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15.03.2014

Clinical assessment of depression test, tinnitus causes fatigue - Plans Download

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Depression is primarily a mood disorder, but it can also be viewed as a cognitive disorder for many older adults. The clinical challenge of treating geriatric depression with cognitive impairment is determining the extent to which cognitive changes are caused by depression versus underlying brain pathology. Although the assessment of cognitive impairment in geriatric depression is predicated on an accurate assessment of depression itself, a full discussion of the clinical assessment of depression is beyond the scope of this article. Research on the neurobiology of depression has provided important insights into the interrelationship between dysfunctions in mood and cognition.
While many persons with depression experience slowed thinking and concentration difficulties, the presentation of cognitive deficits is more heterogeneous among older adults. With or without cognitive impairment, the occurrence of depression in later life is a clinical concern because it may be either a risk factor for or an early symptom of dementia. Clinical screening questionnaires should not be used to formally diagnose depression, but they do provide important information to help identify at-risk individuals by characterizing the nature and extent of symptoms that are associated with depression. Key words: assessment, depression, morbidity, mortality, multiple sclerosis, outcome, prevention, review, suicide, treatment. Depression in MS may be a consequence of the multiple challenges associated with managing a chronic illness. Global physical impairment has been associated with higher levels of depression in some studies [15-17] but not others [11,18]. In addition to temporal variation, certain types of physical disability may be differentially related to depression. Studies have generally found that lower levels of perceived social support are associated with depression in MS [16,25]. Several studies have identified a link between emotion-focused coping and poor adjustment in MS; depression was the most common outcome reported. Importantly, not all studies that assess the association between brain lesions and depression have reported positive findings. Generally, studies that support a relationship between brain lesions and depression appear to focus on damage to particular areas or the interruption of particular pathways within the brain. Initial suspicion of a link between IFN-b and depression in MS arose after reports of a suicide and attempted suicides during the first trial of IFN-b -1b [59]. While the possibility of a link between depression and IFN-b exists and must be considered by the clinician, recent studies have not shown a clear association.
Models that relate stress, cytokines, the endocrine system, and depression are supported in the literature [74-75]. Because depression is common and can temporarily fluctuate in patients with MS, healthcare providers must have the necessary tools to make timely and accurate diagnoses [62]. Historically, there have been two main theoretical frameworks for using validated instruments in the assessment of depression in people with MS. Although the best multidimensional tool for assessing depression in patients with MS is currently unclear, the tool must effectively and independently measure both fatigue and depression. In sum, depression is a major problem facing patients with MS and has significant implications for QOL. Feinstein evaluated risk factors for suicide in MS among patients of an outpatient clinic [10]. The last three decades have seen a substantial increase in the quantity and rigor of empirical studies examining treatment of depression in MS.
In the most comprehensive, randomized, controlled trial of treatment for depression in MS, Mohr et al. A healthcare provider must conduct an adequate trial and assessment period to judge the success of an antidepressant.
In the general population, up to 70 percent of patients with major depression respond to an adequate antidepressant medication trial. Despite studies that support guideline implementation, other reports have shown that guidelines fail to improve depression treatment [134-135]. We would argue that the high frequency of depression in patients with MS makes periodic screening as outlined in Figure 1 a high-yield activity. Treatment algorithms have been developed that address alternative treatments and help the clinician make evidence-based choices. The relationship of depression to cardiovascular disease: epidemiology, biology, and treatment. Development and validation of a geriatric depression screening scale: a preliminary report.
With the growing aging population in the United States and many other countries, it is important for mental health professionals to develop skills to diagnose and treat cognitive impairment in older patients with depression. Table 1 provides a list of elements that are important to a comprehensive evaluation of geriatric depression. Mild cognitive impairment was first proposed to characterize a state of abnormal cognition with a high risk of progression to Alzheimer disease,30 but it is increasingly used in depression to characterize depressed individuals with comorbid cognitive impairment in the absence of dementia. Several studies have found a higher risk of dementia among persons with a remote history of depression (10 to 25 years before onset of dementia),7,36,37 but they also reveal an increased risk for dementia with decreased time between depression onset and dementia diagnosis, which suggests that onset of depression in later life is either a prodromal symptom or that it creates susceptibility for later dementia. The etiology of depression is multifactorial and likely associated with psychosocial stress, focal demyelinating lesions, and immune dysfunction.
