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Toronto Notes 2019
Common Presenting Problems
Family Medicine FM21
Depression
• seePsychiatry,PS10
Etiology
• oftenpresentsasnon-specificcomplaints(e.g.sleepdisturbance,chronicfatigue,pain)
• depressionisaclinicaldiagnosisandtestsaredoneinordertoruleoutothercausesofsymptoms • 2/3ofpatientsmaynotreceiveappropriatetreatmentfortheirdepression
• earlydiagnosisandtreatmentimproveoutcomes
Screening Questions
• CanadianTaskForceonPreventiveHealthCare(2013)recommendsnotroutinelyscreeningfordepression
• ifscreeningindicated,useThePatientHealthQuestionnaire(PHQ-2).“Overthepast2weeks,howoften
have you been bothered by any of the following problems?”: ■ little interest or pleasure in doing things
■ feeling down, depressed, or hopeless
• the PHQ-2 is scored out of 6, with a score of 3 or more considered positive. Those who screen positive should be evaluated with the PHQ-9 to determine whether they meet criteria for depression
• PHQ-9 tool is useful to diagnose and monitor depression; use Geriatric Depression Scale (GDS) for the geriatric population
Assessment
• riskfactors:seePsychiatry,PS10
• personal or family history of depression
• medications and potential substance abuse problems • highriskforsuicide/homicide
■ fill out Form 1 (in Ontario): application by physician to hospitalize a patient against his/her will for psychiatric assessment (up to 72 h)
• functionalimpairment(e.g.work,relationships)
• atleast5outof9criteriaincludingatleastoneofanhedoniaordepressedmood≥2wkforactual
diagnosis to be met (see sidebar)
• validated depression rating scales: Beck’s Depression Inventory, Zung’s self-rating depression scale,
Children’s Depression Inventory, Geriatric Depression Scale, Personal Health Questionnaire Depression
Scale (PHQ-9)
• routinemedicalworkup(physicalexam,CBC,TSH,ferritin,folate,B12,electrolytes,urinalysis,glucose,
etc.)
Treatment
• goal:fullremissionofsymptomsandreturntobaselinepsychosocialfunction
• phasesoftreatment
■ acute phase (8-12 wk): relieve symptoms and improve quality of life
■ maintenance phase (6-12 mo after symptom resolution): prevent relapse/recurrence, must stress
importance of continuing medication treatment for full duration to patients
• treatmentoptionsarepharmacotherapy,psychotherapy,oracombinationofboth
■ combination therapy is synergistic and most effective (refer to EBM in sidebar)
• treatment of youth (age 10-21)
■ for mild depression, a period of active support and monitoring before initiating treatment is recommended
■ fluoxetine is first line among SSRIs (most evidence)
◆ monitor closely for adverse effects such as suicidal ideation and behaviour
■ psychotherapy
◆ CBT or interpersonal therapy (IPT) alone can be used for mild depression
◆ psychotherapy plus medication is recommended for moderate to severe depression
■ treatment should continue for at least 6 months
◆ ongoing management should include assessment in key domains (school, home, social setting) ◆ reassessment and referral is recommended if there is no improvement after 6-8 wk of treatment ◆ consider referral for adolescents with moderate/severe depression and coexisting psychosis and/
Must Ask About/Rule Out
• Suicidal/homicidal ideation
• Psychosis
• Substance use/abuse/withdrawal • Anxiety
• Bipolar/manic/hypomanic episodes • Bereavement
• Intimate partner violence
• Post-partumdepression
• Organic cause
Differential Diagnosis
• Other psychiatric disorders (e.g. anxiety, personality, bipolar, adjustment disorder, schizoaffective, seasonal affective disorder, substance abuse/withdrawal)
• Cancer (50% of patients with tumours, especially of brain, lung, and pancreas, develop symptoms of depression before the diagnosis of cancer is made)
• Chronic fatigue syndrome
• Early dementia
• Endocrine (e.g. hyper/hypothyroidism, DM,
adrenal disorders)
• Infections (mononucleosis)
• Liver failure, renal failure
• Medication side effects (β-blockers,
benzodiazepines, glucocorticoids,
interferon)
• Menopause
• Neurological (Parkinson’s, MS)
• Vitamin deficiency (pernicious anemia,
pellagra)
Criteria for Depression (≥5/9 with at least one of anhedonia or depressed mood for ≥2 wk)
M-SIGECAPS
M Depressed Mood
S Increased/decreasedSleep
I Decreased Interest
G Guilt
E Decreased Energy
C DecreasedConcentration
A Increased/decreased Appetite and weight P Psychomotor agitation/retardation
S Suicidal ideation
Combined Pharmacotherapy and Psychological Treatment for Depression: A Systematic Review
Arch Gen Psychiatry 2004;61:714-719
Purpose: To examine the relationship between adherence and efficacy of antidepressant medications plus psychological treatment versus medications alone in the management of depressive disorders.
Methods: Systematic review of RCTs comparing antidepressant medications alone versus combination therapy with psychological intervention included. Efficacy and adherence to therapy were the main outcomes. Results: 16 trials with 1,842 patients were included. Patients receiving combination therapy showed significantly greater improvements than those receiving medications alone (odds ratio (OR) 1.86, 95% CI 1.38-2.52); dropout and non-responder proportions did not differ in distribution between the two groups (OR 0.86, 0.60-1.24). A significant advantage with combination therapy was noted in studies with follow-up longer than 12 weeks (OR 2.21, 1.22-4.03), accompanied by significant reduction in dropout and non-responder proportions.
Conclusion: Combination therapy with psychological treatment and medication is associated with greater improvement rates than medication alone, and may decrease dropout rates with longer therapies.
or substance abuse
Table 12. Common Medications
Class Examples
SSRI paroxetine (Paxil®) fluoxetine (Prozac®)
sertraline (Zoloft®) citalopram (Celexa®) fluvoxamine (Luvox®) escitalopram (Cipralex®)
SNRI venlafaxine (Effexor®) duloxetine (Cymbalta®)
SDRI bupropion (Wellbutrin®) TCA amitriptyline (Elavil®)
Action
Block serotonin reuptake
Block serotonin and NE reuptake
Block dopamine and NE reuptake
Block serotonin and NE reuptake
Side Effects
Sexual dysfunction (impotence, decreased libido, delayed ejaculation, anorgasmia), headache, GI upset, weight loss, tremors, insomnia, fatigue, increase QT interval (baseline ECG is suggested)
Insomnia, tremors, tachycardia, sweating
Headache, insomnia, nightmares, seizures, less sexual dysfunction than SSRIs
Sexual dysfunction, weight gain, tremors, tachycardia, sweating
Notes
First line therapy for youth is fluoxetine; paroxetine is not recommended for youth (controversial)
Often chosen for lack of sexual side effects, can be used for augmentation of anti-depressant effects with other classes of medication
Narrow therapeutic window, lethal in overdose