Changing the Landscape for Depression Treatment

Changing the Landscape for Depression Treatment in NYC Judy Stein, LMSW, MS Co-Director of Depression Initiative NYC Department of Health and Mental Hygiene February 28, 2006 Outline  Take Care New York  DOHMH Depression Initiative  Geriatric Depression  Prevalence  Suicide  Risk factors  Depression and Chronic Disease  Depression in Primary Care Outline      Depression Screening Depression Management IMPACT Study Bronx Geriatric Depression Pilot Project DOHMH Depression Initiative Projects Take Care New York (TCNY)  A health policy that prioritizes actions to help individuals, health care providers and New York City as a whole to improve health  Sets an agenda for 10 key areas for intervention  Addresses preventable causes of illness/death  Focuses on undeserved communities with disproportionately high disease burden to reduce health disparities 10 Steps to a Healthier New York 1. Have a regular doctor or other health care provider 2. Be Tobacco-Free 3. Keep your Heart Healthy 4. Know your HIV Status 5. Get Help for Depression 6. Live Free of Dependence on Alcohol and Drugs 7. Get Checked for Cancer 8. Get the Immunizations You Need 9. Make Your Home Safe and Healthy 10. Have a Healthy Baby TCNY # 5 Depression can be treated. Talk to your doctor or a mental health professional. TCNY # 5 TCNY Goal: Increase by 10% the number of people treated for depression in NYC by 2008 Baseline: 37% of New Yorkers with depression were receiving mental health treatment (NYCHANES, 2004) DOHMH Depression Initiative  Depression initiative seeks to:  Increase access to treatment by reducing stigma through public education about depression and how to access treatment Address Depression among high risk groups (elderly, perinatal, DPHO regions) Assist primary care physicians (PCPs) with implementing depression screening and management in primary care practice   Depression in Older Adults  Of the nearly 35 million Americans age 65 and older, an estimated 6.5 million have a depressive illness  Depression in the elderly is often untreated  confusion with other illnesses, ie. dementia  expectation that depression is normal part of aging  stigma  Unrecognized and untreated geriatric depression has fatal consequences, ie. suicide, non-suicide mortality Depression and Suicide  Of those with MDD, close to 50% report feelings of wanting to die, 33% consider suicide and 8.8% report a suicide attempt (NCS-R)  Comprising only 13 percent of the U.S. population, individuals age 65 and older accounted for 18 percent of all suicide deaths in 2000   Highest rate of suicide in the US is among older white men Of those who commit suicide, many reach out for help from their primary care doctor---20% see a doctor the day they die, 40% the week they die, and 70% in the month they die Risk Factors for Geriatric Depression           Family or personal history of depression Living alone, social isolation Recent bereavement Presence of other illnesses Presence of chronic or severe pain Damage to body image (from amputation, cancer surgery, or heart attack) Fear of death Use of certain meds or a combination of meds Substance abuse Past suicide attempt (s) Geriatric Depression and Chronic Disease  Symptoms of clinical depression can be triggered by other chronic illnesses common in later life, such as Alzheimer’s disease, Parkinson’s disease, heart disease, cancer and arthritis. Depression and Chronic Disease  Depressive disorders are associated with increased prevalence of chronic diseases  Depressive disorders tend to precipitate chronic disease  Chronic disease exacerbates symptoms of depression  Seven out of 10 office visits to a primary care doctor concern chronic diseases. Depression & Medical Comorbidities Prevalence Stroke Coronary artery disease Myocardial infarction Cancer Diabetes 10%-27% 18% - 20% 16% 20%-25% 25% Comments Following a stroke Current episode of depression 6-months post-MI At some time during illness Meta-analysis of 42 studies HIV Alzheimer’s disease Migraine Multiple sclerosis 36% 17%-31% 22%-32% 40% 12-month prevalence Current episode of depression Lifetime prevalence in young adults Lifetime prevalence Implications of Comorbid Depression  Patients with chronic medical conditions and concomitant major depression have poorer outcomes:    Increased somatic symptoms, eg, multiple pain complaints Excess functional disability Increased morbidity/mortality     Increased healthcare utilization and costs Poor self-care Decreased adherence to treatment regimens Higher drug interaction potential due to polypharmacy Depression in Primary Care  Depression is more commonly seen in primary care than any other conditions except hypertension/diabetes.  17 to 30% of elderly patients treated in primary care identified with depression (compared with 6 to 9% in general population)  PCPs fail to diagnose depression in up to 50% of their depressed patients…this oftentimes translates into more time spent on history taking and physical examination as well as more diagnostic procedures ordered, especially in light of vague presenting somatic complaints. Depression in Primary Care In primary care, physical symptoms are often the chief complaint in depressed patients. In a New England Journal of Medicine study, 69% of diagnosed depressed patients reported unexplained physical symptoms as their chief compliant N = 1146 Primary care patients with major depression Depression in Primary Care  The diagnosis and treatment of depression by PCPs often do not follow current guidelines.  Even when depression is recognized, the dosage and duration of antidepressant therapy may be inadequate.   50% of treated patients stop medication within first 3 months Medication often not used at dosage sufficient to achieve full remission Detection of Depression: Why Screen and Manage in primary care?  Primary care is the 1st line of defense = To find people who may be depressed or at risk for depression who don’t know it  Screening for depression in the primary care setting improves detection rates  US Preventative Service Task Force (USPSTF) recommends screening adults for depression in clinical practices that have systems in place for accurate diagnosis, effective treatment, and followup.  