Diagnose, psykopatologi og forløb ved depression

Transkript

1 Diagnose, psykopatologi og forløb ved depression Lars Vedel Kessing Psykiatrisk Center København

2 Personer behandlet med antidepressive lægemidler i Danmark N (8 %) Ca. 95 % af alle recepter med antid. medicin ordineres af praktiserende læger. Lægemiddelstyrelsen

3 Epidemiologi Tilstande, som kan behandles med antidepressiv medicin 12 måneders prævalens Depression 3.9 % Angsttilstande 6.4% Skizofreni, Bipolar, PD, Anorexi 4.0% I alt, ca. 14% ( personer)

4 Most antidepressant use in primary care is justified; Results from the Netherlands study of depression and anxiety. Piek et al, Plos One, 6, e % af patienter som fik AD i almen praksis fik medicinen på en ikke godkendt indikation.

5 Diagnosticering og behandling af depression Populationsbaseret: % diagnosticeres ikke 15 % behandles ikke sufficient % får korrekt diagnose og behandling i sufficiente doser og tid (Lépine et al, 1997; Munk-Jørgensen et al, 1997; Greden, 2001, Olsen et al, 2004) Nyere undersøgelse: Results from the Netherlands study of depression and anxiety.: 39.5 % af patienter med depression diagnosticeres ikke (Piek et al, J. Affect. Disord.,2012).

6 Development and validation of the current concept of major depression. Maj M. Psychopathology. 2012;45(3): The threshold for the diagnosis of major depression fixed by operational definitions has been criticized for either being too high, excluding many depressive states which do not differ from currently defined major depression on several variables, or too low, so that the milder cases receiving the diagnosis do not respond to antidepressants better than to placebo. It has been stated that current operational criteria do not convey anymore the gestalt of the depressive syndrome, and that they lead to the inclusion under the heading of depression of several homeostatic responses to adverse life events.

7 Diagnosticeres stress, udbrændthed og sorg som depression?

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9 Følelse (= emotion): Forbigående positiv eller negativ oplevelse ofte umiddelbart udløst af en ydre påvirkning Affekt: Kompleks pludselig opstået og noget længerevarende oplevelse oftest begrænset til enkelte mentale områder og påvirkelig af ydre stimuli / ændringer Stemningsleje: Langvarig (> 2 uger) og vedvarende ændring af følelsesmæssig (emotionel) status, som påvirker alle mentale områder (global) og ikke påvirkes af ydre stimuli / ændringer (ingen/nedsat reaktivitet) (Frit efter Andrew Sims: Symptoms in the mind (1988))

10 Stress, genetics and the risk of developing a depressive episode Caspi et al, Science 2003, 301,

11 Forest plot for the 56 human observational studies assessing the relationship between 5- HTTLPR, stress, and depression Karg, K. et al. Arch Gen Psychiatry 2011;68: Copyright restrictions may apply.

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13 Stemningsleje: Klinisk tolkning: Patienten kan (ihht.icd-10 og DSM-V) have ændret stemningsleje selv om patienten: benægter at føle sig nedtrykt eller opstemt angiver ikke at have nogen følelser (følelsesløshed / følelsestomhed) snarere angiver at føle sig angst snarere angiver somatiske klager (ubehag, smerte, m.m.) snarere fremtræder irritabel

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15 Diagnostic stability in depressive disorder as according to ICD-10 in clinical practise Kessing LV. Psychopathology 2005, 38:32-7. In 56% of patients, the initial diagnosis of depressive disorder eventually changed during followup mainly to schizophrenic spectrum (16%) personality disorders (9%) neurotic, stress-related and somatoform disorders (8%) bipolar disorder (8%) Among the 18% of patients who were later diagnosed with depressive disorder, 23% initially had a diagnosis of adjustment disorder.

16 Sensitization in affective disorders Sensitization in affective disorders Post et al, 1996 Episode effekt: Tiltagende risiko for nye episoder med hver episode Tiltagende sværhedsgrad med hver ny episode

17 , Kessing et al, 1998

18 Time to recurrence according to the number of episodes ( ) Kessing et al, 2004.

19 Kessing et Angst, 2004.

20 Episode-effekt i NIMH-studie (Solomon 2000, 2001) 318 patienter med unipolar depression fulgt prospektivt i 10 år Korrektion for den individuelle heterogeneitet v.h.a. mixed-effects, grouped-time survival analyses Resultater: Antallet af tidligere episoder prædikterede øget risiko for recurrence: OR = 1.16 (95 % CI: ) Mænd: 1.17 (95 % CI: ) Kvinder: 1.13 (95 % CI: ) Kessing et Angst, 2004.

21 Life events relation to affective episodes Kendler et al, 2000: Method: 2395 female twins followed for 9 years and interviewed 4 times 1380 onset af major depression Analyses: The association between life events one year prior to the depressive Episode and the depressive episode was analysed for successive depressive epsodes corrected for genetic risk. Survival methods taking the individual risk of recurrence into account. Results: The association between life events and depression decreased successively for the first 6-8 depressive episodes, and subsequently. the association was constant low. Limitations: 1) only women 2) recall-bias

22 Copyright 2008 The Royal College of Psychiatrists Fig. 1 The prevalence of depressive episodes at hospital contacts Kessing, L. V. The British Journal of Psychiatry 2008;192:

23 Cross sectional studies of patients with unipolar disorder in the euthymic phase: Review Approx. 13 studies focus on depressive disorder, exclusively, and find the same kind of dysfunction as in bipolar disorder (Hasselbalch and Kessing, 2011) Meta-analysis 27 studies including 895 patients and 997 healthy control individuals Cognitive function decreased in patients within verbal memory, processing speed and executuive functions. (Bora et al, 2013)

24 Cognitive function in the euthymic phase Some studies suggest that cognitive function in the euthymic phase is associated with the number of prior episodes, and, in particulary, with the number of depressive episodes. No association with medicine or ECT. Kessing, 1998; Van Gorp et al, 1998; El-Badri et al, Hasselbalch et al, 2012.

25 Forest plot of case control studies that evaluated depression as a risk factor for dementia, Alzheimer s disease or vascular dementia. Studies are organised from high quality (top) to lower quality (bottom). da Silva J et al. BJP 2013;202: by The Royal College of Psychiatrists

26 Forest plot of cohort studies that evaluated depression as a risk factor for dementia. Studies are organised from high quality (top) to lower quality (bottom). da Silva J et al. BJP 2013;202: by The Royal College of Psychiatrists

27 Kessing and Andersen, J Neurol, Neurosurg, Psychiatry, Does the risk of developing dementia increase with the number of episodes in patients with affective disorder? N Hazard ratio (95 % CI) 1 episode (ref.) 2 episodes episodes episodes > 5 episodes Episodes ( )

28 Sensitization in affective disorders Sensitization in affective disorders Post et al, 1996

29 How to prevent or stop sensitization in affective disorders? Early intervention (primary? / secondary) Sustained intervention Combined pharmacological and psychological intervention (e.g., group psychoeducation with focus on personal stress, sentizisers and desensitization)