2/27/2010
D
i I
i
Depression Issues in
Academic Medical Centers
Richard C. Shelton, M.D
Richard C. Shelton, M.D..
James G. Blakemore Research Professor
Chief, Mood Disorders Program
Vice Chair for Research
Department of Psychiatry
Vanderbilt University School of Medicine
Presentation Outline
• Depression in the workplace
– Prevalence
– Impact
•
•
•
•
Brief discussion of bipolar disorder
Features of depression: What to look for
Suicide: Epidemiology, causes, assessment
Treatment of depression:
– Psychotherapy
– Medications
– Light therapy
• What to do if you or someone you know is depressed
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Depression in Family Medicine Faculty
• Sample
– Family medicine faculty: n=2347
– Family medicine residency directors: n=475
– Family medicine behavioral faculty: n=392
• Assessments:
– NEOUCOM Survey
NEOUCOM Survey
– Social Readjustment Rating Scale
– Beck Depression Inventory‐II
Costa AJ, et al. Fam Med 2005; 37:271‐275
Depression in Family Medicine Faculty
Stress
Depression
70%
60%
58%
50%
35%
40%
30%
20%
7%
10%
0%
Low
Medium
High
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
88%
Minimal
7%
5%
Mild
Mod/Sev
Costa AJ, et al. Fam Med 2005; 37:271‐275
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The Epidemiology of
Major Depressive Disorder (NCS‐II)
• Depression prevalence: • Treatment (12 months):
– Lifetime: 16.2%
– 12‐month: 6.6%
• Mild: 10.4%
• Moderate: 38.6%
Moderate 38 6%
~6% • Severe: 38%
• Very severe: 12.9%
– Any Rx: 51.6%
– Adequate: 41.9%
– Adequate (total): 21.7%
Kessler RC et al. JAMA 289:3095-3105, 2003
American College of Surgeons Survey
Impact of Stress and Depression
on Job Performance
Design
• 7905 surgeons – Of 24,922 members
• Survey items:
– Maslach Burnout Inventory (subscales):
Results
• Reporting a major medical error in the previous 3 mo: n=700 (8.9%)
• Attribution: Personal: 70%
• Emotional
Emotional exhaustion
exhaustion
• Depersonalization
• Low personal accomplishment
– Mental and physical QOL
– PRIME‐MD MDD
Shanafelt TD, et al. Ann TD, et al. Ann Surg
Surg (in press)
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American College of Surgeons Survey
64.7%
64 7%
Shanafelt TD, et al. Ann TD, et al. Ann Surg
Surg (in press)
American College of Surgeons Survey
Many people in high stress jobs experience depression
Depression adversely affects job performance to the detriment of others
Depression is common even among “good performers”
• However, trouble is always “right around the corner”
Shanafelt TD, et al. Ann TD, et al. Ann Surg
Surg (in press)
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Effects of Depression in the Workplace
• Poor job performance/errors
– Medical mistakes
– Failing to meet deadlines
– ↓output compared to others or prior performance
•
•
•
•
•
•
Burnout – resignation (abrupt)
Family and marital discord
Alcohol and drug abuse or dependence
Alcohol and drug abuse or dependence
Irritability/outbursts of anger/other conflicts
Risk taking behavior
Suicide attempts or completions
Disability Due to Disease ‐ WHO 2002
Disability Adjusted Life Years (Diseases)
100000000
90000000
80000000
70000000
60000000
50000000
40000000
30000000
20000000
0
Lower respirattory …
HIV/A
AIDS
Unipolar depresssive …
Diarrhoeal diseaases
Cerebrovascular diseease
Other unintentio
onal …
Malaaria
Low birth weiight
Road traffic accideents
Tuberculo
osis
Birth asphyxia and birth …
Chronic obstructtive …
Other digestive diseaases
Hearing LLoss
Cataraacts
Meassles
Violence
Alcohol use disord
ders
Malnutrittion
Diabetes mellitus
Schizophreenia
Asth
hma
Congenital heeart …
Osteoarthrritis
Vision disorders, aage‐…
Cirrhosis of the liiver
Bipolar disorrder
10000000
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Mood Disorders
Depression
Bipolar
Bipolar I Bipolar II
“Unipolar”
Major
Depression
Dysthymia
Cyclothymia
Bipolar Disorder:
Myths and Misconceptions
Myth
Fact
• Bipolar disorder is rare
• Bipolar disorder affects about 3‐5% of the population
• BD mood states last days to weeks at a time
• BD is characterized by rapid mood swings
Mania feels “good”
good
• Mania feels Mania often is associated often is associated
• Mania
with tension, agitation, and irritability
• BD is an adult condition
• BD is diagnosable at virtually any age
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This Is Not Bipolar Disorder
WEEKS
This Is Bipolar Disorder
WEEKS
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Treatment of Bipolar Disorder
• Mood stabilizing medications
– Lithium
Lithi
– Anticonvulsants
• Valproic acid (Depakote)
• Lamotrigine (Lamictal)
• Carbamazepine (Tegretol)
– Atypical antipsychotics
i l
i
h i
• Risperidone (Risperdal)
• Aripiprazole (Ablilify), etc.
