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Depression
in
Primary Care
Kimothi Cain, MD MPH
University of New Mexico Department of Psychiatry
Objectives
▪ Inspire you to embrace the role of primary care in screening and
managing depressive disorders
▪ How to identify depressive disorders in primary care
▪ What constitutes management of depressive disorders in primary care
▪ When to refer to and collaborate with mental health colleagues
▪ Increase your knowledge about treatment of depressive disorders
▪ Pharmacologic-including treatment resistant
Two-step Screening
Step One:
Two-Question Depression
Screen
▪ Over the past 2 weeks have you
felt down, depressed, or
hopeless?
▪ Over the past 2 weeks have you
felt little interest or pleasure in
doing things?
A “yes” to either question
is a positive initial screen
for depression…
Step Two: If Screen is Positive…
▪ Probe deeper, be proactive, engage
in conversation about mood and
changes in behavior
▪ 24% - 40% of patients with positive
screen receive MDD diagnosis
▪ Others may have depressive
disorder with mixed features,
dysthymia, subsyndromal
depressive disorders, anxiety,
PTSD, substance abuse, panic
disorder
US Preventive Services Task Force. Screening for depression: recommendations and rationale. Ann Intern Med. 2010;136(10):760-764
Screening Instruments
▪ Validated
PHQ-9:
Patient Health Questionnaire-9
(www.phqscreeners.com)
▪ Quickly and easily
administered and scored
▪ Available to download
▪ Available in English
and Spanish
▪ Helpful for initial screening
AND evaluation of
treatment response
Suicide Risk Screening
Suicide Risk Assessment
Major Depressive Disorder
• One or more major depressive episodes
• Absence of any history of manic, mixed, or hypomanic episodes
• Relapsing and remitting
• Episodes may last months or, more rarely, years
• Half of all episodes fully remit within 6 to 12 months with or without treatment
• Up to 20% of those who experience an initial episode may develop chronic
depression
• After an initial episode, the patient is predisposed to additional episodes which
become more severe and last longer
Major Depressive Disorder
▪ Core symptoms: SIGECAPS
▪ Depressed mood (sad, down, blue) AND/OR
▪ Reduced interest or pleasure (I)
▪ Somatic symptoms:
▪ Change in appetite (A)
▪ Change in sleep pattern (S)
▪ Reduced energy level (E)
▪ Psychomotor agitation/retardation (P)
▪ Cognitive symptoms:
▪ Poor concentration/easy distraction (C)
▪ Inappropriate guilt/self reproach (G)
▪ Thoughts of death, dying, suicide (S)
▪ 5 out of 9 for at least two weeks
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.)
Depressive Disorder with Mixed Features
▪ New to DSM-5: MDD specifier
▪ At least 3 of the following, almost every day for the past 2 weeks,
▪ concurrent with depressive episode
▪
▪
▪
▪
▪
▪
▪
▪
Elevated/euphoric mood
Inflated self-esteem
Pressured speech and increased talking
Decreased need for sleep
Flight of ideas or racing thoughts
Increased distractibility
Increased energy or goal-directed activity
Greater participation in activities which are pleasurable, potential to have bad consequences
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.)
Persistent Depressive Disorder (Dysthymia)
▪ Depressed mood for most of the day, for more days than not, for at least 2 years.
▪ Note: In children and adolescents, mood can be irritable and duration must be at least 1 year.
▪ Presence, while depressed, of two (or more) of the following:
▪ Poor appetite or overeating.
▪ Insomnia or hypersomnia.
▪ Low energy or fatigue.
▪ Low self-esteem.
▪ Poor concentration or difficulty making decisions.
▪ Feelings of hopelessness.
▪ During the 2-year period (1 year for children or adolescents), has never been without the sx for
>2 months at a time.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.)
Depressive Disorder Due to Another Medical
Condition
▪ Prominent and persistent period--depressed mood or diminished interest or
pleasure in all, or almost all, activities that predominates in the clinical picture.
