Week 06 Depression (Moodle Version) PDF

Anxiety + Depression Week 6 Objectives Compare and contrast medical tests used in the evaluation of a patient with depressed and/or anxious mood, based on evidence of accuracy Apply diagnostic evidence to clinical reasoning in the presence of depressed and/or anxious mood Prioritize...

Anxiety + Depression Week 6 Objectives Compare and contrast medical tests used in the evaluation of a patient with depressed and/or anxious mood, based on evidence of accuracy Apply diagnostic evidence to clinical reasoning in the presence of depressed and/or anxious mood Prioritize issues to be addressed in a patient encounter where there is depression and/or anxious mood Develop and refine a differential diagnosis based on new information related to depressed and/or anxious mood Perform clinical examination and medical procedures safely in a patient with depressed and/or anxious mood Identify appropriate strategic patient-centred interviewing skills to establish and sustain patient rapport in the context of depressed and/or anxious mood Demonstrate an understanding of patient-centred care in the context of medical screening for anxiety and/or depression Case stem: Patient presents with Anxiety and Depression Mental Status Exam (MSE) - Appearance + Behaviour - Motor activity - Speech - Affect + Mood - Thought process - Thought content - Perception - Sensorium + Cognition - Insight - Judgement Anxiety Disorders - Generalized Anxiety Disorders (GAD) - Panic Disorder (PD) - Obsessive Compulsive Disorder (OCD) - Various phobia-related disorders (e.g. simple phobia, social phobia, agoraphobia) Consider trauma- and stressor-related disorders: - Stress, not elsewhere classified - Adjustment Disorder - Acute Stress Disorder Also consider organic causes of anxiety: - Endocrine: Hyperthyroidism, Pheochromocytoma, Hyperparathyroidism - Cardiopulmonary: Heart failure, Arrhythmias, Asthma or Chronic obstructive pulmonary disease (COPD) - Neurologic: Temporal lobe epilepsy or Transient Ischemic Attacks (TIAs) - Medication: corticosteroids, cocaine, amphetamines, caffeine; withdrawal Anxiety Disorders - Basic Terminology Fear - an emotional, physical, and behavioral response to an immediately recognizable external threat (within normal or typical range) Phobia - an excessive fear response to a specific object or situation that is out of proportion to the actual danger (can occur with no danger is present) and cause significant dysfunction due to avoidance behavior Anxiety - a distressing, unpleasant emotional state of nervousness and unease; causes are less clear and timing is less tied to a threat (anticipatory, persistent, none identifiable). Can have physical changes and behaviors similar to those caused by fear. Stressor-related Disorder - a single, discrete event or multiple events, or ongoing problems that lead to mental distress that is more intense than what is typically expected or when the person's ability to function is significantly impaired. Generalized Anxiety Disorder (GAD) - an anxiety disorder of excessive worry about everyday issues and situations almost daily for a duration of 6 months or greater, with multiple somatic symptoms. Prevalence - 8-31.2% (Primary Care) mean age of onset: 30 yrs Risk: dysregulation of worry, genetics/fHx, female (2X), adverse life events Dx: by clinical interview (according to DSM-5 criteria), screening tool: GAD-7 - frequency: present more days than not, for more than 6 months - character: anxiety concerning every day or routine circumstances or events, difficult to control, associated symptoms such as restlessness, concentration problems, irritability, tension, and/or fatigue Management: patient education, referral to psychotherapy, psychiatry Prognosis: 43% may develop major depression; 20 - 25% increased risk of suicide GAD - DSM-5: Diagnostic Criteria (APA, 2013) A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities. B. The individual finds it difficult to control the worry. C. The anxiety and worry are associated with 3 (or more) of the following: (1) Restlessness or feeling keyed up or on edge (2) Being easily fatigued (3) Difficulty concentrating or mind going blank (4) Irritability (5) Muscle tension (6) Sleep disturbance (difficulty falling asleep, or restless, unsatisfying sleep) A. The anxiety, worry or physical symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning. B. The disturbance is not attributable to the physiological effects of a substance or another medical condition (e.g. hyperthyroidism) C. The disturbance is not better explained by another mental disorder. GAD - Mental Status Examination (MSE) - Appearance + Behaviour - may present as well-kempt or disheveled - Motor activity - may have psychomotor agitation - excessive motor activity associated with a feeling of inner tension (hand-wringing, hair-pulling, pulling of clothes, pacing, fidgeting, hand or voice tremor, and inability to sit still). - Speech - may be fast or pressured - Affect + Mood - may describe mood as worried, afraid, tense, exhausted, frustrated, or irritable - or depressed; affect may be blunted or guarded - Thought process - may include ruminations - Thought content - may be hyper-focused on their worries; however, commonly focused on somatic symptoms. - Perception - often a negative view of themselves and of the world - Sensorium + Cognition - may have difficulty concentrating or focusing on anything other than their anxious ruminations - Insight - varying levels of awareness - Judgement - tend to use avoidance behaviours  GAD Scale - 7 item (link to PDF version from ADAA) The options for answering the following questions are: Not at all(0), Several days(1), More than half the days(2), Nearly every day(3) Over the last 2 weeks, how often have you been bothered by the following problems? 1. Feeling nervous, anxious or on edge. 2. Not being able to stop or control worrying 3. Worrying too much about different things 4. Trouble relaxing 5. Being so restless that it's hard to sit still 6. Becoming easily annoyed or irritable 7. Feeling afraid as if something awful might happen How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all (0), Somewhat difficult (1), Very difficult (2), Extremely difficult (3) GAD - 7 SCORING - can be patient self-administered or practitioner-administered tool - used in suspected cases of GAD, to assess severity or to monitor treatment. - A score of 5-9 indicates mild anxiety. - A score of 10-14 indicates moderate anxiety. - A score of 15-21 indicates severe anxiety. Likelihood Ratios to Identify Generalized Anxiety Disorder (GAD) Screening Tool Sensitivity LR+ LR- GAD-2 (score ≥ 3) 86% 5.0 0.17 GAD-7 (score ≥ 5) 97% 2.2 0.05 GAD-7 (score ≥ 10) 89% 5.1 0.13 Assessing Severity of Generalized Anxiety Disorder (GAD) Mild Moderate Severe Frequency of anxiety more than half most of time all the time Degree of distress Minor Markedly Between Mild functional interfere with Functional Impairment + Severe impairment functioning GAD - 7 5-9 10 - 14 15+ GAD video: www.osmosis.org Panic Attacks + Panic Disorder (PD) - panic attack: the sudden onset of a discrete, brief period of intense discomfort, anxiety, or fear that reaches a peak within minutes and is accompanied by somatic and/or cognitive symptoms - panic disorder: the occurrence of repeat panic attacks followed by at least 1 month of persistent concern about having another panic attack, worry about the possible implications or consequences of the attacks, or a significant behavioural change related to the attacks - agoraphobia: an anxiety disorder (phobia) with a fear of being in situations where escape might be difficult or that help wouldn't be available if things go wrong; if in a stressful situation, will usually experience symptoms of a panic attack Panic Disorder (PD) Prevalence - 4.7% (4-8% in primary care) median age of onset: 24yrs Risk: genetic, female (2X), increased stress, those who suffer from asthma Dx: by interview (according to DSM-5 criteria), screening via PHQ-PD or ANS - type of symptom (if not reported, ask about all 13 diagnostic symptoms), location, quality and intensity - description of panic attack (rate of onset, description of symptom trajectory, duration of symptoms) - precipitating factors (spontaneous, untriggered or unexpected) - response to symptoms (persistent concern, change in behaviour) Management: patient education, referral to psychotherapy, psychiatry Prognosis: 50% comoridity with major depression, 32% comorbidity with GAD PD - DSM-5: Diagnostic Criteria (APA, 2013) A. Recurrent, unexpected panic attacks during which 4 or more of the following occur: (1) Palpitations, pounding heart or accelerated heart rate, (2) Sweating, (3) Trembling or shaking, (4) Sensations of shortness of breath or smothering, (5) Feelings of choking, (6) Chest pain or discomfort, (7) Nausea or abdominal distress, (8) Feeling dizzy, unsteady, light-headed, or faint, (9) Chills or heat sensations, (10) Paresthesias (numbness or tingling sensations), (11) Derealization (feelings of unreality) or depersonalization (being detached from oneself), (12) Fear of losing control or “going crazy”, (13) Fear of dying B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following: (1) Persistent concern or worry about additional panic attacks