– Antidepressants (+/‐)
Diagnosis of Depression
Essential features: Depressive disorders are Essential
features: Depressive disorders are
typified by persistently depressed mood and/or loss of interest or pleasure in all or almost all activities.
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Major Depressive Disorder
DSM IV Diagnostic Criteria
A. Five of the following for > 2 weeks:
1)) Depressed
p
mood* ((“sad”))
2) Loss of interest* (“flat”)
3) Significant weight/appetite loss/gain (>5 pounds)
4) Sleep disturbance, either insomnia or hypersomnia
5) Psychomotor agitation or retardation
6) Fatigue or loss of energy
7) Feelings of worthless or excessive/inappropriate guilt
8) Diminished ability to think, concentrate, make decisions
9) Thoughts of death, suicide
Common Symptoms of Depression
• Psychological
–
–
–
–
–
–
–
–
–
• Physical
Down (sad)/flat mood*
Low motivation*
Lack of enjoyment*
Guilt
Despair/hopelessness
Pessimism/negativism
Irritability/anger
Suicide (thoughts/actions)
Excessive anxiety/worry
Sleep problems (↓or↑)
Appetite/weight change (↓or↑)
Fatigue/low energy
Cognitive slowing/poor concentration
– Motor slowing/agitation
– Pain
P i
–
–
–
–
• Perfectionism
– Avoidance behaviors
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Suicide: Prevalence Estimates
2001‐2004 (NCS‐R)
• Suicidal:
– Ideation: 3.3%
Id ti
3 3%
– Plans: 1%
– Gestures: 0.2%
– Attempts: 0.6%
• Among those with suicidal ideation:
– Plans: 28.6%
– Gestures: 6.4%
– Attempts: 32.8%
Kessler RC, et al. JAMA 2005; 293:2487‐2495
Suicide Risk Factors
• Severe mental disorder (MDD, schizophrenia, substance abuse, etc.)
AND
• Environmental stress (hopelessness)
– Unemployment
– Financial problem
– Separation/loss (e.g., divorce),
S
ti /l
(
di
)
– Job stress, etc.
Especially
“Chonic
+
+ Acute”
AND
• Impulsivity (biological ‐ serotonin)
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Environmental Stress
(Hopelessness)
Major Mental
Disorder
Suicide
Biological
Impulsivity
SUICIDE PREDICTION vs.
SUICIDE ASSESSMENT
• Suicide Prediction refers to the foretelling of whether suicide
will or will not occur at some future time,, based on the
presence or absence of a specific number of defined factors,
within definable limits of statistical probability
• Suicide (risk) Assessment refers to the establishment of a
clinical judgment of risk in the very near future, based on the
weighing of…the available clinical detail. Risk assessment
carried out in a systematic, disciplined way is more than a
guess or intuition – it is a reasoned, inductive process, and a
necessary exercise in estimating probability over short
periods.
Adapted from Douglas Jacobs, M.D., Associate Clinical Professor of
Psychiatry, Harvard Medical School
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DETERMINATION OF RISK
Psychiatric Examination
Risk
Factors
Protective
Factors
Specific Suicide
Inquiry
Modifiable Risk?
Assign Risk Level:
Low, Med., High
Adapted from Douglas Jacobs, M.D., Associate Clinical Professor of
Psychiatry, Harvard Medical School
Risk Factors for Suicide
•
•
•
•
•
•
•
•
•
Anxiety or panic symptoms
Alcohol/drug abuse
Psychosis
y
Hospitalized for mood disorder due to suicidal
thoughts or actions
Sex, male:female (completed suicide):
• Major depression = 4:1
• Bipolar disorder = 1:1
Ph i l ill
Physical
illnesses (disability>mortality)
(di bili
li )
Social isolation
Family history
Recent severe stressor
Adapted from Douglas Jacobs, M.D., Associate Clinical Professor of Psychiatry, Harvard Medical School
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RELATIVE PROTECTIVE FACTORS
(Resiliance)
 Absence of:
 Ideation
 Plan
 Stated intent
 Children in the home
 Except with
postpartum psychosis
 Pregnancy
 Deterrent religious beliefs
 Life satisfaction
 Intact reality testing
 I.E., “not psychotic”
 Positive coping skills
 Positive social support
 Positive therapeutic
relationship
 None of these are absolute!
 Don’t guess!
Adapted from Douglas Jacobs, M.D.
 Ask for help
Associate Clinical Professor of
Psychiatry, Harvard Medical School
SUICIDE RISKS IN SPECIFIC DISORDERS
Condition
RR
%/y
Prior suicide attempt
Bipolar disorder
Major depression
Mixed drug abuse
Obsessive-compulsive
Panic disorder
Schizophrenia
Personality disorders
Al h l abuse
Alcohol
b
Cancer
38.44
38
21.7
20.4
19.2
11.5
10.0
8.45
7.08
5 86
5.86
1.80
0.549
0
549
0.310
0.292
0.275
0.143
0.160
0.121
0.101
0 084
0.084
0.026
General population
1.00
0.014
From A.P.A. Guidelines, part A, p. 16
%-Lifetime
27.55
27
15.5
14.6
14.7
8.2
7.2
6.0
5.1
42
4.2
1.3
0.72
Adapted from Douglas Jacobs, M.D.
