The document discusses diagnosing depression in medical settings, including the high prevalence of depression among those with medical illnesses like cancer, heart disease, and stroke. It notes that depression is commonly comorbid with physical illnesses and associated with worse health outcomes including higher mortality. The document also examines challenges with conventional depression screening in medical settings and potential new innovations in screening.

1. Diagnosing Depression in Medical Settings:
Symptoms and screening….60min workshop
Alex Mitchell ajm80@le.ac.uk
Consultant in Liaison Psychiatry & Psycho-oncology
RCPsych Workshop 2011

2. 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

3. Special
Symptoms
Physical
Illness
Primary
Symptoms
DSMV Older people Care
ICD11
Detection
Depression
Quality
of care
Scales
Distress
Screening

4. Contents
Overview Depression in medical settings
Comorbidity | impairment | mortality
Prevalence of depression in medical settings
Cancer | IHD | Stroke
Symptoms of Depression in medical settings
Same or different?.....older people?
Conventional screening
Accuracy | acceptability | Does it work?
New Screening innovations
Why?

5. 1.Overview: Depression in medical settings
Comorbidity | impairment | mortality

6. Impairment: Days totally out of role per year
50
Yearly DOR
45 Unique
42.9 42.7
PAR%
41.2
39.8
40 39.3
36.6
35 34.4
33.8
30.6
30
25
20
17.3
15.2
15 14.3
10 9
7.3 7.7
5.1
5 3.9
2.6 2.2 2.5
1.8 1.7 1.9
1.4 1
0.3 0.1
0
Depression Panic disorder PTSD Specific phobia Social phobia Bipolar disorder GAD Alcohol abuse Drug abuse

7. n=245 404 participants from 60 countries
Quality of life: Moussavi et al (2007) Lancet 2007; 370: 851–58

8. Mortality and IHD+depression
Psychosomatic Med (2004) Barth et al

9. 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

10. % 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
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in
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N
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Wang P et al (2007) Lancet 2007; 370: 841–50 => In physical

11. 12mo Service Use (NIH, 2002)
40
34.6
35 32.7 Cancer n=4878
No Cancer n=90,737
30
25
19.1
20
% Receiving Any treatment for Mental Health
% Receiving Any treatment for Mental Health
16.1
14
15
11.7 11
8.9
10 7.7
7.2 6.5
5.7 5.7 5 6.3 6.4 6.2
5
5 3.9 3.2
2.3 1.8
0
l th
l th
ons
nt s
ti o n
s
s
75+
rs
rs
rs
ti o n
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atie
d iti
n di
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44
64
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P
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Al l
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18-
45-
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di ca
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Me
Me
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No
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hr o
hr o
hr o
c hr
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2c
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Two explanations=>
No
Maria Hewitt, Julia H. Rowland Mental Health Service Use Among Adult Cancer Survivors: Analyses of the National Health Interview Survey Journal of Clinical
Oncology, Vol 20, Issue 23 (December), 2002: 4581-4590

12. Audience:
How common are medical co-morbidities in depression?

13. Comorbid Physical Diagnoses in Elderly Depressed
Patients
80
70
60
50
40
30
20
10
0
One Tw o Three+ None
Proctor EK, et al (2003) American Journal of Geriatric Psychiatry;11:329‐38.

14. Ca
rd
io
va
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
sc
u lar
d ise
Fu
nc as
tio e
na
ls
om
at
ic
sy
nd
ro
m
es
Os
te
oa
r ti
cu
lar
dis
or
de
rs
Ne
ur
ol
og
ica
ld
is
ea
se
De s
rm
at
ol
og
ica
ld
ise
as
es
En
d oc
rin
e dis
or
de
rs
Re
sp
ira
to
ry
d ise
as
es
Di
First Episode MDD (n=6090)
ge
st
ive
d
Recurrent Episode MDD (n=4167)
ise
Ur as
in es
ar :U
y lce
tra
ct r
d ise
as
e:
R en
al
lith
ias
is
An
ym
ed
ic
al
d iso
rd
er

