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Clarifying Diagnosis and Monitoring Recovery: Self Report Mental Health Scales can Help!
Dr. Margie Oakander
Sunridge Primary Mental Health
Clinical Associate Professor
University of Calgary
2
Disclosure: Dr. Margie Oakander
Advisory Board or Committee: Astra Zeneca, Biovail, GlaxoSmith Kline, Janssen, Lilly, Lundbeck, Otsuka, Pfizer, Valeant, Wyeth
Honouraria or other fees: Astra Zeneca, Biovail, Bristol Myers Squibb, Janssen, Lundbeck, Lilly, Otsuka, Pfizer, Shire, Wyeth, Valeant
Research: GlaxoSmithKline, Lilly, Lundbeck, Pfizer, Wyeth
CME Development: Canadian Psychiatric Association
University of Calgary
3
70-year-old male
35-year-old female
Let’s Start with the many faces of major depression
+ Depressed mood+ Hypersomnia+ Increased appetite / weight+ Psychomotor retardation+ Difficulty making decisions + Suicidal ideation
- Marked loss of interest / pleasure- Insomnia- Decreased appetite / weight- Psychomotor agitation- Impaired concentration - Inappropriate guilt
DSM-IV criteria
4
DSM 5 Major Depressive Disorder
●Depressed mood
●Loss of interest or pleasure
●Significant changes in weight and/or appetite
●Insomnia or hypersomnia
●Psychomotor agitation or retardation
●Fatigue or loss of energy
●Feelings of worthlessness or excessive/inappropriate guilt
●Diminished ability to think or concentrate, or indecisiveness
●Recurring thoughts of death or suicide, including plans and attempts
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th edition 2013.
5
DSM 5 Criteria: SIGGE-CAPS Mnemonic
S—Suicidal preoccupation
I—Interest/pleasure ()G—Gain/lose weight
G—Guilty feelings
E—Energy ()
C—Concentration
A—Affect ( mood)
P—Psychomotor retardation
S—Sleep disturbance
DSM-5 major depressive disorder: 5 of 9 symptoms x 2 weeks
Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. 2013.
6
Most frequent conditions leading to short-term and long-term disability in Canada
Other
Genitourinary / urogenital
Respiratory
Gastrointestinal
Maternity
Cardiovascular
Cancer
Accident
Musculoskeletal / back
Mental / behavioural health
0 10 20 30 40 50 60 70 80 90
8
3
4
9
16
24
28
37
76
83
8
1
1
1
0
29
63
13
76
85
Long-term disabilityShort-term disability
Respondents, %
n=87
Note: Respondents were asked to select the top three conditions.
The Conference Board of Canada. 2013.
Most frequent conditions leading to short-term and long-term disability in Canada according to employers
Lopez et al. Lancet 2006;26:1747-57.
2.5
2.8
2.8
3.5
3.6
3.6
5.0
5.6
6.0
8.3Ischemic heart disease
Cerebrovascular disease
Unipolar depressive disorders
Alzheimer's & other dementias
Respiratory cancers
Adult-onset hearing loss
COPD
Diabetes mellitus
Alcohol use disorders
Osteoarthritis
% of total DALYs lost
Top 10 Conditions in High-Income Countries
Global Burden of Disease Study
COPD: chronic obstructive pulmonary disease; DALY: disability-adjusted life-year
8
Mental illness carries a huge burden to society
● Is more than 1.5 times that of ALL cancers● Is more than 7 times that of ALL infectious diseases● Contributed to loss of 600,000 health-adjusted life years (HALYs)● Included the top 5 conditions with
highest impact on life and health:– Depression– Bipolar disorder– Alcohol use disorders– Social phobia– Schizophrenia
The burden of mental illness and addictions in Ontario:
Health-adjusted life years (HALYs): A combination of years lived with less than full function and years lost to early death.Ratnasingham S, et al. Institute for Clinical Evaluative Science, 2012.
Considerations for Measurement-based Care (MBC)
How many people would consider… Treating diabetes without measuring and following a
patient’s HbA1c?
Prescribing an antihypertensive and not measuring a patient’s BP?
Measurement-based care (MBC) provides specific and objective information on which to base clinical decisions and should therefore
enhance quality of care and treatment outcomes.
Rush J. et al., Psychiatric Times. Vol. 26 No. 9 , 2009
Why don’t clinicians use scales to measure outcome when treating depressed patients?
How often do you use a rating scale to monitor the course of treatment for depression?
Why not? Please indicate all that apply.
Zimmerman & McGlinchey, J Clin Psychiatry 2006.
