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Depression: The Hidden Co-Morbidity. Neil Korsen, MD, MS MaineHealth January 18, 2007. Overview. Depression and chronic medical illnesses Chronic medical illness and serious persistent mental illness (SPMI) Using the PHQ-9 for screening and management of depression. Pop Quiz – Question #1.

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depression the hidden co morbidity

Depression: The Hidden Co-Morbidity

Neil Korsen, MD, MS


January 18, 2007

  • Depression and chronic medical illnesses
  • Chronic medical illness and serious persistent mental illness (SPMI)
  • Using the PHQ-9 for screening and management of depression
pop quiz question 1
Pop Quiz – Question #1
  • Which is true?
    • Depression increases risk for diabetes.
    • Diabetes increases risk for depression.
    • Both are true.
    • Neither is true.
pop quiz question 2
Pop Quiz – Question #2
  • What is the most common cause of death in people with SPMI?
    • Heart Disease
    • Suicide
    • Accidents
    • Cancer
pop quiz question 3
Pop Quiz – Question #3
  • The PHQ-9 is useful for:
    • Screening for depression
    • Assessing response to treatment
    • Measuring outcomes
    • All of the above
depression and chronic medical illness
Depression and Chronic Medical Illness
  • The rate of depression in the general population is 5-10% per year.
  • The rate of depression in people with chronic medical illness is higher:
    • CV Disease 20-30%
    • Diabetes 20-30%
    • Stroke 30% or higher
depression increases the risk of diabetes
Depression Increases the Risk of Diabetes
  • 13-year prospective community-based follow-up study: Depressed subjects 2.2 times as likely to develop diabetes
  • 8-year Japanese workplace follow-up study:

Depressed men 2.3 times as likely to develop diabetes

Eaton WW. Diabetes Care. 1996; 10:1097-1102.

Kawakami N, et al. Diabetes Care. 1999; 7:1071-1076

impact of depression on diabetes outcome
Impact of Depression on Diabetes Outcome
  • Increased functional impairment
  • Decreased glycemic control
  • Increased vascular complications

Williams et al. Ann Int Med. 2004;140:1015-1024

depression is a risk factor for stroke and coronary artery disease
Depression is a risk factor for stroke and coronary artery disease
  • Likelihood of developing myocardial infarction 4X
  • Likelihood of stroke 2.6 X general population
  • Increased Platelet Activation, reversed by SSRI’s
  • Independent of age, gender, lifestyle

Larson et al, Stroke. 2001;32:1979; Yamanaka et al, Biomed Pharmacother. 2005 Oct; 59 Suppl 1:S31;Marzari et al, J Gerontol A Biol Sci Med Sci. 2005;60(1):85-92

impact of depression on outcome of cardiovascular disease
Impact of Depression on Outcome of Cardiovascular Disease

Frasure-Smith, et al., Circulation; 1995:999; Lesperance, et al. J. Am Coll Cardiol. 1998;

Freedland. Psychosom Med.. 1998

impact of depression on stroke outcome
Impact of Depression on Stroke Outcome
  • Decreased benefit from rehab
  • Increased inpatient and outpatient utilization
  • Increased mortality

Ghose et al. Med Care. 2005 Dec;43(12):1259-64

deaths from heart disease by age group dmh enrollees with smi compared to massachusetts 1998 2000
Deaths from Heart Disease by age group.DMH Enrollees with SMI compared to Massachusetts 1998-2000




3.5 RR

using the phq 9
Using the PHQ-9
  • Screening
  • Diagnosis
  • Response to treatment
  • Outcomes
screening who and how
Screening – Who and How

US Preventive Services Task Force,

2003 statement supporting screening for depression:

(We) recommend screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow-up.

screening for depression who do you screen
Screening for Depression: Who do you screen?
  • All adults at least every 5 years (as part of a health maintenance visit?)
  • High risk groups every year
    • History of depression
    • Family history of depression or bipolar
    • Chronic illnesses such as diabetes, heart disease, pain problems
    • High utilization of services
  • People with complaints that suggest depression such as insomnia or fatigue
screening for depression
Screening for Depression:

The first two questions of the PHQ-9 have been validated as a sensitive way to screen for depression

  • 96% of people with depression will say yes to one of those two questions
  • Answer of ‘2’ or ‘3’ on either of those questions is a positive screen
  • Administer the full PHQ-9 to those who screen positive
what is watchful waiting
What is Watchful Waiting?
  • It is estimated that a third of people with mild symptoms will recover without treatment.
  • Watchful waiting means you are seeing the patient about once a month and monitoring their PHQ-9 score, but not starting active treatment.
  • Self-care activities such as exercise or relaxation are usually a component of watchful waiting.
  • If the patient’s symptoms have not resolved after 2-3 months, active treatment ought to be considered.
how often should the phq be done
How often should the PHQ be done?
  • Once a month until the patient reaches remission (score 0-4) or for the first 6 months of treatment
  • Every 3 months after that while the patient is on active treatment
  • Once a year for people with a history of depression who are no longer on active treatment
treatment goals
Treatment Goals
  • BEST
    • Remission = Score of 0-4
  • Good
    • Score between 5-9
    • Score drop by more than 50% of baseline
things to consider in initiating use of the phq 9 in your daily work
Things to Consider in Initiating Use of the PHQ-9 in your daily work
  • How will you identify those patients who should fill out a PHQ?
  • Who will give the patient the PHQ?
  • Who will score the PHQ?
  • Who will enter the results into the registry? When will that be done?
useful websites
Useful Websites
  • MaineHealth
  • MacArthur Foundation Initiative on Depression and Primary Care
  • Robert Wood Johnson Foundation Depression in Primary Care program