Episode 161: Depression Fundamentals Future doctors Madeline Tena and Jane Park define depression and explain different methods to diagnose it. Non-pharmacologic and pharmacologic treatment is mentioned briefly at the end. Written by Madeline Tena, MSIII, and Jane Park, MSIII. Western University of Health Sciences, College of Osteopathic Medicine of the Pacific. Editing by Hector Arreaza, MD.
Episode 161: Depression Fundamentals
Future doctors Madeline Tena and Jane Park define depression and explain different methods to diagnose it. Non-pharmacologic and pharmacologic treatment is mentioned briefly at the end.
Written by Madeline Tena, MSIII, and Jane Park, MSIII. Western University of Health Sciences, College of Osteopathic Medicine of the Pacific. Editing by Hector Arreaza, MD.
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Definition.
Per the language of Mental Health, depression can be defined as a mood, a symptom, a syndrome of associated disorders, or a specific mental disorder.
As a state of mood, depression is associated with feelings of sadness, despair, emptiness, discouragement, and hopelessness. The sense of having no feelings or appearing tearful can also be a form of depressed mood. A depressed mood also can be a part of a collection of symptoms that explain a syndrome.
Depression as a mental disorder can encompass depressive syndromes. Per the American Psychiatric Association DSM-5-TR, depressive disorders commonly include sad, empty, irritable mood, accompanied by changes in one’s functional capacity. They can be classified by severity and recurrence, and associated with hypomania, mania, or psychosis. Depressive disorders include major depressive disorder (including major depressive episodes), persistent depressive disorder, premenstrual dysphoric disorder, substance-induced depressive disorder, depressive disorder due to medical condition, other specified depressive disorder, and unspecified depressive disorder.
Today, we will cover unipolar depressive disorder, also known as major depressive disorder.
MDD.
Major depressive disorder is a mood disorder primarily characterized by at least one major depressive episode without manic or hypomanic episodes. Depressive episode is a period of at least 2 weeks of depressed mood or anhedonia in nearly all activities for most of the day nearly every day, with four or more associated symptoms in the same 2 weeks. We will discuss specific symptoms for diagnosis further on.
Epidemiology of depression.
Nationally or regionally representative surveys in 21 countries estimate that the 12-month prevalence of major depressive disorder across all countries is 5 percent. Furthermore, the prevalence of major depressive disorder plus persistent depressive disorder in developed countries (United States and Europe) is approximately 18 percent.
Multiple studies consistently indicate that in the general population of the United States, the average age of onset for unipolar major depression and for persistent depressive disorder (dysthymia) is approximately 30 years old.
During 2020, approximately ⅕ US adults have reported receiving a diagnosis by a healthcare provider, with the highest prevalence found among young adults age (18-24 year age… generation Z). Within the US there was considerable geographic variation in the prevalence of depression, with the highest state and county estimates of depression observed along the Appalachian and southern Mississippi Valley regions.
Why do we care about depression?
Because depression is associated with impaired life quality. It can impair a patient’s social, physical, and psychological functioning. Also, depression is associated with mortality. A study done by UPenn Family Practice and Community Medicine in 2005 showed that among older, primary-care patients over a 2-year follow-up interval, depression contributed as much to mortality as did myocardial infarction or diabetes.
A prospective study from 2005-2017 that followed 186 patients for up to 38 years further showed that patients with major depressive disorder had 27 times higher incidence rate of suicide than the general population. (1, 2). Also, patients dying by suicide visit primary care physicians more than twice as often as mental health clinicians. It is estimated that 45% of patients who died by suicide saw their primary care physician in the month before their death. Only 20% saw a mental health professional a month before their death. (3)
Suicidality in depression.
It seems that primary care physicians often do not ask about suicidal symptoms in depressive patients. A 2007 study by Mitchell Feldman at the University of California San Francisco showed that 152 family physicians and internists who participated in a standardized patient with antidepressants, suicide was explored in only 36% of the encounters. (4)
Physicians, including primary care physicians, should ask patients with depression about suicidality with questions such as: Do you wish you were dead? In the past few weeks, have you been thinking about killing yourself? Do you have a plan to kill yourself? Have you ever tried to kill yourself? (5)
Screening for depression.
The USPSTF recommends screening for depression in all adults: 18 years old and over regardless of risk factors. Some factors increase the risk of positive screening, such as temperament (negative affectivity/neuroticism), general medical illness, and family history. First-degree family members of people with MDD have a 2-4 times higher risk of MDD than the general population. Furthermore, social history can increase risk as well: sexual abuse, racism, and other forms of discrimination.
It is important to highlight the risk in women because they may also be at risk related to specific reproductive life stages (premenstrual period, postpartum, perimenopause). The USPSTF includes pregnant individuals and patients in the postpartum period to be screened for depression.
Screening tools.
The US Preventive Services Task Force recommends depression screening for major depressive disorder (MDD) in adolescents aged 12 to 18 years (grade B). Similarly, the Guidelines for Adolescent Depression in Primary Care (GLAD-PC) has also recommended annual screening for depression in children aged 12 and older. (6) Some tools used for screening in this age group are the Patient Health Questionnaire for Adolescents (PHQ-A) and the primary care version of the Beck Depression Inventory (BDI).
