Rcpsych Workshop - Depression in medical settings (Mar11)
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Rcpsych Workshop - Depression in medical settings (Mar11)



Rcpsych liaison faculty workshop on; depression in medical settings: symptoms and screening. This is an update on the latest on screening for depression in medical settings.

Rcpsych liaison faculty workshop on; depression in medical settings: symptoms and screening. This is an update on the latest on screening for depression in medical settings.



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Rcpsych Workshop - Depression in medical settings (Mar11) Rcpsych Workshop - Depression in medical settings (Mar11) Presentation Transcript

  • Diagnosing Depression in Medical Settings: Symptoms and screening….60min workshop Alex Mitchell ajm80@le.ac.uk Consultant in Liaison Psychiatry & Psycho-oncology RCPsych Workshop 2011
  • Special Physicians Symptoms Physical Illness Primary Symptoms DSMV Older people Care ICD11 Cultural effects Detection Under- Depression served Quality of care PrescribingImpairment Scales Distress Follow-up Screening Monitoring Help Seeking Se Change
  • Special Symptoms Physical Illness Primary Symptoms DSMV Older people Care ICD11 Detection Depression Quality of care ScalesDistress Screening View slide
  • Contents Overview Depression in medical settings Comorbidity | impairment | mortality Prevalence of depression in medical settings Cancer | IHD | Stroke Symptoms of Depression in medical settings Same or different?.....older people? Conventional screening Accuracy | acceptability | Does it work? New Screening innovations Why? View slide
  • 1.Overview: Depression in medical settings Comorbidity | impairment | mortality
  • Impairment: Days totally out of role per year50 Yearly DOR45 Unique 42.9 42.7 PAR% 41.2 39.840 39.3 36.635 34.4 33.8 30.6302520 17.3 15.215 14.310 9 7.3 7.7 5.15 3.9 2.6 2.2 2.5 1.8 1.7 1.9 1.4 1 0.3 0.10 Depression Panic disorder PTSD Specific phobia Social phobia Bipolar disorder GAD Alcohol abuse Drug abuse
  • n=245 404 participants from 60 countriesQuality of life: Moussavi et al (2007) Lancet 2007; 370: 851–58
  • Mortality and IHD+depression Psychosomatic Med (2004) Barth et al
  • 90 84.384.5 Depression Alone (=883) 77.7 80 Anixety Alone (n=314) 70 Depression and Anxiety (n = 439) 60 50 46 40.9 43 40 28.3 30.3 29.9 28.9 30 25.323.2 20.521.7 20.3 17.7 15.617.5 20 12.8 14.8 10.8 10 0 e * e* r) r) us e* se . 1-y 1-y a .. us us nu ng dic it ( ng it ( t en o eli vi s me vis ati eli ns a tm dic ns ist ou er ty u t re x ie on me ial yc co ti ec te an An te te ct i ria sp nt i ria ria pra op ra h op op alt pr re to pr pr Ap he ca Ap Ap an tal ary ss en pre rim ym deyp An ntiAn ya Young et al (2001) The Quality of Care for Depressive and Anxiety Disorders in the United States. Arch Gen Psychiatry. 2001;58:55-61 An
  • % Receiving Any treatment for Depression (CIDI) 20 17.9 18 n=84,850 face-to-face interviews 16 15.4 13.8 14 12 11.3 10.9 10.9 10 8.8 8.1 8 7.2 6.8 6 5.6 5.5 4.3 4 3.4 2 0 SA in n ly na ca m l e a y ne ce e nd e s m bi pa an m It a a nd ra u hi i an U ai la Sp fr co om co gi Ja m Is C kr rla A a Fr el In er In Ze ol U h B he G w ut h C ew et ig Lo SoH N NWang P et al (2007) Lancet 2007; 370: 841–50 => In physical
  • 12mo Service Use (NIH, 2002)40 34.635 32.7 Cancer n=4878 No Cancer n=90,7373025 19.120 % Receiving Any treatment for Mental Health % Receiving Any treatment for Mental Health 16.1 1415 11.7 11 8.910 7.7 7.2 6.5 5.7 5.7 5 6.3 6.4 6.2 55 3.9 3.2 2.3 1.80 l th l th ons nt s ti o n s s 75+ rs rs rs ti o n ti o n H ea H ea y ea y ea y ea atie d iti n di n di n di l Il l l Il l con 44 64 74 l co P l co l co Al l n ta nt a 18- 45- 65- di ca cal di ca di ca Me Me edi me me me No cm nic nic nic o ni hr o hr o hr o c hr 1c 2c 3c Two explanations=> No Maria Hewitt, Julia H. Rowland Mental Health Service Use Among Adult Cancer Survivors: Analyses of the National Health Interview Survey Journal of Clinical Oncology, Vol 20, Issue 23 (December), 2002: 4581-4590
  • Audience:How common are medical co-morbidities in depression?
  • Comorbid Physical Diagnoses in Elderly Depressed Patients80706050403020100 One Tw o Three+ None Proctor EK, et al (2003) American Journal of Geriatric Psychiatry;11:329‐38.
