Depression in Primary Care:Decision Support for Chronic Care Model

Steven Cole, MDProfessor 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, alcoholismsuicide, tobacco use, alcoholism risk of MI, CVA, DMrisk of MI, CVA, DM adherence to medical therapy function (home and work)function (home and work) achievement (education, work)achievement (education, work)

Cumulative Mortality

0

5

10

15

20

1 3 5 7 9 11 13 15 17 19 21 23

Weeks Post-MI

% M

orta

lity

DepressedNot Depressed

CUMULATIVE MORTALITY FOR DEPRESSED AND NONDEPRESSED PATIENTS AFTER MI

Frazure-Smith, JAMA 1993;270:1819-1825

Depressed (n=35)

Nondepressed (n=187)

Cox HazardRatio = 5.74p=0.0006

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, 2003Katon, Biological Psychiatry, 2003

Groot et al Psychosom Med 2001Groot et al Psychosom Med 2001

Van Tilburg et al Psychosom Med 2001Van Tilburg et al Psychosom Med 2001

1990

1 Lower respiratory infection

2 Conditions arising during the perinatal period

3 Diarrheal diseases

4 Unipolar major depression

5 Ischemic heart disease

6 Vaccine-preventable disease

20201 Ischemic heart disease

2 Unipolar major depression

3 Road traffic accidents

4 Cerebrovascular disease

5 Chronic obstructive pulmonary disease

6 Lower respiratory infections

Murray & Lopez, WHO: Global Burden of Disease, 1996; Michaud, JAMA, 2001

GLOBAL BURDEN OF DISEASE:WORLD HEALTH ORGANIZATION

0

500

1000

1500

2000

2500

3000

3500

4000

4500

IMPACT OF MENTAL DISORDERS:COSTS OF DEPRESSION

AnnualCosts($)

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 MOODHallmark 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 1999Kroenke K et al, Medical Care, 2003Kroenke K et al, J Gen Int Med, 2001

More than NearlyNot Several half the every

at all days days day0 1 2 3

PHQ PHQ -- 9 Symptom Checklist9 Symptom Checklist

a. Little interest or pleasure in doing things

b. Feeling down, depressed, or hopeless

c. Trouble falling or staying asleep, or sleeping too much

d. Feeling tired or having little energy

e. Poor appetite or overeating

f. Feeling bad about yourself, or that you are a failure . . .

g. Trouble concentrating on things, such as reading . . .

h. Moving or speaking so slowly . . .

i. Thoughts that you would be better off dead . . .

1. Over the last two weeks have you beenbothered by the following problems?

Subtotals: 3 4 9TOTAL: 16

2. ... how difficult have these problems madeit for you to do your work, take care of thingsat home, or get along with other people?

Oxman, 2003

USE OF THE PHQ-9

• Universal screening/ orUniversal screening/ or

• High-risk, ‘red flag’ patients*High-risk, ‘red flag’ patients*

– Chronic illnessChronic illness

– Unexplained physical complaintsUnexplained physical complaints

• sleep disorder, fatiguesleep disorder, fatigue

– Patients who appear sadPatients who appear sad

– Recent major stress or lossRecent major stress or loss

INTERPRETING THE PHQ: ASSESSMENT AND SEVERITY

• Count numerical values of symptomsCount numerical values of symptoms

– 0-40-4 not clinically depressed not clinically depressed

– 5-95-9 mild depression mild depression

– 10-14 moderate depression10-14 moderate depression

• 88%sensitivity, 88%specificity (MDD)88%sensitivity, 88%specificity (MDD)

– >14>14 severe depression 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

27% (OCD + MD)

37%

(SAD + MD)

62%

(GAD + MD)

56% (Panic + MD)

48%

(PTSD + MD)42% (phobia +MD)

GAD

PanicSpecific Phobia PTSD

SAD

OCD

Depression

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 activityRacing 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

• TT ell – provide basic information about illness ell – provide basic information about illness

• AA sk – about concerns/beliefs sk – about concerns/beliefs

(cognitive/emotional)(cognitive/emotional)• C C are – develop rapport; respond to emotionsare – develop rapport; respond to emotions• CC ounsel – provide information relevant to ounsel – provide information relevant to

concerns and explanatory model concerns and explanatory model • T T ailor – develop plan collaborativelyailor – 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

Time

Sym

pto

m S

ever

ity

Normal

AcutePhase (3 months+)

ContinuationPhase (4-9 months)

MaintenancePhase (years)

Response

RemissionRemission

Relapse

Relapse Recurrence

> 50% STOP Rx

65 to 70% STOP Rx

RecoveryRecovery

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

1. Paykel ES, et al. Psychol Med. 1995;25:1171-1180.2. Thase ME, et al. Am J Psychiatry. 1992;149:1046-1052.3. Judd LL, et al. J Affect Disord. 1998;59:97-108.4. Miller IW, et al. J Clin Psychiatry. 1998;59:608-619.5. Simon GE, et al. Gen Hosp Psychiatry. 2000;22:153-

162.

6. Druss BG, et al. Am J Psychiatry. 2001;158:731-734.7. Frasure-Smith N, et al. JAMA. 1993;270:1819-1825.8. Penninx BW, et al. Arch Gen Psychiatry. 2001;58:221-227. 9. Rovner BW, et al. JAMA. 1991;265:993-996.

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

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

1.1. Start with SSRI or new agentStart with SSRI or new agent2. Elicit commitment to take medication

regularly (self-management plan)3.3. Early follow-up (1-3 weeks)Early follow-up (1-3 weeks)4.4. Increase dose every 2-4 weeks (to Increase dose every 2-4 weeks (to evaluate effect of each dose change)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

Obligate change in plan (as above); consider specialist consultation, collaboration, referral

InadequateDrop of 1 point, no change or increase

Consider change in plan: increase dose or change medication; increase intensity of SMS, psychotherapy

Possibly InadequateDrop of 2-4 points from baseline

No treatment change needed. Follow-up monthly until remission, then every 6 months.

AdequateDrop of 5 points from baseline or PHQ < 5

Treatment PlanTreatment

ResponsePHQ-9

Adapted from Oxman, 2002

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.

Risk recurrence (%) following recovery during long-term follow-up*

RECURRENCE BECOMES MORE LIKELY WITH EACH EPISODE OF DEPRESSION

Firstepisode1,2

Secondepisode2

Third +episode2,3

0 20 40 60 80 100

>50%

≈70%

80%-90%

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”