Download Unique Aspects of Depression

DEPRESSION IN
MEDICAL SETTINGS:
STRATEGIES FOR INTEGRATION
Steven Cole, MD
Professor of Clinical Psychiatry
S.U.N.Y. Stony Brook Health Sciences Center
Rural Quality Program Conference, Office of Rural Health Policy
Health Resources Services Administration
September 1, 2009
DEPRESSION IN MEDICAL
PATIENTS IS COMMON
• 20-50% of patients w/diabetes, CAD, PD, MS,
CVA, asthma, cancer... (etc) have MD
• Prevalence varies by illness,
pathophysiology, severity, and research
methodology
• Depressed patients visit PCPs 3x more often
than patients not depressed
DEPRESSION IS SIGNIFICANT
• Increased morbidity and
mortality in medical conditions
• Increased utilization
• Increased costs
• 4th leading cause of disability
worldwide (2nd in 2020)
GLOBAL BURDEN OF DISEASE:
WORLD HEALTH ORGANIZATION
1990
1
Lower respiratory infection
2020
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
Cerebro-vascular 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
CUMULATIVE MORTALITY FOR DEPRESSED
AND NONDEPRESSED PATIENTS AFTER MI
Cumulative Mortality
% Mortality
20
15
Depressed (n=35)
Depressed
Not Depressed
10
5
Nondepressed (n=187)
Weeks Post-MI
Frazure-Smith, JAMA 1993;270:1819-1825
Circulation 1995;91:999-1005
23
21
19
17
15
13
11
9
7
5
3
1
0
Cox Hazard
Ratio = 5.74
p=0.0006
DEPRESSION
IN CARDIAC DISEASE
•  risk of hypertension;  CVA;  CAD
•  death risk after MI (controlling for other risks)
•  HPA activation
•  sympatho-medullary activity
•  platelet aggregation;  HR variability
» Musselman et al Archives Gen Psych 1998
» van Kanel et al Psychosom Med 2001
DEPRESSION IN DIABETES
•  non-adherence
•  GHb
•  retinopathy; neuropathy; nephropathy
•  macrovascular complications (CAD, etc)
» Groot et al Psychosom Med 2001
» Van Tilburg et al Psychosom Med 2001
UNDER-RECOGNITION/
UNDERTREATMENT
• 30%-70% of depression missed
• 50% stop medication in 3 months
• 50% of treated patients in primary
care remain depressed after 1 year
PATIENT HEALTH
QUESTIONNAIRE: (PHQ)
• 9-item, self-administered questionnaire
• Validated for diagnostic assessment
• Validated for follow-up of outcomes
• Clinically significant depression
(“CSD”): PHQ = 10 or greater
PHQ - 9 Symptom Checklist
More than Nearly
Not Several half the every
at all days
days
day
0
1
2
3
1. Over the last two weeks have you been
bothered by the following problems?
a. Little interest or pleasure in doing things
b. Feeling down, depressed, or hopeless
c. Trouble falling or staying asleep, or sleeping too much
d. Feeling tired or having little energy
e. Poor appetite or overeating
f.
Feeling bad about yourself, or that you are a failure . . .
g. Trouble concentrating on things, such as reading . . .
h. Moving or speaking so slowly . . .
i.
Thoughts that you would be better off dead . . .
2. ... how difficult have these problems made
it for you to do your work, take care of things
at home, or get along with other people?
Subtotals:
TOTAL:
3
16
4
9
Oxman, 2003
SCORING THE PHQ:
DIAGNOSTIC ASSESSMENT
Count numerical values of
symptoms
• 0-4 not clinically depressed
• 5-9 mild depressive symptoms
or...
»adjustment disorder
»dysthymic disorder
• 10-14 mild/moderate depression
» CSD (88% sens/spec for major
depression)
USE OF THE PHQ
• Assess high-risk, ‘red flag’ patients
– Chronic illness
– Unexplained physical complaints
– Patients who appear sad/ stressed
– Patients who have lost interest or
pleasure in their lives
MANAGEMENT GUIDELINES
I: Acute Phase
• Start with medication or psychotherapy
• Elicit commitment to take medication or
attend therapy regularly (action plan)
• Arrange early (1-3 week) follow-up
• Repeat PHQ every 1-2 months
• Re-evaluate treatment every month
depending on PHQ score (adjust meds; adjust
therapy)
OUTCOME TARGETS:
DEFINITIONS
• “Clinically significant improvement (CSI)”
– 5 point decrease in PHQ score
• “Response”
– 50% decrease in PHQ score
• “Remission”
– PHQ score <5 for three months
SELF-MANAGEMENT SUPPORT
• Integrate SMS into routine care in all
visits
• Three minute goal-setting (SMS)
– Goal 1: “Are you willing to take this every
day?”
• “What is your confidence on a 1 to 10 scale
that you will actually take the medicine every
day?”
– Goal 2: “To make sure the medicine is
working, we need to see you again (or talk
by phone) in a week or so.”
• “What is your confidence that you will make it
for this visit (or phone call) that we agreed to?”
– Chart Note
• “PAP: agrees to take meds regularly (cl = 8)”
• “PAP: agrees to return for visit in 2 weeks
Early Steps in Depression
Care
Activities in the Six Components
of the Care Model
Dan Ford, MD
Unique Aspects of Depression
• Depression is a chronic relapsing
condition (like asthma)
• Depressive symptoms closely linked
with function in time
• Diagnosis and monitoring based on
self-report, not labs or exam (telephone
is ideal)
Unique Aspects of Depression
• Depression itself may interfere
with patient’s self-care planning
– Overly pessimistic about
effectiveness of treatment
– Difficulty monitoring oneself and
making decisions
Unique Aspects of Depression
• Social stigma
• Health personnel have varying degree
of comfort with depression
• Largest gulf between primary care
providers and specialists in depression
• Depression care may be
reimbursed/funded at lower level than
other chronic conditions
Where should you start?
First Steps: Depression Self
Management
• Examine the patient handouts provided
(e.g. Depression Self-Action Plan)
• Try these materials out with a sample
of patients and determine how they
might have to be adapted for patients
with chronic medical conditions
First Steps: Decision Support
• Identify one or two local mental health
specialists to help support your
depression treatment program
(medications and psychotherapy)
– Let cluster directors know if not successful
• Develop a suicide protocol
– Train staff in suicide assessment
– Establish referral protocols
First Steps: Clinical
Information Systems
• Learn how to enter PHQ scores in
registry
• Learn how to interpret longitudinal PHQ
scores for patients
• Maximize efficiency in data entry
First Steps: Delivery System
Design
• Identify one person on team to be the
champion for depression care
• Integrate depression education into
other programs
First Steps: Organization of
Health Care
• Identify what resources will be needed for
the depression care program
• Identify and address any objections from
senior leaders and staff members to
expanding care to depression
• Common barriers include: 1) our patients do
not want to address depression; 2) somatic
care is more important; 3) we do not have the
right staff; 4) our patients need help with
social and economic issues, not depression
First Steps: Community
• Begin to identify community resources for
patients with depression
– Local
– National
• National Depressive and ManicDepressive Association www.ndmda.org
• National Mental Health Association
www.nmha.org
8 Early Steps
1. Identify a mental health specialist
2. Develop a suicide protocol
3. Develop initial antidepressant
guidelines
4. Integrate SMS (‘ultra-brief
personal action plan’) into clinical
practice/select a SMS tool
Eight early steps
5. Administer the PHQ to two patients
suspected to have depression
6. Initiate antidepressant protocol and
ultra-brief PAP/SMS tool
7. Repeat PHQ at one month and two
months
8. Review results with team - PDSA