  • Ca rd io va 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 sc u lar d ise Fu nc as tio e na ls om at ic sy nd ro m es Os te oa r ti cu lar dis or de rs Ne ur ol og ica ld is ea se De s rm at ol og ica ld ise as es En d oc rin e dis or de rs Re sp ira to ry d ise as es Di First Episode MDD (n=6090) ge st ive d Recurrent Episode MDD (n=4167) iseUr as in es ar :U y lce tra ct r d ise as e: R en al lith ias is An ym ed ic al d iso rd er
  • Hy pe 0 0.05 0.1 0.15 0.2 0.25 0.3 0.35 rte ns io Os n te oa r th rit is He ad acCh Hy he ro pe nic rli pi fat de ig m ue ia sy nd ro m e Ch ro nic pa Irr in Se ita bo bl eb rrh ow oe el ic de rm at iti s Mi gr ain Di sc e h er ni at io n Di ab et Fi es br om ya lg ia Ec ze m Di ge a st ive Ul ce r As th First Episode MDD (n=6090) Th m yr oi a d di Recurrent Episode MDD (n=4167) se as e CO PD Ps or ia sis Re na l li th Ac ias ut is e inf ar ct io n Ep ile p sy Pa rk in so n
  • 40 Physical C omorbidity in S chiz ophrenia and D epression3530 Schizophrenia Depression25 NHANES201510 Sokal 2004 J Nerv Ment Dis 192: 421– 427 5 0 Angina Ulcer Heart condition Any cancer Asthma Diabetes Chronic bronchitis Stroke Emphysema Hypertension Myocardial infarction Rheumatoid arthritis Osteoarthritis Coronary heart Weak/failing kidneys Congestive heart Liver problems disease failure NHANES ‐ US Department of Health National Health and Nutrition Examination Survey , 1988 –1994
  • Prevalence Depression in medical settings Methodological | Scale vs interview | Current vs 12mo vs lifetime Cancer | IHD | Stroke
  • Isc hem 0 1 2 3 4 5 6 7 8 9 10 ic h ear t di sea Rhe se um ato id ar th r iti s Dia bet es m elli tus Pr o Suicide odds ratio s ta te c anc Hyp era er ci d ity s ynd rom es Bre ast can c er Par k in s o nd isea C hr se oni c lu ng d is ea s Con g es e tive hea rt fa i lur e Mo d er ate pai Uri n nar y in c on ti ne nc e Se i zur ed A nx i so rd e ie ty an d r s le ep d is Psy ord cho ers ses a nd ag i ta ti on Dep res si o nJuurlink (2004) 1354 older individuals who died of suicide in Ontario, CA Sev e re p ain B ip o la r di sor der
  • National Health Interview Survey (NHIS) – CIDI‐SF1816141210 8 6 4 2 0 1) ) 4) ) er 1) 10 ) 31 ) 68 91 91 79 37 rd =7 =4 =1 34 =3 =1 so =7 (n (n (n = (n (n di (n (n VA re PD re so n is ilu teN lu C io O D be Fa ai ns C y tF ia er te al D rt ar er en A He yp R y H ar ge e iv on ta st -S or ge C don EnC Egede (2007) 12mo prevalence rates from the Data on 30,801 adults from the US 1999 National Health
  • Prevalence of depression in Oncology settings Plumb & Holland (1981) Proportion meta-analysis plot [random effects] 0.7750 (0.6679, 0.8609) Levine et al (1978) 0.5600 (0.4572, 0.6592) Ciaramella and Poli (2001) 0.4900 (0.3886, 0.5920) Massie et al (1979) 0.4850 (0.4303, 0.5401)70 studies involving 10,071 individuals;14 countries. Bukberg et al (1984) Passik et al (2001) 0.4194 (0.2951, 0.5515) 0.4167 (0.2907, 0.5512)16.3% (95% CI = 13.9% to 19.5%) Baile et al (1992) Morton et al (1984) Hall et al (1999) 0.4000 (0.2570, 0.5567) 0.3958 (0.2577, 0.5473) 0.3722 (0.3139, 0.4333) Burgess et al (2005) 0.3317 (0.2672, 0.4012) Jenkins et al (1991) 0.3182 (0.1386, 0.5487)Mj 15% Mn 19% Adj 20% Anx 10% Dysthymia 3% Green et al (1998) 0.3125 (0.2417, 0.3904) Kathol et al (1990) 0.2961 (0.2248, 0.3754) Hosaka and Aoki (1996) 0.2800 (0.1623, 0.4249) Fallowfield et al (1990) 0.2565 (0.2054, 0.3131) Golden et al (1991) 0.2308 (0.1353, 0.3519) Spiegel et al (1984) 0.2292 (0.1495, 0.3261) Evans et al (1986) 0.2289 (0.1438, 0.3342) Grandi et al (1987) 0.2222 (0.0641, 0.4764) Maunsell et al (1992) 0.2146 (0.1605, 0.2772) Berard et al (1998) 0.2100 (0.1349, 0.3029) Joffe et al (1986) 0.1905 (0.0545, 0.4191) Berard et al (1998) 0.1900 (0.1184, 0.2807) Devlen et al (1987) 0.1889 (0.1141, 0.2851) Leopold et al (1998) 0.1887 (0.0944, 0.3197) Akizuki et al (2005) 0.1797 (0.1376, 0.2283) Razavi et al (1990) 0.1667 (0.1189, 0.2241) Gandubert et al (2009) 0.1597 (0.1040, 0.2300) Alexander et al (1993) 0.1333 (0.0594, 0.2459) Kugaya et al (1998) 0.1328 (0.0793, 0.2041) Payne et al (1999) 0.1290 (0.0363, 0.2983) Ibbotson et al (1994) 0.1242 (0.0776, 0.1853) Prieto et al (2002) 0.1227 (0.0825, 0.1735) Morasso et al (1996) 0.1121 (0.0593, 0.1877) Desai et al (1999) [early] 0.1111 (0.0371, 0.2405) Silberfarb et al (1980) 0.1027 (0.0587, 0.1638) Costantini et al (1999) 0.0985 (0.0535, 0.1625) Morasso et al (2001) 0.0985 (0.0535, 0.1625) Ozalp et al (2008) 0.0971 (0.0576, 0.1510) Love et al (2002) 0.0957 (0.0650, 0.1346) Alexander et al (2010) 0.0900 (0.0542, 0.1385) Coyne et al (2004) 0.0885 (0.0433, 0.1567) Kawase et al (2006) 0.0851 (0.0553, 0.1240) Walker et al (2007) 0.0831 (0.0568, 0.1165) Grassi et al (1993) 0.0828 (0.0448, 0.1374) Grassi et al (2009) 0.0826 (0.0385, 0.1510) Reuter and Hart (2001) 0.0761 (0.0422, 0.1244) Lee et al (1992) 0.0660 (0.0356, 0.1102) Pasacreta et al (1997) 0.0633 (0.0209, 0.1416) Sneeuw et al (1994) 0.0540 (0.0367, 0.0761) Singer et al (2008) 0.0519 (0.0300, 0.0830) Katz et al (2004) 0.0500 (0.0104, 0.1392) Mehnert et al (2007) 0.0472 (0.0175, 0.1000) Lansky et al (1985) 0.0455 (0.0291, 0.0676) Derogatis et al (1983) 0.0372 (0.0162, 0.0720) Hardman et al (1989) 0.0317 (0.0087, 0.0793) Massie and Holland (1987) 0.0147 (0.0063, 0.0287) Colon et al (1991) 0.0100 (0.0003, 0.0545) combined 0.1730 (0.1375, 0.2116) 0.0 0.3 0.6 0.9 proportion (95% confidence interval)
  • Meta regression using the random effects model on raw porportions Estimated slope = - 0.02 % per month (p=0.0016). Circles proportional to study size. 0.4 0.3Proportion 0.2 0.1 0.0 0 20 40 60 80 100 Time (months)
  • 1a. Routine Recognition of Depression Is depression a disease; disorder (syndrome) or normally distributed
  • Audience:Is depression categorical or dimensional?
  • Graphical – two diseases Comment: Slide illustrates the concept of discrimination using one symptom severity of “low mood” Healthy Stroke # of Individuals With symptom Point of Rarity Ischaemic change on mri
  • Graphical – two disorders Healthy # ?Point of Rarity of Individuals Optimal cut With symptom Diabetes HBA1c
  • Graphical - Dimension Comment: Slide illustrates added hypothetical distribution of mood scores in a population with hidden depression Non-Depressed Depressed # of Individuals With symptom Severity of Low Mood
  • 0 1000 1500 2000 2500 3000 500 Ze r o O ne Tw o Th re e Fo ur Fi ve Si x Se HADS-D ve n ei gh t N in e Te n El ev en Tw el ve Th irt ee Fo n ur te en Fi ft e en Si xt eeSe n ve nt ee Ei n gh te en
  • Comment: Slide illustrates added proportion of alldepression treated in each setting. Most depressionis treated in primary care 1.20 1.00 1.00 0.80 0.64 0.60 0.40 0.26 0.20 0.10 0.00 All visits (N =14,372) Primary care (N =3,605) Psychiatrists (N =293) Medical specialists (N =10,474) J Gen Intern Med. 2006 September; 21(9): 926–930.
  • Comment: Slide illustrates added actual distributionof mood scores on the HADS in a cancerpopulation with hidden depression from theEdinburgh cancer centre
  • 0.05 0.15 0.25 0 0.1 0.2 0.3 Ei gh t N in e Te n El ev en Tw el ve Th irt ee HADS-D n Fo ur te en Fi fte en Si xt ee nSe ve nt Proportion Missed ee n Proportion Recognized Ei gh te en N in et ee n Tw enTw ty en ty -o ne
  • 80 74 70 69.670 61.5 59.660 56.7 56.7 55.6 54.250 45.7 43.9 39.74030 28.4 22.2 21 19.32010 0 s L ris i n a n r z go an i na tle e iro ak en ha te TA ar ge n rli r lo Pa ai ad ia ro at es as ne h g k Be in TO ga M nt An an Se At Ve Ib ch g Ja nSa n Na ro Sh an Ba de G M o Ri Recognition from WHO PPGHC Study (Ustun, Goldberg et al)
  • Audience:What are the predictors of improved recognition?
