Major Depression, Bipolar Affective Disorder, Mood Disorders and Menopause

Transcription

1 Major Depression, Bipolar Affective Disorder, Mood Disorders and Menopause A Clinical Psychiatric Underwriting Update Dean Knudson, M.D. Medical Director, NationsCareLink May 2007

2 Overview Does depression increase dementia risk by a little or a lot? What does the data say? Why is there such an increase in the diagnosis of Bipolar Affective Disorder, and the use of antipsychotic medications? Why do so many perimenopausal women end up on antidepressants?

3 Mood Disorders and Dementia Bipolar Affective Disorder and Major Depression

4 Gray Matter Loss in Patients With Schizophrenia vs Controls Over 5 Years

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8 Permanent Loss in Gray Matter Volume Observed in a Study of Patients With Bipolar Disorder 1

9 Depression and Alzheimer s Risk Meta-analysis and Systematic Literature Review, May 2006 Pooled odds ratios increased risk: 2.03 (95% confidence interval, ) for case-control and of 1.90 (95% confidence interval, ) for cohort studies Ownby, Arch Gen Psychiatry. 2006;63:

10 Cumulative Risk with Mood Disorder Danish researchers found that a patient's risk of developing dementia appears to increase by 13 percent each time the patient is hospitalized for major depression, or by 6 percent for each hospitalization for bipolar disorder. Dementia incidence overall during the study period was equal between Bipolar and MDD groups Kessing J Neurol Neurosurg Psychiatry

11 Increased Risk with Prior Episodes Risk of dementia in depression and bipolar increases with increasing number of prior episodes In depression five or more episodes significantly increased risk of dementia compared with a single episode: hazard ratio 6.16 (95% CI 1.39 to 27.22) Kessing, J Neurol Neurosurg Psychiatry 2004;75:1662 6

12 Depression History and Dementia Risk:Jorm 2001 Meta-analysis: six prospective and seven case control studies Case control: 2.01 times increased risk Prospective: 1.87 times increased risk Aust NZ J Psychiatry Dec:35(6):776-81

13 Depressive Symptoms and Functional Decline: Mehta subjects, 2 year prospective study Cognition and depression: < 1.5 SD Independent in ADL at study initiation 2.3 times risk of ADL loss: cognitive group 1.9 times risk of ADL loss: depressive group J Am Geriatr Soc 2002 Jun;50(6):

14 Dementia, Depression, Illness and Mortality, Arfken rehabilitation inpatients, 60+, 1 year Increased mortality: mild depression: 1.64 times risk; moderate depression 2.49 times, for whole group Cognitively intact: moderate depression 4.95 times increased mortality Cognitive impairment: 2.13 times risk J Gerontol A Biol Sci Med Sci 1999 Mar;54(3):M152-6

15 Geriatric Depression Outcomes: Steck Dutch hospitalized elderly: 8 year study 40% dead at 8 years 33% fared well 24% relapsing course 22% residual symptoms 11% continuously ill 9% demented at 8 years Aging Ment Health 2002 Aug;6(3):282-5

16 Depressive Symptoms and Cognitive Decline: Wilson 2002 Cognitively intact clergy 65+, 7 year study Annual screens for depression, dementia 8 depressive symptoms screened For each depressive symptom, risk of Alzheimer s increased 19% and annual cognitive score decreased 24%, per subject year. Neurology 2002 Aug 13;59(3):364-70

17 Bipolar Affective Disorder Atypical antipsychotic use Why the increase in the diagnosis? Why the increase in antipsychotic use?

18 Bipolar Affective Disorder Type I Classic Mania: Euphoria, elation, pressured speech, racing thoughts, grandiosity, financially and sexually risky behavior Significant Depression Periodic mood swings Type II Hypomania: much less intense state, mild elation, less pronounced symptoms Significant Depression Periodic mood swings

19 Prevalence of Bipolar Affective Disorder Previously thought only to affect 0.5% of the population Recent revised estimates suggest that 3.7% of the population suffers from either Bipolar Type I or Bipolar Type II

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26 Differential Diagnosis of Unresponsive Mood Disorder Symptoms Bipolar Affective Disorder type I or II Chemical dependency Treatment resistant Major Depressive Disorder Personality Disorder (Axis II Cluster B) Very Early Schizophrenia or Schizoaffective Dx Antipsychotics are used in all these diagnoses!

27 Underwriting Hints: Mental Illness Single vs Multiple episodes Employed: long term? Married Hospitalizations Total percentage of life spent experiencing significant depressive symptoms Simple or complex medication regimen History of multiple medication trials Cognitively intact Currently independent Suicide Attempts

28 Menopause related Depression Any link to future dementia?

29 Depression and Perimenopause Although a hormonal link has not been conclusively documented, many midlife women do suffer from despair, irritability, and fatigue. These mood disturbances have been observed in up to 10% of peri- and postmenopausal women participating in community-based studies. Ann Epidemiol. 1994;4: Kaufert PA, Gilbert P, Tate R. The Manitoba Project Maturitas. 1992;14:

30 Perimenopausal Depression Odds Ratios: Early menopause: 1.55 Late menopause: 2.89 Post menopause: 0.78 Depression diagnosis history: 2.45 Hot Flashes: 1.27 Poor Sleep: 2.95 Severe PMS by history: 3.8 Unemployed: 1.97 Arch Gen Psychiatry 2004;61:62 70.

31 Questions?

32 Questions?