tom janzen, m.d. london, ont may 1, 2014 -...
TRANSCRIPT
Reactive or Endogenous … Does it Matter?
Major Depressive Disorder
Tom Janzen, M.D.
London, Ont
May 1, 2014
• Recognize that MDD is heterogeneous
and as such optimizing outcomes requires
individualizing care plan
• Understand that functional recovery requires a full
appreciation of psychosocial, physical as well as mental
health issues
• Identify and explore solutions for helping disabled
workers regain mental health
Learning Objectives
• Health
◦ “… a state of complete physical, mental and social
well-being and not merely the absence of infirmity”
• Mental Health
◦ “… a feeling of well-being in which the individual
realizes his/her own abilities, can cope with normal
stresses of life, can work productively and fruitfully,
and is able to make contributions to his or her
community”
WHO Definitions
• DSM IV-TR (1992-2013)
◦ “A mental disorder is a clinically significant
behavioral or psychological syndrome or
pattern that occurs in an individual and that is
associated with present distress or disability or
with a significantly increased risk of suffering,
death, pain, disability, or an important loss of
freedom.”
Defining Mental Illness
• DSM 5 (May 16, 2013 -)
◦ "A mental disorder is a syndrome
characterized by clinically significant
disturbance in an individual's cognition,
emotion regulation, or behavior that reflects a
dysfunction in the psychological, biological, or
developmental processes underlying mental
functioning. Mental disorders are usually
associated with significant distress in social,
occupational, or other important activities.”
DSM 5 Definition of a Mental Illness
• An expectable or culturally approved response to a
common stressor or loss, such as the death of a loved one
• Socially deviant behavior (e.g., political, religious, or
sexual) and conflicts that are primarily between the
individual and society are not mental disorders unless the
deviance or conflict results from a dysfunction in the
individual
DSM 5: A Mental Illness IS NOT…
62% Canadian Employees
• Founder of Research on Stress
◦Good Stress – contributes to wellness
◦ Bad Stress – contributes to disease and
sickness
Canadian Pride: Hans Selye (1907-1982)
• Committed to Employer
◦ 1991 – 66%
◦ 2001 – 45%
• 7% Canadians off work
for MH
• Estimated 17% of wage
bill spent on mental
illness
Impact
Making the Diagnosis
Major Depressive Disorder
• Diagnosis no longer requires
differentiation
• Treatments identical
• Many clinicians remain skeptical
Reactive or Endogenous
• 43 y.o male factory worker
• 23 year history with company
• Non-work related injury (fractured tibia)
• Surgery + 3 months rehab
• Return to work but re-injures leg
• Repeat surgery with complications
• Chronic pain – off work X 9 months
Case Presentation: M.R.
• Presents with complaints of depression
• Nervous about return to work
• Restrictions from surgeon – can’t do his old job
• Financial concerns
• Marital strain
M.R.
Acronym for DSM 5 Criteria: MDD
SIGECAPS
Measurement Based Care
Sig: E Caps and PHQ-9
SIGECAPS PHQ-9
Core Symptoms of Depression
Depressed Mood
Sleep decreased
Interest decreased in activities (anhedonia)
Guilt or worthlessness
Energy decreased
Concentration difficulties
Appetite disturbance or weight loss
Psychomotor retardation / agitation
Suicidal thoughts
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American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, 2000:352.
Ohayon MM, et al. J Clin Psychiatry 2004;65[suppl 12]:5–9
BCMJ, Vol. 44, No. 8, October 2002, page(s) 415-419
Measurement Based Care
HAM-D 7 and Sig: E Caps
SIGECAPS HAMD-7
Core Symptoms of Depression
Depressed Mood
Sleep decreased
Interest decreased in activities (anhedonia)
Guilt or worthlessness
: Associated Symptoms
Energy decreased
Concentration difficulties
Appetite disturbance or weight loss
Psychomotor retardation / agitation
Suicidal thoughts
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, 2000:352.
Ohayon MM, et al. J Clin Psychiatry 2004;65[suppl 12]:5–9.
