Depression: How to treat, avoid misdiagnosis

Although depression is one of the most common diagnosed disorders, providers still have difficulties diagnosing and treating people with depression.

Nearly 70% of people with bipolar disorder are initially misdiagnosed, which leads to incorrect prognosis and treatment, according to Leslie Citrome, MD, MPH, clinical professor of psychiatry and behavioral sciences for New York Medical College. Due to the misdiagnoses, 20% of primary care patients who may have depression symptoms are being treated with antidepressants used to treat bipolar disorders.

Citrome

The “Improving Diagnosis and Treatment Strategies for Major Depressive Disorder” talk was presented by Citrome at the National Association of Managed Care Physicians (NAMCP) Spring Managed Care Forum 2017. During the presentation, Citrome outlined ways that practitioners can make greater distinctions between patients with major depressive disorder (MDD) and those with bipolar disorders. He also gave participants insight on more accurate ways to treat patients.

Part of the reason why it is easy to misdiagnose patients with MDD is because the symptoms are very similar to bipolar, Citrome says. As a result, patients can see three to four different clinicians before a correct diagnosis is made.

“Bipolar depression is defined by having major depressive episodes (MDEs) and manic/hypomanic episodes,” Citrome says. “On cross-sectional examination, the symptoms of an MDE are the same for both major depressive disorder and bipolar disorder.”

Patients with MDD often have symptoms that start at a younger age, reoccurring episodes, cardiovascular disease and more alcohol and drug use. They also have functional impairment that makes employment and school more difficult, Citrome says.

“Comorbidity is common and can be confusing,” Citrome says, adding that 50% to 70% of patients with MDD have at least one comorbid psychiatric or mental condition. “Examples include anxiety, substance use, obesity and cardiovascular disease.”

By using the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), which includes new specifiers with MDD, clinicians can be more detailed with their diagnosis, Citrome says.

“Core mood criterion now includes hopelessness, potentially broadening the diagnosis. DSM-5 allows for clinical judgment in distinguishing normal reactions to significant loss from a disorder in need of clinical attention,” Citrome says. “New specifiers of MDD ‘with anxious distress’ and ‘with mixed features’ allow characterization of additional symptoms.”

By using the patient health questionnaire-9 (PHQ-9), Citrome says primary care physicians can match a patient’s answers with possible diagnosis in the DSM-5.

“Ideally, primary care physicians should be proactively asking about emotional health when conducting routine examinations,” Citrome says. “The PHQ-9 has been used as a routine screen as well as a more directed way of quantifying the intensity of a person's depression. Each item on the PHQ-9 corresponds to a diagnostic criterion from the DSM-5, and also serves as an educational tool for persons who may not necessarily be aware that depression is not only about mood symptoms, but also physical symptoms and cognitive problems.”

Citrome adds that patient portals can be used to administer emotional health questions, but providers should follow up if questions are unanswered by patients.

“If the answers are left blank, they should be asked about,” Citrome says. “In my own experience, patients may not feel comfortable answering the last item on the PHQ-9, ‘thoughts that you would be better off dead, or of hurting yourself in some way.’ If left blank, the clinician should definitely ask why.”

Providers should take several factors under consideration when prescribing medicine for MDD treatment, including patient history and preferences. Measurement-based care can be used to monitor the course and effects of treatment, and guide treatment change. Patient-reported outcome scales also correspond with PHQ-9 criteria for MDD.

“For example, if worries about weight gain are predominant, then the system would suggest medicines with a lower propensity for weight gain. Other effects such as sedation can also be minimized in patients who give a history of easily being tired on medications,” Citrome says.