15. Hy
pe
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
rte
ns
io
Os n
te
oa
r th
rit
is
He
ad
ac
Ch Hy he
ro pe
nic rli
pi
fat de
ig m
ue ia
sy
nd
ro
m
e
Ch
ro
nic
pa
Irr in
Se ita
bo bl
eb
rrh ow
oe el
ic
de
rm
at
iti
s
Mi
gr
ain
Di
sc e
h er
ni
at
io
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Di
ab
et
Fi es
br
om
ya
lg
ia
Ec
ze
m
Di
ge a
st
ive
Ul
ce
r
As
th
First Episode MDD (n=6090)
Th m
yr
oi a
d di
Recurrent Episode MDD (n=4167)
se
as
e
CO
PD
Ps
or
ia
sis
Re
na
l li
th
Ac ias
ut is
e
inf
ar
ct
io
n
Ep
ile
p
sy
Pa
rk
in
so
n

16. 40
Physical C omorbidity in S chiz ophrenia and D epression
35
30
Schizophrenia
Depression
25
NHANES
20
15
10 Sokal 2004
J Nerv Ment Dis 192: 421–
427
5
0
Angina
Ulcer
Heart condition
Any cancer
Asthma
Diabetes
Chronic bronchitis
Stroke
Emphysema
Hypertension
Myocardial infarction
Rheumatoid arthritis
Osteoarthritis
Coronary heart
Weak/failing kidneys
Congestive heart
Liver problems
disease
failure
NHANES ‐ US Department of Health National Health and Nutrition Examination Survey , 1988 –1994

17. Prevalence Depression in medical settings
Methodological | Scale vs interview | Current vs 12mo vs lifetime
Cancer | IHD | Stroke

18. Isc
hem
0
1
2
3
4
5
6
7
8
9
10
ic h
ear
t di
sea
Rhe se
um
ato
id ar th
r iti s
Dia
bet
es m
elli
tus
Pr o
Suicide odds ratio
s ta
te c
anc
Hyp
era er
ci d
ity
s ynd
rom
es
Bre
ast
can
c er
Par
k in s
o nd
isea
C hr se
oni
c lu
ng
d is
ea s
Con
g es e
tive
hea
rt fa
i lur
e
Mo
d er
ate
pai
Uri n
nar
y in
c on
ti ne
nc e
Se i
zur
ed
A nx i so
rd e
ie ty
an d r
s le
ep
d is
Psy ord
cho ers
ses
a nd
ag i
ta ti
on
Dep
res
si o
n
Juurlink (2004) 1354 older individuals who died of suicide in Ontario, CA
Sev
e re p
ain
B ip
o la
r di
sor
der

19. National Health Interview Survey (NHIS) – CIDI‐SF
18
16
14
12
10
8
6
4
2
0
1)
)
4)
)
er
1)
10
)
31
)
68
91
91
79
37
rd
=7
=4
=1
34
=3
=1
so
=7
(n
(n
(n
=
(n
(n
di
(n
(n
VA
re
PD
re
s
o
n
is
ilu
te
N
lu
C
io
O
D
be
Fa
ai
ns
C
y
tF
ia
er
te
al
D
rt
ar
er
en
A
He
yp
R
y
H
ar
ge
e
iv
on
ta
st
-S
or
ge
C
d
on
En
C
Egede (2007) 12mo prevalence rates from the Data on 30,801 adults from the US 1999 National Health