Given that a majority of patients with MS lose their jobs and about one-third experience a decrease in standard of living [32-33], vocational and financial losses may mediate the relationship between MS and depression. In cross-sectional surveys, emotion-focused coping has been related to lower self-esteem [41], global distress [42-44], and depression [13,15,45-46].
Problem-focused coping has been linked to higher self-esteem [41], global distress [42], and depression [15,45], but other studies have failed to find a correlation [13,43-44]. Like patients with depression, patients with MS have higher serum concentrations of proinflammatory cytokines [72]. One difficulty in diagnosing depression in MS is that many depressive symptoms are observed in MS patients without mood disorders. In the first framework, the main goal of assessment is to directly address the symptoms of depression.
This inventory has a long history of proven validity for assessing depression in the general public.
Data indicate that depressive symptoms can independently predict fatigue severity [90], and improvement in depressive symptoms appears to be closely associated with decreased fatigue severity [91].
Finally, recent research indicates that accurate assessment of the effect of depression on a patient with MS requires a scale that assesses fatigue and cognitive function. Severity of major depression, history of alcohol abuse, and living alone had an 85 percent predictive accuracy for suicidal intent.
The earliest reports in the literature typically described group-based interventions that improved psychosocial functioning, such as depression, anxiety, understanding of physical limitations, and reduced use of medical services [103-104]. Individuals who received the intervention (n = 23) reported significantly lower levels of depression and anxiety at follow-up, whereas the control group (n = 21) reported increased symptoms. Recognizing that physical impairments and fluctuating symptoms may affect a patient's ability to attend clinic appointments and participate in therapy, Mohr et al.
Crawford and McIvor evaluated an insight-oriented group psychotherapy for treating depression in MS patients [110]. Schiffer and Wineman presented results of the first double-blind placebo-controlled treatment trial of major depressive disorder in patients with MS [117].
The reasons for this underdiagnosis likely parallel those found in general primary care settings where depression is also frequently underdiagnosed. The Texas Medication Algorithm Project (TMAP) published a depression treatment algorithm that was recently implemented at a number of sites [136]. In this article, we focus on interviewing and screening for depression, the influence of medical comorbidities on cognitive impairment and depression, and the differentiation of cognitive impairment secondary to depression from comorbid depression and Alzheimer disease. However, a clearer relationship between depression and impairment appears when studies use more focused measures of physical impairment.
Some studies have indicated that patients with MS-related cognitive impairment report higher levels of depression than patients without cognitive impairment [24-25]. The rates of depression were higher among persons with disabilities than persons without disabilities; unemployment status explained nearly 30 percent of the elevated depression found in the group with disabilities.
Similar results were found in studies that examined the relationship between coping styles and depression over time [47-48]. Longitudinal studies have sometimes found associations between problem-focused coping and depression.
The presence of depression was related to T1 lesions in the superior frontal and superior parietal regions.


Thyroid disease may masquerade as depression, and this possibility should be evaluated as part of the clinical assessment. Current evidence suggests that pharmacotherapy or psychotherapy for treatment of depression in MS, irrespective of its association to IFN-b, is a prudent strategy [65]. For example, both fatigue and cognitive dysfunction associated with MS are common and must be considered by the provider in the differential diagnosis of depression.
Figure 2 offers a model of depression assessment in a typical initial or follow-up clinical visit.
If this is not possible in the clinician's office, referral to a neuropsychologist who specializes in MS may be warranted. While all patients with MS should be assessed for depression and suicide risk, patients with these additional risk factors should be monitored closely. Individuals were quasi-randomly distributed so that the first 14 consecutive patients visiting an MS outpatient clinic were assigned to the intervention group and the next 15 were assigned to the control group. Significant reductions in depression and anxiety and increases in problem-focused coping were reported in the SIT group but no corresponding changes were reported for the control group.