  • 0.25 65% 0.22 0.21 0.20 Geraghty JGIM 2007 0.050.05 0.03 0.02 0.02 0.01 0.01 0.01 0.01 0.01 0.010.00 s s s s s s s s s s s s s s in in in in in in in in in in in in in in m m m m m m m m m m m m m 5m 10 15 20 25 30 35 40 45 50 55 60 65 70
  • CNS in Oncology N=401100.0 5.9 11.1 14.3 90.0 Comment: Slide illustrates diagnostic 21.4 accuracy according to score on DT 11.8 25.9 80.0 38.7 38.1 43.5 22.2 14.3 46.7 70.0 59.6 21.4 72.4 60.0 Judgement = Non-distressed 33.3 Judgement = Unclear 19.4 19.0 Judgement = Distressed 50.0 26.1 24.4 82.4 40.0 71.4 66.7 30.0 25.0 57.1 41.9 42.9 40.7 20.0 15.8 30.4 28.9 10.0 15.4 11.8 0.0 Zero One Two Three Four Five Six Seven Eight Nine Ten
  • Sl e ep di s turb an Los ces so ; in fa som ppe ni a De tite ; ea ; ov rly 0 10 20 30 40 50 60 70 80 90 pre ere wa 100 sse a tin ke n dm g; w ing ood e ig ; ho ht c pe han 86.8 Los Ap les so a th sne ges f in y; l ss; ter eth sad est arg ;w y; t ; gl oom ithd raw ired nes y al; s; l 55.6 54.4 Los in d ass so iffe i tud fe ren e ner ce; Los gy; lo n 43.3 so l os eli n f lib so ess ido f dr ; lo i ve 36 ss ; bu An of s rnt xio ex ou Sleep us; d ri v t ag e; i mp 29.8 itat ed; Te ote irri t ars nceSo ;w Low ma Fe abl eep tic; eli n e; r est ing Appetite ve g gw les ; cr eta ort s, t yi n tive hl e ss; ens g sym gui e; s pt o l ty; t res Energy ms lac sed ;m ko ala f se i se 26.2 25.6 25.2 Su ;m lf e i ci d ste Los ulti ple em so e th f co ou con 23.8 nce ght sul ntr s; t ta t hou ion atio n; p ght s 24 oor of s Dim me el f ini s mo inj u hed ry, ry per poo f or r th ma i nk nce ing Em ; in Los otio abi 21.4 21.2 na lity so fa l la to copBeh Los ffec t; f bil i ty; e avi so lat mo our fe a ff od al p njo ect sw rob ym ; lo ing lem ent ss s s; a or of e 13.9 12.8 ggr pl e mo ess asu tion ive re ; nes lac 9.5 Pe ko s; b fh ssi eh um mis avi or m; our ne al c 7.2 What do GPs Ask about: gat han Ps ive ges ych atti tud 7 Ap om es, pe oto wo ara r re rry nce tar ing ; sp dat 7 eec i on h; e ; sl xce He ow nes ssi ve ada che s sm 5.9 He s; d avy i lin izz g; v ine use a gu ss of a ene 4.8 l co ss, De hol etc l us , to . i on bac Re co 4.1 s; h act allu or ion ci n dru to p atio gs rob ns; 2.6 abl con Fa ec fus mil aus ion yo es or l 1.8 r pa ife st h looking for depression i sto eve ry n ts Ob of d 1.8 ses epr siv ess e id i on eat 1.3 i on ; ph ob ias Comment: Slide illustrates which Lac symptoms are asked about by GPS 0.9 Pe ko ri o f in do sig f lif ht e( 0.4 me no pau se ) 0.4
  • GP Recognizes: Proportion of Individual Symptoms Recognised by GPs80.0 36.4 34.6 31.630.0 21.620.0 16.7 13.3 9.1 8.3 8.310.0 0.0 s ng d a gy s ia st ty ism es oo si ni ex re xie pi er ia m ln m m te Co or en dr An so fu in i An w ss on ar In t of Lo No of Pe Te ch ss ss po Lo Lo Hy O’Conner et al (2001) Depression in primary care. Int Psychogeriatr 13(3) 367-374.
  • Cancer Staff Psychiatrists Other/Uncertain 9% Other/Uncertain ICD10/DSMIV 2% 0% ICD10/DSMIV 13%Short QQ 3% 1,2 or 3 Sim ple QQ 15% Clinical Skills Use a QQ Alone 15% 55% Clinical Skills Alone 73% 1,2 or 3 Sim ple QQ 15% Comment: Slide illustrates preferences of cancer clinicians vs psychiatrists for detectingCurrent Method depression
  • 3. Symptoms of Comorbid Depression Same or different? Older People?
