Web Based Education Module 4: “Doc, I’m Tired and Have Little Energy”

FINAL DRAFT - CORE CONTENT

OUTLINE / CONTENT
I. Case Based Introduction / Mr. George is a 44 year old male with a past medical history of hypertension for 4 years. He comes to this visit requesting his serology results from his last visit. At that time, he complained of feeling tired and having little energy especially in the morning hours. Mr. George denied shortness of breath, chest pains, palpitations, fevers, or anxiety. No GI complaints, no melena, no hematochezia. He read on the internet about thyroid disease, anemia, and Lyme disease which all could explain his symptoms. He has not been traveling outside of Manhattan and did not visit a wooded area recently. Those laboratory tests from his last visit one month ago are completely negative today. He also had a recent annual physical examination two months ago and everything was normal.
Past Medical History – Hypertension
Medication – Hydrochlorothiazide 25mg once a day
Past Social History – Works as an office manager. Heavy stressors under a new boss. Married to his wife of 14 years, monogamous, and has one 10 year old daughter. Denies alcohol, drug, and tobacco use. Sexually active with his wife about once a year only – “as we just don’t have time or energy anymore.” No interpersonal conflicts at home with family, although she laments that they don’t go out much anymore.
Family History – Father is alive and suffers from gout, hypertension, and cholesterol. Mother is alive and has been diagnosed with diabetes last year.
ROS – He has trouble falling asleep almost every night and he wanted to ask you about “safe” sleeping pills that he heard about on television commercials. This has been going on for 8 weeks.
PE –
BP 135/80 P70 R21 Wgt 210 lbs (was 195 lbs 5 months ago)
General – In no acute distress
HEENT – WNL, No JVD, No thyromegaly or nodules
Lungs – CTA B
Cor – RRR No M
Abd – S / NT Pos BS
Ext – No C / C / E
Neuro – No tremors; reflexes 2+ upper and lower extremities; normal hand to nose coordination, normal gait – essentially a normal neurological exam
Psych – Admits to less pleasure in doing things he used to like to do, and feels down occasionally but does not feel he is depressed. He has increased appetite having gained 15 pounds since his visit 5 months ago. He attributed the weight gain to stress at work. Denies suicidal ideation or homicidal ideation. He also notices trouble concentrating at work and “can’t get into television shows or movies” in the same way he did prior.
Labs:
Guaiacs Neg x 3
TSH 1.44 (WNL 0.34 – 4.25)
Chem 7 WNL
Hct 40
Lyme Titers Neg
Question 1) Mr. George feels tired and has little energy. His physical examination and lab work are negative. He completely denies being depressed. Upon further questioning he does describe losing interest in activities he used to like to do, increased appetite and weight gain, problems with concentration, and insomnia. At this point, Mr. George wants to know the next appropriate step in his assessment and management. Of the following, which one is the most appropriate recommendation?
a)  Perform a whole body CT or MRI scan to look for an occult source
b)  Recommend that Mr. George and his family go on a vacation
c)  Consider testing for underlying neurological disease
d)  Refer him to a gastroenterologist for a colonoscopy screen
e)  Have Mr. George complete a standardized screening questionnaire for depression
f)  Write him a prescription for sleeping medications
The correct answer is e. Mr. George has many classic signs and symptoms of depression (e.g., anhedonia, insomnia, weight gain, etc.), and performing a standardized screening questionnaire for major depression is appropriate to assist in making the diagnosis. Many people who suffer from depression do not report a depressed mood. Although some neurological diseases can have depressive symptoms, major depression is much more common in the primary care setting and should be evaluated first. He also has no neurological findings. A colonoscopy would not seem appropriate in a 44 year old man at this point without gastrointestinal complaints, no findings of anemia, and weight gain. A whole body CT or MRI scan is not cost effective, and may cause more physical and emotional harm than benefit. Insomnia may be a sentinel symptom of depression, and prescribing sleeping medications without assessing the patient for depression would not be “best practice”. Although a vacation may be in order for Mr. George and his family, it will not effectively treat an underlying depressive disorder.