▪ Evidence from the history, physical examination, or laboratory findings that the
disturbance is the direct pathophysiological consequence of another medical
condition.
▪ The disturbance is not better explained by another mental disorder (e.g.,
adjustment disorder, with depressed mood, in which the stressor is a serious
medical condition).
▪ The disturbance does not occur exclusively during the course of a delirium.
▪ The disturbance causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.)
Comorbid Medical Conditions
▪ Asthma1
▪ Pain2
▪ Arthritis1
▪ Cardiovascular disease1
▪ Stroke3
▪ Diabetes1
▪ Obesity1
1. Chapman, DP
2. Gureje, O
3. Gillen, R
CVD and Depression
•
Patients with cardiovascular disease (CVD) more likely to
experience depression1
•
Patients with depression 1.6 times more likely to develop coronary
artery disease (CAD); even more likely with MDD1
•
Also 4 times more likely to experience a myocardial infarction
(MI)1
•
Post-MI patients with depression less likely to follow lifestyle
changes2
1. Pratt LA 2. Ziegelstein RC
Diabetes increases risk of depression
• Depression twice as prevalent in those with diabetes
• More prevalent in women with diabetes than in men
with diabetes
Anderson RJ et al
Obesity and depression
• 65% of the US population is overweight or obese
• More obese women than men (54% vs. 46%)1
• BMI ≥30 in women associated with nearly 50% increase
in lifetime prevalence of depressive disorders2
1.Ogden CL
2.Chapman DP
Explore the differentials
▪ Psychiatric
▪ PTSD
▪ BPAD
▪ General Medical
▪ Hypothyroidism = classic rule-out
▪ Post-CVA, Post-MI
▪ Ca of head of pancreas
▪ Substance-Related
▪ Alcohol abuse, cocaine/amphetamine withdrawal
▪ Rx meds: steroids, b-blockers, a-methyldopa
Best Practice Recommendation
•
Base a choice of antidepressant on the patient’s prior response,
patient and clinician preference, potential side effects, and cost.
•
Choose any class of antidepressant as a first-line treatment for
MDD.
•
Psychotherapy
AAFP Approved source: National Guideline Clearinghouse. http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=9632&nbr=5152
Steps for Choosing an Effective Antidepressant
1.
Recognize that some antidepressants may be more effective in certain
populations even though most are generally of equal effectiveness.
2.
Ask about personal or family history of treatment with antidepressants,
particularly about side effects.
3.
Consider the burden of side effects, particularly weight gain and sexual side
effects.
4.
Consider drug-drug interactions with other medications the patient is taking or
may take.
5.
Consider the potential lethality of the antidepressant in the case of an
overdose.
6.
Use antidepressant side effects for efficacy.
APA practice guidelines, 2010
Best Practice Recommendation
▪ Follow up with patients on antidepressants for MDD:
▪ At least once within the first month
▪ At least once more 4 to 8 weeks after the first contact
▪ Assess for adherence, side effects, suicidal ideation, and
response.
AAFP Approved Source: National Guideline Clearinghouse. http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=9632&nbr=5152
Strength of evidence: Consensus-based. A practice is recommended based on the consensus or expert opinion of the Guideline Development Team.
Treatment of Depressive Disorders
Level 1 Initial Treatment:
 Discuss treatment options, including evidence-based psychotherapy [Cognitive-behavioral therapy (CBT),
Interpersonal psychotherapy (IPT)]
 Monotherapy 4-8 week trial at adequate dose and evaluate:
 (SSRI)*, (SNRI)
 Bupropion (if tolerability concerns) or mirtazapine (if insomnia a focus of clinical concern)
 If partial response at 4 weeks may continue for another 2-4 weeks or go to Level 2
 If no response at 4 weeks go to Level 2
*consider propensity for drug-drug interactions, differential risk for teratogenicity
Level 2 If Level 1 is ineffective and/or not well tolerated:
 Evaluate adherence
 Dose optimization
 Switch to different monotherapy
 Agent from different or same class (SSRI, SNRI, mirtazapine, bupropion)
 Combine existing monotherapy with:
 Evidence-based psychotherapy (e.g. CBT, IPT)
 Atypical antipsychotic FDA-approved for major depressive disorder (e.g. aripiprazole, brexpiprazole)
 An antidepressant (do not combine SSRI and SNRI) (e.g. buspirone, mirtazapine)
APA Practice Guidelines 2010; 2015 Florida Best Practice Psychotherapeutic Medication Guidelines for Adults (2015).
