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Depression in Primary Care: Decision Support for Chronic Care Model

Depression in Primary Care: Decision Support for Chronic Care Model. Steven Cole, MD Professor of Psychiatry Stony Brook University Health Center. OUTLINE. The problem Assessment Engagement Management. DEPRESSION IN MEDICAL PATIENTS IS COMMON.

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Depression in Primary Care: Decision Support for Chronic Care Model

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  1. Depression in Primary Care:Decision Support for Chronic Care Model Steven Cole, MD Professor of Psychiatry Stony Brook University Health Center

  2. OUTLINE • The problem • Assessment • Engagement • Management

  3. DEPRESSION IN MEDICAL PATIENTS IS COMMON • 20-50% of patients with diabetes, CAD, PD, MS, CVA, asthma, cancer... (etc) have MD • Evans et al, Biological Psychiatry 2005 (review) • Prevalence varies by illness, pathophysiology, severity, and research methodology • Depressed patients visit PCPs 3x more often than patients not depressed

  4. DEPRESSION IS SIGNIFICANT •  medical morbidity and mortality •  medical disability •  healthcare utilization •  suicide, tobacco use, alcoholism •  risk of MI, CVA, DM •  adherence to medical therapy •  function (home and work) •  achievement (education, work)

  5. Depressed (n=35) Nondepressed (n=187) Cox Hazard Ratio = 5.74 p=0.0006 Frazure-Smith, JAMA 1993;270:1819-1825

  6. DEPRESSION IN CORONARY ARTERY DISEASE • Dep is risk factor for future CAD, MI • 15-23% of MI patients have major depression •  risk (3-5x) of death after MI •  HPA axis;  sympatho-medullary axis •  cytokines, other immunological markers •  platelet aggregation •  HR variability • Genetics (5-HTTLPR serotonin-transporter region) • short allelle --  depression  death Jiang et al, Am Heart Journal 2005 Shimbo et al Am Journal of Cardiology 2005 Carney et al Arch Int Med 2005

  7. DEPRESSION IN STROKE • Depression predicts future CVA • 14-23% major depression after CVA • Anatomy (pathophysiology) • “Robinson hypothesis” • left anterior (anterior cingulate) • left basal ganglia • PSD predicts  morbidity,  mortality Robinson RG. Biol Psychiatry 2003;54:376-387

  8. DEPRESSION IN DIABETES • 11-15% major depression (OR 2:1) •  non-adherence •  GHb (physiological relationships) • Lustman et al, J Diabetes Complications 2005 • Lustman et al, Psychosom Med 2005 •  retinopathy; neuropathy; nephropathy •  macrovascular complications (CAD, etc) • Katon, Biological Psychiatry, 2003 • Groot et al Psychosom Med 2001 • Van Tilburg et al Psychosom Med 2001

  9. GLOBAL BURDEN OF DISEASE: WORLD HEALTH ORGANIZATION • 2020 • Ischemic heart disease • Unipolar major depression • Road traffic accidents • Cerebrovascular disease • Chronic obstructive pulmonary disease • Lower respiratory infections • 1990 • Lower respiratory infection • 2 Conditions arising during the perinatal period • 3 Diarrheal diseases • Unipolar major depression • Ischemic heart disease • Vaccine-preventable disease Murray & Lopez, WHO: Global Burden of Disease, 1996; Michaud, JAMA, 2001

  10. IMPACT OF MENTAL DISORDERS:COSTS OF DEPRESSION Annual Costs ($) Depressed Non depressed Simon G, Am J Psychiatry. 1995

  11. UNDER-RECOGNITION/UNDERTREATMENT • 30%-70% of depression missed • 50% stop medication within 3 months • 50% of treatedpatients in primary care remain depressed after 1 year

  12. ASSESSMENT • Types of depression • Symptoms • PHQ-9 • Suicide assessment • Co-morbidity (Anxiety) • Bipolarity

  13. TYPES OF DEPRESSION • Major depression • Chronic depression (dysthymia) • Minor depression • adjustment disorder • depressive disorder nos

  14. MAJOR DEPRESSION • Four Hallmarks: • Depressed mood • Anhedonia • Physical symptoms • Psychological symptoms

  15. DEPRESSED MOODHallmark 1 • Neither necessary, nor sufficient • Can be misleading • Beware of asking the question, “Are you depressed?”

