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Depression: A primary care approach - Gerald W. Smetana, M.D
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Association of depression with mood disorder is common in psychiatry. Can occur at all ages but is most common age 18-45. Invite you read the reference Sermon depression: the approach of primary care to learn about basic questions and Epidemiology of depression.
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Nội dung Text: Depression: A primary care approach - Gerald W. Smetana, M.D
- Depression: A Primary
Care Approach
Gerald W. Smetana, M.D.
Division of General Medicine
Beth Israel Deaconess Medical Center
Associate Professor of Medicine
Harvard Medical School
- Key Questions
• Does screening for
depression work?
• How long to treat?
• Are newer
antidepressants more
effective than SSRIs?
• How do side effect
profiles differ between
drugs?
• Which is better:
switching or augmenting?
- Epidemiology of Depression
• Twice as common in women as in men
• 2-3 fold increase in risk if family history
in parent or sibling
• 2-5% incidence of suicide among
depressed patients
• 3-fold increase in number of sick days
from work
• Leading cause of disability among people
aged 18-44 years
CMAJ 2002;167:1253
- Question #1
• Does screening for depression work?
• How do I follow up on a positive
screening survey?
- Does Screening for Depression Work?
• US Preventive Health Services Task Force
• December 2009 Update
• Recommends screening for depression (Grade B
recommendation - fair evidence) when
resources for Rx and follow up are available
• Good evidence that screening improves the
accurate identification of depression in primary
care settings and
• Treatment in the primary care setting
decreases clinical morbidity
Ann Intern Med 2009;151:784
- Screen for Depression If
• Sadness, low energy, apathy, irritability or
anxiety
• Sexual complaints
• Unexplained physical symptoms or
unexpectedly frequent use of medical services
• Frequent symptoms with unrevealing workups
• Concurrent general medical illness
• Recent stressful life events and lack of social
supports
- Which Screening Tools to Use?
• Multiple available questionnaires
• Administration times range from 1-5 minutes
• In a systematic review of screening tools:
• Positive likelihood ratio (LR+)
– 3.3 (range 2.3-12.2)
• Negative likelihood ratio (LR-)
– 0.19 (range 0.14-0.35)
• High sensitivity (80-90%) but only fair specificity
(57-85%)
The Rational Clinical Examination. Is this patient clinically
depressed? JAMA 2002;287:1160
- Simple Screening Tool:
Ask Two Questions
1. ‘During the past month, have you often been
bothered by feeling down, depressed or
hopeless?’
2. ‘During the past month, have you often been
bothered by having little interest or pleasure
in doing things?’
• 96% sensitive but only 57% specific
for at least one positive response
• Recommended by USPSTF
J Gen Intern Med 1997;12:439
- Phan Vietnamese Psychiatric Scale
• Culturally sensitive mental health
questionnaire derived from Vietnamese
individuals
• Four domains
– Depression - affective
– Depression - psycho-vegetative
– Anxiety
– Somatic symptoms
Tuong Phan et al. Transcultural
Psych 2004;41:200 9
- Phan Scale: Sample Questions
Affective
• Did you feel lonely or empty?
• Did you become pale or have dark rings under your
eyes?
• Did you feel your life had become meaningless?
• Did you feel disgraceful or ashamed of yourself without
any reason?
Psycho-vegetative
• Did you feel confused or in a daze?
• Did you cry without any reason?
• Did you feel like not getting out of bed?
10
- Prevalence of Symptoms Among 2000
Adult Vietnamese Refugees to U.S.
West J Med 1995;163:341
Symptom Prevalence (%)
Physical symptoms
Headaches 21
Anxiety about symptoms 25
Loss of appetite 20
Psychological symptoms
Sad 31
Difficulty concentrating 30
Hopeless 7
Culture-specific symptoms
Bothered 10
Shameful and dishonored 7
11
Desperate 6
- Suicide Screening Questions
• Three simple questions
– Do you ever think of hurting yourself or
taking your own life?
– Do you currently have a plan?
– What is your plan?
• Do not fear that asking questions will
suggest the idea of suicide to a patient
• Emergency mental health evaluation if
patient can’t contract for safety
N Engl J Med 2000;343:1942
- Ms. Tran
• Ms. Tran is a 24 year old woman who
sees you for sadness
• It has been present for 2 months
• She is sleeping poorly and has lost 5 kg.
in weight
• She is distracted and has a hard time
concentrating while at work
• You are contemplating antidepressant
mediations
- Question #2
• What are response rates to initial Rx?
• How long should one continue
antidepressant medication?
- STAR*D Trial of Citalopram: Time to
Response Among Responders
• Mean dose 40 mg
qd
• Results at 14
weeks
• Response
– 47%
• Remission
– 28%
• Most responders
do so by 8 weeks
• Consistent with
previous reports
Am J Psychiatri 2006;163:28
- Systematic Review: SSRIs More
Alike than Different
Ann Intern Med 2008;149:734-750
- Three Treatment Phases
• Acute Treatment
6-12 Weeks
• Continuation Treatment
3-12
Months • Prevents relapse
• Maintenance Treatment
Long term • Prevents Recurrence
- Approach to Relapse After Initial Rx
• Initial Rx may have been too brief
– Continuation Rx for at least 6-9 months
• Relapse after adequate duration of Rx
– Suggests need for maintenance Rx
– At least 2-3 years
• First strategy is to resume the same med
that led to initial remission
• Consider psychotherapy in addition to
meds
- Special Considerations in the Elderly
• Depression increases risk of mortality post MI,
post stroke, and after nursing home admit
• Higher rates of completed suicides
• SSRI’s preferred 1st line due to favorable side
effect profile
• SNRI’s second line
• Observational data suggest increased
morbidity and mortality with drug therapy*
Coupland C, et al. BMJ 2011
epub ahead of print
- Important Considerations
• Initial med Rx response rates 50%
• Rx for at least 6-9 months
• Withdrawal symptoms if abrupt d/c of SSRIs
• Risk of serotonin syndrome for SSRIs increases
with certain drug interactions
• Increased suicidal behavior for SSRIs for
patients aged 18-29 years
• Increased risk of GI bleeding for SSRIs in older
patients
• Medication probably not beneficial for minor
depression
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