Workshop (1hr 15mins) from 2010 RCPsych meeting Edinburgh. Topic was update on depression symptoms and signs

1. Diagnosing Depression in Primary Care and Hospital
Settings - Towards a change in clinical practice
Alex Mitchell ajm80@le.ac.uk
Consultant in Liaison Psychiatry & Psycho-oncology
RCPsych Workshop 2010 – 9.45 – 11am

2. Which Are Recognized Symptoms of MDD?
Loss of confidence
Low motivation / drive
Withdrawal
ALL
Avoidance
Social isolation
Worry SOME
Feelings of dread
Helplessness
Hopelessness NONE
Psychic anxiety
Somatic anxiety
Anger UNSURE
Lack of reactive mood
Cognitive Change (=> memory complaints)
Perceptual distortion
=> plan

3. Special
Physicians
Symptoms
Physical
Illness
Primary
Symptoms
DSMV Older people Care
ICD11
Cultural
effects
Detection
Under-
Depression
served Quality
of care
Prescribing
Impairment
Scales
Distress
Follow-up
Screening
Monitoring
Help Seeking
Se Change

4. Introduction – What’s Going Wrong?
Background
Contents

5. % Receiving Any treatment for Depression (CIDI)
20
17.9
18 n=84,850 face-to-face interviews
16 15.4
13.8
14
12 11.3
10.9 10.9
10
8.8
8.1
8 7.2
6.8
6 5.6 5.5
4.3
4 3.4
2
0
SA
in
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ly
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ai
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er
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ol
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h
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he
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ut
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ew
et
ig
Lo
So
H
N
N
Wang P et al (2007) Lancet 2007; 370: 841–50 => USA

6. 90 84.384.5 Depression Alone (=883)
77.7
80 Anixety Alone (n=314)
70 Depression and Anxiety (n = 439)
60
50 46
40.9 43
40
28.3 30.3 29.9 28.9
30 25.323.2
20.521.7 20.3
17.7 15.617.5
20 12.8 14.8
10.8
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Young et al (2001) The Quality of Care for Depressive and Anxiety
Disorders in the United States. Arch Gen Psychiatry. 2001;58:55-61
An

8. 1093 (100%)
Population
462 needs
462 (42%) 322 DSMIV
Meetable Needs
17.3%
25%
388 (84%)
Aware of Need
172 (44%)
Requested Help
80 (47%)
Needs Met
Patient & provider factors
=> DUD

9. 94.2%
37.4%
8 yrs N= 9282 NCS‐R

10. N=23 studies; 50% some treatment 33% minimal treatment N=19 studies; 30% 1 in 1/12; 10% 3 in 3 months

11. 5 Steps to Improve QoC….and change clinical practice
1. Re-look at concept / criteria /symptoms
2. Understand Detection Problems
3. Understand special populations
4. Consider Enhanced Detection
5. Tie Detection to Clear Action

12. Depression Care: Who Provides it?
2/3rds 1/3rd
Primary Care
10% 25%
cg42 cg90 Medical Psychiatry

13. Percentage of U.S. retail psychotropic prescriptions written from August 2006 to jul07
Mark et al. PSYCHIATRIC SERVICES September 2009 Vol. 60 No. 9

14. Comment: Slide illustrates added proportion of all
depression treated in each setting. Most depression
is treated in primary care
1.20
1.00
1.00
0.80
0.64
0.60
0.40
0.26
0.20
0.10
0.00
All visits (N =14,372) Primary care (N =3,605) Psychiatrists (N =293) Medical specialists (N
=10,474)
J Gen Intern Med. 2006 September; 21(9): 926–930.

15. 1a. Re-examination of Depression
Is depression a disease; disorder (syndrome) or normally distributed

16. Graphical – two diseases
Comment: Slide illustrates the concept of
discrimination using one symptom severity of “low
mood”
Healthy
Stroke
#
of
Individuals
With symptom Point of Rarity
Severity of Infarct

17. Graphical – two disorders
Healthy
# ?Point of Rarity
of
Individuals Optimal cut
With symptom
Diabetes
HBA1c

18. Graphical - Dimension
Comment: Slide illustrates added hypothetical
distribution of mood scores in a population with
hidden depression
Non-Depressed
Depressed
#
of
Individuals
With symptom
Severity of Low Mood

