Major Depression, Bipolar
Affective Disorder, Mood
Disorders and Menopause
A Clinical Psychiatric Underwriting Update
Dean Knudson, M.D.
Medical Director, NationsCareLink
May 2007
Overview
• Does depression increase dementia risk by a little or
a lot? What does the data say?
• Why is there such an increase in the diagnosis of
Bipolar Affective Disorder, and the use of
antipsychotic medications?
• Why do so many perimenopausal women end up on
antidepressants?
Mood Disorders and Dementia
Bipolar Affective Disorder and Major
Depression
Gray Matter Loss in Patients With
Schizophrenia vs Controls Over 5
Years
Permanent Loss in Gray Matter Volume
Observed in a Study of Patients With
Bipolar Disorder1
Depression and Alzheimer’s Risk
• Meta-analysis and Systematic Literature
Review, May 2006
• Pooled odds ratios increased risk: 2.03
(95%
for case-control and of 1.90
(95% confidence interval, 1.55-2.33) for cohort studies
confidence interval, 1.73-2.38)
Ownby, Arch Gen Psychiatry. 2006;63:530-538
Cumulative Risk with Mood Disorder
• Danish researchers found that a patient's risk of
developing dementia appears to increase by 13
percent each time the patient is hospitalized for
major depression, or by 6 percent for each
hospitalization for bipolar disorder.
Dementia incidence overall during the study period
was equal between Bipolar and MDD groups
Kessing J Neurol Neurosurg Psychiatry 2004 71662
Increased Risk with Prior Episodes
• Risk of dementia in depression and bipolar
increases with increasing number of prior episodes
• In depression five or more episodes significantly
increased risk of dementia compared with a single
episode: hazard ratio 6.16 (95% CI 1.39 to 27.22)
Kessing, J Neurol Neurosurg Psychiatry 2004;75:1662–6
Depression History and
Dementia Risk:Jorm 2001
• Meta-analysis: six prospective and seven
case control studies
• Case control: 2.01 times increased risk
• Prospective: 1.87 times increased risk
Aust NZ J Psychiatry Dec:35(6):776-81
Depressive Symptoms and Functional
Decline: Mehta 2002
• 5697 subjects, 2 year prospective study
• Cognition and depression: < 1.5 SD
• Independent in ADL at study initiation
• 2.3 times risk of ADL loss: cognitive group
• 1.9 times risk of ADL loss: depressive
group
J Am Geriatr Soc 2002 Jun;50(6):1045-50
Dementia, Depression, Illness
and Mortality, Arfken 1999
• 455 rehabilitation inpatients, 60+, 1 year
• Increased mortality: mild depression: 1.64
times risk; moderate depression 2.49
times, for whole group
• Cognitively intact: moderate depression
4.95 times increased mortality
• Cognitive impairment: 2.13 times risk
J Gerontol A Biol Sci Med Sci 1999 Mar;54(3):M152-6
Geriatric Depression Outcomes:
Steck 2002
• 185 Dutch hospitalized elderly: 8 year study
• 40% dead at 8 years
• 33% “fared well”
• 24% relapsing course
• 22% residual symptoms
• 11% continuously ill
• 9% demented at 8 years
Aging Ment Health 2002 Aug;6(3):282-5
Depressive Symptoms and Cognitive
Decline: Wilson 2002
• Cognitively intact clergy 65+, 7 year study
• Annual screens for depression, dementia
• 8 depressive symptoms screened
• For each depressive symptom, risk of
Alzheimer’s increased 19% and annual
cognitive score decreased 24%, per
subject year.
Neurology 2002 Aug 13;59(3):364-70
Bipolar Affective Disorder
Atypical antipsychotic use
Why the increase in the diagnosis?
Why the increase in antipsychotic use?
Bipolar Affective Disorder
• Type I
• Classic Mania:
Euphoria, elation,
pressured speech,
racing thoughts,
grandiosity, financially
and sexually risky
behavior
• Significant Depression
• Periodic mood swings
• Type II
• Hypomania: much less
intense state, mild
elation, less
pronounced symptoms
• Significant Depression
• Periodic mood swings
Prevalence of Bipolar Affective
Disorder
• Previously thought only to affect 0.5% of the
population
• Recent revised estimates suggest that 3.7% of the
population suffers from either Bipolar Type I or
Bipolar Type II
Differential Diagnosis of
Unresponsive Mood Disorder
Symptoms
• Bipolar Affective Disorder type I or II
• Chemical dependency
• Treatment resistant Major Depressive Disorder
• Personality Disorder (Axis II Cluster B)
• Very Early Schizophrenia or Schizoaffective Dx
• Antipsychotics are used in all these diagnoses!
Underwriting Hints: Mental Illness
•
•
•
•
•
Single vs Multiple episodes
Employed: long term?
Married
Hospitalizations
Total percentage of life
spent experiencing
significant depressive
symptoms
•
Simple or complex
medication regimen
•
History of multiple
medication trials
•
•
•
Cognitively intact
Currently independent
Suicide Attempts
Menopause related
Depression
Any link to future dementia?
Depression and Perimenopause
• Although a hormonal link has not been conclusively
documented, many midlife women do suffer from
despair, irritability, and fatigue. These mood
disturbances have been observed in up to 10% of
peri- and postmenopausal women participating in
community-based studies.
•
•
Ann Epidemiol. 1994;4:214-220
Kaufert PA, Gilbert P, Tate R. The Manitoba Project Maturitas. 1992;14:157-160
Perimenopausal Depression Odds
Ratios:
•
Hot
Flashes:
1.27
• Early menopause: 1.55
•
Poor Sleep: 2.95
• Late menopause: 2.89
• Severe PMS by history:
• Post menopause: 0.78
3.8
• Depression diagnosis
• Unemployed: 1.97
history: 2.45
Arch Gen Psychiatry 2004;61:62–70.
Questions?
deanknudson@yahoo.com
Questions?
deanknudson@yahoo.com