Rcpsych Workshop - Depression in medical settings (Mar11)

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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)

  1. 1. 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
  2. 2. 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
  3. 3. Special Symptoms Physical Illness Primary Symptoms DSMV Older people Care ICD11 Detection Depression Quality of care ScalesDistress Screening
  4. 4. 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?
  5. 5. 1.Overview: Depression in medical settings Comorbidity | impairment | mortality
  6. 6. 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
  7. 7. n=245 404 participants from 60 countriesQuality of life: Moussavi et al (2007) Lancet 2007; 370: 851–58
  8. 8. Mortality and IHD+depression Psychosomatic Med (2004) Barth et al
  9. 9. 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
  10. 10. % 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
  11. 11. 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
  12. 12. Audience:How common are medical co-morbidities in depression?
  13. 13. 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.
  14. 14. 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
  15. 15. 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
  16. 16. 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
  17. 17. Prevalence Depression in medical settings Methodological | Scale vs interview | Current vs 12mo vs lifetime Cancer | IHD | Stroke
  18. 18. 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
  19. 19. 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
  20. 20. 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)
  21. 21. 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)
  22. 22. 1a. Routine Recognition of Depression Is depression a disease; disorder (syndrome) or normally distributed
  23. 23. Audience:Is depression categorical or dimensional?
  24. 24. 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
  25. 25. Graphical – two disorders Healthy # ?Point of Rarity of Individuals Optimal cut With symptom Diabetes HBA1c
  26. 26. 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
  27. 27. 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
  28. 28. 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.
  29. 29. Comment: Slide illustrates added actual distributionof mood scores on the HADS in a cancerpopulation with hidden depression from theEdinburgh cancer centre
  30. 30. 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
  31. 31. 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)
  32. 32. Audience:What are the predictors of improved recognition?
  33. 33. 0.25 65% 0.22 0.21 0.20 0.190.200.150.10 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
  34. 34. 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

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