Only 50% of those referred to specialty mental health practitioners complete more than one visit Depression Screening: PHQ2  A physician can simply and quickly screen for depression by asking 2 questions (PHQ2): During the past two weeks, have you been bothered by: 1. little interest or pleasure in doing things? 2. feeling down, depressed, or hopeless?  A positive response to either question requires followup with PHQ9 Depression Screening: PHQ2  Valid and practical tool for depression screening in busy medical settings  Sensitivity:  Specificity: 83% for Major Depression 92% for major Depression The Patient Health Questionnaire (PHQ-9)  A 9-item, self-administered questionnaire  Can be completed by the patient before, during, or after the office visit  Corresponds with the 9 signs and symptoms of the DSM-IV  A screening tool; not a diagnostic tool The Patient Health Questionnaire (PHQ-9) Quantifies the severity of depression (gives a number) Provides measurement over time Available in multiple languages (Spanish, Chinese, Russian, Creole, Bengali, Korean) Strong evidence of reliability and validity:   Sensitivity = 88% for Major Depression Specificity = 88% for Major Depression Why use the PHQ9?  Specific advantages of the PHQ9 are:  Shorter than other depression rating scales  Can be administered in person, by telephone, or self-administered  Facilitates diagnosis of major depression  Provides assessment of symptom severity  Proven effective in geriatric population (Loewe B, et al, 2004 Medical Care)  Well validated and documented in a variety of populations Scoring the PHQ 9 Scorecard for Severity Determination: Total Score: 1-4 5-9 10-14 15-19 20-27 Depression Severity: Minimal Depression Mild Depression Moderate Depression Moderately Severe Depression Severe Depression Consider referral to mental health specialist if:  PHQ 9 > 20  Fails 1-2 medication trials  Suicidal  Psychotic or bipolar depression  Comorbid substance, physical, or sexual abuse  Severe psychosocial problems Consider referral to mental health specialist if:  Requires specialized treatment (MAO inhibitors, ECT)  Deteriorates quickly  Unclear diagnosis For referral resources: Call 1-800 LIFENET/ (800) 543-3638 or 311 and ask for LIFENET Depression Management  Patient Education  Foster provider-patient relationship, reduce stigma, enhance treatment adherence  Treatment (Medication and/or psychotherapy)  Combined treatment with antidepressants and psychotherapy is recommended as first line treatment for patients with severe major depressive disorder Depression is treatable in 65 to 75% of elderly patients   Ongoing Monitoring  Care management, follow-up PHQ9 Depression Management  Self-Management   Emphasize the patients central role in managing their illness use of effective SMS strategies, ie. assessment, goal setting, action planning, problem-solving, and follow-up organize internal and community resources to provide ongoing self management support to patients  Self-Management Tools available from MacArthur Depression Initiative website: www.depression-primarycare.org Sample Action Plan: Self Management: Three Component Model  Prepared primary care physician  Mental health specialist support  Care manager  National IMPACT Study (Improving Mood-Promoting Access to Collaborative Treatment for Late-Life Depression)  PHQ9 screening and Three Component Model used with older adults  1801 depressed older adults from 8 diverse health care systems in 5 states participated Impact Study Results  IMPACT participants were more likely than usual care patients to  Receive antidepressants or psychotherapy according to treatment guidelines Report high satisfaction with depression care Experience a substantial improvement in depressive symptoms Experience improvements in health related functional impairment and quality of life    Bronx Depression Screening and Management Pilot Project  DOHMH collaboration with MHANYC and DFTA  6 month duration, began 1/06  Project seeks to  educate seniors and senior center staff about depression  identify depressed seniors  refer seniors for assessment and treatment  provide supportive follow-up contact Bronx Depression Screening and Management Pilot Project  Target population:  Bronx Seniors in CDs 1-6  Attend DFTA senior centers (24 centers)  Participate in SOS case management program (200 seniors)  Voluntary participants Bronx Depression Screening and Management Pilot Project  Interactive educational workshops  Depression Bingo  Screening sessions with PHQ9  Referrals for those who score 10 or above  Care manager follow-up contacts  Educational information to approx. 200 Bronxbased PCPs Bronx Depression Screening and Management Pilot Project Current Data:  62 seniors screened  12 seniors scored above 10 on PHQ9  3 seniors scored 20-27  14 seniors made follow-up contact with a PCP  2 seniors made follow-up contact with a mental health professional Bronx Depression Screening and Management Pilot Project  Next steps:  Meeting with mental health providers in the Bronx  Continue to meet with PCPs in the Bronx  Future considerations:  Follow-up with PHQ9 at senior centers  Follow-up with Bronx PCPs to evaluate changes in practice DOHMH Depression Initiative Projects  CHI  Health Bulletin  DPHO Detailing Campaign  Public Education Campaign DOHMH Depression Initiative Projects  Outreach to primary care providers     HHC Voluntary hospitals FQHCs University student health centers  Enhance primary care systems through centralized care management  Insurance providers/ employers and PCP management of depression Final Note  Seniors are a population at high risk for depression  Geriatric Depression is inadequately identified and undertreated, despite serious consequences  Depression Screening with the PHQ9 in primary care can have a significant impact on this growing public health problem  DOHMH Depression Initiative staff can assist primary care MDs with implementing depression screening and management