20. Prevalence of depression in Oncology settings Plumb & Holland (1981)
Proportion meta-analysis plot [random effects]
0.7750 (0.6679, 0.8609)
Levine et al (1978) 0.5600 (0.4572, 0.6592)
Ciaramella and Poli (2001) 0.4900 (0.3886, 0.5920)
Massie et al (1979) 0.4850 (0.4303, 0.5401)
70 studies involving 10,071 individuals;14 countries. Bukberg et al (1984)
Passik et al (2001)
0.4194 (0.2951, 0.5515)
0.4167 (0.2907, 0.5512)
16.3% (95% CI = 13.9% to 19.5%) Baile et al (1992)
Morton et al (1984)
Hall et al (1999)
0.4000 (0.2570, 0.5567)
0.3958 (0.2577, 0.5473)
0.3722 (0.3139, 0.4333)
Burgess et al (2005) 0.3317 (0.2672, 0.4012)
Jenkins et al (1991) 0.3182 (0.1386, 0.5487)
Mj 15% Mn 19% Adj 20% Anx 10% Dysthymia 3%
Green et al (1998) 0.3125 (0.2417, 0.3904)
Kathol et al (1990) 0.2961 (0.2248, 0.3754)
Hosaka and Aoki (1996) 0.2800 (0.1623, 0.4249)
Fallowfield et al (1990) 0.2565 (0.2054, 0.3131)
Golden et al (1991) 0.2308 (0.1353, 0.3519)
Spiegel et al (1984) 0.2292 (0.1495, 0.3261)
Evans et al (1986) 0.2289 (0.1438, 0.3342)
Grandi et al (1987) 0.2222 (0.0641, 0.4764)
Maunsell et al (1992) 0.2146 (0.1605, 0.2772)
Berard et al (1998) 0.2100 (0.1349, 0.3029)
Joffe et al (1986) 0.1905 (0.0545, 0.4191)
Berard et al (1998) 0.1900 (0.1184, 0.2807)
Devlen et al (1987) 0.1889 (0.1141, 0.2851)
Leopold et al (1998) 0.1887 (0.0944, 0.3197)
Akizuki et al (2005) 0.1797 (0.1376, 0.2283)
Razavi et al (1990) 0.1667 (0.1189, 0.2241)
Gandubert et al (2009) 0.1597 (0.1040, 0.2300)
Alexander et al (1993) 0.1333 (0.0594, 0.2459)
Kugaya et al (1998) 0.1328 (0.0793, 0.2041)
Payne et al (1999) 0.1290 (0.0363, 0.2983)
Ibbotson et al (1994) 0.1242 (0.0776, 0.1853)
Prieto et al (2002) 0.1227 (0.0825, 0.1735)
Morasso et al (1996) 0.1121 (0.0593, 0.1877)
Desai et al (1999) [early] 0.1111 (0.0371, 0.2405)
Silberfarb et al (1980) 0.1027 (0.0587, 0.1638)
Costantini et al (1999) 0.0985 (0.0535, 0.1625)
Morasso et al (2001) 0.0985 (0.0535, 0.1625)
Ozalp et al (2008) 0.0971 (0.0576, 0.1510)
Love et al (2002) 0.0957 (0.0650, 0.1346)
Alexander et al (2010) 0.0900 (0.0542, 0.1385)
Coyne et al (2004) 0.0885 (0.0433, 0.1567)
Kawase et al (2006) 0.0851 (0.0553, 0.1240)
Walker et al (2007) 0.0831 (0.0568, 0.1165)
Grassi et al (1993) 0.0828 (0.0448, 0.1374)
Grassi et al (2009) 0.0826 (0.0385, 0.1510)
Reuter and Hart (2001) 0.0761 (0.0422, 0.1244)
Lee et al (1992) 0.0660 (0.0356, 0.1102)
Pasacreta et al (1997) 0.0633 (0.0209, 0.1416)
Sneeuw et al (1994) 0.0540 (0.0367, 0.0761)
Singer et al (2008) 0.0519 (0.0300, 0.0830)
Katz et al (2004) 0.0500 (0.0104, 0.1392)
Mehnert et al (2007) 0.0472 (0.0175, 0.1000)
Lansky et al (1985) 0.0455 (0.0291, 0.0676)
Derogatis et al (1983) 0.0372 (0.0162, 0.0720)
Hardman et al (1989) 0.0317 (0.0087, 0.0793)
Massie and Holland (1987) 0.0147 (0.0063, 0.0287)
Colon et al (1991) 0.0100 (0.0003, 0.0545)
combined 0.1730 (0.1375, 0.2116)
0.0 0.3 0.6 0.9
proportion (95% confidence interval)

21. Meta regression using the random effects model on raw porportions
Estimated slope = - 0.02 % per month (p=0.0016). Circles proportional to study size.
0.4
0.3
Proportion
0.2
0.1
0.0
0 20 40 60 80 100
Time (months)

23. 1a. Routine Recognition of Depression
Is depression a disease; disorder (syndrome) or normally distributed

24. Audience:
Is depression categorical or dimensional?

25. 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
Ischaemic change on mri

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

27. 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

28. 0
1000
1500
2000
2500
3000
500
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
ft e
en
Si
xt
ee
Se n
ve
nt
ee
Ei n
gh
te
en

29. 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.

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

31. 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

33. 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
s
L
ris
i
n
a
n
r
z
go
an
i
na
tle
e
iro
ak
en
ha
te
TA
ar
ge
n
rli
r
lo
Pa
ai
ad
ia
ro
at
es
as
ne
h
g
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)

34. Audience:
What are the predictors of improved recognition?

35. 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

36. 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