For the general adult population, it is recommended that all patients not currently receiving treatment for depression be screened using the Patient Health Questionnaire-2 (PHQ-2) (7)
PHQ 2 is a survey scored 0-6. The survey asks two questions: Over the last 2 weeks, how often have you been bothered by any of the following problems?
Answers should be given in a numerical rating. 0=Not at all; 1=Several days; 2=More than half the days; 3=Nearly every day. A score ≥ 3 is considered positive, and a follow-up full clinical assessment is recommended.
The PHQ-2 has a sensitivity of 91% and a specificity of 67% when compared to a semi-structured interview. Keep in mind that the PHQ-2 may be slightly less sensitive to older individuals. Individuals who screen positive with PHQ-2 should have additional screening with the PHQ-9, which is a nine-item, self or clinician-administered, brief questionnaire that is specific to depression. (8) Its content maps directly to the DSM-5 criteria for major depression. (9)
The PHQ-9 is a set of 9 questions. The answers are scored similarly to PHQ-2, with a numerical scoring between 0 and 3. (0=Not at all; 1=Several days; 2=More than half the days; 3=Nearly every day). Dr. Arreaza, you will be my patient today, are you ready?
It’s important that you think about the last 2 weeks.
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Jane: Your score is 12.
Maddy: Regarding severity, a total score of 1-4 suggests minimal depression. 5-9 suggests mild, 10-14 moderate, 15-19 moderately severe, and 20-27 severe depression. PHQ-9 with patients’ scores over 10 had a specificity of 88% and sensitivity of 88% for MDD. (10)
But if there are at least 4 non-zero items, including question #1 or #2, consider a depressive disorder and add up the scores. If there are at least 5 non-zero items including questions #1 or #2, consider major depressive disorder specifically. The questionnaire is the starting point for a conversation about depression.
A couple of things to note: 1. Physicians should make sure to verify patient responses given the questionnaire can be self-administered. Diagnosis also requires impairment in the patient’s job, social, or other important areas of functioning. 2. Diagnosis requires a ruling-out of normal bereavement, histories of manic episodes, depressive episodes better explained by schizoaffective disorder, any superimposed schizophrenia, a physical disorder, medication, or other biological cause of depressive symptoms.
Once a patient is newly diagnosed and/or started on treatment, a regular interval administration (e.g. 2 weeks or at every appointment) of PHQ-9 is recommended. The PHQ-9 has good reliability, validity, and high adaptability for MDD patients in psychiatric hospitals for screening and evaluation of depression severity. (12) Other than PHQ-9, there is also Geriatric Depression Scale-15 for older patients with mini mental status exam (MMSE) that scored over 10. (13)
For postpartum depression, the preferred screening tool is the Edinburgh postnatal depression scale[Click here (stanford.edu)].
Non-pharmacologic and pharmacologic treatment.
Now that we have diagnosed the patient, we have to start management. Patients can consider non-pharmacologic treatment such as lifestyle modifications. This can include sleep hygiene, reduction in drug use, increased social support, regular aerobic exercise, finding time for relaxation, and improved nutrition.
Furthermore, based on severity, patients can start psychotherapy alone or psychotherapy + pharmacotherapy. Admission is required for pts with complex/severe depression or suicidality. There should be an assessment of efficacy at 6 weeks.
There is a warning about patients aged 18-24 who are at increased risk of suicide when taking SSRI within the first couple weeks of treatment.
Mediations: SSRI, SNRI, tricyclic antidepressants, MAOIs, and Atypical antidepressants: including trazodone, mirtazapine (Remeron), bupropion (Wellbutrin SR). More research is being done on psychedelic drugs such as ketamine and psilocybin as possible treatments. There are therapies such as ECT available too.
Potential Harm of Tx:
Potential harms of pharmacotherapy:
-SNRI: initial increases in anxiety, insomnia, and restlessness, and possible sexual dysfunction and headaches as well. Compared with the SSRI class, the SNRI class tends to induce more nausea, insomnia, dry mouth, and in rare cases hypertension.
-Tricyclic: Cause of numerous side effects, very infrequently prescribed unless the patient is not responding to other forms of treatment. Side effects that are included are: dry mouth. slight blurring of vision, constipation, problems passing urine, drowsiness, dizziness, weight gain, excessive sweating (especially at night). Avoid TCAs in elderly patients.
-MAOIS: MAO-IS can cause side effects too, including dizziness or lightheadedness, dry mouth, nausea, diarrhea or constipation, drowsiness, and insomnia. Furthermore, other less common side effects can include involuntary muscle jerks, hypotension, reduced sexual desire/ ability to orgasm, weight gain, difficulty starting urine flow, muscle cramps, and paresthesia.
Remember to screen your patients. In case you establish a diagnosis, discuss treatments, including non-pharmacologic and pharmacologic options. Warn your patients about side effects and the timing to see the benefits of the medication, usually after 6 weeks.
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Conclusion: Now we conclude episode number 161, “Depression Fundamentals.” Future doctors Park and Tena discussed depression and its risk factors, screening, and treatment. They went through the PHQ2 and PHQ9 as screening tools, as well as commonly used treatments and their side effects, such as SSRIs. Dr. Arreaza also highlighted the importance of asking about suicidality in your depressed patients, there is a lot of room for improvement in that aspect.
This week we thank Hector Arreaza, Madeline Tena, and Jane Park. Audio editing by Adrianne Silva.
Talk_Outro
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