II. Facts About Depression / Web Based Education Module 4: “The Diagnosis and Management of Depression in The Primary Care Setting”
Facts About Depression
Depression is one of the most common conditions seen by primary care physicians second only to hypertension. The point prevalence in the outpatient primary care setting is between 4.8 – 8.6%, and the point prevalence in the inpatient setting is 14.6% Large scale studies have suggested that 7 – 12% of men will suffer an episode of major depression at one point in their lives, while the percentage for women is more on the order of 20 – 25%. Bipolar disorder is less common than depression (0.4% in men and 1.6% in women over their lifetimes) but has no gender difference. Depression can begin in early adulthood, with a peak onset between ages 20 – 30. Over half the people who experience an episode of major depression are at risk for a relapse and recurrence (Cutler, J. Charon, R. 1999).
Depression costs the United States economy more than 43 million dollars every year in medical treatments and lost work productivity (Kahn, 1999). Globally, depression accounts for 4.4% of the disease burden, which is similar to that of diarrheal diseases and ischemic heart disease (Mann, 2003). 300 million people in the world suffer from depression with 18 million of them in the United States (Harvard Press, 1996).
Depression has a high rate of morbidity and mortality when left untreated. Most patients do not necessarily complain of feeling depressed, but rather that they have a lack of interest or pleasure in activities, may have somatic complaints, or vague unexplained complaints. In one study, 69% of diagnosed depressed patients reported unexplained physical symptoms as their chief complaint (NYCDOH, 2006). Unlike patients with depression in psychiatric inpatient or outpatient care settings, persons suffering from depression in primary care settings often present as “undifferentiated” patients.
Depression is often undiagnosed and untreated, and even when it is diagnosed it is often under treated. Primary care physicians must remain alert to effectively screen for depression in their patients. Barriers to effective screening include inadequate education and training, limited coordination with mental health resources, time constraints, poor systematic follow up, and inadequate reimbursement (NYCDOH, 2006). It is sometimes difficult for primary care providers to determine if a patient is depressed as opposed to experiencing a normal response to the challenges of everyday life. Gender, age, culture, and language of the patient and the physician may create further barriers. Furthermore, persons with mood disorders also may have enormous stigma associated with being mentally ill – and may see it as a sign of weakness, fear the criticism of other people, or be concerned that they will be institutionalized.
Patients who suffer from diabetes, ischemic heart disease, stroke, or lung disorders that have concurrent depression have poorer outcomes than those without depression. Depressed patients have a higher risk of death from heart disease, respiratory disorders, stroke, accidents, and suicide (Mann, 2005). Fifteen percent of patients with severe mood disorders die from suicide. In one study among older patients who committed suicide, 20% visited their primary care physician on the same day as their suicide (NYCDOH, 2006).
III. Goals and Objectives / Educational Goal: Students will be able to demonstrate competencies in knowledge, skills, and attitudes of an effective clinician in evaluating and caring for patients with depression and mood disorders in the primary care setting.
Medical Knowledge
The students will:
1.  Apply the nationally recognized guidelines for screening and diagnosing depression and other mood disorders in patient care.
2.  Apply the practice guidelines for the treatment of patients with major depressive disorders.
3.  Identify appropriate elements of a suicide risk assessment and action plan.
Patient Care
The students will:
1.  Recognize the importance of effective detection and treatment of depression in adults.
2.  Review the depressed mood algorithm and the DSM-IV to guide the differential diagnosis in the primary care setting.
3.  Identify manic and hypomanic symptoms associated with bipolar disorder in depressed patients.
4.  Formulate management plans for the longitudinal care of patients with depression.
5.  Develop prevention plans, including health education and behavioral change strategies, for patients with depression.
Interpersonal and Communication Skills
The student will:
1.  Explore relevant psychosocial and cultural issues that impact on care.
2.  Provide effective education and counseling to patients with mood disorders and their families.
3.  Demonstrate awareness of improved health care outcomes through effective communication and forming therapeutic alliances with patients.
4.  Discuss behaviors with patients, in an empathic, respectful and non judgmental manner.
Practice Based Learning
The student will:
1.  Use information technology to access medical information and support self-education and clinical decision making.
2.  Critically review the medical literature regarding new evidence based clinical trials and its implication on current treatment guidelines of depression and mood disorders.
3.  Use information technology to access patient and family education resources on depression.
Professionalism
The student will:
1.  Demonstrate professionalism by completing this web module during the assigned period.
Systems Based Practice
The student will:
1.  Identify which cases can be managed by the primary care physician and which should be referred for co-management with a specialist.