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Other Scales to Identify Additional Symptoms
GAF to WHODAS: Assessing Function
PLANNING CARE
Patient Factors
Quality Safety Health Care 2002;11:214–218
Severity of Illness
Patient Preference
Medication Side Effects
Cultural and Spiritual beliefs
Motivation
Willingness to participate in Care Planning
Family History
RA
TIO
NA
LE
Planning Care: Patient Factors
What to Consider
Planning Care: Resource Availability
Resource Intensity
Bower et al. BMJ 2013;346:f540
Hospitalization, ECT, rTMS, DBS
Medications
Live Psychotherapy
Internet Resources
Books, Self Help, Videos
Low Resource
Intense
Interventions
High Resource
Intense
Interventions
https://moodgym.anu.edu.au
Talk Meds Combo
Planning Care:
Talk Therapy, Medications or Both
Do they help you decide?
TREATMENT GUIDELINES
• What is your best therapeutic choice?
• What is the impact of comorbid psychiatric or medical
conditions, psychosocial factors?
• Age, gender differences: do they matter?
• How well do guidelines reflect my clinical practice?
Treatment Guidelines: Do they help you decide?
J Couns Psychol. 2012 Jan;59(1):134-49. Epub 2011 Oct 24
• Depression duration <4 weeks or >24 months
• Another comorbid Axis I disorder
• Borderline Personality Disorder
• Dysthymic Disorder
• Bipolar disorder
• Psychotic features
• Insufficient symptom severity
• Substance abuse in prior 6 months
• Suicidal ideation
• Comorbid anxiety
Problem... these issues are also common in ‘real world’ patients!
Zetin & Hoepner. J Clin Psychopharmacol 2007; 27: 295-301.
Top 10 Exclusion Criteria in Antidepressant RCTs
Medication Choices
MAJOR DEPRESSIVE DISORDERCANADIAN GUIDELINES
Canadian Guidelines
First Line Antidepressants
Medication Required?
12 Choices: First Line Equal Efficacy
Level1 Evidence
Created by Tom Janzen, M.D.
R.W. Lam et al. Journal of Affective Disorders 117 (2009) S26–S43
How do you
decide?
MATCHING PATIENT COMPLAINTS TO NEUROBIOLOGY
DSM 5Core Symptoms
5-HT NE DAImportant Brain Regions
Involved in MDD symptoms
Depressed Mood VMPFC, A VMPFC, A VMPFC, A• Prefrontal Cortex (PFC)
• VentroMedial (VMPFC)
• DorsoLateral (DLPFC)
• Orbital (OFC)
• Basal Forebrain (BF)
• Hypothalmus (Hy)
• Thalmus (Th)
• Spinal Cord (SC)
• Nucleus Accumbens (NA)
• Striatum (S)
• Cerebellum (C)
• Amygdala (A)
SleepPFC, BF, Hy,
ThPFC, BF, Hy,
ThPFC, BF, Hy,
Th
InterestApathy
PFC, Hy PFC, Hy, NA
GuiltWorthlessness
VMPC, A
Energy PFC, SC PFC, S, NA
ConcentrationExec. Function
DLPFC DLPFC
Appetite/Weight Hy
PsychomotorAgitation orRetardation
PFC, NA, S PFC, C PFC, NA, S
SuicideVMPFC, OFC, A
Linking Symptoms and Circuits
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Adapted from Stephen Stahl, Essential Psychopharmacology, March 2008Created by Tom Janzen, M.D.
Associated Symptoms
5-HT NE DAImportant Brain Regions
Involved in MDD symptoms
Anxiety PFC, A, Th, S
• Prefrontal Cortex (PFC)
• VentroMedial (VMPFC)
• DorsoLateral (DLPFC)
• Orbital (OFC)
• Basal Forebrain (BF)
• Hypothalmus (Hy)
• Thalmus (Th)
• Spinal Cord (SC)
• Nucleus Accumbens (NA)
• Striatum (S)
• Cerebellum (C)
• Amygdala (A)
Pain PFC, Th, SC PFC, Th, SC
Sexual Dysfunction
NA, SC
Sleepiness/ Hypersomnia
PFC, BF, T, Hy
PFC, BF, T, Hy
Vasomotor Hy Hy
Associated Symptoms: Commonly Seen in MDD
Adapted from Stephen Stahl, Essential Psychopharmacology, March 2008Created by Tom Janzen, M.D.