or their consequences (2) a significant maladaptive change in behaviour related to the attacks Panic Disorder - Mental Status Examination (MSE) - Appearance + Behaviour - may present as well-kempt or disheveled - Motor activity - may have psychomotor agitation - Speech - may be fast or pressured; if in a panic attack, may have difficulty speaking (stammering, vocal tremor) - Affect + Mood - may describe mood as anxious, afraid, tense, exhausted, frustrated, "on edge", or irritable - or depressed; may show more lability - Thought process - may include ruminations - Thought content - extreme fear, sense of impending doom (in an attack); anticipatory anxiety about having another attack (between attacks) - Perception - often a negative view of themselves and of the world - Sensorium + Cognition - may have difficulty concentrating, mind blank or confused during an attack - Insight - often aware fears are out of proportion to the actual threat - Judgement - tend to use avoidance behaviours PHQ - PD module 1. In the last 4 weeks, have you had an anxiety attack with sudden fear or panic? [PHQ-PD 1] yes or no 2. Has this ever happened before? yes or no 3. Do some of these attacks come suddenly, out of the blue, in situations where you do not expect nervousness? yes or no 4. Do these attacks bother you a lot or are you worried about having another attack? yes or no 5. If yes, have you had these symptoms during your last bad anxiety episode: Shortness of breath, Heart palpitation, Chest pain or chest pressure, Sweating, Feelings of choking, Hot flashes or chills, Nausea or an upset stomach, or diarrhea, Feeling dizzy, unsteady, or faint, Tingling or numbness in parts of your body, Trembling or shaking, Afraid of dying. Autonomic Nervous System (ANS) questionnaire 1. In the past 6 months, did you ever have a spell or an attack when all of a sudden you felt frightened, anxious or very uneasy? yes or no 2. In the past 6 months, did you ever have a spell or attack when for no reason your heart suddenly began to race, you felt faint, or you couldn’t catch your breath? yes or no Panic Disorder Screening Questionnaires SCORING - can be patient self-administered or practitioner-administered tools - PHQ-PD (1- or 5-item) and ANS can be used to screen for panic disorder - Severity often assessed using a different questionnaire (re: PDSS-SR) Yes = 1 point No = 0 points Likelihood Ratios to Identify Panic Disorder (PD) Screening Tool Sensitivity LR + LR - PHQ-PD 1 (score = 1) 71 - 83% 2.42 - 4.4 0.26 - 0.34 PHQ-PD 5 (score ≥ 8) 81% 78 0.20 ANS (score ≥ 1) 94-100% 1.25-2.44 0-0.24 panic disorder video: www.osmosis.org Stress, not elsewhere classified - a physical or mental response to an external stressor, which may be a one-time, short-term, or long-term (repeated) occurence - can be positive or negative - considered a risk factor, an exacerbating factor and a treatment target – not a diagnosis itself Risk: life events, impact can be estimated via the Life-Stress Inventory assessment via history - intensity: 10-point scale rating, or estimated using Perceived Stress Scale (PSS) Management: patient education (including self care), possibly refer for counselling Adjustment Disorder (AD) - a maladaptive emotional and/or behavioural response to an identifiable psychosocial stressor (difficulty adjusting after a stressful event at a level disproportionate to the severity or intensity of the stressor) Prevalence - 1-2% (general); 5-20% (outpatient mental health visit); 27% (recently unemployed), 18% (bereaved) Risk: significant life event(s) Dx: by clinical interview (according to DSM-5 criteria), no validated assessment tools - timeline: onset shortly after stressor, typically resolves within 6 months after stressor has stopped (or becomes classified as ‘chronic adjustment disorder’) - character: with anxiety, depressed mood (may include suicide attempt), mixed, with misconduct or unspecified Management: patient education, referral to psychotherapy, psychiatry Prognosis: 71% recover within 5yrs; 76% comorbidity with substance abuse Adjustment Disorder - DSM-5: Diagnostic Criteria (APA, 2013) A. Onset of emotional or behavioural symptoms must occur in response to identifiable stressor, and within 3 months of the stressor. B. These symptoms are clinically significant, marked by one of the following: a. Distress that is disproportionate to the severity or intensity of the stressor, taking into account contextual and cultural factors. b. Significant impairments in social, occupational or other domains of functioning C. The disturbance does not meet the diagnostic criteria for another mental disorder, and is not an exacerbation