Tricyclic antidepressants are among the oldest and have a long track record of success in treating depression. Studies in the general population have shown that regular exercise effectively reduces depression [121]. A number of studies have shown that providers' use of guidelines along with a thorough follow-up program in primary care settings can facilitate successful identification and treatment of patients with depression [129-130].
Patients who meet the criteria for depression should be treated with a single antidepressant or psychotherapy based on the previously discussed results. Italian version of the Chicago multiscale depression inventory: translation, adaptation and testing in people with multiple sclerosis. The relationship between disability and depression in multiple sclerosis: the role of uncertainty, coping, and hope.
Depression in multiple sclerosis as a function of length and severity of illness, age, remissions, and perceived social support.
Depressive symptoms and severity of illness in multiple sclerosis: epidemiologic study of a large community sample. The relation between objective and subjective impairment in cognitive function among multiple sclerosis patients-The role of depression.
Cognitive functioning and depression in patients with chronic fatigue syndrome and multiple sclerosis. The interaction between depressive affective disorder and neuropsychological test performance in multiple sclerosis patients. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). Depression is an independent risk factor in the development of and mortality associated with cardiovascular disease in otherwise healthy persons. The mnemonic SIG E CAPS + Mood (Table 1) can be used to remember these assessment criteria.Assessing for depression in patients with myocardial infarction requires an understanding of the risk factors for depression. Patients with MS also have more severe depressive symptoms compared with patients with other chronic neurological diseases [7-9]. Perceptions regarding the uncertainty in disease, intrusiveness in daily activities, and lack of hope have been associated with depression [13]. The authors argue that the effects of unemployment and disability on depression are independent and additive.
Lesions in the suprainsular white matter (arcuate fasciculus) were significantly associated with depressive symptoms. Depression severity was related to T11 lesions in the superior frontal, superior parietal, and temporal areas. In a review of the literature on MRI findings in psychiatric disorders, Kanner noted that changes in the prefrontal cortex, mesial temporal structures, and the basal ganglia appeared to be related to depression [55]. Using criterion from the Diagnostic and Statistical Manual of Mental Disorders (DSM), Third Edition-Revised, they classified six patients with major depression, seven with minor depression, and five with no depression. However, no relationship was found between ventricular size and depression as measured by the BDI. Hence, for some patients, an association may exist between the use of IFN-b and symptoms of depression.
Whether these hormonal changes are primary or secondary pathological defects in the origin depression has yet to be determined.
Research on QOL indicates that the effects of depression on the overall well-being of patients with MS cannot be fully understood without consideration of the presence and severity of fatigue [92]. For clinicians who do not have enough time to complete objective depression measures, the rapid two-question screening test (Figure 1) gives at least rudimentary information about depressive symptoms and the possibility of a DSM-IV diagnosis.
A neuropsychological evaluation provides a thorough cognitive and psychiatric evaluation and an in-depth assessment of the interaction of depression, cognition, and fatigue.
Although depression in the intervention group was not significantly decreased relative to the control group, the use of depressive coping strategies was significantly improved.
Small but significant reductions in depression were noted in the treatment group as compared with the other two groups. As evaluated by the Hamilton Rating Scale for Depression and the BDI, patients treated with desipramine improved significantly more than patients in the placebo group.
Two frequently cited guidelines for depression treatment were published in 1993 by the Agency for Health Care Policy and Research (AHCPR) [131] and the American Psychiatric Association [132]. Monitoring with the BDI, BDI-FS, or a similar assessment tool should be performed 4 to 6 weeks after initiation and periodically thereafter. The method used for measuring depression in the MS population differs depending on the goals of the assessment. These include female gender, previous history of depression, family history of depression, lack of social support (especially if living alone) and loss of functioning or major life role. While more therapeutic trials for depression in MS are needed, MS patients have been shown to respond to current antidepressant medications and psychotherapy. Depression, in particular, is frequently seen in patients with MS but has only recently received attention in the literature.
