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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.