of a pre-existing disorder. D. The symptoms do not represent normal bereavement. E. Symptoms do not last for more than six additional months after the stressor or its consequences have been resolved. Mood Disorders - Depression (aka. Major Depressive Disorder) - Bipolar Disorder - Adjustment Disorder with Depressed Mood (e.g. grief) - Seasonal Affective Disorder (SAD) - Premenstrual Dysphoric Disorder or Postpartum/Peripartum-onset Depression - Substance/Medication-Induced Mood Disorder - including alcohol, cannabis - Borderline Personality Disorder Anxiety Disorders - Clinical Burn-out - Obsessive Compulsive Disorder (OCD) Consider organic causes (“Depressive disorder due to another medical condition”): - Endocrine: Hypothyroidism, Addison’s Disease - Neurological: Multiple Sclerosis, Stroke, Cerebral tumour - Other: Vitamin B12 Deficiency, Coronary Artery Disease (CAD), Fibromyalgia Depression - Basic Terminolgy - dysphoria - a mood state, as indicated by feelings of sadness, despair, anxiety, emptiness, discouragement, or hopelessness; having no feelings; or appearing tearful (may be normal or a symptom of a psychopathological syndrome or a general medical disorder). - minor depressive episode - a mood syndrome with clinically significant distress and impaired functioning, but with fewer symptoms (2 to 4), and tends to have shorter episodes, less comorbidity, less psychosocial and physical impairment, and fewer recurrences than major depression - major depressive disorder - a mood syndrome with clinically significant distress and impaired functioning, but with greater symptoms (≥ 5) and tends to have greater psychosocial and physical impairment - dysthymia (persistent depressive disorder) - similar to minor/major depression, but symptoms persist for 2 or more years  Major Depressive Disorder, Continuum of Adjustment Disorder with depressed mood Mood Disorders Dysthymia*, Minor Depression**, * Persistent Depressive Disorder Normal Bereavement **Subsyndromal or subclinical Depression Elation/ Severe Mild Mania + + Suicide or Sad Euthymia Happy hypo- Mania Depression Depression Psychosis Psychosis mania Loss of Function “Normal” or “Typical” Loss of Function Type II Bipolar Disorder Type I Bipolar Disorder, Schizoaffective Symptoms of Depression (symptoms occur nearly every day) - D = Depressed mood (Dysphoria), most of the day - E = Energy loss (Anergia) - fatigue - P = Pleasure lost (Anhedonia) - markedly diminished interest or pleasure most of the day - R = Retardation or excitation (psychomotor, observable by others) - E = Eating changed - significant appetite or weight change - S = Sleep changed - either decreased (insomnia) or increased (hypersomnia) - S = Suicidality - recurrent thoughts of death or suicide, or suicide attempt - I = I'm a failure (loss of confidence, thoughts of worthlessness or hopelessness) - O = Only me to blame (inappropriate guilt or regret) - N = No concentration - impaired concentration or memory Minor Depression (aka. other specified depressive disorder) - a depressive syndrome that causes distress and psychosocial impairment for at least 2 weeks, but is not considered clinical depression (aka. major depression) Prevalence - 2-16% Risk: female, Hx of anxiety, substance use, adverse life events (including divorce and unemployment) Dx: by clinical interview (not in DMS-5), screening by PHQ-9 - frequency: nearly every day for at least 2 weeks - character: 2 - 4 symptoms of depression Management: patient education, screen for suicidality, referral to psychotherapy Prognosis: 21yrs Risk: female (2x), genetic (1st degree relative), Hx of anxiety, substance use, adverse life events Dx: by clinical interview (according to DSM-5 criteria), screening by PHQ-9 - frequency: for most of the day, nearly every day - duration: for at least 2 years - character: depressed mood plus at least 2 dysthmic symptoms Management: patient education, referral to psychotherapy, psychiatry Prognosis: 45.2% relapse within 2 yrs, increased risk for suicide attempts PDD - DSM-5: Diagnostic Criteria (APA, 2013) A. Depressed mood for most of the day, more days than not, for at least 2 years. B. Presence, while depressed, of 2 (or more) of the following: (1) Poor appetite or overeating, (2) Insomnia or hypersomnia, (3) Low energy or fatigue, (4) Low self-esteem, (5) Poor concentration or difficulty making decisions, (6) Feelings of hopelessness. C. During the 2-year period of the disturbance, the individual has never been without the symptoms in A and B for more than 2 months. D. Criteria for a MDD may be continuously present for 2 years. E. There has never been a manic or hypomanic episode, and criteria have never been met for cyclothymic disorder. F. The disturbance is not better explained by a persistent schizophrenia spectrum and other psychotic disorder. G. The symptoms are not attributable to the physiological effects of a substance (e.g. drug, medication) or another medical condition. H. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Major Depressive Disorder (aka. Unipolar Major Depression) - a syndromal, depressive disorder characterized by a history of one or more major depressive episodes and no history of mania/ hypomania. - a major depressive episode manifests with 5 or more symptoms of depression (one being dysphoria or ahedonia), for at least two consecutive weeks Prevalence - 5-10% (primary care), 2-4% (community) median age of onset: 30 Risk: female (2-3x), genetic (1st degree relative), Hx of anxiety, substance use, adverse life events (including divorce) Dx: by clinical interview (according to DSM-5 criteria), screening by PHQ-9 - frequency: most of the day, nearly every day for at least (≥) 2 weeks - character: ≥ 5 depressive symptoms, including dysphoria or anhedonia Management: patient education, referral to psychotherapy, psychiatry Prognosis: 25X greater risk of suicide; 52% increased risk of all-cause mortality 5-30% progress to schizophrenia-spectrum disorders in psychiatric setting Major Depression - DSM-5: Diagnostic Criteria (APA, 2013) A. Five or more of the following symptoms have been present during the same 2-week period: (1) Dysphoria (depressed mood most of the day, nearly every day), (2) Anhedonia (markedly diminished interest or pleasure most of the day, nearly every day), (3) Significant appetite or weight change, (4) Insomnia or hypersomnia nearly every day, (5) Psychomotor agitation or retardation (observable by others), (6) Anergia (fatigue nearly every day), (7) Thoughts of worthlessness or inappropriate guilt nearly every day, (8) Impaired concentration or memory nearly every day, (9) Recurrent thoughts of death or suicide, or suicide attempt B. At least one of the symptoms includes dysphoria or anhedonia C. The symptoms cause clinically significant distress or impairment D. The symptoms are not due to the physiologic effects of a substance, medication, or general medical condition E. The mood disturbance doesn’t occur during a psychotic disorder F. There has never been a manic or hypomanic episode. Depression - Mental Status Examination (MSE) - Appearance + Behaviour - may present as well-kempt or disheveled; may self-harm, weight loss/gain; may have stooped posture, poor eye contact - Motor activity - may have psychomotor retardation (occasionally agitation) - Speech - often decreased rate and volume; reduced variation in tone (ie. monotone); may have paucity of speech (major depression) - Affect + Mood - many describe mood as depressed: numb, hopeless, worthless, irritable, sad, etc.; constricted, blunted, or flat affect - Thought process - often include negative views of self and world - Thought content - perserverations about negative themes; suicidality? - Perception - often a negative view of themselves and of the world - Sensorium + Cognition - may have delusions or hallucinations - Insight - often difficult to convince improvement is possible - Judgement - depends on patient actions/behaviours  PHQ-2 item (link to PDF version from BCHealth) The options for answering the following questions are: Not at all(0), Several days(1), More than half the days(2), Nearly every day(3) Over the past 2 weeks, how often have you been bothered by the following problems? 1.Little interest or pleasure in doing things 2.Feeling down, depressed or hopeless 3.Trouble falling asleep, staying asleep or sleeping too much 4.Feeling tired or having little energy 5.Poor appetite or overeating 6.Feeling bad about yourself or that you're a failure or have let yourself or your family down 7.Trouble concentrating on things, such as reading the newspaper or watching TV 8.Moving or speaking so slowly that other people could have noticed or the opposite, being so fidgety and restless that you have been moving around a lot more than usual.  PHQ-9 item (link to PDF version from BCHealth) The options for answering the following questions are: Not at all(0), Several days(1), More than half the days(2), Nearly every day(3) Over the past 2 weeks, how often have you been bothered by the following problems? 