1. Depression for WIPHL Workers Kenneth Kushner, Ph.D. March 27, 2008

2. The Significance of Depression According to the W.H.O. Global Burden of Disease Project (GBD 2000), worldwide –Depression was ranked #1 among leading causes of years of life lived with disability, accounting for 12% of the total. –5.8% of men and 9.5% of women experience depression in a given year –Estimated that 121 million people world wide currently experiencing major depression

3. The Significance of Depression The prevalence of major depression in adults in the U.S. is 5.3% with an estimate of 17 million cases Up to 15% of people with major depressive disorder will eventually commit suicide Death rates (from all causes) of people with major depressive disorder over 55 are 4 times those in the general population In medical settings, patients with major depressive disorder have more pain and physical illness and decreased physical, social functioning

4. The Significance of Depression Patients with major depressive disorder are more likely to become diabetic

5. The Nosology of Depression DSM-IV lists multiple diagnoses that may be referred to as depression –Major Depressive Disorder (MDD) –Dysthymic Disorder –Bipolar Disorder –Adjustment Disorder (with Depressed mood) –Schizoaffective Disorder

6. The Nosology of Depression Other conditions may have significant mood symptoms similar to depression –Post-traumatic Stress Disorder (PTSD) –Schizophrenia Depression might arise secondary to other conditions –Ie panic disorder –Diabetes

7. DSM Major Depressive Disorder A. A minimum of 5 symptoms during the same 2- week period and represent change in previous functioning. One symptom must be #1 or #2 below: 1)Depressed mood 2)Diminished interest or pleasure 3)Significant weight loss or weight gain or increase or decrease in appetite nearly every day 4)Insomnia or hypersomnia nearly every day

8. DSM Major Depressive Disorder A. A minimum of 5 symptoms during the same 2-week period and represent change in previous functioning (Cont). 5) Psychomotor retardation or agitation 6) Fatigue or loss of energy 7) Feelings of worthlessness or excessive or inappropriate guilt 8) Diminished ability to think or concentrate or indecisiveness 9)Recurrent thought of death or suicidal ideation/attempt/plan

9. DSM Major Depressive Disorder B. The symptoms do not meet criteria for a mixed episode (bipolar disorder) C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning D. The symptoms are not due to direct effects of a substance or general medical condition E. The symptoms are not better accounted for by bereavement

10. Dysthymic Disorder Characterized as chronic, but less severe depression as compared to MDD Standard is 2 symptoms, majority of days for 2 years, never absent for more than 2 months

11. Bipolar Disorder Major depressive symptoms alternating with mania or hypomania

12. Adjustment Disorder An adjustment disorder is a debilitating reaction, usually lasting less than six months, to a stressful event or situation. The development of emotional or behavioral symptoms in response to an identifiable stressor(s) occurring within 3 months of the onset of the stressor(s). These symptoms or behaviors are clinically significant as evidenced by either of the following: – Distress that is in excess of what would be expected from exposure to the stressor. –Significant impairment in social, occupational or educational functioning. The symptoms are not caused by Bereavement.Bereavement.

13. Depression Screening

15. Two Question Verbal Screen Two questions were shown to be good at ruling out depression and identifying most of those who were depressed in general practices in New Zealand (Arroll, Khin & Kerse, 2003) –During the last 2 weeks have you been often been bothered by feeling down, depressed or hopeless? –During the past month have you been bothered by little interest or pleasure in doing things? Questions were delivered by physicians verbally to 476 general practice Answers were recorded as yes or no

16. Two Question Screen Answering no to both questions ruled out likelihood of depression when assessed further (Negative Predictive Value=99.7%) Answering yes to either question identified most patients with depression (sensitivity=97%) but with many false positive identifications (positive predictive value=18%)