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Assessment of Depression Diagnosis Risk Assessment Risk Management FormulationTreatmentOutcome.

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Presentation on theme: "Assessment of Depression Diagnosis Risk Assessment Risk Management FormulationTreatmentOutcome."— Presentation transcript:

1 Assessment of Depression Diagnosis Risk Assessment Risk Management FormulationTreatmentOutcome

2 Associated symptoms in increasing importance:  Insomnia  Fatigue  loss of interest/pleasure  Morbid self-opinion  Impaired concentration  Hopelessness ± suicidal thoughts. (Blacker and Clare ‘88)

3 Diagnostic domains  Affective symptoms  Physical symptoms  Cognitive symptoms

4 Affective Diagnostic Criteria. Must haves!  Depressed mood (irritable in children or adolescents).  Or markedly diminished interest or pleasure  Must be most of the time over at least 2 weeks.  Change from normal functioning

5 Physical symptoms  Weight change when not dieting  Sleep disturbance –insomnia (particularly middle insomnia and EMW), hypersomnia.  Agitation or retardation  Fatigue/loss of energy

6 Cognitive symptoms  Worthlessness, xs/inappropriate guilt  Diminished ability to think and concentrate  Recurrent thoughts of death and suicide

7 Diagnosis  Eye contact - observe body language.  Open questions.  Attend to “distinct quality of mood” eg.Coldness/deadness/emptiness.  Attend to “distinct quality of mood” eg.Coldness/deadness/emptiness. Paykel ’85

8 Comorbidity and missed diagnosis  Presentation affected by-  Gender (Women 2:1 Men)  Age  Insight  Comorbid physical illness

9 Gotland survey. Pop 56,000  60% GPs trained in depression diagnosis 1981/2  By 1985 - ↓ referrals 50%, inpatient by 75% and sick leave by 50%  Suicide rates dropped from 20 to 7/100,000  Antidepressant prescribing increased 60%  Anxiolytic prescribing decreased 25%

10 Suicides  ♀:♂ ratio 2:3 before the programme 1:7 after.  Of increased px 1/3 ♂, 2/3 ♀  Of increased ♂ px most were for elderly!  Improved ability in Primary Care benefits those in contact with Primary Care i.e. Women!

11 Male Depressive Syndrome  Lowered stress tolerance  Acting out/aggression/low impulse control/ Transitional sociopathy  Burnt out feeling/emptiness  Chronic fatigue  Irritability/restlessness/dissatisfaction  Indecision  Sleep disturbance/morning anxiety

12 Missed depression  Depressed mood may be absent  Watch for “inner emptiness or deadness”  Prominent anhedonia  Somatic complaints in patients with poor verbal skills or the elderly  Pseudo dementia- behavioural withdrawal, memory problems  Unexplained physical symptoms associated with depression e.g. pain. Impt to rule out organic cause

13 Reference: 1.Simon GE, et al. N Engl J Med. 1999;341(18):1329-1335. Depression – the physical presentation In primary care, physical symptoms are often the chief complaint in depressed patients N = 1146 Primary care patients with major depression In a New England Journal of Medicine study, 69% of diagnosed depressed patients reported unexplained physical symptoms as their chief complaint 1

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15 Is your depressed patient bipolar?  Co morbid substance abuse  Bipolar family history *  Seasonality  Early onset <25 yrs *  Postpartum onset *  Psychotic features <35 yrs */ Atypical features  Rapid on/off pattern, frequent recurrence, < 3mth duration * /Mixed affective state **  Antidepressant mania/hypomania **  Ask about symptoms of hypomania just preceding or following depression either 1 st episode or early-onset depression

16 Prevalence of Bipolar Spectrum subtype  26-39% depressed patients in Primary Care  45% depressed outpatients Allilaire et al “EPIDEP Trial”. Encephale 2001;27:149- 158

17 Risk Assessment  Risk - aggression to self, others & property - substance misuse - substance misuse - vulnerability/ exploitation - vulnerability/ exploitation  Ask direct questions about suicide – “have you thought about or are you thinking about hurting or killing yourself”  If yes or unsure, enquire about plan.  If yes but wouldn't do it then “What is stopping you from doing something?" (protective factors)

18 Predictors of Risk  S – lack of significant others, stress events.  U – unsuccessful attempts, unemployment, unexplained improvement.  I – identification with family history/peer group suicide.  CI – chronic illness or severe illness of recent onset

19 Predictors of Risk 2  D – depression + hostility/hopelessness or frustration, decision that suicide is an option  A – age, alcohol, availability.  L – lethality of previous attempts e.g. guns, hanging, jumping

20 BEHAVIOURAL THEORY  Stimulus-Response-Reward-Repetition  Risk Assessment  Risk Management – current and FUTURE  Therapeutic Risk/ Responsiblity

21 PRESCRIPTIVE DISASTER  DISclosure  Anxiety.  narrowed choiceS  Taking responsibility.  PatiEnt out of control.  Referral to other.

22 Interview Style  Be Perceptive- listen and understand, take distress seriously do not dismiss, minimise or ignore- build rapport.  Be Peaceful and calm. Do not appear threatened.  Partnership approach- they share responsibility for choosing the treatment approach. Empowerment reduces helplessness reduces risk!

23 Interview Style 2  Be Persuasive- discuss the thoughts/plans in a reasoned manner- “these are symptoms of a treatable condition, they are very common and are often temporary.  Be Positive – instillation of HOPE is the most protective thing you can do.

24 Collaborative risk management  Disclosure.  Further enquiry.  Normalisation  Informed choices.  Agreed plan.

25 Consequences of risk management  Patient retains responsibility  Patient understood and in control.  Self image stronger.  Risk lower in subsequent stress

26 What is Case Formulation?  “Case formulation aims to describe a person’s presenting problems and use theory to make explanatory inferences about causes and maintaining factors that can inform interventions” Kuyken 2006

27 Case formulation 2  Predisposing factors  Precipitating factors  Protective factors  Perpetuating factors  Hypothesis –Inferred mechanisms- goals  Exercise  Examples

28 TREATMENT  Keep taking the tablets!! –Effective drug & dose  Psychological – counselling, CBT, psychodynamic psychotherapy  Social- don’t forget these interventions; common sense and can make a lot of difference!

29 Outcome – response v remission  Aim for remission “are you back to your normal self?”  Use outcome measure GAF/Honos


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