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Depression: How it Impacts Your Patients with Diabetes and CV Disease

Depression: How it Impacts Your Patients with Diabetes and CV Disease. Neil Korsen, MD, MS Medical Director, MaineHealth Caring for ME Depression in Primary Care Program. Case Scenario #1. 62 year old man 1 month s/p acute MI. c/o fatigue, poor sleep and poor appetite since his MI. Do you:

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Depression: How it Impacts Your Patients with Diabetes and CV Disease

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  1. Depression: How it Impacts Your Patients with Diabetes and CV Disease Neil Korsen, MD, MS Medical Director, MaineHealth Caring for ME Depression in Primary Care Program

  2. Case Scenario #1 • 62 year old man 1 month s/p acute MI. c/o fatigue, poor sleep and poor appetite since his MI. • Do you: • Explain this as a normal reaction to the stress of having an MI? • Begin treatment? • Which meds are safe post MI?

  3. Case Scenario #2 • 48 year old woman with Type II DM under poor control. She doesn’t follow her diet or exercise. Her Hgb A-1-c is 9.2%. Her LDL is 150. Her BMI is 35. • How likely is depression part of the cause of her poor diabetic control? • Can you expect her diabetic control to improve if you address her depression?

  4. Why is depression important? • It is a common condition: • Estimated 5-10% annual prevalence • Lifetime prevalence ~10% men ~20% women • Higher prevalence with common medical illnesses: • Diabetes-20-30% • Heart disease-20-30% • Cancers-up to 40% • Stroke-30%

  5. Why is depression important? • It causes substantial morbidity and mortality: • Leading risk factor for suicide • Functional impairment - 2nd only to heart disease worldwide • Substance abuse and chronic pain often seen with unrecognized depression • Co-morbid depression has impact on common chronic medical conditions

  6. Why is depression important for Primary Care Providers? • About 50% of pts treated for depression exclusively by PCPs • Depression complicates treatment of other common chronic conditions • Only 30%-50% of those patients achieve remission of their symptoms • Better systems of care increase the number of people reaching remission

  7. Depression and Diabetes: Impact on diabetes • Associated with poor glycemic control • Associated with increased complications • Adds to impaired function and disability • Depressive symptoms independent predictors of CAD • Often precedes onset of Type 2 (Eaton, Diabetes Care 1996 and Kawakami, Diabetes Care, 1999)

  8. Depression and Diabetes:Effects of Treatment • Williams et al, Annals of Internal Medicine, 2004, Vol. 140, pp. 1015-1024. • Office system intervention led to better depression outcomes and better function in 417 people with diabetes who were part of a large trial in people aged 60 or older. • There were no significant changes in diabetic outcomes in this population at 12 months of followup.

  9. Depression and Diabetes:Effects of Treatment • Lin et al, Annals of Family Medicine, 2006, Vol. 4, pp. 46-53. • Study of 329 patients with diabetes and depression. Primary focus was on improving care of depression. • No changes in diabetes self-management activities at 12 months of followup.

  10. Depression in People with Cardiovascular Disease • Increased risk of onset of CV disease in people with depression. (approx 1.5-2X) • Increased risk of long term mortality in people with depression and CV disease. • Poorer post-MI outcomes • 4X increased risk of death at 6 months • 3.5X increased risk of death at 5 years

  11. Treating Depression in People with CV Disease • SSRI’s have been shown to be safe and effective for people with CV disease, even post-MI. • Tricyclic antidepressants are relatively contraindicated because of effects on cardiac conduction system. • Cognitive behavioral therapy is an evidence-based approach to treatment of mild to moderate depression that has been shown to be effective in people post MI.

  12. Health System Community Resources and Policies Health Care Organization ClinicalInformationSystems Self-Management Support DeliverySystem Design Decision Support Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Improved Outcomes / ICIC

  13. Planned care model for depression • There are approaches to primary care treatment of depression that are proven to lead to better outcomes.

  14. Improving Depression Care: Five Key Changes • PHQ-9, an outcome measure for depression • Registry or another clinical information system • Support for self-management • Care management • Informal psychiatric consultation

  15. Key Changes and the Planned Care Model

  16. Why a registry? • Population based care • Who are your patients with depression? • Are they getting the care they need? • Are they achieving the outcomes you and they expect? • Information at the touch of a button • Information about individuals • Information about the population

  17. CIR Visit Summary

  18. Why the PHQ? • Help with diagnosis • Recommended treatment is different depending on whether the diagnosis is major depression or something else. • Can help the patient accept the diagnosis. • Help with management • Having a measure helps you decide if the patient has reached the treatment goal. • The PHQ-9 is the Hgb A-1-C for depression!

  19. Why Self-Management? • Depression is often chronic or recurrent. • The more the patient takes an active role in their care, the better the outcomes are likely to be. • Depression treatments take time to work. • Self-care activities such as exercise or relaxation can help the patient feel better while they wait for active treatment to begin to work.

  20. Depression Care Management • Periodic phone calls from nurse or social worker associated with primary care practice. • Proven effective in a variety of clinical settings with a variety of populations.

  21. Why Care Management? • Primary care clinicians may not have time to do everything they need to and want to with patients with depression. • Patients with depression are at high risk for not adhering to the treatments that are recommended. • Care managers have been shown to help with adherence and to improve outcomes! A team approach works!

  22. Studies including depression care management

  23. Why consulting psychiatrists? • Collaborative approaches to care have been shown to improve outcomes. • A psychiatrist can offer help with care for many more patients using this model than using a traditional face-to-face consult model. • The psychiatrist can help decide which patients are most in need of specialty mental health care this way.

  24. For More Information: • MaineHealth website www.mainehealth.org • Follow links to depression • MacArthur Initiative website http://www.depression-primarycare.org/ • Robert Wood Johnson program website http://www.wpic.pitt.edu/dppc/

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