Depression in Primary Care Decision Support for Chronic Care

							  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

                20
  % Mortality




                15
                                     Depressed (n=35)
                                                                           Depressed
                10
                                                                           Not Depressed
                 5                                  Nondepressed (n=187)


                 0                                                         Cox Hazard
                                                                           Ratio = 5.74
                 1
                     3
                         5
                             7
                                 9
                                     11
                                     13
                                                15
                                                17
                                                           19
                                                           21
                                                                      23
                                                                           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
       1990             2020
1   Lower respiratory infection              1    Ischemic heart disease
2 Conditions arising during                  2    Unipolar major
  the perinatal period                            depression
3 Diarrheal diseases                         3    Road traffic accidents
4   Unipolar major                           4    Cerebrovascular disease
    depression                               5    Chronic obstructive
5   Ischemic heart disease                        pulmonary disease
6   Vaccine-preventable disease              6    Lower respiratory
                                                  infections

    Murray & Lopez, WHO: Global Burden of Disease, 1996; Michaud, JAMA, 2001
IMPACT OF MENTAL DISORDERS:
    COSTS OF DEPRESSION

Annual   4500
Costs
($)      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)
                               Panic                      48%
                  Specific                           (PTSD + MD)
    42%                                   PTSD
                  Phobia
 (phobia +MD)




  62%           GAD                                       SAD
(GAD + MD)                   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
                    Remission           Recovery
 Normal

                         Relapse         Recurrence
    Response
                      Relapse
      > 50%
      STOP          65 to 70%
        Rx           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.   Paykel ES, et al. Psychol Med. 1995;25:1171-1180.
2.   Thase ME, et al. Am J Psychiatry. 1992;149:1046-1052.   6.   Druss BG, et al. Am J Psychiatry. 2001;158:731-734.
3.   Judd LL, et al. J Affect Disord. 1998;59:97-108.        7.   Frasure-Smith N, et al. JAMA. 1993;270:1819-1825.
4.   Miller IW, et al. J Clin Psychiatry. 1998;59:608-619.   8.   Penninx BW, et al. Arch Gen Psychiatry. 2001;58:221-227.
5.   Simon GE, et al. Gen Hosp Psychiatry. 2000;22:153-      9.   Rovner BW, et al. JAMA. 1991;265:993-996.
     162.
 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                Treatment          Treatment Plan
                            Response
Drop of  5 points          Adequate         No treatment change
from baseline or PHQ                         needed. Follow-up
<5                                           monthly until
                                             remission, then every
Drop of 2-4 points     Possibly Inadequate   6 months.change in
                                             Consider
from baseline                               plan: increase dose or
                                            change medication;
                                            increase intensity of
                                            SMS, psychotherapy
Drop of 1 point, no        Inadequate       Obligate change in
change or increase                          plan (as above);
                                            consider specialist
                                            consultation,
                                            collaboration, referral
                                        Adapted from Oxman, 2002
RECURRENCE BECOMES MORE LIKELY
WITH EACH EPISODE OF DEPRESSION

      First                                      >50%
 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”