19. Do We Have Good Data in Psychiatry?

20. 0
500
1000
1500
2000
2500
3000
Ze
r o
O
ne
Tw
o
Th
re
e
Fo
ur
Fi
ve
Si
x
Se
ve
n
ei
gh
HADS-D N=18,414
t
N
in
e
Te
n
El
ev
en
Tw
el
ve
Th
irt
ee
Fo n
ur
te
en
Fi
fte
en
Si
xt
ee
Se n
ve
nt
ee
Ei n
gh
te
en

21. Comment: Slide illustrates added actual distribution
of mood scores on the HADS in a cancer
population with hidden depression from the
Edinburgh cancer centre

22. Distress Ratings (n=2,200) clinical significance criterion
Proportion
20.0%
Insignificant Minim al Mild Moderate Severe
18.0%
16.0%
14.0%
12.0%
10.0%
18 .4 %
8.0%
12 .9 %
6.0% 12 . 3 %
11.9 %
11.2 %
p124
4.0% 8 .1%
7.7%
7.2 %
5. 0 %
2.0%
2 .8 % 2 .6 %
0.0%
Zero One Tw o Three Four Five Six Seven Eight Nine Ten
50%

23. Back to Basics Lessons
Depression is on a continuum using current
scales……..
There will always be a trade-off of sensitivity vs specificty
=> Categorial

24. 1b. Re-examination of Criteria of Depression
=> ICD10

25. Core Symptoms ICD10 DSMIV
Persistent sadness or low mood Yes (core)‫‏‬ Yes (core)‫‏‬
Loss of interests or pleasure Yes (core)‫‏‬ Yes (core)‫‏‬
Fatigue or low energy Yes (core)‫‏‬ Yes
Disturbed sleep Yes Yes
Poor concentration or Yes Yes
indecisiveness
Low self-confidence Yes No
Poor or increased appetite Yes No
Suicidal thoughts or acts Yes Yes
Agitation or slowing of Yes Yes
movements
Guilt or self-blame Yes Yes
Significant change in weight No Yes

26. Symptom Significance in Depression
Depression ICD10 DSMIV HADs D Score
Severity
Healthy 0 or 1 0 symptom 0-3
symptom
Sub-syndromal 2 or 3 1 or No core 4-7
symptoms symptoms
Mild 4 symptoms 2-4 symptoms 8 -11
(2+2)‫‏‬ (minor)‫‏‬
Moderate (5 or )6 5 symptoms 12 - 15
symptoms (Mj)‫‏‬
Severe (7 or) 8 Unspecified 16 - 21
symptoms
(3+4)‫‏‬
Change in practice – ICD10 2/4/6/8 + CS

27. “Common” Symptoms of Depression
Item Depressed Frq Non-Depressed Frq
Depressed mood 0.93 0.18
Diminished drive 0.88 0.30
Loss of energy 0.87 0.32
Concentration/indecision 0.87 0.27
Sleep disturbance 0.83 0.32
Diminished concentration 0.82 0.24
Diminished interest/pleasure 0.81 0.12
Insomnia 0.70 0.27
Anxiety 0.69 0.42
Worthlessness 0.61 0.12
Psychic anxiety 0.59 0.33
Thoughts of death 0.56 0.12
Mitchell, Zimmerman et al n=2300

28. “Uncommon” Symptoms
Non-Depressed
Item Depressed Proportion Proportion
Somatic anxiety 0.46 0.25
Decreased appetite 0.45 0.11
Anger 0.44 0.26
Psychomotor agitation 0.34 0.09
Psychomotor retardation 0.28 0.04
Decreased weight 0.23 0.06
Lack of reactive mood 0.22 0.06
Increased appetite 0.19 0.07
Hypersomnia 0.19 0.06
Increased weight 0.16 0.06
Mitchell, Zimmerman et al MIDAS Database. Psychol Med 2009

29. -0.10
0.00
0.10
0.20
0.30
0.40
0.50
A nge
r
A nxie
ty
Decr
ea s e
d app
eti te
Decr
ea s e
d we
ig ht
Depr
es sed
m oo
d
Dimin
is hed
c onc
entr
at ion
identifying non-depressed
Dimin
is hed
dr ive
Dimin
is hed
int er
est /p
leasu
re
Exc e
ss ive
guilt
Help
le
Comment: Slide illustrates added value of each
ss nes
s
symptom when diagnosing depression and when
Hope
le s snes
s
Hy pe
rsom
n ia
Inc re
ased
appe
t ite
Inc re
ased
w eig
ht
Indec
isiv e
ne ss
Ins om
nia
L ac k
of re
act iv
e mo
od
L os s
o f en
erg y
Ps ych
i c an
x iety
Ps ych
omot
or a g
i tatio
n
Ps ych
omot
or c h
ang e
Ps ych
o mot o
r ret a
rdatio
n
Sl eep
dis tu
rban
ce
Soma
ti c a
n x iety
Rule-In Added Value (PPV-Prev)
Thou
g
Rule-Out Added Value (NPV-Prev)
hts o
f dea
th
Wor t
hle s sne
ss

