Diagnosis and Classification of Depression

Aim: •Can I outline the clinical characteristics of depression?•Can I discuss issues relating to the reliability and validity of diagnosis and/or classification of depression?

POST IT …Write down 7 characteristics of depression?

POST IT …Write down 7 characteristics of depression?

http://www.healthtalkonline.org/mental_health/Depression/Topic/1495/Interview/875/Clip/3322/

Outline

What is depression Symptoms Causes Types Risk Factors

Women Elderly Young Adults

Outline

Racial/Ethnic Disparities Psychosocial/Environmental Factors Burden Detailing Messages

What Is Depression? A very common, highly treatable, medical

illness.

Affects physical, mental and emotional well-being.

Affects basic, everyday activities like eating and sleeping.

Affects how people think about things and feel about themselves.

What is Depression?

In contrast to the normal emotional experiences of sadness, loss, or passing mood states, clinical depression is persistent and can interfere significantly with an individual's ability to function.

People with depressive illness cannot just “pull themselves together” and “get over it.”

Depression often takes on a life of its own – without treatment, symptoms can last months or even years.

Symptoms of Depression

Feeling sad, blue, or down in the dumps

Loss of interest in things you usually enjoy

Feeling slowed down or restless

Having trouble sleeping or sleeping too much

Symptoms of Depression

Loss of energy or feeling tired all the time

Having an increase or decrease in appetite or weight

Having problems concentrating, thinking, remembering or making decisions

Feeling worthless or guilty

Having thoughts of death or suicide

Symptoms of Depression

People with Major Depression experience at least five of these symptoms all day, nearly every day, for at least 2 weeks.

The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Causes of Depression

Causes not known, but current theories include: Genetic

• Runs in families • However, depression can also occur in

people who have no family history. Environmental

• A serious loss, difficult relationship, financial problem, or any stressful (unwelcome or even desired) change in life patterns can trigger a depressive episode.

Causes of Depression Personality Characteristics

low self-esteem, pessimistic world view, low stress tolerance

Whether this represents a psychological predisposition or an early form of the illness is not clear.

Biological Continues to be studied extensively Current thinking explores problems in brain

functioning in the following areas: Limbic system, neurotransmitters and neurons, hormones and the endocrine system

Causes of Depression

Combination a combination of genetic, psychological,

environmental, and/ or biological factors may contribute to the onset of a depressive disorder.

Forms of Depression

Major Depression At least 5 of the 9 symptoms of

depression present including either loss of interest/pleasure or depressed mood; symptoms interfere with daily functioning

Minor Depression Fewer symptoms than major depression

with significant disability; shorter duration than chronic depression

Forms of Depression Bipolar Disorder

Cycling mood changes with severe highs (mania) and severe lows (depression)

Dysthymia Low grade chronic symptoms of

depression that last for a minimum of 2 years

Depression and Suicide

Of those with MDD, close to 50% report feelings of wanting to die, 33% consider suicide and 8.8% report a suicide attempt.

More than 90% of those who commit suicide have a diagnosable psychiatric illness at the time of death, usually depression, alcohol abuse or both

Who is at risk for Depression?

Anyone is potentially at risk for a depressiveillness. Yet, these groups are believed to be athigher risk: Older adults Young adults Women, pregnant and post partum women

Note: women report depression about twice as often as men. This may result from a greater likelihood to discuss depression or to seek help.

Depression in Women Depression is the second leading cause of

disease-related disability among women

1 in 4 women will suffer from a Major Depressive Episode during the course of their lives as compared to 1 in 10 men.• Women may be more likely to discuss

depression or to seek help.

Women of childbearing age are at increased risk for major depression• Pregnancy and new motherhood may

increase the risk of depressive episodes

Depression in Older Adults Of the nearly 35 million Americans age 65 and older, an

estimated 2 million have a depressive illness (major depressive disorder, dysthymic disorder, or bipolar disorder).

Symptoms of clinical depression can be triggered by other chronic illnesses common in later life, such as Alzheimer’s disease, Parkinson’s disease, heart disease, cancer and arthritis.

