General Introduction to Depression

Public Health Detailers Training NYC Department of Health and Mental Hygiene Sandra Ramos, PhD Deputy Director, Office of Program Development Judy Stein, LMSW, MS Co-Director, NYC DOHMH Depression Initiative

Outline
What is depression Symptoms Causes Types Risk Factors Women Elderly Young Adults

Outline
Racial/Ethnic Disparities Psychosocial/Environmental Factors Burden Detailing Messages

What Is Depression?
A very common, highly treatable, medical illness. Affects physical, mental and emotional well-being. Affects basic, everyday activities like eating and sleeping. Affects how people think about things and feel about themselves.

What is Depression?
In contrast to the normal emotional experiences of sadness, loss, or passing mood states, clinical depression is persistent and can interfere significantly with an individual's ability to function. People with depressive illness cannot just pull themselves together and get over it.

Depression often takes on a life of its own without treatment, symptoms can last months or even years.

Symptoms of Depression
Feeling sad, blue, or down in the dumps
Loss of interest in things you usually enjoy

Feeling slowed down or restless

Having trouble sleeping or sleeping too much

Symptoms of Depression
Loss of energy or feeling tired all the time Having an increase or decrease in appetite or weight

Having problems concentrating, thinking, remembering or making decisions

Feeling worthless or guilty Having thoughts of death or suicide

Symptoms of Depression
People with Major Depression experience at least five of these symptoms all day, nearly every day, for at least 2 weeks. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Causes of Depression
Causes not known, but current theories include: Genetic Runs in families However, depression can also occur in people who have no family history. Environmental A serious loss, difficult relationship, financial problem, or any stressful (unwelcome or even desired) change in life patterns can trigger a depressive episode.

Causes of Depression
Personality Characteristics low self-esteem, pessimistic world view, low stress tolerance Whether this represents a psychological predisposition or an early form of the illness is not clear. Biological Continues to be studied extensively Current thinking explores problems in brain functioning in the following areas: Limbic system, neurotransmitters and neurons, hormones and the endocrine system

Causes of Depression
Combination a combination of genetic, psychological, environmental, and/ or biological factors may contribute to the onset of a depressive disorder.

Forms of Depression
Major Depression At least 5 of the 9 symptoms of depression present including either loss of interest/pleasure or depressed mood; symptoms interfere with daily functioning Minor Depression Fewer symptoms than major depression with significant disability; shorter duration than chronic depression

Forms of Depression
Bipolar Disorder Cycling mood changes with severe highs (mania) and severe lows (depression) Dysthymia Low grade chronic symptoms of depression that last for a minimum of 2 years

Depression and Suicide

Of those with MDD, close to 50% report feelings of wanting to die, 33% consider suicide and 8.8% report a suicide attempt. More than 90% of those who commit suicide have a diagnosable psychiatric illness at the time of death, usually depression, alcohol abuse or both

Who is at risk for Depression?

Anyone is potentially at risk for a depressive illness. Yet, these groups are believed to be at higher risk: Older adults Young adults Women, pregnant and post partum women Note: women report depression about twice as often as men. This may result from a greater likelihood to discuss depression or to seek help.

Depression in Women
Depression is the second leading cause of disease-related disability among women 1 in 4 women will suffer from a Major Depressive Episode during the course of their lives as compared to 1 in 10 men. Women may be more likely to discuss depression or to seek help. Women of childbearing age are at increased risk for major depression Pregnancy and new motherhood may increase the risk of depressive episodes

Depression in Older Adults

Of the nearly 35 million Americans age 65 and older, an estimated 2 million have a depressive illness (major depressive disorder, dysthymic disorder, or bipolar disorder). Symptoms of clinical depression can be triggered by other chronic illnesses common in later life, such as Alzheimers disease, Parkinsons disease, heart disease, cancer and arthritis. Depression is one of the most common conditions associated with suicide in older adults. Individuals age 65 and older have highest rates of suicide High suicide rate among older people (85 and older) is largely accounted for by White men.

Depression in Young Adults

10% of college students have been diagnosed with depression, including 13% of college women.
Lifetime prevalence for MDE highest among young adults age 18-25 (10%) Suicide is the third leading cause of death for those aged 15-24

Additional Risk Factors for Depression

Family or personal history of depression Current substance abuse problem

A major life stressor or change in life events; i.e.: loss of a loved one or a job
Chronic disease

Depression in Racial/Ethnic Minorities

Mental health needs of minority racial/ ethnic groups remain largely unmet . Certain groups have higher rates of major depression
Native Americans Women (middle aged, separated or divorced, low-income)

Mexican- American and white individuals

Have significantly earlier onset of major depressive disorder compared with African Americans.

Depression in Racial/Ethnic Minorities

Latinos with self reported depression are less likely to: receive any treatment for depression fill an antidepressant prescription receive adequate course of psychotherapy African American and Latinos are more likely than Whites to be under-diagnosed and undertreated Minorities are less likely than Whites to receive treatments that adhere to treatment guidelines

Explanatory Factors
Lack of insurance coverage Poor access to appropriate screening and early detection Tendency to attribute mental health problems to religious and other cultural belief systems Lack of access to receptive and culturally compatible providers

Psychosocial/Environmental Factors
Psychosocial health has been associated with mental health in general and with depression in particular Neighborhood social disorganization is associated with depressive symptoms, Living in socio-economically deprived areas is associated with depression. A recent study found
29 % - 58% were more likely to report part 6 month depression 36% - 64 % were more likely to report lifetime depression

Depression Burden
Untreated depression causes distress, disability, and, most tragically suicide.
Depressive disorders are associated with increased prevalence of chronic diseases (e.g. asthma, diabetes)

Increased use of general medical services as well as costlier health services, such as Emergency Room and Inpatient.

Depression Burden
Patients who are depressed are more likely to engage in behaviors that contribute to poor health, such as smoking, limited or no exercise, poor eating habits and are likely to have greater difficulty managing their comorbid conditions.

Depressive disorders are projected to become the leading cause of disability and the second leading contributor to the global burden of disease by 2020

US workers with depression cost employers an estimated $44 billion per year.

Detailing Messages
Primary care physicians can effectively detect and manage depression. Routinely screen for depression using a simple 2-question tool (PHQ2) Depression can be treated! Medication and psychotherapy, alone or in combination, can help most patients.

Detailing Messages
Primary care physicians can effectively detect and manage depression.

Detection of Depression: Why Screen and Manage in primary care?

Primary care is the 1st line of defense = To find people who may be depressed or at risk for depression who dont know it

Screening for depression in the primary care setting improves detection rates US Preventative Service Task Force (USPSTF) recommends screening adults for depression in clinical practices that have systems in place for accurate diagnosis, effective treatment, and follow-up.
Only 50% of those referred to specialty mental health practitioners complete more than one visit

Detailing Messages

Routinely screen for depression using a simple 2-question tool (PHQ2)

Depression Screening: PHQ2

A physician can simply and quickly screen for depression by asking 2 questions (PHQ2): During the past 2 weeks, have you been bothered by: 1. little interest or pleasure in doing things? 2. feeling down, depressed, or hopeless? The PHQ-2 is a valid and practical tool for depression screening in busy medical settings.

Detailing Messages

Depression can be treated! Medication and psychotherapy, alone or in combination, can help most patients.

Detailing Messages
More than 80% of people with clinical depression can be successfully treated. Antidepressants are the 1st line treatment for moderate to severe depression About half of the moderate to severe episodes of depression will improve with antidepressant treatment A combination of pharmacotherapy and psychotherapy may improve treatment response , reduce risk of relapse, enhance quality of life, and increase adherence to pharmacotherapy.