30. 1 Depressed Mood
S Diminished interest/pleasure
e Diminished drive
0.9 n
s Loss of energy
i Sleep disturbance
0.8
t Diminished concentration
i
0.7 v
i
t
0.6 y
0.5
0.4
0.3 Comment: Slide illustrates summary ROC curve
sensitivity/1-specficity plot for each mood
symptom
0.2
0.1
1 - Specificity
0
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
n=1523

31. Back to Basics Lessons
Symptoms of depression are not
necessarily optimal
Further research is required against course and burden

32. 2. Recognition in Routine Care
Is “diagnosis as usual” sufficient?

33. Cancer Staff Psychiatrists
Current Method (n=226)
Other/Uncertain
9% Other/Uncertain
ICD10/DSMIV 2%
0% ICD10/DSMIV
13%
Short QQ
3%
1,2 or 3 Sim ple
QQ
15%
Clinical Skills
Use a QQ Alone
15% 55%
Clinical Skills
Alone
73% 1,2 or 3 Sim ple
QQ
15%
=> Psychiatrists

34. Cancer Staff Psychiatrists
Other/Uncertain
9% Other/Uncertain
ICD10/DSMIV 2%
0% ICD10/DSMIV
13%
Short QQ
3%
1,2 or 3 Sim ple
QQ
15%
Clinical Skills
Use a QQ Alone
15% 55%
Clinical Skills
Alone
73% 1,2 or 3 Sim ple
QQ
15%
Comment: Slide illustrates preferences of cancer
clinicians vs psychiatrists for detecting
Current Method
depression

35. Sl e
ep
di s
tur
ban
Los ces
so ; in
fa som
ppe ni a
De ti te ; ea
; ov rly
0
10
20
30
40
50
60
70
80
90
pre
sse ere wa 100
dm a tin ke n
ood g; w ing
; ho e ig
pe ht c
Los Ap les han 86.8
so a th sne ges
f in y; l ss;
ter eth sad
est arg
;w y; t ; gl
oom
ithd
raw
ired
nes y
al ; s; l
55.6 54.4
Los in d ass
so iffe i tud
fe ren e
ner ce;
Los gy; lo n
43.3
so l os eli n
f lib so ess
ido f dr
; lo i ve
36
ss ; bu
An of s rnt
xio ex ou
Sleep
us; dri
ve; t
ag i mp
29.8
itat
ed; Te ote
irri t ars nce
So Fe abl ;w
ma eli n e; r eep
tic; est ing
Appetite
ve g gw l es ; cr
eta ort s, t yi n
tive hl e
ss; ens g
sym gui e; s
pt o l ty; t re
Low
sse
ms
;m lac
ko d
ala f se
i se
26.2 25.6 25.2
Su ;m lf e
i ci d ste
Los ulti
ple em
so e th
f co ou con
Energy
23.8
nce ght sul
ntr s; t ta t
hou ion
atio
n; p ght s
of
24
Dim oor sel
ini s me f in
mo jur
hed ry, y
per poo
f or r th
ma i nk
nce i ng
Em ; in
Los otio abi
21.4 21.2
na li ty
so
fa l la to
cop
Be
ha Los ffec
t; f
bil i
ty; e
vi o so lat mo
ura fe
njo a ff od
l pr ym
ect
; lo sw
ing
obl
em ent ss s
s; a or of e
13.9 12.8
ggr pl e mo
ess asu tion
ive re ;
nes lac
9.5
Pe ko
s; b fh
ssi eh um
mi s avi or
m; our
ne al c
7.2
What do GPs Ask about:
gat han
Ps ive ges
ych atti
tud
7
Ap om es,
pe oto wo
ara r re rry
nce tar ing
; sp dat
7
eec i on
h; e ; sl
xce He ow
nes
ssi
ve
ada
che s
sm
5.9
He s; d
avy i li n izz
g; v i ne
use ag ss
of a uen
4.8
l co ess
De hol , et
l us , to c.
i on bac
Re co
4.1
s; h
act all u or
ion ci n dru
to p atio gs
rob ns;
2.6
abl con
Fa ec fus
mil aus ion
yo es
or
1.8
r pa life
st h
looking for depression
i sto eve
ry nts
Ob of d
1.8
ses epr
si v ess
e id i on
eat
1.3
i on
; ph
ob
ias
Comment: Slide illustrates which
Lac
symptoms are asked about by GPS
0.9
Pe ko
ri o f in
do sig
f l if ht
e(
0.4
me
no
pau
se )
0.4