2.  Improve patient care outcomes through effective communication with other health care professionals, partnerships through community resources, and government agencies.
IV. The Etiology of Mood Disorders / The Etiology of Mood Disorders
Neurotransmitters, genetics, and psychosocial stressors all seem to play a part in mood disorders.
The same depressed patient may have variable clinical symptoms from one major depressive episode to another. Despite this variability, major depression may have the same underlying cause. The variable presentations may be due to differing patterns in neurotransmitter abnormalities. Deficiencies in serotonin, norepinephrine, dopamine, GABA, and peptide neurotransmitters (somastatin, thyroid-related hormones, and brain derived neurotrophic factors) have all been hypothesized as contributing to depression. Over activity in other neurotransmitters including substance P, and acetylcholine, and elevated serum cortisol (with lack of diurnal variation) has also been proposed to contribute to depression.
Although no specific genes that affect neurotransmitters or hormones have been identified, both depression and bipolar disorder are clearly inheritable. The first degree relatives of a patient with recurrent major depression have a 1.5 – 3 times higher risk of depression themselves as compared to the general population. 27% of children with one parent with a mood disorder will develop a mood disorder themselves, and that increases to 50 – 75% if both parents are affected. First degree relatives of patients with bipolar disorder have an estimated 12% lifetime prevalence of bipolar disorder, which is 10 times higher than the general population (Cutler, J. Charon, R. 1999). Genetic predisposition is not enough to result in a patient with a mood disorder, however. Identical twins have incomplete concordance in regards to depression. Depression also occurs in patients with no family history of mood disorders, which may infer that they have another acquired biological deficiency such as a viral insult, genetic or perinatal insult, or vascular brain disease.
Psychosocial stressors in combination with a genetic predisposition have been postulated to alter the size of neurons, neuronal function, repair capabilities, and production of new neurons. Elevated cortisol in some depressed patients may reduce hippocampus volume, especially if their depression has not been treated in some time. Brain imagery has also noted some altered structures, which suggest some changes in neurocircuitry. Psychosocial theories suggest that experiences of “loss” in certain vulnerable individuals may cause depression, either through trauma, parental loss, loss of love from others, or loss of self-esteem.
“On the Threshold of Eternity / At Eternity’s Gate / Old Man in Sorrow” - Vincent van Gogh
LINK: Vincent van Gogh (Wikipedia: http://en.wikipedia.org/wiki/Vincent_van_Gogh)
V. Diagnosing Mood Disorders
A.  Screening for Depression
B.  Major Depressive Episode
C.  Approaches To The Clinical Interview
D.  Depressive Spectrum Disorders: The Depressed Mood Algorithm
E.  Mood disorder due to a general medical condition
F.  Substance-induced depression
G.  Dysthymic Disorder
H.  Bereavement
I.  Adjustment disorder with depressed mood
J.  Seasonal affective disorders
K.  Postpartum depression
L.  Pseudodementia
M.  Manic and Hypomanic Symptoms and Bipolar Disorders
N.  Suicidal Patients – students to identify / Screening for Depression
The primary care physician’s most powerful screening tool for depression is patient observation and active listening skills. Most depressed patients do not realize they are depressed – and this is especially true in elderly patients. A physician should consider that a patient may have depression in the setting of unexplained physical symptoms or complaints. The higher the number of somatic complaints that a patient has, the higher the risk that they may have a mood disorder. Other clues may be a patient with persistent worries or concerns about medical illness, complaints that do not respond to typical interventions, or complaints outright of anxiety or panic attacks. Patients with substance abuse issues may also suffer from a mood disorder. A careful history of present illness, past medical history, social and family history, and review of systems may yield more important information for making the diagnosis.
The primary care physician should ask open-ended questions of the patient about normal patterns as well as variations to determine baseline function and mood. Mood is a range of emotions that a person feels over a period of time, while affect is how a person displays his or her mood. The presence of a mood disorder may affect a person’s concentration, attention, motivation, interest, and sleep, as well as energy level, hunger and satiety levels, sexual pleasure, and pain sensation. These patients also frequently lose interest and lose pleasure (anhedonia) in things, people, or activities that they used to enjoy. Interruption in personal relationships with others can be a side effect due to increasing anger and conflicts, lower frustration tolerance, or from apathy and lack of enthusiastic feelings towards other people. Patients with depression may become emotionally constricted and lose their emotional flexibility.