DSM 5
Core Symptoms5-HT NE DA PHQ -9 Questionnaire
No
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da
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Mo
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Interest/Apathy 1. Little interest or pleasure in doing things 0 1 2 3
Depressed Mood 2. Feeling down, depressed, or hopeless 0 1 2 3
Sleep3. Trouble falling or staying a sleep, or
sleeping too much0 1 2 3
Energy 4. Feeling tired or having little energy 0 1 2 3
Appetite/Weight 5. A or B A. Poor appetite 0 1 2 3
B. Overeating 0 1 2 3
Guilt
Worthlessness
6. Feeling bad about yourself—or that you are
a failure or have let yourself or your family
down
0 1 2 3
Concentration
Exec. Function7. Trouble concentrating on things, such as
reading the newspaper or watching tv0 1 2 3
Psychomotor Agitation or
Retardation8. A or B
A. Moving or speaking so slowly
that other people could have
noticed. 0 1 2 3
B. Being so fidgety or restless that
you have been moving around a lot
more than usual0 1 2 3
Suicide9. Thoughts that you would be better off dead,
or of hurting yourself in some way0 1 2 3
Adapted from Stephen Stahl, Essential Psychopharmacology, March 2008
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Current Symptoms:
Connecting Neurotransmitters and Scales
Created by Tom Janzen, M.D.
Associated Symptoms
5-HT NE DA Possible Questions to Ask
Anxiety Experience anxiety and worry about the future
Pain
Experiencing pain of unknown origin or excessively worried about their pain (back
pain, muscle or joint pain, headaches, stomach pain, etc.)
Sexual DysfunctionLow sexual interest, difficulty achieving
orgasm, decreased satisfaction
Sleepiness/ Hypersomnia
Tired all day and fall asleep at any tme
Vasomotor Symptoms
(perimenopausal)
Prominent hot flushes more pronounced than similar aged friends
Consider Associated Symptoms of Depression
Adapted from Stephen Stahl, Essential Psychopharmacology, March 2008Created by Tom Janzen, M.D.
• Marriage breakup
• Financial stressors
• Substance abuse
• Friendships/relationships
• Concerns re physical health
Consider Life Circumstances:How does this impact treatment considerations?
Circuits and Side Effects
Adapted from Stephen Stahl, Essential Psychopharmacology, March 2008, Clinical Handbook of Psychotropic Drugs
R.W. Lam et al. Journal of Affective Disorders 117 (2009) S26–S43
Adapted from Virani et al. Clinical Handbook of Psychotropic Drugs Online 2012.
• Dyspepsia, nausea, headaches, nervousness, akathesia, EPS, anorexia, sexual side effects
5HT Reuptake Transporter
Blockade
• Tremors, tachycardia, hypertension, sweating, insomnia, erectile and ejaculatory problems
NE Reuptake Transporter
Blockade
• Psychomotor activation, aggravation of psychosisDA Reuptake Transporter
Blockade
• Hypotension, ejaculatory problems, sedation, weight gain (5HT2C)
5HT2A Receptor Blockade
• Dry mouth, blurred vision, constipation, urinary retention, tachycardia, memory disturbances, sedation, glaucoma
M1 Receptor Blockade
• Sedation, postural hypotension, weight gainH1 Receptor Blockade
• Helping patients achieve functional recovery requires a
coordinated care plan developed in conjuction with your
patient
• Rational choices should be made using knowledge of
your patients physical, mental and psychosocial
circumstances
• Understanding how symptoms of depression link to brain
circuits can help inform medication choices
Summary