Associate Clinical Professor of
Psychiatry, Harvard Medical School
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PSYCHOSOCIAL SITUATION:
FIREARMS AND SUICIDE
 Firearms account for 55-60% of suicides (Baker 1984, Sloan 1990).
 Firearms at home increase risk for adolescents:
• Guns are twice as likely to be found in the homes of suicide victims as in the
homes of attempters (OR 2.1) or in the homes of control group (OR 2.2)
(Brent et al 1991)
• Type of gun (handgun, rifle, etc.) was not statistically correlated with
increased risk for suicide
 Inquire about firearms when indicated and document
instructions and response.
Adapted from Douglas Jacobs, M.D., Associate Clinical Professor of Psychiatry, Harvard Medical School
Treatment of Depression
• Medications
– Lots of medicines, combinations
– Who needs a medicine?
• Prior response to medicine
• Family history of response to medications
• Moderate to severe depression
– Impairment
• Chronic depression, psychosis, suicidal thoughts
• Psychotherapy
• Family/marital therapy
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Psychotherapy for Depression
• Most types of psychotherapy either don’t work
or have no empirical support
h
ii l
t for depression!
f d
i !
• Types of psychotherapy that work for depression
– Cognitive behavioral therapy
– Behavioral activation therapy
– Problem solving therapy (mild depression only)
Problem solving therapy (mild depression only)
Cognitive Behavioral Therapy
• CBT seeks to produce change in emotions and behavior by systematically evaluating db h i b
t
ti ll
l ti
thoughts and beliefs and changing repetitive behavior patterns to produce more adaptive responses.
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Cognitive Behavioral Therapy
Stimulus
Sti
l
(Event)
Beliefs
Emotions
Behaviors
Thoughts
(“Automatic”)
“I am a failure”
“I’m useless”
“I’ll never succeed”
“No one will ever love me”
“I am ugly”
“I am stupid”
Cognitive therapy vs medications in the treatment of moderate to severe depression (CPT II)
Acute Phase (16 weeks)
Continuation Phase (12 months)
3b t
3 booster sessions
i
Prior CT
CT
Follow‐up Phase (12 months)
(N=33)
(N= 60)
ADM
(N=34)
*ADM
(N= 120)
PLACEBO
(N=34)
PLACEBO
(N= 60)
ADM = Paroxetine 10-50 mg./day (+augmentation)
DeRubeis Arch Gen Psychiatry 2005; 62:409‐416
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2/27/2010
CPT‐II: Percent Responders (HRSD < 12)
(CT vs. Paroxetine vs. Placebo)
60%
57%
50%
58%
Percentage
49%
40%
40%
30%
20%
25%
5%
Placebo (n=60)
ADM (n=120)
10%
CT (n=60)
0%
8 Weeks
16 Weeks
DeRubeis RJ, et al. Arch Gen Psychiatry 2005;62:409-416
Prevention of Relapse and Recurrence Following Successful Treatment
Followup
24
22
20
18
16
14
12
8
10
6
4
Placebo (n=35)
Drug (n=34)
Compliant (n=30)
Prior CT (n=35)
2
0
% Survival
Continuation
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Months (following active treatment)
Slide courtesy of Steve Hollon, Ph.D.
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Antidepressants:
Myths and Misconceptions
• Myth: Antidepressants don’t work better than placebo
– Fact: Drug/placebo differences in short term studies are greater in moderate to severe depression
– Fact: Antidepressants beat placebo in longer‐term treatment
• Myth: Antidepressants increase risk for suicide
Myth: Antidepressants increase risk for suicide
– Fact: Antidepressants dramatically reduce risk for suicide
– Fact: Antidepressants may increase risk for self injury
(not suicide) in the short‐term
Seasonal Affective Disorder
Fall Winter Spring Summer
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Phototherapy Devices (“Light Boxes”)
30 minutes
http://www.northernlighttechnologies.com/products.php
What to do if you think you or someone you know is depressed?
• At work:
– Rule
Rule 1: Call the 1: Call the
Employee Assistance Program (EAP)
– Rule 2: Consult Rule 1!
– Discuss with your supervisor
• At home:
– Contact the Employee Assistance Program
– Contact your primary care physician
• In all situations:
– Don’t
Don t be afraid to ask
be afraid to ask
– Don’t be afraid to suggest EAP/PCP
– You won’t make someone commit suicide by asking!
• My question: Have you h d
had any thoughts about th
ht b t
harming or killing yourself?
– Be a good consumer
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Summary
• Depression is a common and serious condition
– It often affects work performance
• P
People in high stress jobs often become l i hi h
j b f
b
depressed
• Common symptoms of depression are both psychological and physical
• Depression is treatable
p
• Suicide is preventable in most people, IF:
– Suicide risk is detected
– Depression is treated
• REMEMBER: Don’t do this alone – get help!
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