Download TITLE

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
• 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
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)
CUMULATIVE MORTALITY FOR DEPRESSED
AND NONDEPRESSED PATIENTS AFTER MI
Cumulative Mortality
15
Depressed (n=35)
Depressed
Not Depressed
10
5
Nondepressed (n=187)
23
19
21
15
17
11
13
9
7
5
3
0
1
% Mortality
20
Cox Hazard
Ratio = 5.74
p=0.0006
Weeks Post-MI
Frazure-Smith, JAMA 1993;270:1819-1825
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
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
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
GLOBAL BURDEN OF DISEASE:
WORLD HEALTH ORGANIZATION
2020
1990
1
Lower respiratory infection
1
Ischemic heart disease
2
Conditions arising during
the perinatal period
2
Unipolar major
depression
3
Diarrheal diseases
3
Road traffic accidents
4
Unipolar major
depression
4
Cerebrovascular disease
5
Chronic obstructive
pulmonary disease
6
Lower respiratory
infections
5
Ischemic heart disease
6
Vaccine-preventable disease
Murray & Lopez, WHO: Global Burden of Disease, 1996; Michaud, JAMA, 2001
IMPACT OF MENTAL DISORDERS:
COSTS OF DEPRESSION
Annual
Costs
($)
4500
4000
3500
3000
2500
2000
1500
1000
500
0
Depressed
Non depressed
Simon G, Am J Psychiatry. 1995
UNDER-RECOGNITION/
UNDERTREATMENT
• 30%-70% of depression missed
• 50% stop medication within 3 months
• 50% of treated patients in primary care
remain depressed after 1 year
ASSESSMENT
•
•
•
•
•
•
Types of depression
Symptoms
PHQ-9
Suicide assessment
Co-morbidity (Anxiety)
Bipolarity
TYPES OF DEPRESSION
•
Major depression
• Chronic depression (dysthymia)
• Minor depression
– adjustment disorder
– depressive disorder nos
MAJOR DEPRESSION
• Four Hallmarks:
–Depressed mood
–Anhedonia
–Physical symptoms
–Psychological symptoms
DEPRESSED MOOD
Hallmark 1
• Neither necessary, nor sufficient
• Can be misleading
• Beware of asking the question, “Are
you depressed?”
ANHEDONIA
Hallmark 2
• Loss of interest or pleasure
• May be most useful hallmark
• Ask, “What do you enjoy doing?”
PHYSICAL SYMPTOMS
Hallmark 3
• Sleep disturbance
• Appetite or weight change
• Low energy or fatigue
• Psychomotor changes
PSYCHOLOGICAL SYMPTOMS
Hallmark 4
• Low self-esteem or guilt
• Poor concentration
• Suicidal ideation or persistent
thoughts of death
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
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
MINOR DEPRESSION
• Depressed mood or anhedonia
•
•
•
•
At least two other symptoms
Symptoms present <2 yrs
Significant disability
Specific diagnoses
–Adjustment disorder
–Depressive disorder nos
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
Oxman, 2003
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
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
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…?”
ANXIETY
IN MAJOR DEPRESSION
• 58% have an anxiety disorder
• >70% have anxiety symptoms
Kessler RC et al. Br J Psychiatry Suppl. 1996;30:17-30.
PREVALENCE OF MAJOR DEPRESSION
IN PATIENTS WITH ANXIETY
56% (Panic + MD)
42%
Specific
Phobia
48%
Panic
PTSD
(PTSD + MD)
(phobia +MD)
62%
(GAD + MD)
SAD
GAD
Depression
37%
(SAD + MD)
OCD
27% (OCD + MD)
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
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”
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
MANAGEMENT
•
•
•
•
•
•
Referral
Three phases of depression
Outcome targets/definitions
Treatment selection
Medications
Office counseling
REFERRAL
• Suicidality
• Psychosis
• Bipolarity
• Chemical dependency
• Personality disorder
THREE PHASES OF TREATMENT
Normal
Remission
Relapse
Recovery
Recurrence
Response
Relapse
> 50%
STOP
Rx
65 to 70%
STOP
Rx
Acute
Continuation
Maintenance
Phase (3 months+) Phase (4-9 months) Phase (years)
Time
Oxman, 2001
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
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
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.
2.
3.
4.
5.
Paykel ES, et al. Psychol Med. 1995;25:1171-1180.
Thase ME, et al. Am J Psychiatry. 1992;149:1046-1052.
Judd LL, et al. J Affect Disord. 1998;59:97-108.
Miller IW, et al. J Clin Psychiatry. 1998;59:608-619.
Simon GE, et al. Gen Hosp Psychiatry. 2000;22:153162.
6.
7.
8.
9.
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.
TREATMENT SELECTION:
CONSIDER FOUR OPTIONS
• Watchful waiting
• Psychotherapy
• Antidepressant medication
• Combination therapies
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)
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
PHARMACOTHERAPY
• Effective
– major depression
– chronic depression (dysthymia)
• Equivocal
– minor depression
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
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.
MEDICATION GUIDELINE I: Acute
1. Start with SSRI or new agent
2. Elicit commitment to take medication
regularly (self-management plan)
3. Early follow-up (1-3 weeks)
4. 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)
PHQ-9: MONTHLY FOLLOW-UP GUIDE
PHQ-9
Drop of  5 points
from baseline or PHQ
<5
Treatment
Response
Treatment Plan
Adequate
Drop of 2-4 points
from baseline
Possibly Inadequate
Drop of 1 point, no
change or increase
Inadequate
No treatment change
needed. Follow-up
monthly until
remission, then every
6
months.change in
Consider
plan: increase dose or
change medication;
increase intensity of
SMS, psychotherapy
Obligate change in
plan (as above);
consider specialist
consultation,
collaboration, referral
Adapted from Oxman, 2002
RECURRENCE BECOMES MORE LIKELY
WITH EACH EPISODE OF DEPRESSION
>50%
First
episode1,2
Second
episode2
≈70%
80%-90%
Third +
episode2,3
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.
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
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”