Survey of 314 psychiatrists attending a CME conference in 2006 and 2007.
Reason (N=248) %
Do not believe it would be clinically helpful. 28
Do not know what scale to use. 21
Takes too much time. 34
Too disruptive to practice. 19
Wasn’t trained to use them. 34
Percent
Rosenbluth M et al., The Canadian Journal of Diagnosis, June 2011
Does Measurement-based Care Help Guide Treatment?Canadian Practice Reflective Audit Results
* Physicians may have changed more than one part of a patient’s treatment regimen, therefore, percentages do not equal 100%.
Change Med-ication
Increase dose of current
medication
Add-on therapy
No change0%
20%
40%
60%
80%
100%
20%30%
22%33%
25%38%
23% 23%
Primary CareSpecialist
% o
f Pat
ient
s67% of Primary Care and 77% of psychiatrists made changes to treatment regimens
A Quick Look at the Scales
PHQ-15
GAD-7 PHQ-9
A Quick Look at the ScalesWhat makes a scale useful to clinicans and patients?
• Validated• Sensitive to change• Brief enough to allow routine administration• Preferably patient rated• Easy to administer and require minimal training
PHQ -9 (for Major Depressive Disorder) GAD-7 (for Generalized Anxiety) Sheehan Disability Scale (For Functionality) PHQ-15 (for Physical Symptoms) BC-CCI (for Cognitive Complaints)
When Time Is Limited…The 30 second PHQ-2 depression screen:
Kroenke et al. Med Care 2003;41:1284-94
Cut-off score of 3
• Sensitivity = 83%, specificity = 92% for MDD
Over the past 2 weeks, how often have you been bothered by any of the following items?
Not at All
Several Days
More Than Half the Days
Nearly Every Day
1. Little interest or pleasure in doing things 0 1 2 3
2. Feeling down, depressed or hopeless 0 1 2 3
Practical Screening Tool
Patient Health Questionnaire- PHQ 9• Self-rated scale is the “HbA1c”
of depression.• Designed specifically for
primary care.• Highly sensitive and specific
for the diagnosis of depression.
• Useful in monitoring treatment response
TOTAL SCORE DEPRESSION SEVERITY
1-4 Minimal Depression
5-9 Mild Depression
10-14 Moderate Depression
15-19 Moderately-severe Depression
20-27 Severe MDD
PHQ-9 is adapted from PRIME MD TODAY, developed by Drs Robert L. Spitzer, Kurt Kroenke, and Janet B.W. Williams. Copyright ©1999 Pfizer Inc
16
Treatment options based on the PHQ9 score
Score Severity Proposed Treatment Plan 0 – 4 None-minimal None 5 – 9 Mild Watchful waiting; repeat at follow-up 10 – 14 Moderate Consider psychotherapy and/or pharmacotherapy
15 – 19 Moderately Severe Consider pharmacotherapy and/or psychotherapy 20 – 27 Severe Initiate pharmacotherapy and, if severe
impairment, or actively suicidal considerconsultation +/- admission to psychiatry
GAD: DSM-IV Diagnostic criteria
Excessive anxiety and worry (apprehensive expectation) occurring more days than not for at least 6 months, about a number of events or activities (such as work, school performance)
The individual finds it difficult to control the worry.
Screening Questions for GAD
Are you by nature a worrier?
Do you worry more than other people?
What do you worry about?
Does the worry interfere with your life?
GAD-7 For Scoring Symptom Severity In GAD
Spitzer RL. Arch Intern Med 2006;166:1092-1097.
following problem?
Feeling nervous, anxious, on edge
Generalized Anxiety Disorder - GAD-7
Spitzer RL. Arch Intern Med 2006;166:1092-1097.
TOTAL SCORE Provisional Diagnosis
0-4 Minimal anxiety
5-9 Mild anxiety
10-14 Moderate anxiety
15-21 Severe anxiety
• Self rated• Specific for GAD but
useful to detect an anxiety disorder in depression
• Can be used to monitor treatment progress
*GAD-2 is the first 2 questions of the GAD-7
Substance/Medication-Induced Anxiety Disorder
• Examples of Substances that can cause anxiety:• Alcohol• Caffeine• Cannabis• Phencyclidine• Other Hallucinogens• Inhalant• Opioid• Sedative, hypnotic or anxiolytic• Amphetamine• Cocaine
How Patients with Depression & Anxiety Initially Present to Primary Care Physicians
Most people with psychological problems go to their family doctor with a physical complaint rather than recognizing that they have a form of mental distress.