Treatment of Depressive Disorders, cont.
Level 3 If Levels 1 and 2 are ineffective and/or not well tolerated:
 Evaluate adherence
 Seek psychiatric consultation
 (SSRI or SNRI) + quetiapine (tolerability concerns)
 (SSRI or SNRI) + (lithium or T3)
 (SSRI or SNRI) + (L-methylfolate )
 Tricyclic antidepressant (TCA)
 Electroconvulsive therapy (ECT)
 Transcranial magnetic stimulation (TMS)
APA Practice Guidelines 2010; 2015 Florida Best Practice Psychotherapeutic Medication Guidelines for Adults (2015).
Treatment of Depressive Disorders, cont.
Level 4 If Levels 1 – 3 are ineffective and/or not well tolerated:
• Re-evaluate diagnosis if patient has failed to respond to two or more
treatments
• Consider referral to Psychiatry
• L-methlyfolate augmentation
• Triple drug combination (little evidence exists supporting or refuting this
strategy)
 (SSRI or SNRI) + mirtazapine + bupropion
 (SSRI or SNRI) + mirtazapine + lithium
 (SSRI or SNRI) + bupropion + second generation antipsychotic (SGA)
• Other neuromodulatory approaches (e.g. vagus nerve stimulation)
APA Practice Guidelines 2010; 2015 Florida Best Practice Psychotherapeutic Medication Guidelines for Adults (2015).
Treatment-MDD with Mixed Episode
Level 1 Initial Treatment:
 Minimal evidence
 Evidence-based psychotherapy [Cognitive-behavioral therapy (CBT),
Interpersonal psychotherapy (IPT)]
 Consider second generation antipsychotic (SGA)
 Antidepressant monotherapy 4-8 week trial at adequate dose and evaluate
(antidepressant monotherapy in MDD with subsyndromal hypomania may be
associated with a higher rate of suboptimal therapeutic outcomes when compared
to MDD without subsyndromal hypomania):
 SSRI, SNRI
 Bupropion (if tolerability concerns) or mirtazapine (if insomnia a focus of
clinical concern)
 For all Level 1 treatments, if partial response at 4 weeks, may continue for another
4 weeks or go to Level 2
 If no response at 4 weeks, go to Level 2
APA Practice Guidelines 2010; 2015 Florida Best Practice Psychotherapeutic Medication Guidelines for Adults (2015).
Treatment-MMD with Mixed Episode
Level 2 If Level 1 is ineffective and/or not well tolerated:







Reassess for hypomania/mania
Dose optimization of medication used in Level 1
Switch to different monotherapy SGA
Antidepressant monotherapy from different or same class
Combine existing antidepressant with different SGA
Combine SGA with antidepressant
If ineffective—consider referral to Psychiatry
APA Practice Guidelines 2010; 2015 Florida Best Practice Psychotherapeutic Medication Guidelines for Adults (2015).
If Initial Treatment Ineffective
▪ Medication trial should last 8-12 weeks
▪ If no side effects or tolerability issues, increase dosage every 2-3
weeks until
▪ Remission achieved
▪ Max dose achieved
▪ Side effects limit titration
▪ Combine antidepressants and psychotherapy
▪ Combine antidepressants or consider augmentation trial
▪ Considering tailoring your treatment for specific sub-populations (e.g.,
elderly, midlife women, etc.)
APA Practice Guidelines 2010; 2015 Florida Best Practice Psychotherapeutic Medication Guidelines for Adults (2015).
Patient Adherence
▪ More than 1/2 of patients treated for depression in primary care
practices stopped drug treatment within 3 weeks.