1.Little interest or pleasure in doing things 2.Feeling down, depressed or hopeless 3.Trouble falling asleep, staying asleep or sleeping too much 4.Feeling tired or having little energy 5.Poor appetite or overeating 6.Feeling bad about yourself or that you're a failure or have let yourself or your family down 7.Trouble concentrating on things, such as reading the newspaper or watching TV 8.Moving or speaking so slowly that other people could have noticed or the opposite, being so fidgety and restless that you have been moving around a lot more than usual. PHQ-9 item (link to PDF version from BCHealth) Follow with: If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all (0) Somewhat difficult (1) Very difficult (2) Extremely difficult (3) Depression Screening Questionnaires SCORING - can be patient self-administered or practitioner-administered tools - PHQ-2 or PHQ-9 can used to screen for and assess severity of depression A total score of 5-9 shows mild major depression. A total score of 10-14 shows moderate major depression. A total score of 15-19 shows moderately-severe major depression. A total score of >20 shows severe major depression. Likelihood Ratios to Identify Major Depressive Disorder (MDD) Screening Tool Sensitivity LR + LR - PHQ-2 (score ≥ 2) 86% 2.76 0.13 PHQ-9 (score ≥ 10) 86% 5.47 0.21 Clinically Classifying Major Depressive Episodes Mild Moderate Severe Number of Symptoms 5 5-6 7+ Type + Symptom Severity Minor Markedly Between Mild functional interfere with Functional Impairment + Severe impairment functioning PHQ - 9 5-9 10 - 14 15 - 20 MDD video: www.osmosis.org Clinical Burn-out - a syndrome characterized by emotional exhaustion, depersonalization and reduced personal accomplishment, resulting from chronic workplace stress that has not been successfully managed. Prevalence - 6-33% (in GPs and Healthcare Workers) Risk: employment Dx: by history, validated questionnaires available - Emotional Exhaustion: feelings of energy depletion or exhaustion - Depersonalization: increased mental distance (reduced compassion), or feelings of negativism or cynicism related to one's job - Personal accomplishment (lack sense of): reduced professional efficacy Management: patient education, referral to psychotherapy Prognosis: increased risk of psychopathology, esp. anxiety and depression Clinical Burn-out (ICD-11 criteria) 1. Persistent and distressing complaints of increased fatigue after mental effort, or persistent and distressing complaints of bodily weakness and exhaustion after minimal effort. 2. At least 4 of the following additional symptoms: insomnia, cognitive deficits, pain, palpitations, gastroenteric problems, sound and light sensitivity. 3. These complaints and symptoms must be present nearly every day for at least two weeks. 4. These complaints and symptoms are due to work-related psychosocial stressors that have been present for at least six months before diagnosis. 5. These complaints and symptoms lead to clinically significant distress or impairment.  Phases in the Development of Clinical Burn-out Phase Main features Symptoms Lack of Recovery: stressful events Need for recovery 1 combined with limited recuperation Aversion to spending effort Changes in Stress Physiology: higher Hyperactivity, inability to relax, 2 homoeostatic stress values sleep difficulties, restlessness Chronic Stress Symptoms: physical + Headaches, digestive concerns, 3 mental symptoms, emotional + muscle tension, chest pain, behavioural problems indecisiveness, irritability, anxiety, etc Pseudopsychopathology: cognitive compulsive + rigid behaviour, 4 simplification by applying more rigid dependent on others; reduced ways of problem solving creativity, empathy + self-reflection Clinical Burnout: reduced motivation Emotional breakdown, severe fatigue, 5 and passivity inability to motivate oneself, etc.  Burnout Measure - Short Version Please use the following scale to answer the question: never(1), almost never(2), rarely(3), sometimes(4), often(5), very often(6), always(7) When you think about your work overall, how often do you feel the following? 1. Tired 1 2 3 4 5 6 7 2. Disappointed with people 1 2 3 4 5 6 7 3. Hopeless 1 2 3 4 5 6 7 4. Trapped 1 2 3 4 5 6 7 5. Helpless 1 2 3 4 5 6 7 6. Depressed 1 2 3 4 5 6 7 7. Physically weak / sickly 1 2 3 4 5 6 7 8. Worthless / like a failure 1 2 3 4 5 6 7 9. Difficulties sleeping 1 2 3 4 5 6 7 10. “I’ve had it” 1 2 3 4 5 6 7 Burnout Measure - Short Version: Scoring Add the responses to the 10 items and divide by 10. - up to 2.4 Indicates a very low level of burnout - 2.5 - 3.4 Indicates danger signs of burnout - 3.5 - 4.4 Indicates burnout - 4.5 - 5.4 Indicates a very serious problem of burnout - 5.5 Requires immediate professional help Note: The Maslach Burnout Inventory (MBI) is often considered the gold standard for measuring burnout; however, it is a copyrighted measure and cannot be reproduced by any means