1. Depressive Disorders A Patient-Centered, Evidence-Based Diagnostic and Treatment Process 1,2,3 Kendall L. Stewart, MD, MBA, DLFAPA January 17, 2014 1 My aim is to offer practical clinical insights that you can use right away in caring for patients. 2 Please let me know whether I have succeeded on your evaluation forms. 3 Depression is one of the most common problems you will see in your clinical practice.

2. Why is this important? This is a common, serious disorder. 1,2 The lifetime prevalence is between 15 and 20-percent. About 10-percent of patients who present to primary care physicians are depressed.primary care physicians About 15-percent of medical inpatients are depressed. Women are depressed about twice as often as men. It is as disabling as coronary artery disease or arthritis. It is among the most common reasons for seeing a physician. After listening to this presentation, you will be able to answer the following questions: – Why is this important? – In what psychiatric diagnoses does depression play a major role? – How do these patients present? – What are the diagnostic criteria for Major Depressive Disorder? – What is the differential diagnosis? – What is the treatment? – What are some of the treatment challenges? 1 Depression is frequently missed and often inadequately treated. 2 What is the most effective screening tool?

3. In what psychiatric diagnoses does depression play a major role? Bipolar and Related Disorders – Bipolar I Disorder – Bipolar II Disorder – Cyclothymic Disorder – Substance/Medication-Induced Bipolar Disorder – Bipolar and Related Disorder Due to Another Medical Condition – Other Specific Bipolar and Related Disorder – Unspecified Bipolar and Related Disorder Depressive Disorders – Disruptive Mood Dysregulation Disorder 1 – Major Depressive Disorder – Persistent Depressive Disorder (Dysthymia) – Premenstrual Disorder 2 – Substance/Medication-Induced Depressive Disorder – Depressive Disorder Due to Another Medical Condition – Other Specific Depressive Disorder – Unspecified Depressive Disorder 1 Severe recurrent temper outbursts with an onset before age 10 2 Patient must have had significant symptoms associated with most menstrual cycles during the previous year.

4. How do patients with depression present? 1 Treating your older patients’ unrealistic expectations that they will sleep through the night will challenge you. 2 Major depressive episodes are often superimposed on Dysthymic Disorder. “I’m just down all the time.” “I just can’t seem to get myself going.” “Life doesn’t seem to mean much anymore.” “I don’t get along with my husband like I used to.” “I can’t sleep.” 1 “I have a lot of headaches.” “I have this hurting in my chest now and then.” “I’ve been depressed on and off throughout my life.” 2 “It usually didn’t last very long, but now I’m depressed for weeks at a time.” “I’ve seriously considered suicide, but I wouldn’t want to do that to my children.” “I can’t seem to fall asleep, but then I wake up early and can’t get back to sleep.” “I feel helpless, hopeless and worthless.” “I can’t concentrate.” “I don’t enjoy anything anymore.” “I’m tired all the time.” “I don’t enjoy sex at all.” “I have a pretty good life; I can’t figure out why I would feel this way.” You can view the BBC documentary on depression here.BBC documentary on depression here

5. What are the diagnostic criteria for a Major Depressive Disorder? 1 This remains highly controversial. A change from a previous level of functioning One of the following – Depressed mood – Inability to experience pleasure Five or more of the following symptoms during a continuous two-week period – Depressed mood – Markedly diminished interest – Significant weight loss or gain without explanation – Insomnia or hypersomnia – Psychomotor agitation or retardation – Fatigue – Feelings of worthlessness or guilt – Inability to concentrate – Recurrent thoughts of death No evidence of a mixed episode Significant distress or impairment Not due to substances or better explained by another mental disorder Not caused by bereavement 1

6. What is the course of Major Depression? Normal Life

7. What is the course of Dysthymic Disorder? Normal Life

8. What is the course of Bipolar I Disorder? Normal Life

9. What is the course of Bipolar II Disorder? Normal Life

10. What is the course of Cyclothymic Disorder? Normal Life

11. What are some possible differential diagnoses? Normal depression – Grief Other depressive disorders – Bipolar disorders Depression secondary to a general medical condition – Cancer Substance-induced depression – Recent use of steroids 1 Depression secondary to other psychiatric disorders – Panic Disorder 1 I have often seen steroids cause both depression and mania.