Why??
▪ Were not informed how long it would take to feel better
▪ Were not warned about side effects
▪ “Was not told I needed to continue once I felt better”
Sexual Dysfunction and Antidepressants
▪ Selective Serotonin Reuptake Inhibitors (SSRIs)
▪ Increases serotonin levels in both sexes
▪ Decreases sex drive
▪ Impairs orgasm
▪ 5HT2A Agonist
▪ Tricyclic Antidepressants (TCAs)
▪ Drying of mucosal membranes
▪ Reduction of lubrication
▪ Stimulation of 5HT2A receptors
▪ Inhibits erection and ejaculation
Consequences of Failing to Achieve Remission
•
Increased risk of relapse
•
Continued psychosocial limitations
•
Continued impairments at work
•
Worsened prognosis of Axis III disorders
•
Increased utilization of medical services
•
Sustained elevation of suicide and
substance abuse risks
•
Increased risk of treatment resistance
Nierenberg AA; Thase ME
Factors that Predispose to Incomplete
Remission
•
Chronicity
•
Medical co-morbidity
•
Older age
•
Axis I or II co-morbidity
•
Severity
•
Inadequate treatment
Thase ME; Nierenberg AA
Maintenance
•
Patients with one lifetime episode of MDD who achieve remission on
antidepressants should continue to take them for another 6 - 12 months.
•
Patients with two or more episodes should be maintained an additional
12 months to 3 years, possibly for a lifetime
•
Patients with chronic MDD or MDD with concurrent dysthymia should be
continued on antidepressants an additional 18 - 36 months after the
acute phase treatment.
Kaiser Permanente Care Management Institute. Depression clinical guidelines.
http://www.guideline.gov/summary/summary.aspx?doc_id=9632&nbr=5152&ss=6&xl=999
References
▪
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
▪
Anderson RJ et al. The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care. 2001;24(6):1069-1078.
▪
Chapman DP et al. The vital link between chronic disease and depressive disorders. Prev Chronic Dis. 2005;2(1):A14.
▪
Gillen R et al. Depressive symptoms and history of depression predict rehabilitation efficiency in stroke patients. Arch Phys Med Rehabil. 2001;82(12):1645-1649.
▪
Gureje O et al. A cross-national study of the course of persistent pain in primary care. Pain. 2001;92(1-2):195-200.
▪
Kaiser Permanente Care Management Institute. Depression clinical guidelines. http://www.guideline.gov/summary/summary.aspx?doc_id=9632&nbr=5152&ss=6&xl=999
▪
Moore DP, Jefferson JW. Mood Disorders. In: Moore & Jefferson: Handbook of Medical Psychiatry, 2nd ed. Philadelphia: Mosby; 2004.
▪
National Guideline Clearinghouse. http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=9632&nbr=5152
▪
Nierenberg AA, et al. J Clin Psychiatry. 1999;60(suppl 22):7-11.
▪
Ogden CL et al. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA. 2006;295(13):1549-1555.
▪
Pratt LA et al. Depression, psychotropic medication, and risk of myocardial infarction. Prospective data from the Baltimore ECA follow-up. Circulation. 1996;94(12):3123-3129.
▪
Texas Medication Algorithm Project (TMAP) Treatment of Major Depressive Disorder Clinician’s Manual- http://www.dshs.state.tx.us/mhprograms/tmapover.shtm
▪
Thase ME. J Clin Psychiatry. 1999;60(suppl 22):3-6.
▪
US Preventive Services Task Force. Screening for depression: recommendations and rationale. Ann Intern Med. 2002;136(10):760-764
▪
Weilburg JB, O'Leary KM, Meigs JB, Hennen J, Stafford RS. Evaluation of the adequacy of outpatient antidepressant treatment. Psychiatr Serv. 2003;54(9):1233-1239.
▪
Ziegelstein RC et al. Patients with depression are less likely to follow recommendations to reduce cardiac risk during recovery from a myocardial infarction. Arch Intern Med.
2000;160(12):1818-1823.