without written permission. Summary Anxiety + Depression Comorbidity 48% of patients with anxiety have comorbid major depressive disorder 50% of patients with depression have anxiety symptoms Review: Symptoms of Anxiety Excessive Physiologic Distorted Cognitive Poor Coping Strategies Arousal Processes - Muscle tension - Poor concentration - Avoidance - Irritability - Unrealistic - Procrastination - Fatigue assessment of - Poor problem-solving - Restlessness problems skills - Insomnia - Worries Generalized Anxiety Disorder 1. Establish presence of anxiety, fear, avoidance and/or increased arousal 2. Ensure symptoms occur most of the day, more days than not and are persistent (at least 6 months) 3. Determine chronology of current anxiety symptoms and any history of panic attacks, physical symptoms or psychiatric diagnoses 4. Determine the impact of anxiety upon occupational and interpersonal functioning 5. Elicit alleviating or aggravating factors (including specific worries, stressful life events, substance/medications and social or occupational circumstances) 6. Assess comorbidity (re: psychiatric or general medical) - esp. depression 7. Evaluate family history and social history 8. Complete MSE and relevant PE guided by medical history/review of systems 9. Requisition labs (to rule out potential organic causes) complete algorithm: GrepMed Differentiate - Anxiety vs. ______ - Depression - character of worry tends to be self-criticism of previous events and/or circumstances; early morning awakening, diurnal variation in mood, marked guilty preoccupations, and suicidal thoughts more commonly present; can be comorbid - Panic disorder - presence of unexpected or paroxysmal panic attacks - Adjustment disorder with anxiety - presence of an identifiable stressor or stressors occurring within three months of the onset of symptoms - Obsessive-compulsive disorder - fears focus on primal themes (e.g. contamination, harm), compulsions tend to be ritualistic or “rule driven” and either unrelated to feared outcome or clearly excessive Differentiate - Anxiety vs. Organic Disease Other medical illnesses are distinguished via history, physical exams and labs: - Hyperthyroidism - ↓ serum TSH - Pheochromocytoma - urinary normetanephrine and platelet norepinephrine, abdominal CT - Heart failure - ECG - Arrhythmias - Holter monitor, ECG - Asthma - spirometry - Chronic obstructive pulmonary disease (COPD) - spirometry - Anemia (iron-deficiency) - ↓ serum hemoglobin and red blood cells, ↓ ferritin Differentiate - Anxiety vs. Medication Patients using medications can present with anxiety - Alcohol or its withdrawal - Cannabis - Amphetamines - Carbon mon- and di-oxide - Analgesics - Corticosteroiods - Anesthetics - Cocaine - Anticholinergics - Hallucinogens (LSD, Phencyclidine) - Anticonvulsants - Mood stabilizers (e.g. Lithium) - Antidepressants (e.g. SSRIs) - Organophosphate insecticide - Antihistamines - Sedative withdrawal - Antiparkinsonians - Sympathomimetics - Antipsychotics - Thyroid medications - Caffeine - Volatile substances (gasoline, paint) Review: Symptoms of Depression ( occur nearly every day) - D = Depressed mood (Dysphoria), most of the day - E = Energy loss (Anergia) - fatigue - P = Pleasure lost (Anhedonia) - markedly diminished interest or pleasure most of the day - R = Retardation or excitation (psychomotor, observable by others) - E = Eating changed - significant appetite or weight change - S = Sleep changed - either decreased (insomnia) or increased (hypersomnia) - S = Suicidality - recurrent thoughts of death or suicide, or suicide attempt - I = I'm a failure (loss of confidence, thoughts of worthlessness or hopelessness) - O = Only me to blame (inappropriate guilt or regret) - N = No concentration - impaired concentration or memory Major Depressive Disorder 1. Establish presence of depressive symptoms 2. Ensure depressed mood that occurs most of the day, more days than not and is persistent (at least 2 weeks) 3. Determine chronology of current depressive symptoms and any history of prior depressive episodes 4. Determine the impact of the depressive episode upon occupational and interpersonal functioning 5. Elicit alleviating or aggravating factors (including stressful life events and social or occupational circumstances) 6. Assess comorbidity (re: psychiatric or general medical) - esp. mania, substance 7. Assess suicide risk 8. Evaluate family history and social history 9. Complete MSE and relevant PE guided by medical history/review of systems 10. Requisition labs (to rule out potential organic causes) complete algorithm: UpToDate Differentiate - Major Depression vs. ______ - Burnout - specific