  16. ANHEDONIAHallmark 2 • Loss of interest or pleasure • May be most useful hallmark • Ask, “What do you enjoy doing?”

  17. PHYSICAL SYMPTOMSHallmark 3 • Sleep disturbance • Appetite or weight change • Low energy or fatigue • Psychomotor changes

  18. PSYCHOLOGICAL SYMPTOMSHallmark 4 • Low self-esteem or guilt • Poor concentration • Suicidal ideation or persistent thoughts of death

  19. DIAGNOSIS OF MAJOR DEPRESSION • Depressed mood OR anhedonia, most of the day,nearly every day for the last two weeks • A total of five out of nine symptoms of depression • depressed mood or • anhedonia • physical symptoms • sleep, appetite/weight, energy, psychomotor change • psychological symptoms • low self-esteem, poor concentration, hopelessness

  20. CHRONIC DEPRESSION (DYSTHYMIA) • Characterized by 2 years of depressed mood, more days than not • Persists with at least 2 other symptoms of depression • Increases risk of major depressive episodes

  21. MINOR DEPRESSION • Depressed mood or anhedonia • At least two other symptoms • Symptoms present <2 yrs • Significant disability • Specific diagnoses • Adjustment disorder • Depressive disorder nos

  22. PATIENT HEALTH QUESTIONNAIRE (PHQ-9) • 9-item, self-administered questionnaire • Validated for diagnostic assessment • 88% sensitivity and specificity for MDD • Validated for follow up of outcomes • 1st two questions for screening (PHQ2) • 83% sensitivity and 92% specificity • Performs well after stroke (and other illness) • Williams et al, Stroke 2005 Spitzer R, et al. JAMA 1999 Kroenke K et al, Medical Care, 2003 Kroenke K et al, J Gen Int Med, 2001

  23. Oxman, 2003

  24. USE OF THE PHQ-9 • Universal screening/ or • High-risk, ‘red flag’ patients* • Chronic illness • Unexplained physical complaints • sleep disorder, fatigue • Patients who appear sad • Recent major stress or loss

  25. INTERPRETING THE PHQ: ASSESSMENT AND SEVERITY • Count numerical values of symptoms • 0-4 not clinically depressed • 5-9 mild depression • 10-14 moderate depression • 88%sensitivity, 88%specificity (MDD) • >14 severe depression

  26. ASSESS SUICIDALITY:5 QUESTIONS 1. “Have you ever thought life was not worth living?” 2. “Have you had thoughts of hurting yourself” (if yes, “What have you thought about…?”) 3. “Having a thought and acting on it are different, have you ever made an attempt on your life?” 4. “What are the chances that you would actually hurt yourself?” 5. “If you feel out of control, will you contact me…?”

  27. ANXIETYIN MAJOR DEPRESSION • 58% have an anxiety disorder • >70% have anxiety symptoms Kessler RC et al. Br J Psychiatry Suppl. 1996;30:17-30.

  28. PREVALENCE OF MAJOR DEPRESSION IN PATIENTS WITH ANXIETY 56% (Panic + MD) 48% (PTSD + MD) Panic Specific Phobia 42% (phobia +MD) PTSD SAD 62% (GAD + MD) GAD Depression 37% (SAD + MD) OCD 27% (OCD + MD)

  29. BIPOLAR DISORDER • 10% of depressed primary care patients have bipolar disorder (hypomania/mania) • Look for: • Euphoria/irritability • Personal or family hx of bipolar disorder • Decreased need for sleep • Impulsive or risky behavior • Increased verbal/motor activity • Racing thoughts • Mood swings last days to weeks

  30. ENGAGEMENT:SPECIAL CHALLENGES • Overcome stigma • “Only weak people get depressed” • “Depressed people are inadequate, weak…” • Overcome ‘barrier’ health beliefs • “I have good reasons to be depressed” • “Medicine can’t help a depression”

  31. Use T.A.C.C.T.For Engagement • T ell – provide basic information about illness • A sk – about concerns/beliefs (cognitive/emotional) • C are – develop rapport; respond to emotions • C ounsel – provide information relevant to concerns and explanatory model • T ailor – develop plan collaboratively

  32. MANAGEMENT • Referral • Three phases of depression • Outcome targets/definitions • Treatment selection • Medications • Office counseling

  33. REFERRAL • Suicidality • Psychosis • Bipolarity • Chemical dependency • Personality disorder

  34. THREE PHASES OF TREATMENT Remission Recovery Normal Relapse Recurrence Response Relapse > 50% STOP Rx Symptom Severity 65 to 70% STOP Rx Acute Phase (3 months+) Continuation Phase (4-9 months) Maintenance Phase (years) Time Oxman, 2001

  35. OUTCOME TARGETS: DEFINITIONS 1. “Clinically significant improvement (CSI)”* • 5 point decrease in PHQ score 2. “Response” • 50% decrease in PHQ score 3. “Remission” • PHQ score <5 for three months *MCID = minimal clinically important difference

  36. GOAL: FULL REMISSION • Remission of symptoms treatment goal • Resolution of emotional/physical symptoms • Restoration of full functioning • Return to work, hobbies, relationships • PHQ score < 5 for three months 1

