Depression and Chronic Disease

Depression and Chronic Disease Public Health Detailers’ Training NYC Department of Health and Mental Hygiene Ann M. Sullivan, M.D. Regional Director of Psychiatry for the Queens Health Network New York City Health and Hospitals Corporation Outline  Recognition & Treatment  Primary Care  Challenges  Depression-Medical Comorbidities Recognition and Treatment of Depression in U.S.  Only 50% of adults with Major Depression receive any healthcare treatment at all for depression Of the 50%, only 40% receive adequate treatment Only 25-30% of adults receive adequate treatment for major depression 50% of patients stop anti-depressants within the first 3 months    Primary Care Recognition and Treatment of Depression  6-9% of patients in a Primary Care Practice have a treatable Depressive Disorder: Major Depression Disorder or Dysthymic Disorder Most Primary Care Practices Diagnose only 2-3% of their patients as depressed Among recognized and treated patients in Primary Care only 25% are adequately treated. 50% of patients with Major Depression, who do receive treatment, receive all their treatment in primary care.    Identified Challenges in the Care of Depression Practice:  “Pandora’s Box”  Detection and correct diagnosis (about 10% on benzodiazepines)  Primary care physicians frequently use medication only to treat depression  Antidepressants used at lower intensity in primary care  Almost 40% of patients stop antidepressant in first 30 days  Only 50% of those referred to specialty mental health practitioners complete more than one visit  Patients are not staying on antidepressants for continuation and maintenance phase  Difficulty accessing specialty care/consultation when needed Patient:  Somatic presentation  Stigma  Co-morbidity – multiple problems – “too time consuming”  Cultural Variation Depression-Medical Comorbidities* Prevalence General Population Coronary artery disease Myocardial infarction Cancer Diabetes HIV 10% 18% 16% 20%-25% 25% 36% Comments 12-month prevalence Current episode of depression 6-month post-MI At some time during illness Meta-analysis of 42 studies 12-month prevalence Alzheimer’s disease Migraine Multiple sclerosis * R. Swift 17%-31% 22%-32% Up to 50% Current episode of depression Lifetime prevalence in young adults Lifetime prevalence DEPRESSION – MEDICAL COMORBIDITIES CONDITION Emphysema Cerebral Vascular Renal Failure Rheumatoid Arthritis PREVALENCE 20-40% 20-40% 6.5-20% 17-27% Depression CARDIAC DISEASE  Risk of hypertension, CVA, CAD   Risk of death after MI  Mechanisms: Sympatho/Medullary activity Platelet aggregation coagulation Fibrinolysis Heart rate variability DIABETES  Non-adherence   Hb1AC   Retinopathy, Neuropathy, Nephropathy  Microvascular complications