  • Core Symptoms ICD10 DSMIVPersistent sadness or low mood Yes (core) Yes (core)Loss of interests or pleasure Yes (core) Yes (core)Fatigue or low energy Yes (core) YesDisturbed sleep Yes YesPoor concentration or Yes YesindecisivenessLow self-confidence Yes NoPoor or increased appetite Yes NoSuicidal thoughts or acts Yes YesAgitation or slowing of Yes YesmovementsGuilt or self-blame Yes YesSignificant change in weight No Yes
  • Symptom Significance in DepressionDepression ICD10 DSMIV HADs D ScoreSeverityHealthy 0 or 1 0 symptom 0-3 symptomSub-syndromal 2 or 3 1 or No core 4-7 symptoms symptomsMild 4 symptoms 2-4 symptoms 8 -11 (2+2) (minor)Moderate (5 or )6 5 symptoms 12 - 15 symptoms (Mj)Severe (7 or) 8 Unspecified 16 - 21 symptoms (3+4)Change in practice – ICD10 2/4/6/8 + CS | DSMIV‐TR Mn => NOS
  • Symptoms Clinical Significance DurationICD-10 Depressive Episode Requires two of the first three At least some difficulty in 2 weeks unless symptoms are symptoms (depressed mood, loss of continuing with ordinary work unusually severe or of rapid interest in everyday activities, and social activities onset). reduction in energy) plus at least two of the remaining seven symptoms (minimum of four symptoms)DSM-IV Major Depressive Disorder Requires five or more out of nine These symptoms cause 2 weeks symptoms with at least at least one clinically important distress OR from the first two (depressed mood impair work, social or personal and loss of interest). functioning.DSM-IV Minor Depressive Disorder Requires two to four out of nine These symptoms cause 2 weeks symptoms with at least at least one clinically important distress OR from the first two (depressed mood impair work, social or personal and loss of interest). functioning.DSM-IV Adjustment disorder Requires the development of These symptoms cause marked Acute: if the disturbance lasts emotional or behavioral symptoms in distress that is in excess of less than 6 months response to an identifiable stressor(s) what would be expected from Chronic: if the disturbance occurring within 3 months of the exposure to the stressor OR lasts for 6 months onset of the stressor(s). Once the significant impairment in social stressor has terminated, the or occupational (academic) symptoms do not persist for more functioning than an additional 6 months.DSM-IV Dysthymic disorder Requires persistently low mood two The symptoms cause clinically Requires depressed mood for (or more) of the following six significant distress OR most of the day, for most days symptoms: impairment in social, (by subjective account or (1) poor appetite or overeating occupational, or other observation) for at least 2 years (2) Insomnia or hypersomnia important areas of functioning. (3) low energy or fatigue (4) low self-esteem (5) poor concentration or difficulty making decisions (6) feelings of hopelessness
  • Audience:Which of the following are recognized symptoms of MDD
  • Which Are Recognized Symptoms of MDD?Loss of confidenceLow motivation / driveWithdrawal ALLAvoidanceSocial isolationWorry SOMEFeelings of dreadHelplessnessHopelessness NONEPsychic anxietySomatic anxietyAnger UNSURELack of reactive moodCognitive Change (=> memory complaints)Perceptual distortion => plan
  • “Common” Symptoms of DepressionItem Depressed Frq Non-Depressed FrqDepressed mood 0.93 0.18Diminished drive 0.88 0.30Loss of energy 0.87 0.32Concentration/indecision 0.87 0.27Sleep disturbance 0.83 0.32Diminished concentration 0.82 0.24Diminished interest/pleasure 0.81 0.12Insomnia 0.70 0.27Anxiety 0.69 0.42Worthlessness 0.61 0.12Psychic anxiety 0.59 0.33Thoughts of death 0.56 0.12 Mitchell, Zimmerman et al n=2300
  • “Uncommon” Symptoms Non-DepressedItem Depressed Proportion ProportionSomatic anxiety 0.46 0.25Decreased appetite 0.45 0.11Anger 0.44 0.26Psychomotor agitation 0.34 0.09Psychomotor retardation 0.28 0.04Decreased weight 0.23 0.06Lack of reactive mood 0.22 0.06Increased appetite 0.19 0.07Hypersomnia 0.19 0.06Increased weight 0.16 0.06 Mitchell, Zimmerman et al MIDAS Database. Psychol Med 2009
  • -0.10 0.00 0.10 0.20 0.30 0.40 0.50 A nge r A nxie ty Decr ea s e d app eti te Decr eas e d weig ht Depr es sed m ood Dimin is hed c onc entr a t io n identifying non-depressed Dimin is hed dr iveDimin is hed int er est /p leasu re Exc e ss ive guilt Help less n Comment: Slide illustrates added value of each ess symptom when diagnosing depression and when Hope le s snes s Hy pe rsom ni a Inc re a sed a ppet ite Inc re a sed w eight Indec isiv enes s Ins om nia L ac k of re act iv e mo od L os s of en erg y Ps ych i c a nx iety Ps ych o mot o r agi ta tion Ps ych o mot o r c han ge Ps ych o mot o r ret ar da tion Sl eep dis tu rban ce Soma ti c a nx iet y Rule-In Added Value (PPV-Prev) Thou g hts Rule-Out Added Value (NPV-Prev) of de ath Wor t hles s ness
  • 1 Depressed Mood S Diminished interest/pleasure e 0.9 Diminished drive n s Loss of energy i Sleep disturbance 0.8 t Diminished concentration i 0.7 v i t 0.6 y 0.5 0.4 0.3 Comment: Slide illustrates summary ROC curve sensitivity/1-specficity plot for each mood symptom 0.2 0.1 1 - Specificity 0 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1n=1523
  • 3a. Depression in Older People Does it go unrecognized? Are Somatic Symptoms Common in Older People?