  37. Potential Consequences of Failing to Achieve Remission • Increased risk of relapse and resistance1-3 • Continued psychosocial limitations4 • Decreased ability to work and productivity5,6 • Increased cost for medical treatment6 • Sustained depression may worsen morbidity/mortality of other conditions7-9 1. Paykel ES, et al. Psychol Med. 1995;25:1171-1180. 2. Thase ME, et al. Am J Psychiatry. 1992;149:1046-1052. 3. Judd LL, et al. J Affect Disord. 1998;59:97-108. 4. Miller IW, et al. J Clin Psychiatry. 1998;59:608-619. 5. Simon GE, et al. Gen Hosp Psychiatry. 2000;22:153-162. • Druss BG, et al. Am J Psychiatry. 2001;158:731-734. • Frasure-Smith N, et al. JAMA. 1993;270:1819-1825. • Penninx BW, et al. Arch Gen Psychiatry. 2001;58:221-227. • Rovner BW, et al. JAMA. 1991;265:993-996.

  38. TREATMENT SELECTION:CONSIDER FOUR OPTIONS • Watchful waiting • Psychotherapy • Antidepressant medication • Combination therapies

  39. WATCHFUL WAITING (WW) • Many depressions remit spontaneously • WW is an acceptable “treatment plan” • Initial TOC for minor depression • Variable intensity of WW • Low: repeat PHQ only (mild depression) • Moderate: w/care management (mod. depression)

  40. PSYCHOTHERAPY • Effective (CBT/IPT/PST) • Mild to moderate major depression • Adjunct to antidepressants • Possibly effective • Dysthymia (chronic depression) • Minor depression • For patients in life transitions or with personal conflicts

  41. PHARMACOTHERAPY • Effective • major depression • chronic depression (dysthymia) • Equivocal • minor depression

  42. ANTIDEPRESSANTS • TRICYCLICS • SSRIs • citalopram (Celexa) • escitalopram (Lexapro)* • fluoxetine (Prozac) • paroxetine (Paxil) • sertraline (Zoloft) • OTHER NEW AGENTS • bupropion (Wellbutrin SR, XL) - DA/NE • desvenlafaxine (Pristiq)* - SNRI • duloxetine (Cymbalta)* - SNRI • mirtazapine (Remeron) - NE/5HT • venlafaxine (Effexor XR)* - SNRI *no generic available at present time

  43. Key Educational Messages • Antidepressants only work if taken every day. • Antidepressants are not addictive. • Benefits from medication appear slowly. • Continue antidepressants even after you feel better. • Mild side effects are common, and usually improve with time. • If you’re thinking about stopping the medication, call me first. • The goal of treatment is complete remission; sometimes it takes a few tries.

  44. MEDICATION GUIDELINE I: Acute • Start with SSRI or new agent • Elicit commitment to take medication regularly (self-management plan) • Early follow-up (1-3 weeks) • Increase dose every 2-4 weeks (to evaluate effect of each dose change) 5.Repeat PHQ every month 6.Raise dose or change treatment until PHQ<5 for 3 months (remission)

  45. PHQ-9 Treatment Response Treatment Plan Drop of  5 points from baseline or PHQ < 5 Adequate No treatment change needed. Follow-up monthly until remission, then every 6 months. Drop of 2-4 points from baseline Possibly Inadequate Consider change in plan: increase dose or change medication; increase intensity of SMS, psychotherapy Drop of 1 point, no change or increase Inadequate Obligate change in plan (as above); consider specialist consultation, collaboration, referral PHQ-9: MONTHLY FOLLOW-UP GUIDE Adapted from Oxman, 2002

  46. RECURRENCE BECOMES MORE LIKELY WITH EACH EPISODE OF DEPRESSION >50% First episode1,2 Second episode2 ≈70% Third + episode2,3 80%-90% 0 20 40 60 80 100 Risk recurrence (%) following recovery during long-term follow-up* 1. Judd LL, et al. Am J Psychiatry. 2000;157:1501-1504. 2. Mueller TI, et al. Am J Psychiatry. 1999;156:1000-1006. 3. Frank E, et al. Arch Gen Psychiatry. 1990;47:1093-1099.

  47. MEDICATION GUIDELINE III: Continuation/Maintenance • Upon remission, maintain dose 4-9 months during ‘continuation’ phase • Repeat PHQ every 4-6 months • Consider long-term ‘maintenance’ at treatment-effective dose for recurrent depressions

  48. OFFICE COUNSELING • BUILD THE ALLIANCE • Reflection, Legitimation, Support, Partnership, Respect • ENGAGEMENT • “TACCT” • SELF-MANAGEMENT SUPPORT • UB-PAP (ultra-brief personal action planning) • 5 A’s • OFFICE PSYCHOTHERAPY • “BATHE” • “SPEAK”

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