Depression is one of the most common conditions associated with suicide in older adults.

Individuals age 65 and older have highest rates of suicide

High suicide rate among older people (85 and older) is largely accounted for by White men.

Depression in Young Adults

10% of college students have been diagnosed with depression, including 13% of college women.

Lifetime prevalence for MDE highest among young adults age 18-25 (10%)

Suicide is the third leading cause of death for those aged 15-24

Additional Risk Factors for Depression

Family or personal history of depression

Current substance abuse problem

A major life stressor or change in life events; i.e.: loss of a loved one or a job

Chronic disease

Depression in Racial/Ethnic Minorities Mental health needs of minority racial/

ethnic groups remain largely unmet . Certain groups have higher rates of major

depression Native Americans Women (middle aged, separated or divorced,

low-income) Mexican- American and white individuals

Have significantly earlier onset of major depressive disorder compared with African Americans.

Depression in Racial/Ethnic Minorities

Latinos with self reported depression are less likely to: receive any treatment for depression fill an antidepressant prescription receive adequate course of psychotherapy

African American and Latinos are more likely than Whites to be under-diagnosed and under-treated

Minorities are less likely than Whites to receive treatments that adhere to treatment guidelines

Explanatory Factors

Lack of insurance coverage Poor access to appropriate screening and early

detection Tendency to attribute mental health problems

to religious and other cultural belief systems Lack of access to receptive and culturally

compatible providers

Psychosocial/Environmental Factors Psychosocial health has been associated

with mental health in general and with depression in particular

Neighborhood social disorganization is associated with depressive symptoms,

Living in socio-economically deprived areas is associated with depression. A recent study found 29 % - 58% were more likely to report part 6

month depression 36% - 64 % were more likely to report lifetime

depression

Depression Burden

Untreated depression causes distress, disability, and, most tragically suicide.

Depressive disorders are associated with increased prevalence of chronic diseases (e.g. asthma, diabetes)

Increased use of general medical services as well as costlier health services, such as Emergency Room and Inpatient.

Depression Burden Patients who are depressed are more likely to engage in

behaviors that contribute to poor health, such as smoking, limited or no exercise, poor eating habits and are likely to have greater difficulty managing their co-morbid conditions.

Depressive disorders are projected to become the leading cause of disability and the second leading contributor to the global burden of disease by 2020

US workers with depression cost employers an estimated $44 billion per year.

Detailing Messages

Primary care physicians can effectively detect and manage depression.

Routinely screen for depression using a simple 2-question tool (PHQ2)

Depression can be treated! Medication and psychotherapy, alone or in combination, can help most patients.

Detailing Messages

Primary care physicians can effectively detect and manage depression.

Detection of Depression: Why Screen and Manage in primary care?

Primary care is the 1st line of defense = To find people who may be depressed or at risk for depression who don’t know it

Screening for depression in the primary care setting improves detection rates

• US Preventative Service Task Force (USPSTF) recommends screening adults for depression in clinical practices that have systems in place for accurate diagnosis, effective treatment, and follow-up.

Only 50% of those referred to specialty mental health practitioners complete more than one visit

Detailing Messages

Routinely screen for depression using a simple 2-question tool (PHQ2)

Depression Screening: PHQ2

A physician can simply and quickly screen for depression by asking 2 questions (PHQ2):

During the past 2 weeks, have you been botheredby:

1. little interest or pleasure in doing things?

2. feeling down, depressed, or hopeless?

The PHQ-2 is a valid and practical tool for depression screening in busy medical settings.

Detailing Messages

Depression can be treated! Medication and psychotherapy, alone or in combination, can help most patients.

Detailing Messages More than 80% of people with clinical depression can be

successfully treated.

Antidepressants are the 1st line treatment for moderate to severe depression

About half of the moderate to severe episodes of depression will improve with antidepressant treatment

A combination of pharmacotherapy and psychotherapy may improve treatment response , reduce risk of relapse, enhance quality of life, and increase adherence to pharmacotherapy.