  • Comorbid Physical Diagnoses in Elderly Depressed Patients80706050403020100 One Tw o Three+ None Proctor EK, et al (2003) American Journal of Geriatric Psychiatry;11:329‐38.
  • Questions More or less difficult to detect late-life depression? More or less Low mood Agitation Insomnia Poor concentration
  • 1.00 Post-test Probability Routine Case-Finding Late-Life Routine Exclusion Late-life0.90 Baseline Probability Routine Case-Finding Mixed Routine Exclusion Mixed0.80 Routine Case-Finding Younger Routine Exclusion Younger0.700.600.500.400.300.200.10 Pre-test Probability0.00 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 Comment: Slide illustrates detection of late life vs mid-life depression in primary care – GPs are least successful with late-life depression
  • -0.25 -0.2 -0.15 -0.1 -0.05 0 0.05 0.1 Helplessness Ho pelessness Worthlessness Anxiety (Som atic anxiety) Anger Indecisiveness Thoughts of Death Dim inished Co ncentratio n Anxiety (Com bined) Increased Appetite Sleep Disturbance (Hypersom nia) Sleep Disturbance (Com bined) Increased Weight Loss of Energy More common in early-life depression More common in late-life depression Psychom otor Agitation Anxiety (Psychic anxiety) Excessive G uilt Dim inished Interestmid-life depression Sleep Distu rbance (Insom nia) Decreased AppetiteComment: Slide illustrates simple Depressed Moodfrequency of symptoms in late life vs Psychom otor Retardatio n Decreased Weight
  • A 0.000 0.100 0.200 0.300 0.400 0.500 0.600 0.700 0.800 nx ie A A ty ng nx (C er ie om ty (P bi ne A sy d) nx ch ie ic ty an (S xi om et >64 >59 >54 <55 at y) D ic ec an re xi as et ed y) A D pp ec et re it e as ed D W D ep ei im re gh in ss t is ed he M d C oo on d ce D nt im ra in t io is n he d In * te re * Ex st ce ss iv e G H ui el lt pl es sn H es op s el In es cr sn ea es se s d Ap In pe cr tit ea e se d W In ei de gh ci t si ve Lo ne ss Ps ss yc of ho E Ps m ne ot rg yc or y ho A Sl ee m gi ta * p ot tio D or n Sl is R ee tu et p rb ar D an da is ce tio tu n rb (C an om Sl ce bi ee (H ne p D yp d) is er tu so rb m an ni ce a) ( In so Th m ou ni gh a) tsof symptoms in late life vs mid-life of W D ea or th th * ledepression – few have special significance ss *Comment: Slide illustrates diagnostic value ne ss * * *
  • Comment: Slide illustrates actualphenomenology of late life depression Mid-life Depression Late-life Depression Poor conc worthlessness
  • 3b. Comorbid Depression Back to Basics
  • Approaches to Somatic Symptoms of Depression Inclusive Uses 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. Exclusive Eliminates somatic symptoms but without substitution. There is concern that this might lower sensitivity. with an increased likelihood of missed cases (false negatives) Etiologic Assesses the origin of each symptom and only counts a symptom of depression 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). Substitutive Assumes somatic symptoms are a contaminant and replaces these additional cognitive symptoms. However it is not clear what specific symptoms should be substituted
  • Comment: Slide illustrates concept ofphenomenology of depressions inmedical disease Primary Depression Alone Fatigue Anorexia Insomnia Concentration Secondary Medically Unwell Alone Depression
  • Which are the least somatic scales?
