Depressive Disorders
A Patient-Centered, Evidence-Based Diagnostic
and Treatment Process1,2,3
Kendall L. Stewart, MD, MBA, DLFAPA
January 17, 2014
1My
aim is to offer practical clinical insights that you can use right away in caring for patients.
let me know whether I have succeeded on your evaluation forms.
3Depression is one of the most common problems you will see in your clinical practice.
2Please
Why is this important?
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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.
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.
1Depression
2What
is frequently missed and often inadequately treated.
is the most effective screening tool?
• 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?
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
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1Severe
2Patient
• Depressive Disorders
– Disruptive Mood Dysregulation
Disorder1
– Major Depressive Disorder
– Persistent Depressive Disorder
(Dysthymia)
– Premenstrual Disorder2
– Substance/Medication-Induced
Depressive Disorder
– Depressive Disorder Due to
Another Medical Condition
– Other Specific Depressive Disorder
– Unspecified Depressive Disorder
recurrent temper outbursts with an onset before age 10
must have had significant symptoms associated with most menstrual cycles during the previous year.
How do patients with depression
present?
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“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.”
1Treating
2Major
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“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.
your older patients’ unrealistic expectations that they will sleep through the night will challenge you.
depressive episodes are often superimposed on Dysthymic Disorder.
What are the diagnostic criteria for a
Major Depressive Disorder?
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A change from a previous level of functioning
One of the following
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Five or more of the following symptoms during a continuous two-week
period
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Depressed mood
Inability to experience pleasure
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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
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No evidence of a mixed episode
Significant distress or impairment
Not due to substances or better explained by another mental disorder
Not caused by bereavement1
1This
remains highly controversial.
What is the course of Major
Depression?
10
8
6
4
2
Normal
Life 0
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Week 8
-2
-4
-6
-8
-10
Symptom Intensity Scale
Week 9
Week 10 Week 11 Week 12
What is the course of Dysthymic
Disorder?
10
8
6
4
2
Normal
Life 0
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Week 8
-2
-4
-6
-8
-10
Symptom Intensity Scale
Week 9
Week 10 Week 11 Week 12
What is the course of Bipolar I
Disorder?
10
8
6
4
2
Normal
Life 0
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Week 8
-2
-4
-6
-8
-10
Symptom Intensity Scale
Week 9
Week 10 Week 11 Week 12
What is the course of Bipolar II
Disorder?
10
8
6
4
2
Normal
Life 0
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Week 8
-2
-4
-6
-8
-10
Symptom Intensity Scale
Week 9
Week 10 Week 11 Week 12
What is the course of Cyclothymic
Disorder?
10
8
6
4
2
Normal
Life 0
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Week 8
-2
-4
-6
-8
-10
Symptom Intensity Scale
Week 9
Week 10 Week 11 Week 12
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 steroids1
• Depression secondary to other psychiatric
disorders
– Panic Disorder
1I
have often seen steroids cause both depression and mania.
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.
– Consider referral to a psychiatrist.
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Suicidal risk
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Insomnia
– Conduct a careful risk assessment.
– Document your assessment.
– Take appropriate precautions.
– Consider the short-term use of your
favorite sleeper.
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Other comorbid disorders
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Maladaptive attitudes and
behaviors
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– Diagnose and treat these conditions
vigorously.
– Consider cognitive behavioral
psychotherapy (CBT)
Education and self help
– Provide educational resources.
– Recommend a daily exercise
regimen.
– Recommend a healthy diet.
– Suggest healthy distractions.
– Recommend meditation.
– Recommend online resources with
caution.
– Recommend self help groups with
caution.
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.
– 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.
The Psychiatric Interview
A Patient-Centered, Evidence-Based Diagnostic and Treatment Process
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Introduce yourself using AIDET1.
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.
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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.
Acknowledge the patient. Introduce yourself. Inform the patient about the Duration of tests or treatment.
Explain what is going to happen next. Thank your patients for the opportunity to serve them.
1
How can you access the OU-HCOM
psychiatry flash cards online?
• Go to Quizlet.
• Create a free account.
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window, click on this link to join the class.
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• Enjoy. I hope you find these cards helpful.
• Please post your feedback or suggestions on the Quizlet
site.
Where can you learn more?
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American Psychiatric Association, Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition, 2013
Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third
Edition, 2008
Stern, et. al., Massachusetts General Hospital Comprehensive Clinical
Psychiatry, 2008. You can read this text online here.
Flaherty, AH, and Rost, NS, The Massachusetts General Hospital Handbook of
Neurology, 2011
Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship,
Third Edition, 2011
Klamen, D, and Pan, P, Psychiatry PreTest Self-Assessment and Review,
Thirteenth Edition, 2012
Blitzstein, Sean, Lange Q&A Psychiatry, 2011
Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain,
2008
Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at Home,
Work and School, 2010
Where can you find evidence-based
information about mental disorders?
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Explore the site maintained by the organization where
evidence-based medicine began at McMaster University here.
Sign up for the Medscape Best Evidence Newsletters in the
specialties of your choice 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.
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.
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
Are there other questions?1,2
Justin Greenlee, DO
Director
Family Medicine
Residency
 Safety  Quality  Service  Relationships Performance 
Thomas Carter, DO
Director
Emergency Medicine
Residency
1Learn
2Learn
more about Southern Ohio Medical Center.
more about our Family Medicine and Emergency Medicine Residencies.