36. GP Recognizes:
Proportion of Individual Symptoms Recognised by GPs
80.0 76.1
70.0
60.0
50.0
40.0 36.4
34.6
31.6
30.0
21.6
20.0 16.7
13.3
9.1 8.3 8.3
10.0
0.0
s
ng
a
d
gy
s
ia
st
ty
ism
es
oo
si
ni
ex
re
xie
pi
er
ia
m
ln
m
m
te
Co
or
en
dr
An
so
fu
in
i
An
w
ss
on
ar
In
t
of
Lo
No
of
Pe
Te
ch
ss
ss
po
Lo
Lo
Hy
O’Conner et al (2001) Depression in primary care.
Int Psychogeriatr 13(3) 367-374.

37. GP Detection of Depression – Meta-analysis
Methods
– 140 studies of GP recognition
rate =>
– 90 depression
– 40 interview
– 19 se sp (+2)
– 10 countries

38. Accuracy 2x2 Table
Depression Depression
PRESENT ABSENT
Test +ve True +ve False +ve PPV
Test -ve False -Ve True -Ve NPV
Sensitivity Specificity Prevalence

39. N=35 studies
Accuracy of GP’s Diagnoses
Depression Depression
PRESENT ABSENT
GP +ve 2503 2515 5018
PPV 42.8%
GP -ve 4050 25,125 6678
NPV 85.1%
6553 27,640 9559
Sensitivity Specificity
Prevalence 19%
48% 80.1%

40. N = 100
100 weekly referrals
GP Opinion n = 20 n = 80
20 D 80 ND
Se 50%
GP Assessment Sp 80%
Screen #1 Screen #1
+ve -ve
PPV 28% NPV 88%
TP = 10 TN =64
10TP 10FN FP = 16
64TN 16FP FN = 10
50% TP and 25% FP Offered Treatment
50‐80% accept initial treatment

41. N = 100
100 weekly referrals
GP Notation n = 20 n = 80
20 D 80 ND
Se 30%
GP Assessment Sp 90%
Screen #1 Screen #1
+ve -ve
PPV 50% NPV 80%
TP = 10 TN =64
7TP 13FN FP = 16
72TN 8FP FN = 10
50% TP and 25% FP Offered Treatment
50‐80% accept initial treatment
3/20TP Offered Rx => appropriate treatment rate of 5-20%
2/80FP Offered Rx => inappropriate treatment rate of 1-2%
1/3 of screen positive patients with no treatment well
at follow‐up

42. N = 100
Weekly Population
n = 20 n = 80
Depression No Depression
77%
Se 50%
GP Assessment Sp 80%
Screen #1 Screen #1
+ve -ve
PPV 28% NPV 88%
TP = 10 TN =64
Possible case FP = 16
Probable Non-Case FN = 10
Se 50%
2nd Assessment Sp 80%
Screen #2 Screen #2
+ve +ve
PPV 44% NPV 77%
TP = 56 TN =288
89% Probable Depression FP = 72
Probable Non-Case FN = 84
TN = 728 FP = 72 Se 28% PPV 44%
Cumulative Yield TP = 56 FN = 144 Sp 91% NPV 83%

43. Back to Basics Lessons
Single assessment inadequate
False +ve’s are more of a problem than expected

44. 3. Predictors of Recognition

45. 0.25
65%
0.22
0.21
0.20
0.19
0.20
0.15
0.10
Geraghty JGIM 2007
0.05
0.05
0.03
0.02 0.02
0.01 0.01
0.01 0.01 0.01 0.01
0.00
s
s
s
s
s
s
s
s
s
s
s
s
s
s
in
in
in
in
in
in
in
in
in
in
in
in
in
in
m
m
m
m
m
m
m
m
m
m
m
m
m
5m
10
15
20
25
30
35
40
45
50
55
60
65
70