If patient presents with somatic symptoms instead of psychological symptoms thediagnosing of depression or anxiety is much less
Pre
sen
tatio
n
Phy
sici
an D
iagn
osis
of
Dep
ress
ion
or A
nxi
ety
Dis
ord
er
83%
22%
77%
17%
Kirmayer LJ, et al. Somatization and the recognition of depression and anxiety in primary care. Am J Psychiatry 1993;150:734-41.
Somatic Symptoms Somatic SymptomsPsychological SymptomsPsychological Symptoms
0-1 2-3 4-5 6-8 ≥9
Strong Correlation Between Number of Physical Symptoms and Prevalence of Psychiatric Disorders
The more physical complaints there are, the more likely there is a psychiatric problem.
Kroenke K, et al. Arch Fam Med 1994;3:774-9.
0
20
40
60
80
100
Number of Physical Complaints
Pa
tie
nts
wit
h
P
sy
ch
iatr
ic D
iso
rde
rs (
%)
Anxiety Disorder Mood Disorder Any Psychiatric Disorder
TOTAL SCORE
SEVERITY OF SOMATIC SYMPTOMS
5-9 Low
10-14 Moderate
15-20 HIgh
• Brief, self-rated somatic symptom scale
• Useful for screening somatization as well as monitoring somatic symptom severity.
• Strong correlation between PHQ15 and functional status, disability days and symptom related difficulty.
Kroenke K et al. The PHQ 15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med. 2002 Mar-Apr, 64(2):258-66
The Somatic Symptom Scale – PHQ-15
26
Patient language to describe cognitive symptoms
ATTENTION MEMORY
PSYCHOMOTOR SPEED EXECUTIVE FUNCTION
CONFUSEDINADEQUATE
OVERWHELMED
Tired / lethargic
Slow motion
Forgetful
Loss of short-term memory
Concentration
Lack of focus
Indecisive
Procrastinate
Not listeningAttention
Lacking confidence
Lose train of thought
Brain is cloudy
Patients use a diverse range of
language to describe their
cognitive symptoms
Some terms are specific to an
individual domain,
whereas others encompass
multiple domains of cognitive
dysfunction
26
Qualitative market research with patients (July 2011)on patients in Canada and Europe, conducted by H. Lundbeck A/S
27
Mini-Mental State Exam (MMSE) and the Montreal Cognitive Assessment (MoCA)
● Common bedside tests to assess cognitive impairment● Not very sensitive for milder degrees of cognitive impairment
seen in depression
British Columbia Cognitive Complaints Inventory (BC-CCI)
• 6 item scale that measures perceived cognitive problems.
• Brief, self-rated, easy to incorporate clinically, ensures standardized cognitive assessment
• Sensitive to cognitive complaints in patients with depression
• Can be used to monitor change over time • Should be used in conjunction with a
depression rating scale eg PHQ-9
TOTAL SCORE
SEVERITY OF PERCEIVED COGNITIVE SYMPTOMS
0-4 Broadly normal
5-8 “mild” cognitive complaints
9-14 “moderate” cognitive complaints
15-18 “severe” cognitive complaints
Iverson GL, Lam RW, Rapid screening for perceived cognitive impairment in major depressive disorder, Ann Clin Psychiatry, 2013 May; 25(2) 135-40
The Sheehan Disability Scale- SDS
Sheehan DV. The Anxiety Disease. New York. Charles Scribner and Sons, 1983.
• 10-point self-rated scale• Assists clinician to monitor
function in 3 domains - work, social and family functioning
• Uses visuospatial, numeric and verbal descriptive anchors
• Reflects change over time with effective treatment
SCORING
No recommended cut-off score; change-over-time useful in monitoring response
Clinicians should pay attention to patients with scores over 5 in any domain
30Prepared in response to an unsolicited request – Not for further distribution
Arizona Sexual Experience Scale (ASEX)
The Arizona Sexual Experience Scale (ASEX) is designed to assess five major global aspects of sexual dysfunction: • Drive• Arousal• Penile erection/vaginal lubrication• Ability to reach orgasm• Satisfaction from orgasm
All of these are domains most commonly impaired by psychotropic dugs Items are rated 1-6; higher scores = greater dysfunction Sexual dysfunction is defined as:
• ASEX total score 19 or 1 item 5 or 3 items 4
ASEX, Arizona Sexual Experience Scale McGahuey CA et al. J Sex Marital Ther. 2000;26(1):25-40.
31Prepared in response to an unsolicited request – Not for further distribution
Arizona Sexual Experiences Scale (ASEX)
How strong is your sex drive?