character of low mood occurs in the context of chronic job- related stress; can lead to MDD - Adjustment disorder with depressed mood - dysphoria occurs in the context of psychosocial stressors; diagnosis of exclusion - Attention Deficit Hyperactivity Disorder (ADHD) - impaired concentration, inattention, and fidgeting are pervasive in ADHD (vs. only become pronounced during an episode); can be co-morbid - Bipolar disorder - presence of mania/hypomania episode - Borderline personality disorder - mood states that fluctuate within a single day (vs. marked dysphoria), can also include identity disturbance, frantic efforts to avoid abandonment, and chronic feelings of emptiness - Schizophrenia and schizoaffective disorders - psychotic symptoms (including delusions and hallucinations) can and do occur in the absence of MDD (vs. only in an episode) Differentiate - Major Depression vs. Organic Disease Other medical illnesses are distinguished via history, physical exams and labs: - Systemic Lupis Erythematosus (SLE) - positive anti-nuclear antibodies (ANA) - Addison disease - ↓ cortisol + aldosterone; Cushing syndrome - ↑ cortisol - Diabetes mellitus - ↑ fasting blood sugar (FBS) and hemoglobin A1c (HbA1c) - Hyper- or hypo-thyroidism - ↓ or ↑ TSH - Head trauma - examination of head, CT - Multiple sclerosis - imaging (MRI, identifies demyelinating lesions) - Parkinson’s disease - bradykinesia + resting tremor or limb rigidity - Stroke (left frontal lobe) - imaging (MRI or CT) - Pernicious anemia (Vitamin B12 deficiency) - ↓ serum B12 levels - Coronary artery disease - BP, cholesterol, ECG, stress test, coronary angiography - Fibromyalgia - Widespread Pain Index (WPI) scale, Symptom Severity (SS) scale - Renal failure - ↑ serum creatinine, ↓ eGFR; ↑ protein in urine Differentiate - Major Depression vs. Medication Patients using medications can present with persistently depressed or irritable mood - Amphetamine withdrawal - Mercury - Amphotericin B - Methyldopa - Anticholinesterase insecticides - Metoclopramide - Barbiturates - Oral Contraceptives - Beta-blockers (e.g. propranolol) - Phenothiazines - Cimetidine - Reserpine - Corticosteroiods - Thallium - Cylcoserine - Vinblastine - Estrogen therapy - Vincristine - Indomethacin Putting it into Practice - Subjective history: - Clinical syndrome (i.e. signs and symptoms): - Epidemiology (i.e. likely cause of concern): - Timing (i.e. frequency and duration): - Objective data - Physical Exam / MSE - Screening tool - Labs + Imaging - Pretest probability (or prevalence) - Use of Sensitivity/ Specificity / Likelihood ratios to influence threshold model of medical decision making - Natural history (prognosis if left untreated) CASE - Subjective Data information from the case - ONSET - - Epidemiology (likely cause): - LOCATION - - DURATION - - CHARACTER - Symptoms suggestive of Anxiety - Symptoms suggestive of Depression: - AMELIORATING factors - - RELIEVING factors - - TIMING - - SEVERITY - CASE - Objective: physical + mental status exam PE MSE - Appearance + Behaviour: - Motor activity: - Speech: - Affect + Mood: - Thought process: - Thought content: - Perception: - Sensorium + Cognition: - Insight: - Judgement: CASE - Objective: screening tool(s) GAD - 7 - score: - interpretation: PHQ - 9 - score: - interpretation: CASE - Assessment involves assessing severity of disease as well as functional capacity how has their mental health impacted the way they: - live independently - learn - work - socialize - self-care Key Resources 1. Snyderman, D., & Rovner, B. (2009). Mental status examination in primary care: a review. American family physician, 80(8), 809-814. AAFP 2. Ebell, M. H. (2008). Diagnosis of anxiety disorders in primary care. American family physician, 78(4), 501-502. AAFP 3. Locke, A. B., Kirst, N., & Shultz, C. G. (2015). Diagnosis and management of generalized anxiety disorder and panic disorder in adults. American family physician, 91(9), 617-624. AAFP 4. Barnhill, JW. Overview of Anxiety Disorders. Merck Manuals - Professional Version. Merck Manual 5. Herr, N. R., Williams, J. W., Benjamin, S., & Mcduffie, J. (2014). Does this patient have generalized anxiety or panic disorder?: The Rational Clinical Examination systematic review. Jama, 312(1), 78-84. JAMA 6. Maurer, D. M., Raymond, T. J., & Davis, B. N. (2018). Depression: screening and diagnosis. American family physician, 98(8), 508-515. AAFP 7. Coryell, W. Depressive Disorders. Merck Manuals - Professional Version. Sep 2022. Merck Manual 8. Williams Jr, J. W., Noël, P. H., Cordes, J. A., Ramirez, G., & Pignone, M. (2002). Is this patient clinically depressed?. Jama, 287(9), 1160-1170. JAMA