46. Is 10‐15 minutes enough?

47. Severity

48. 0
500
1000
1500
2000
2500
3000
Ze
r o
O
ne
Tw
o
Th
re
e
Fo
ur
Fi
ve
Si
x
Se
HADS-D
ve
n
ei
gh
t
N
in
e
Te
n
El
ev
en
Tw
el
ve
Th
irt
ee
Fo n
ur
te
en
Fi
fte
en
Si
xt
ee
Se n
ve
nt
ee
Ei n
gh
te
en

49. 0.05
0.15
0.25
0
0.1
0.2
0.3
Ei
gh
t
N
in
e
Te
n
El
ev
en
Tw
el
ve
Th
irt
ee
HADS-D
n
Fo
ur
te
en
Fi
fte
en
Si
xt
ee
n
Se
ve
nt
Proportion Missed
ee
n
Proportion Recognized
Ei
gh
te
en
N
in
et
ee
n
Tw
en
Tw ty
en
ty
-o
ne

51. CNS in Oncology N=401
100.0
5.9
11.1
14.3
90.0 Comment: Slide illustrates diagnostic 21.4
accuracy according to score on DT 11.8
25.9
80.0 38.7 38.1
43.5 22.2 14.3
46.7
70.0 59.6
21.4
72.4
60.0 Judgement = Non-distressed
33.3 Judgement = Unclear
19.4 19.0 Judgement = Distressed
50.0
26.1
24.4 82.4
40.0
71.4
66.7
30.0
25.0 57.1
41.9 42.9 40.7
20.0 15.8
30.4 28.9
10.0
15.4
11.8
0.0
Zero One Two Three Four Five Six Seven Eight Nine Ten

52. 80
74
70 69.6
70
61.5
59.6
60 56.7 56.7 55.6
54.2
50 45.7
43.9
39.7
40
30 28.4
22.2
21
19.3
20
10
0
ns
L
ri s
i
n
a
n
r
go
z
an
ai
a
tle
re
ro
ak
te
TA
ge
ar
n
rli
n
gh
he
lo
Pa
ai
i
ad
ia
ro
at
es
as
ne
k
Be
in
TO
ga
M
nt
An
an
Se
At
Ve
Ib
ch
g
Ja
n
Sa
n
Na
ro
Sh
an
Ba
de
G
M
o
Ri
Recognition from WHO PPGHC Study (Ustun, Goldberg et al)

53. Clinician traits eg confidence

54. Low confidence = more cautious, fewer false positives, more false negatives p180
1.00 Post-test Probability
0.90
0.80
0.70
0.60
Ave Confidence+
0.50
Ave Confidence-
0.40 Baseline Probability
Above Ave Confidence+
0.30
Above Ave Confidence-
High Confidence+
0.20
High Confidence-
0.10
Pre-test Probability
0.00
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
High confidence = less cautious, more false positives, low false negatives

56. Predictors of Recognition
Prevalence
10% rural 15% mean 20% urban 20% (oncology 25%)
Severity
70% mild 20% moderate 10% severe
International
Low in developing but in Western:
Italy > Netherlands >Australia > UK > US
Contact
Cummulative: 77% single 89% 3-6 months
Appointment Duration
Confidence &trust

57. 4. Comorbid Depression
Back to Basics

58. Approaches to Somatic Symptoms of Depression
Inclusive
Uses all of the symptoms of depression, regardless of whether they may or
may not be secondary to a physical illness. This approach is used in the
Schedule for Affective Disorders and Schizophrenia (SADS) and the Research
Diagnostic Criteria.
Exclusive
Eliminates somatic symptoms but without substitution. There is concern that
this might lower sensitivity. with an increased likelihood of missed cases (false
negatives)‫‏‬
Etiologic
Assesses the origin of each symptom and only counts a symptom of
depression if it is clearly not the result of the physical illness. This is proposed
by the Structured Clinical Interview for DSM and Diagnostic Interview Schedule
(DIS), as well as the DSM-III-R/IV).
Substitutive
Assumes somatic symptoms are a contaminant and replaces these additional
cognitive symptoms. However it is not clear what specific symptoms should be
substituted

59. Who Uses Specific Non-Somatic scales?

60. Comment: Slide illustrates concept of
phenomenology of depressions in
medical disease
Primary Depression Alone
Fatigue
Anorexia
Insomnia
Concentration
Secondary
Medically Unwell Alone Depression

63. Study: Coyne Thombs Mitchell
N= 4500; Pooled database study; All comparative
studies
Physical illness+comorbid depression
Vs
Physical illness alone
Vs
Primary depression alone