How RELIABLE are current methods of diagnosing depression?

Are the measuring instruments used such as questionnaires or scales CONSISTENT?

I will know if… Two independent assessors give the similar

diagnosis = INTER-RATER RELIABILITY or Test used to deliver the diagnosis are the

same over time = TEST – RETEST RELIABILITY

Kraemer et al (2012) – much researchon evaluation of medical treatments, but little on quality of diagnosis

Kraemer et al (2012) – much researchon evaluation of medical treatments, but little on quality of diagnosis

How VALID are diagnostic measures/classification systems?

Does it measure something that is real and distinct from other disorders?

Does it measure what it claims to measure? Comorbidity – extent that 2 or more condition co-

occur Content validity – does it measure what is sets out

to measure? Concurrent validity – extent to which it

agrees/corresponds with (concurs) with other existing standards

Why are reliability and validity important?

• Faulty diagnosis• Incorrect treatment

How is depression diagnosed and measured?

Structured Clinical Interview for the assessment of major depressive disorder

Beck Depression Inventory (BDI) International Classification of Diseases

(ICD) Diagnostic and Statistical Manual of

Mental Disorders (DSM) GP diagnosis/primary care diagnosis

DSM

Used in AmericaRequires that 5 of the clinical characteristics occur every day for 2 weeks+depressed mood or disinterest in pleasure+impair functioning/cause significant distress+not simply be attributed to bereavementEndogenous depression = hormonesReactive depression = triggered by external events

Evaluation…

Equally valid to ICD Keller (1995) – ‘fair to good’ inter-rater reliability but ‘fair’ at best test-retest reliability This is supported by Zanarini (2000) Keller suggested that this may be because: sometimes 1 item disagreement makes a crucial difference

for diagnosis on the threshold (5/9 must be present) Zimmerman (2010) deems the DSM-IV too lengthy Krupski and Tiller (2001) found only 1/4 Aus and NZ doctors

could list 5 symptoms which could lead to unreliable diagnosis Zimmerman created a brief version based on DSM based only

on the mood and cognitive symptoms and found 95% agreement with full DSM IV

ICD-10

Used in the UK and Europe Very similar to DSM but requires that

TWO of three key symptoms must be present:

(sad, depressed mood; loss of interest and/or lack of energy)

Andrews (1999) found this difference not to produce a significant number of discrepant responses = equal validity

Research into reliability

Lobbesteal et al (2011) = inter-reliability tested the Structured Clinical Interview mixed sample of patients and non-patient controls found moderate agreement (coefficient of .66)

• Beck et al (1996) = test-retest reliability tested responses of 26 outpatients at 2 therapy sessions one week apart using the BDI found significant reliability (coefficient.93)

Beck Depression Inventory (BDI)21-item self-report questionnairedesigned to measure severity thus helping to distinguish between e.g. major depression and dysthemia

The BDI is also high in content validity ( as the criteria based on consensus among clinicians and basedon psychiatric patients) ANDconcurrent validity ( as it concurs with other measures such as the Hamilton DepressionScale)

Research into validity McCullough (2003) found few differences on a range of clinical,

psychosocial and treatment response variables when comparing outpatients with different types of depression = invalid distinctions between

different sub-types of depression• Weel-Baumgarten (2006) suggests that GP diagnoses may be biased based on previous patient knowledge = invalid * Comorbidity – often two or more condition co-occur. Specifically, anxiety

disorders and major depression. Goodwin (2001) found suicidal thoughts with just depression vs no psychiatric disorder to be 5x more likely and tripple that if depression was combined with an panic disorder.

Cultural Differences

Karanz (2005) – NY (36 South Asian and 37 European American) Tested cultural differences and found that Ethnic minorities = identified the ‘problem’ in terms of social and moral terms with suggested

treatments self-management and referral to non-professional help.

European Americans = emphasised biological explanations for the symptoms, including hormonal imbalance’ and ‘neurological problems’.