evidenced-supported interventions to treat MDD, including options such as cognitive-behavioral psychotherapy (CBT), SSRI medication, bright-light therapy, behavioral activation with moderate intensity exercise, avoidance of alcohol and drugs, and positive, strengths-focused social contacts with family and friends. 1 major depressive episode = major depressive disorder* *unless: 1. Clear medical cause 2. Clear medication/substance use cause 3.OHSUHypomanic or manic episodes in past (=Bipolar DO) 4. Psychosis sx more prominent (=Schizoaffective DO) Impacts of Major Depressive Disorder Individual Impacts Family Impacts Decreased Quality of Life Income Loss • Even up to 60% of remitted patients still have reduced QOL Increased days missed of work and decreased work performance Social Isolation Higher risk of developing chronic and neurodegenerative diseases Caregiver Burnout • CAD, DM, Parkinson’s, MCI, others Higher risk of worse outcomes with preexisting chronic and neurodegenerative diseases Familial Pessimism Higher all-cause mortality Increased Alcohol Abuse • 50-100% greater (ex 39% greater in cancer pts, 200% greater in DM females) Shorter life expectancy Divorce OHSU• 11-15 years shorter in males, 7-13 years shorter in females Higher incidence of suicide (27x greater in MDD than in Gen Pop) Decreased Bonding/attachment to children Higher risk of death to homicide (2.6x greater in MDD than in Gen Pop) Higher risk of death in accidents (2x greater in MDD than in Gen Pop) Impacts of Major Depressive Disorder OHSUFor 4 employers adapted from Loeppke RJ. Occup Environ Med, 2009. Major Depressive Disorder Brief Epidemiology: • Lifetime prevalence of MDD in US is 17% OHSU[2005] Major Depressive Disorder Course of illness over lifespan OHSU• First episode in teens-20s most often Zisook S, et al. Effect of age at onset on the course of major depressive disorder. Am J Psychiatry. 2007 Oct;164(10):1539-46. Elevated Mood 18 yo Average Mood 2+ weeks 5/9 DSIGECAPS OHSUMDD How long to remission OHSU• Major depressive episodes may remit in <8 weeks, although median time to recovery is 20 weeks. Qaseem, et al. 2016. Nonpharmacologic Versus Pharmacologic Treatment of Adult Patients With Major Depressive Disorder: A Clinical Practice Guideline From the American College of Physicians; Ann Intern Med. 2016;164(5):350-359. Major Depressive Disorder 1. Early episodes likely precipitated by life stressor 2. But after more episodes, subsequent episodes come more quickly and require OHSUless life stress to occur (accelerating susceptibility) Stressor Contribution to depression SCORE HAS NO FACTOR IN WHETHER A STRESSOR CONTRIBUTES TO DEPRESSION. Perceived lack of control over stressor or lack of support around stressor mediatesOHSU degree a stressor will lead to depression. Case – Devon – Part 3 Major Depressive Disorder At her appointment with the PCP, Devon expresses concern about medications, as a friend close to her with a family history of severe mood disorders took fluoxetine and it caused her to not sleep for days and do risky things. She thus declines to start a medication at the current time, as she would like to try the non-pharmacological options first. She is not completely opposed to such medication in the future, as she knows they have helped her father in the past. The PCP writes a letter to support FMLA leave from her TA position, asks her to hold off on making big decisions about school for now, and OHSUpoints Devon to the Psychology Today Therapist Finder website that will help Devon find an in-network CBT therapist. They schedule to follow-up in 2 weeks to see how she is doing. Programmed Neuron- and Network-Level Stress Genetic Neurotransmitter- Changes OHSUResponse Level Changes Euthymia: Robust/Balanced/Responsive connections between critical parts: 1) GPS (Salience) 2) Gas/Brake (Central Executive) 3) Baseline Idle/Motor (Default Mode) OHSU Depression: Loss of balance and connections between critical parts: 1) Diminished GPS (Salience) – loss of response to external cues 2) Diminished Gas/Brake (Central Executive) – hard to make decisions 3) Increased Baseline Idle/Motor (Default Mode) - RUMINATION OHSU Case – Devon – Part 4 Major Depressive Disorder 2 weeks after the initial appt, Devon returns to the clinic for f/u. She has begun with her therapist, but her physical symptoms have not improved significantly so far. Devon agrees to start escitalopram, an SSRI antidepressant available in generic form, to help assist her other treatments. She was cautioned that she may experience headache and stomach upset for the first few days, but was told it would likely remit, and was urged to continue the medication for at least a week. 4 weeks after the initial appt, Devon returns to the clinic for f/u. She reports that she is tolerating the medication, has noticed improvements in sleep and motivation, but doesn’t feel less depressed. She is recommended to continue her current treatments. 6 weeks after the initial appt, Devon returns to the clinic for f/u. She reports she no longer feels depressed mood, as if strong feelings “don’t stick anymore”, although she still maintains some residual feeling of being mildly slowed down, her appetite and concentration have not completely normalized, and she does not feel OHSUcompletely ready to return to school yet. PHQ9 is now 6. 12 weeks after the initial appt, Devon return to the clinic for f/u. She reports depression is in remission (PHQ9=1), she has returned to school with a slight change in perspective, which she realized was necessary through her psychotherapy. The PCP recommends remaining on the antidepressant medication for at least 12 months from the point of remission, at which time they can discuss possible trial taper of the medication. OHSU Mild Depression Moderate to Severe Depression Medications (see next slide) Monotherapy or Medications (see next slide) Monotherapy