  • Study: Coyne Thombs Mitchell N= 4500; Pooled database study; All comparative studies Physical illness+comorbid depressionVsPhysical illness aloneVs Primary depression alone
  • A gi ta tio n (C A om 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 gi or ta bi tio d) n A (P nx rim ie ty ar (C y) om * A or nx bi ie d) A ty pp (P et rim it e ar (C y) om A * C pp orn=4069 vs 4982 on et bi ce it e d) nt (P ra ri tio m C n ar on (C y) ce om nt or ra bi tio n d) Fa (P t ig rim ue ar y) (C om Fa or t ig bi ue d) (P G ri ui m lt ar (C y) om * H or op el G bi es ui d) lt sn (P es ri H s m op (C ar el om y) es * sn or bi es d) In s so (P ri m m ni ar a y) (C In om * so or Lo m bi ss ni d) In a te (P ri re st m Lo ar (C y) ss om In * te or re bi st d) Lo w (P M rim oo ar d y) (C Lo om w * M or R oo bi d) et d ar da (P rim t io n ar (C y) R et om ar or da bi t io d) n Su (P ic ri id m primary depression e ar y) (C om * Su or W ic bi ei id d) gh e tL (P ri os m s ar W (C y) ei om gh symptoms profile in comorbid vs tL or Comment: Slide illustrates similar os bi Co-morbid Depression vs Primary Depression d) s (P rim ar y) Prim ary Depression Com orbid Depression *
  • Comment: Slide illustrates concept ofphenomenology of depressions inmedical disease Primary Depression Alone Secondary Depression Agitation Retardation
  • A nx ie t y (C om 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 A or C nx bi on ie d) ce ty nt (M r at ed io ic C n al on (C ) om * ce nt or ra bi tio d) n (M Fa ed t ig ic ue al (C ) * om or H Fa bin= 4069 vs 1217 op t ig d) el ue es sn (M es ed H s ic al op (C ) In om * so el es or m sn bi ni d) a es (a s ny (M In ty ed so pe ic m )( al ) ni C a om * (a ny or ty bi Lo pe d) ss )( In M te ed r es ic al Lo t( C ) om * ss In or te bi r es d) Lo t( w M M ed ic oo al d ) (C om * Lo w or M bi d) R oo et d ar (M da ed t io ic n al ) (C R * et om ar or da bi t io d) n (M Su ed ic ic id e al ) (C * om Su or bi W ic i d) ei de gh (M t Lo ed ss ic al W (C ) om * ei gh or W t bi or Lo d) th ss le (M ss ne ed ss ic W (C al ) or th om le or ss bi ne d ) ss symptoms profile in comorbid (M ed ic Medical Illness Alone al ) Com orbid Depression Comment: Slide illustrates distinct depression vs medical illness alone Co-morbid Depression vs Medical Illness Alone
  • Comment: Slide illustrates concept ofphenomenology of depressions inmedical disease Primary Depression Alone Fatigue Anorexia Insomnia Concentration Secondary Medically Unwell Alone Depression
  • Comment: Slide illustrates actualphenomenology of depressions inmedical disease Primary Depression Secondary Depression Weight loss Agitation Retardation Medically Unwell
  • D A ec pp A re e t nh -0.2 ite e d 0 0.2 0.4 0.6 0.8 1 as ed Ap de on D ac pe t cr ia ec tiv ite e a re i i s as ty i ncr e ed nv ea o s D sex lve e is ua m t in e G ct l in nt m ter as tr oo e oi d stIm nt qu pa es al ire tin it d al Fa y co sy t nc m igu In en H pto e yp m so tr e m atio rso s ni a n m (E /att nia a en In rly ti so m on m or In ni n te Ins a ( ing rp om Mi ) er d so nia dle na (O ) l ns Le se et ad ns ) en itiv M pa ity oo ra d ly M (a si o o nx s M d io M o (ir us oo o d rit ) d re a va ac Mo ble ri tiv od ) N atio ity (s eg n i ad at by mp ) iv e tim air N o ed Pa eg utl e o ni ati oo f d c v k a or e o (fu y ph utl tu Ps ob oo re) yc ic k ho sy (se Ps m m lf ) y c oto pto ho r m m a s So o gita m tor tio at sl n ic o co w in S m g Sy uic p m ida lai n pa l t t h id e s et at W i i Differential e i c a on gh ro W t d us a ei e l gh cre t i as nc e re as e Rate in Depression Alone Rate in Depressed+Medical
  • -10 -5 0 5 10 15 Lead en p G ast ar aly roi nt sis est in al sy mp to ms Sym path e tic a rou sal So m at ic co m plain ts Inso mnia (Mid dle) Moo d (irr Inso itabl mnia e) ( Ear ly m or nin Psy c g) hom o tor agita Psy c tion ho m otor slo w ing Inso mnia (O ns et) Fatig ue We ig h t de c reas e Appe tite d Pani ecre co a se r p ho b ic s ymp t om s Appe tite i n cre as e We ig ht in c rea Nega tive se o ut lo Decr ok (f e ase uture d ac ) t ivity in vo lv em e nt Anhe don i a Suic id al id eatio Decr e ase n d se xual in te r More common in est Moo d (an xio u Dist i s) Comorbid Depressions nct m ood Moo qual d r ea ity ctivi ty im pair e d Impa Moo ired d (sa co nc d) e ntra t io n/ Moo atten d va t ion riat io n by time of da Neg a y t ive o ut lo Less common in ok (s Inte r e lf) pers ona l sens iti vit y Comorbid Depressions Hype rsom nia
  • 4. Conventional Screening (in medical settings) Methods Accuracy
  • General Physical Trained Self-Report Confident Skilled Clinician Alone Signs of DS 6 Mood DISCS Observation Screening VisualCDSS#10 VA-SES SMILEY ET/DT YALE Interview HAMD-D 17 MADRAS 10
  • => Is it accurate?