1Extremely Strong
2Very Strong
3Somewhat Strong
4 Somewhat Weak
5Very Weak
6No Sex Drive
How easily are you sexually aroused?
1Extremely Easily
2Very Easily
3Somewhat Easily
4 Somewhat Difficult
5Very Difficult
6Never Aroused
Male: Can you easily get and keep an erection? / Female: How easily does your vagina become moist?
1Extremely Easily
2Very Easily
3Somewhat Easily
4 Somewhat Difficult
5Very Difficult
6Never
How easily can you reach an orgasm?
1Extremely Easily
2Very Easily
3Somewhat Easily
4 Somewhat Difficult
5Very Difficult
6Never Reach Orgasm
Are your orgasms satisfying?
1Extremely Satisfying
2Very Satisfying
3Somewhat Satisfying
4 Somewhat
Unsatisfying
5Very
Unsatisfying
6Can’t Reach Orgasm
For each item, please indicate your OVERALL level during the PAST WEEK, including TODAY.
ASEX, Arizona Sexual Experience Scale McGahuey et al. J Sex Marital Ther. 2000;26(1):25-40.
32
Evaluating Comorbidity
32
• Beck Depression Inventory• HAMD-7• PHQ-9MDD• MDQBipolar Disorder
• Fear Questionnaire• GAD-7• Hamilton Anxiety Scale GAD• Substance Abuse and Dependence Scale
Substance Use Disorder
• Adult ADHD Self-Report Scale (ASRS)ADHD
Hirschfeld RM, et al. Am J Psychiatry. 2000;157(11);1873-75.
Patient self-assessment screening tool for a broad diagnosis of the bipolar spectrum according to DSM-IV criteria
13 questions covering hypo/mania symptoms, clustering of symptoms, and impaired functioning
Criteria for a diagnosis within the bipolar spectrum: 7 positive questions + clustering of symptoms + moderate-to-severe impairment
9 out of 10 correctly identified (specificity)7 out of 10 ruled out (sensitivity)
Mood Disorder Questionnaire“… useful screening instrument”
Lifecycle of ADHD
Hyperactive as child
Drop out of school
Job performance Parent
RelationshipIssues
Alcohol/Substance Abuse
Accidents
34
When to Screen?
Patients presenting with:
Major Mood and Anxiety D/O (including poor response to treatment)
Drug abuse or drug dependence
Family history or children with ADHD
Poor school performance as a child (not reaching potential)
Frequent job changes or moving often
Frequent driving infractions
Higher number of accidents than average population
Forgetfulness (missed appointments, trouble with adherence to medications)
History of maternal smoking during pregnancy
35
Questions for Suspected ADHD
McIntosh D, Kutcher S, Binder C, et al. Neuropsychiatr Dis Treat. 2009.
Anything positive – move to Step 2
Anything positive – move to Step 3
36
Do you currently have substantial difficulties with forgetfulness, attention, impulsivity or restlessness that are interfering with your relationships or your success at work?
Have you ever been diagnosed with ADHD? Do you have a family history of ADHD (siblings, children, parents or extended family)? Did you have any difficulty in school?
Did you daydream or have difficulty paying attention? Did you get your homework done on time? Were you disruptive?
Complete ASRS & Complete Diagnostic Interview
The Adult ADHD Self-Report Scale (ASRS-V1.1)1 Symptom Checklist• A checklist of 18
questions about symptoms that are based on the diagnostic criteria for ADHD from the DSM-IV
• Developed in conjunction with the World Health Organization and the Workgroup on Adult ADHD.
1. ASRS-v1.1 Screener COPYRIGHT ©2003 World Health Organization (WHO). Reprinted with permission of WHO. All rights reserved.37
RemissionNot officially
defined; varies between studies
(e.g., HAM-D <7-10)
Functional Recovery
Outcomes were here
Outcomes are now here
Ideal outcome should be here
Defining Treatment Goals
Adapted from: Nierenberg & DeCecco. J Clin Psychiatry 2001;62 (Suppl 16):5-9.
Response
50% improvement in a validated depression
rating scale from baseline (e.g., HAM-D)
Defining “remission” from a patient’s perspective
Factors identified as very important, in rank order:
1. Presence of positive mental health (e.g. optimism, vigour, self-confidence)
2. Feeling like your usual, normal self
3. Return to usual level of functioning at work, home or school
4. Feeling in emotional control
5. Participating in, and enjoying, relationships with family and friends
6. Absence of symptoms of depression
Zimmerman et al. Am J Psychiatry 2006; 163:148-150
Thanks! Q&A Time!
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