One study found that only about one-third of patients with MS and major depression or suicidal thoughts received treatment by their healthcare providers [10]. Some evidence exists that the specific type of cognitive impairment may be differentially related to depression. At the end of treatment, Beck Depression Inventory (BDI) scores were positively associated with right temporal periventricular lesion volume and left temporal gray-white junction lesion volume. Depression severity was also related to lateral and third ventricle enlargement and frontal atrophy. Videbech and Ravnkilde reported that white matter lesions in the frontal lobes, insula, and areas adjacent to the basal ganglia were associated with major depression [56]. Worsening depression was not indicated in this study but rather a slight improvement in symptoms of depression and anxiety. For this reason, several studies have sought to develop questionnaires that assess depressive symptoms in a less time-intensive manner. A more recently developed multidimensional scale is the Functional Assessment of MS (FAMS).
Given that both depression and fatigue may independently affect [93] and predict [94] QOL, how depression affects the well-being of patients with MS cannot possibly be understood without an evaluation of fatigue. Given that this screen has not been validated, however, a formal objective measure of depression that has been used in research on patients with MS is preferable. CBT treatment focused on behavioral activation for increasing pleasant activity and social interaction, and on cognitive restructuring for identifying and challenging maladaptive thoughts and beliefs associated with depression.
Outcome analyses demonstrated significantly reduced depression in the treatment group but no change in the control group. Significant reductions in depression were noted across all three treatment groups; however, CBT and sertraline more effectively reduced depression scores than SEG. A positive response to a particular antidepressant is typically defined as a 50 percent reduction in a standardized depression scale score. Another algorithm, called sequenced treatment alternatives to relieve depression (STAR*D), is under development [137]. These initial screening questions all require confirmation by the physician using a detailed clinical interview or a longer, but more specific, diagnostic instrument. Physicians can assess patients for depression by using one of several easily administered and scored self-report inventories, including the SIG E CAPS + mood mnemonic.


Unfortunately, patients with MS and major depression or suicidal thoughts are often underassessed and therefore not diagnosed.
This article highlights the unique features, assessment, and treatment of depression in MS. Similarly, another study found increased prevalence of depression during times of MS exacerbations and increased physical impairment [13].
This contrasts with a large community-based sample of patients with MS in which unemployment was not associated with depression [17].
They monitored patients for relapse and conversion to MS and found an increased rate of depression in patients who were developing MS. The authors postulated that depression in MS may be related to atrophy and disconnections between cortical and subcortical regions as a result of frontal and parietal destructive lesions in white matter. However, the authors reported a significant relationship between depression scores and MS disability as measured by the Expanded Disability Status Scale. Moreover, treatment of depression with both psychotherapy or pharmacotherapy may decrease IFN-g  production. Given the overlap of symptoms between depression and MS, the diagnosis of depression in patients with MS is often complicated.
One should note that, in addition to measurement of fatigue, a thorough multidimensional assessment of QOL in depressed MS patients should include, at minimum, a screen of cognitive assessment.
The most promising of these formal instruments is the BDI-FS; the Chicago Multiscale Depression Inventory also appears to be a useful unidimensional depression measure for patients with MS. Large, statistically significant reductions in depression were noted across most outcome measures in the treatment group, while small increases in depression were observed in the control group. The authors noted that this result opposes findings in nonmedical populations in which all treatments for depression are generally considered equal.
A nonresponse to medication is defined as no net change from baseline of the standardized depression scale score [120]. For severe depression in MS, electroconvulsive therapy (ECT) has been shown to be useful [123-124].
While more therapeutic trials for depression in MS are needed, patients with MS have been shown to respond to current antidepressant medications.
In addition, any of the selfreport measures presented in Table 211–15 can be used to assess for depression in patients with myocardial infarction. As a result, activity may be restricted, which can hinder recovery, maintain depression and increase the risk for developing other health problems.
Further research will clarify the relationship between vocation and depression in patients with MS. Moreover, unsupportive relationships are significantly and independently correlated with depression and a lower sense of purpose [39]. They also reported an association between lesions in the right temporal region and depression severity. Therefore, researchers and clinicians have used psychometrically validated measures of mood to aid their differential diagnosis. Another argument against the use of the BDI with patients with MS is that, because of the high number of items that assess neurovegetative symptoms, it overdiagnoses depression in this population [15]. In the last few years, the complex interactions among depression, fatigue, and cognition have been repeatedly described in the literature [95-97]. Clinicians who complete a more comprehensive, multidimensional evaluation of depression will find that the results are more helpful in understanding their patients' QOL.
