DEPRESSION IN CHRONIC ILLNESS
adapted from
The MacArthur Foundation Depression Education Program
Cole, Raju, Barrett, Gerrity, Dietrich General Hospital Psychiatry, 2000
WHEN DO YOU STOP?
Maintain dose 4-9 months after remission Chance of relapse • 50% if 1 prior episode • 75% if 2 prior episodes • 90% if 3 prior episodes Patient may need lifetime therapy Maintenance should be full dose
OUTLINE
The problem Types of depression PHQ Decision support
DEPRESSION IS COMMON
10-50% of patients with diabetes cardiac disease, or asthma have major depression Depressed patients visit primary care physicians 3 times more often than patients not depressed
DEPRESSION IS SIGNIFICANT
Increased
morbidity and mortality in medical conditions Increased utilization Increased costs Leading cause of disability worldwide
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
DEPRESSION IN CARDIAC DISEASE
risk of hypertension; CVA; CAD risk of death after MI (independent of other risks) HPA activation sympatho-medullary activity platelet aggregation; coagulation; fibrinolysis; BP variability
– – Musselman et al Archives Gen Psych 1998 van Kanel et al Psychosom Med 2001
DEPRESSION IN ASTHMA
Depression associated with nonadherence, increased symptoms/decreased function 50% of mothers of asthmatic children have depression Depression in mothers associated with 40% in ER visits of children
UNDER-RECOGNITION/ UNDERTREATMENT
30%-70% of depression is
missed 50% of patients stop medication within first 3 months
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
CHRONIC DEPRESSION
(DYSTHYMIA)
Characterized by 2 years of depressed mood, occurring more days than not Persists with at least 2 other symptoms of depression Increases risk of major depressive episodes
MINOR DEPRESSION
Adjustment disorder Depressive disorder nos Significant disability
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
USE OF THE PHQ
Assess
high-risk, „red flag‟ patients • Chronic illness • Unexplained physical complaints • Patients who appear sad or stressed • Patients who have lost interest or pleasure in their lives
Scoring The PHQ: Severity
Count
numerical values of symptoms
• 0-4 • 5-9 • 10-14 • >14
not clinically depressed mild depression moderate depression severe depression
PHQ-9 Compared to Clinician Assessment of MDD
Result
Using DSM-IV criteria method
Sensitivity 73%
88%
Specificity 98%
88%
Score > 10
Score > 15
68%
95%
BARRIERS TO RECOGNITION
Culture and stigma Somatization Comorbidity Fallacy of „good reasons‟ „Pandora‟s box‟ Discomfort with emotional issues
DECISION SUPPORT: ACUTE DEPRESSION
Treatment selection
• Consider four options
Referral Support/office counseling
REFERRAL
Suicidality Psychosis
Bipolarity
Chemical dependency Personality
disorder
OFFICE COUNSELING
S schedule regular activities P plan pleasant events E exercise A assertiveness K kind thoughts about self
Christensen et al: Psychiatry for Primary Care, 1998
FOUR TREATMENTS
Watchful waiting Psychotherapy
Antidepressant medication
Combination therapies
WATCHFUL WAITING (WW)
Many depressions remit spontaneously WW is an acceptable “treatment plan” Initial treatment of choice for minor depression Intensity of WW
• Low: repeat PHQ only (mild depression) • Moderate: w/care management (mod. depression)
PSYCHOTHERAPY
Effective
• Mild to moderate major depression • Adjunct to antidepressants • Dysthymia (chronic depression) • Minor depression • For patients in life transitions or with personal conflicts
Possibly effective
PHARMACOTHERAPY
Effective
• Major depression • Dysthymia (chronic depression)
Possibly effective
• Minor depression
MEDICATION ALGORITHM
Start with SSRI or new agent Increase every 2-4 weeks If no response, switch class If partial response at maximum dose, consider augmentation or consultation
TREATMENT GUIDELINES
Titrate agent to achieve therapeutic dose or remission Full effect may take 2-4 weeks Continue for 4-9 months after full remission Use maintenance medication for recurrent depressions
Three Phases of Treatment
Normal
Remission
Relapse
Recovery
Recurrence
Response
Relapse
> 50% STOP Rx
65 to 70% STOP Rx
Maintenance Phase (years)
Oxman, 2001
Acute Continuation Phase (3 months+) Phase (4-9 Time months)
ANTIDEPRESSANTS
TRICYCLICS SSRIs citalopram (Celexa) fluoxetine (Prozac) paroxetine (Paxil) sertraline (Zoloft) escitalopram (Lexapro) OTHER NEW AGENTS bupropion (Wellbutrin) mirtazapine (Remeron) nefazodone (Serzone) venlafaxine (Effexor)
- DA/NE - NE/5HT - SRI/5HT - SRI/NRI
TRICYCLIC ANTIDEPRESSANTS
Side Effects:
anticholinergic antihistaminergic antiadrenergic quinidine-like effects * nortriptyline and desipramine least toxic
ADVANTAGES OF SSRIs AND OTHER NEW AGENTS
Fewer side effects Safety profile Increased patient satisfaction Improved adherence to therapy Cost savings
CHOOSING AMONG SSRIs AND OTHER NEW AGENTS
Evaluate half-life drug interactions side effects
HALF-LIFE
Long (longer than 1 day) fluoxetine (Prozac) Short other SSRIs (once a day) Effexor XR (once a day) Wellbutrin SR (1-2x/day) other new agents (2x/day)
DRUG INTERACTIONS
Obtain medication history Be aware that all drugs can affect the action and serum levels of other drugs Monitor the clinical effects and serum levels of all medications
(ANTIDEPRESSANT INHIBITION OF CYTOCHROME P450)
DRUG INTERACTIONS
IID6
• Moderate inhibition (fluoxetine, paroxetine) • Low inhibition (citalopram, sertraline) • Low inhibtion (other new agents)
IIIA3/4
• use nefazodone with caution
USE CAUTION WITH:
COUMADIN DIGOXIN ANTICONVULSANTS ERTHYROMYCIN KETACONAZOLE ALPRAZOLAM CODEINE DEXTROMETHORAPHAN BETA/CALCIUM CHANNEL BLOCKERS TYPE 1C ANTIARRHYTHMIC AGENTS
SIDE EFFECTS (SSRIs)
Agitation/insomnia GI distress Sexual dysfunction
SIDE EFFECTS (OTHER NEW AGENTS)
bupropion mirtazepine
agitation - sedation, weight gain sedation
distress, elevated BP
nefazodone -
venlafaxine - GI
MANAGING SIDE EFFECTS
Insomnia/agitation
• Use adjunctive sedating agent • Switch to mirtazapine, nefazodone Sexual dysfunction • Switch to bupropion, mirtazapine, nefazodone • Add bupropion, sildenafil, yohimbine
MANAGING SIDE EFFECTS
Sedation
• Give medication HS
GI distress • Give medication after meals
Anticholinergic effects • Bulk in diet, lemon drops Postural hypotension • Hydration, change position slowly, support hose
COMORBID ANXIETY/PANIC
Educate patient Give low dose SSRI, titrate slowly Consider benzodiazepine Use buspirone for anxiety, not panic Consider venlafaxine, nefazodone, or mirtazepine monotherapy
PARTIAL OR NO RESPONSE
Check for adherence Re-evaluate diagnosis Adjust dosage
Change antidepressant Augment (with another class) Consider dual action agent Add psychotherapy Refer for expert consultation