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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 l.jpg

Depression: The Hidden Co-Morbidity

Neil Korsen, MD, MS


January 18, 2007

Overview l.jpg

  • Depression and chronic medical illnesses

  • Chronic medical illness and serious persistent mental illness (SPMI)

  • Using the PHQ-9 for screening and management of depression

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Pop Quiz – Question #1

  • Which is true?

    • Depression increases risk for diabetes.

    • Diabetes increases risk for depression.

    • Both are true.

    • Neither is true.

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Pop Quiz – Question #2

  • What is the most common cause of death in people with SPMI?

    • Heart Disease

    • Suicide

    • Accidents

    • Cancer

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Pop Quiz – Question #3

  • The PHQ-9 is useful for:

    • Screening for depression

    • Assessing response to treatment

    • Measuring outcomes

    • All of the above

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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

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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

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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

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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

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Impact of Depression on Outcome of Cardiovascular Disease disease

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

Freedland. Psychosom Med.. 1998

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Impact of Depression on Stroke Outcome disease

  • Decreased benefit from rehab

  • Increased inpatient and outpatient utilization

  • Increased mortality

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

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Deaths from Heart Disease by age group. Serious Mental Illness?DMH Enrollees with SMI compared to Massachusetts 1998-2000




3.5 RR

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Mortality from Pneumonia/Influenza Serious Mental Illness?Mass DMH clients, ages 25-64

5.0 RR

4.0 RR

3.0 RR

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Ohio SMI Mortality Study Serious Mental Illness? Leading Causes of Death

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Using the PHQ-9 Serious Mental Illness?

  • Screening

  • Diagnosis

  • Response to treatment

  • Outcomes

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Screening – Who and How Serious Mental Illness?

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.

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Screening for Depression: Serious Mental Illness?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

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Screening for Depression: Serious Mental Illness?

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

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What is Watchful Waiting? Serious Mental Illness?

  • 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.

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Interpreting Follow Up Scores Serious Mental Illness?

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How often should the PHQ be done? Serious Mental Illness?

  • 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

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Treatment Goals Serious Mental Illness?

  • BEST

    • Remission = Score of 0-4

  • Good

    • Score between 5-9

    • Score drop by more than 50% of baseline

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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?

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Useful Websites daily work

  • MaineHealth


  • MacArthur Foundation Initiative on Depression and Primary Care


  • Robert Wood Johnson Foundation Depression in Primary Care program