This discrepancy supports the hypothesis that depression in patients with MS and possibly other autoimmune diseases is etiologically different from depression in the general population [113-115]. After discussing the options with the patient, the clinician should choose a therapeutic approach based on patient preference.
STAR*D and TMAP results regarding compliance, remission, and cost-effectiveness will be very useful for patients with depression and their healthcare providers.
Unfortunately, many patients with MS and major depression or suicidal thoughts are under-recognized and undertreated.
The question was tested prospectively in a group of 1,432 men and 1,085 women presenting to an emergency department with an injury. Several of these assessment tools are readily available and can be easily used in a medical setting. Early intervention in depression can prevent declines in quality of life and even death from suicide. The link between cognitive impairment and depression is further complicated by possible bidirectional influence.
For that reason, a number of researchers have attempted to identify the BDI items that contain confounds between somatic MS symptoms and neurovegetative symptoms of depression.
A particular agent should be chosen based largely on its side effect profile, safety, quality of clinical trial data, cost, and patient preference. Recent studies in non-MS populations have found that stimulants such as methylphenidate [126] and modafinil [127-128] are useful adjunctive treatments for depression. Most importantly, studies have suggested that improved treatment of depression within primary care requires an organized treatment program, regular patient follow-up with monitoring of treatment compliance and, in more severe cases, a prominent role for the mental health specialist. More research on the unique treatment issues of MS patients with depression and on the development of effective algorithms is needed. Unlike other aspects of MS, depression is treatable and is a potentially preventable cause of death.
The combination of a selective serotonin reuptake inhibitor with cognitive-behavior therapy is often the most effective treatment for depression in patients with cardiovascular disease. The Zung Self-Rating Depression Scale (SDS) (Figure 1),11 and the Beck Depression Inventory,12 which are 20- and 21-item self-reporting instruments, respectively, cover most of the nine DSM-IV symptom categories for a major depressive episode.
Not only may cognitive impairment precipitate depression, but depression in a patient with MS may also result in reduced attention and working memory capacity [29].
In sum, depression and cognition are clearly related independent of physical disability, but more research is required for a better understanding of this link. When attempting to refine and expand multidimensional QOL measures, researchers must understand that depression does not exist in a vacuum for patients with MS.
Alternatively, the healthcare provider should question the diagnosis and rule out potential depression masqueraders. Results from another study6 showed that depression contributes to a greater chance of developing or dying of heart disease in persons who are otherwise healthy, even after controlling for smoking status, gender, weight, activity, blood pressure and cholesterol levels. Family members often experience feelings of helplessness, loss and depression similar to those of the patient. This study confirms that although depression is certainly a factor in adjustment to MS-related disability, other issues must also be considered and assessed. Specifically, for such instruments to effectively portray the effects of depression on an MS patient's well-being, they must include items or scales that assess fatigue and cognitive function.
Furthermore, multidimensional QOL scales should include some method for interpreting the interaction among depression, fatigue, and cognition.
A positive screen for problem drinking should be followed by a more detailed clinical interview to confirm the diagnosis. In a recent study,9 depression was shown to be associated with an increased risk of developing coronary heart disease in men and women.
In contrast, the Controlled High-Risk Subjects Avonex" MS Prevention Study group, which evaluated IFN-b-1a therapy during a first demyelinating event, reported significantly more depression in the treatment group than the placebo group [64]. Data from the study supported the concurrent and discriminative validity of the BDI-FS, which indicates that the test did not confound MS-related neurological symptoms.
Only then can clinicians and researchers obtain a comprehensive picture of the QOL of depressed MS patients. Hence, evidence to date from controlled studies does not establish a strong link between treatment with IFN-b and depression. The Chicago Multiscale Depression Inventory is an alternative short instrument that was developed for assessing depression in patients with MS [84].
Despite these benefits, the greatest risk associated with depression screening instruments is the generation of false positive results that may result in harmful labeling and unnecessary treatment or further testing.



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