12. What is a typical treatment plan for depression? Depression – Provide reassurance. – Consider paroxetine 20 mg/day and increase to maximum dose of 60 mg/day. – Follow an evidence-based algorithm for treatment resistant depression.evidence-based algorithm for treatment resistant depression – Consider referral to a psychiatrist. Suicidal risk – Conduct a careful risk assessment.risk assessment – Document your assessment. – Take appropriate precautions. Insomnia – Consider the short-term use of your favorite sleeper.sleeper Other comorbid disorders – Diagnose and treat these conditions vigorously. Maladaptive attitudes and behaviors – Consider cognitive behavioral psychotherapy (CBT)cognitive behavioral psychotherapy (CBT) Education and self help – Provide educational resources. – Recommend a daily exercise regimen.exercise – Recommend a healthy diet. – Suggest healthy distractions. – Recommend meditation. – Recommend online resources with caution. – Recommend self help groups with caution.

13. What are some of the treatment challenges you can expect? Only 30 to 40-percent of patients achieve a complete remission with the first adequate trial of antidepressant medication. The treatment of the rest of these folk is tough and complicated. – Failure to comply is often an issue. – Accompanying personality disorders are very tough to treat.personality disorders – Partial remission is often the best result you can realistically achieve. – Depression usually recurs, and is best managed as a chronic illness. – Chronically-suicidal patients are particularly challenging. Consider TMS as an augmenting strategy.TMS

14. The Psychiatric Interview A Patient-Centered, Evidence-Based Diagnostic and Treatment Process Review my laboratory data and other available records. Tell me what diagnoses you have made. Reassure me. Outline your recommended treatment plan while making sure that I understand. Repeatedly invite my clarifying questions. Be patient with me. Provide me with the appropriate educational resources. Invite me to call you with any additional questions I may have. Make a follow up appointment. Communicate with my other physicians. Introduce yourself using AIDET 1.AIDET 1 Sit down. Make me comfortable by asking some routine demographic questions. Ask me to list all of my problems and concerns. Using my problem list as a guide, ask me clarifying questions about my current illness(es). Using evidence-based diagnostic criteria, make accurate preliminary diagnoses. Ask about my past psychiatric history. Ask about my family and social histories. Clarify my pertinent medical history. Perform an appropriate mental status examination. 1 A cknowledge the patient. I ntroduce yourself. Inform the patient about the D uration of tests or treatment. E xplain what is going to happen next. T hank your patients for the opportunity to serve them.

15. How can you access the OU-HCOM psychiatry flash cards online? Go to Quizlet.Quizlet Create a free account. When you receive a confirmatory email, click on the link to activate your new account. With your activated account open in another browser window, click on this link to join the class.link You can download the free Quizlet app to your iPhone or import these learning sets to the more robust Flashcards Deluxe app. Enjoy. I hope you find these cards helpful. Please post your feedback or suggestions on the Quizlet site.

16. Where can you learn more? American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, 2013Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, 2008Concise Textbook of Clinical Psychiatry, Third Edition Stern, et. al., Massachusetts General Hospital Comprehensive Clinical Psychiatry, 2008. You can read this text online here.here Flaherty, AH, and Rost, NS, The Massachusetts General Hospital Handbook of Neurology, 2011The Massachusetts General Hospital Handbook of Neurology Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship, Third Edition, 2011First Aid© for the Psychiatry Clerkship, Third Edition Klamen, D, and Pan, P, Psychiatry PreTest Self-Assessment and Review, Thirteenth Edition, 2012Psychiatry PreTest Self-Assessment and Review, Thirteenth Edition Blitzstein, Sean, Lange Q&A Psychiatry, 2011Lange Q&A Psychiatry Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, 2008Spark: The Revolutionary New Science of Exercise and the Brain Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, 2010Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School

17. Where can you find evidence-based information about mental disorders? Explore the site maintained by the organization where evidence-based medicine began at McMaster University here.here Sign up for the Medscape Best Evidence Newsletters in the specialties of your choice here.here Subscribe to Evidence-Based Mental Health and search a database at the National Registry of Evidence-Based Programs and Practices maintained by the Substance Abuse and Mental Health Services Administration here.here Explore a limited but useful database of mental health practices that have been "blessed" as evidence-based by various academic, administrative and advocacy groups collected by the Iowa Consortium for Mental Health here.here

18. How can you contact me? Kendall L. Stewart, MD, MBA, DLFAPA VPMA and Chief Medical Officer Southern Ohio Medical Center Chairman & CEO The SOMC Medical Care Foundation, Inc. 1805 27th Street Waller Building Suite B01 Portsmouth, Ohio 45662 740.356.8153 StewartK@somc.org KendallLStewartMD@yahoo.com www.somc.org www.KendallLStewartMD.com

19. Are there other questions? 1,2  Safety  Quality  Service  Relationships  Performance  1 Learn more about Southern Ohio Medical Center.Southern Ohio Medical Center 2 Learn more about our Family Medicine and Emergency Medicine Residencies.Family Medicine and Emergency Medicine Residencies Justin Greenlee, DO Director Family Medicine Residency Thomas Carter, DO Director Emergency Medicine Residency