  • Methods to Evaluate Depression Unassisted Clinician Conventional Scales Untrained Trained Short (5-10) Long (10+) Other/Uncertain Ultra-Short (<5) 9% ICD10/DSMIV 0%Short QQ 3% Other/Uncertain Other/Uncertain 9% 9% ICD10/DSMIV ICD10/DSMIV 0% 0% Short QQ Short QQ 1,2 or 3 Simple 3% 3% QQ 15% Clinical Skills 1,2 or 3 Sim ple 1,2 or 3 Sim ple Alone QQ QQ 73% 15% 15% Clinical Skills Clinical Skills Alone Alone 73% 73% Verbal Questions Visual-Analogue Test PHQ2 Distress Thermometer WHO-5 Depression Thermometer Whooley/NICE
  • 1.00 Comment: Slide illustrates Bayesian Post-test Probability curve comparison from indirect studies of clinician and HADS0.90 This illustrates POTENTIAL gain from screening0.800.70 Benefit0.60 Gain?0.500.40 Clinician Positive (Fallowfield et al, 2001)0.30 Clinician Negative (Fallowfield et al, 2001) Baseline Probability0.20 HADS-D Positive (Mata-analysis) HADS-D Negative (Meta-analysis)0.10 Pre-test Probability0.00 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
  • 1.00 HADS+ Post-test Probability HADS- Baseline Probability0.90 GDS30+ GDS30-0.80 GDS15+ GHQ28+ HDRS+0.70 ZUNG+ GDS15-0.60 GHQ28- HDRS- ZUNG-0.50 PHQ9+ PHQ9-0.40 WHOOLEY2Q+ WHOOLEY2Q- BDI+0.30 BDI- BDI-SF+0.20 BDI-SF- CESD+ CESD-0.10 1Q+ 1Q- Pre-test Probability GHQ12+0.00 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 GHQ12- PHQ2 = HIGH NPV
  • Comment: Slide illustrates actual gain inmeta-analysis of screeningimplementation in primary care
  • 1.00 Post-test Probability Clinical+ Clinical-0.90 Baseline Probability Screen+ Screen-0.800.700.600.500.40 Comment: Slide illustrates Bayesian0.30 curve comparison from RCT studies of clinician with and without screening0.20 This illustrates ACTUAL gain from screening in Study from Christensen0.10 Pre-test Probability0.00 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
  • 5. Enhanced Detection Strategies Acceptability Algorithm Not just depression
  • Distress Thermometer
  • 1.00 Distress Post-test Probability 0.90 0.80 0.70 0.60 DT+ [N=4] 0.50 DT+ [N=4] Baseline Probability 1Q+ [N=4] 1Q- [N=4] 0.40 2Q+ 2Q- DT/IT+ DT/IT- 0.30 HADST+ [N=13] HADST+ [N=13] PDI+ 0.20 PDI- 0.10 Pre-test Probability 0.00 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1Mitchell AJ. Short Screening Tools for Cancer Related Distress A Review and Diagnostic Validity Meta-analysis JNCI (2010) in press
  • Proportion20.0% Insignificant Minim al Mild Moderate Severe18.0%16.0%14.0%12.0%10.0% 18 .4 %8.0% 12 .9 %6.0% 12 .3 % 11.9 % 11.2 %4.0% 8 .1% 7.7% 7.2 % 5.0 %2.0% 2 .8 % 2 .6 %0.0% Zero One Tw o Three Four Five Six Seven Eight Nine Ten 50%
  • DepT DT 23%37% 4% 3% 3% DT DepT 7% 1% Non-Nil 8% 0% Nil 9% 59% 41% 4% 1% AnxT 2% AngT 15% 2%AnxT AngT47% 18%
  • =86.4% =82.2%Beals AGP 2004 =57.6%
  • Of the 293 Non-Nil DepT 23% 0.3% DepT 3% 2% 18% Dysfunction Distress 28% 26% 22%Dysfunction Distress 76% 69%
  • 100% 0.02 0.00 0.00 0.00 0.00 0.00 0.03 0.04 0.03 0.01 0.06 0.08 0.09 0.07 0.1790% 0.20 0.18 0.11 0.19 0.28 0.31 0.1880% 0.31 0.4770% 0.20 0.48 0.4060% 0.50 0.40 0.5350% 0.4540% 0.80 0.40 0.69 0.6230% 0.50 3=Extremely Difficult” 0.43 0.4120% 2=Very Difficult 0.32 0.33 0.27 0.2510% 1=Somewhat Difficult 0.20 Unimpaired 0% Zero One Tw o Three Four Five Six Seven Eight Nine Ten
  • Depression_HADS 1 Post-test Probability 0.9 0.8 0.7 0.6 Baseline Probability 0.5 HADSd+ 0.4 HADSd- HADS-T+ 0.3 HADS-T- HADS-A+ 0.2 HASD-A- 0.1 Pre-test Probability 0 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
  • Depression_all1.00 Post-test Probability0.900.800.700.60 1Q+ 1Q-0.50 Baseline Probability DT+ DT- 2Q+0.40 2Q- HADSd+ HADSd- HADS-T+ HADS-T-0.30 BDI+ BDI- EPDS+ EPDS- HADS-A+0.20 HASD-A-0.10 Pre-test Probability0.00 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
  • Summary Questions