Diagnosis and Treatment of Depression Educating Nurses and Providers to Improve Quality of Care for our Patients with Diabetes

Transcription

1 Diagnosis and Treatment of Depression Educating Nurses and Providers to Improve Quality of Care for our Patients with Diabetes Derek Seib Niyati Mukherjee November 9, 2009

2 What is depression? The DSM-IV defines major depression as having 5 of the following 9 symptoms, one being depressed mood or loss of interest/pleasure, present most of the day nearly every day for at least two consecutive weeks: There are many different psychopathological syndromes in which depressed mood is a feature. **Mnemonic: SIG E CAPS** -- Change in Sleep -- Loss of Interest or pleasure -- Thoughts of Guilt or worthlessness -- Loss of Energy -- Trouble Concentrating -- Change in Appetite or weight -- Change in Psychomotor activity -- Suicidal ideation

3 Why is depression important in diabetes? Depression affects 5-10% of patients in the primary care setting. 1 Patients with co-morbid disease like diabetes, coronary artery disease, stroke, obesity, and HIV have twice the risk of depression of the general population. 2 Untreated depression is likely a barrier to effective treatment of diabetes 3,4, associated with: Poor glycemic control. Increased diabetic complications. Decreased adherence to medical therapy.

4 Depression and diabetes in our clinic a snapshot from July 7 Number of patients in the internal medicine clinic: ~13,000 Number of clinic visits per year: ~40,000 Number of Patients with DM (in the Enhanced Care Program): 1948 Number of DM patients who have ever scored >9 on PHQ9: 296 (15.2%)

5 How can we efficiently screen for depression? The frequency of each symptom is measured Questions correspond The initial 2 questions of to SIG E CAPS the PHQ-9 are referred to as the PHQ-2 A PHQ2 score 3 has a sensitivity of 83% and a specificity of 92% for A positive PHQ-2 triggers completion of the PHQ-9. A major score depression of >= 10 has 5. a sensitivity of 88% and a specificity of 88% for major depression 6.

6 Our current process

7 Ben Vincent s work 3/74 pts of attendings and 3/61 pts of residents had initial PHQ Initial PHQ-2 screening by RNs was excellent (97%). Usage of depression prompt by MDs was good (83%). Care assistants have not been reliably notified for positive initial screens.

8 Ben Vincent s work, continued: Provider behavior Data is limited, but suggests that providers need education not only as to process, but also as to appropriate treatment.

9 New process RN administers PHQ-2 Score 3? NO Record on visit planner YES RN hands patient PHQ-9 for self-administration MD scores PHQ-9 and records score **Role of the care assistant will fit within this overall framework and is yet to be determined. MD intervenes appropriately

10 Dx and Tx Algorithm MD scores PHQ-9 PHQ-9 < 10 PHQ-9 = PHQ-9 15 No depression or mild depression. Re-screen at next visit with PHQ-2. Depression education. Re-screen at next visit with PHQ-2. NO Current Rx? YES Start Rx. Follow up in 4-6 weeks. Rescore PHQ-9 at time of follow up. NO Optimal dose? YES If no response, consider changing medications. Otherwise, optimize dose. Alternately, consider second agent. Follow up in 4-6 weeks. Rescore PHQ-9 at time of follow-up. Consider changing medications or adding second agent. Follow up in 4-6 weeks. Rescore PHQ-9 at time of follow-up.

11 Treatment guidelines Severity Score Depression Severity Your Response 0-4 Not clinically depressed No action; screen next year 5-9 Mild depression Moderate depression Depression education; reassess 6 months 15 or greater Severe depression Depression education; start Rx; repeat PHQ-9 in 6 weeks. Possible psych referral for higher scores.

12 Dosing Trade Name Total Daily Dosing Range (mg) Starting-Low Middle High Fluoxetine Prozac 10 qam x 1 wk, then 20 qam Citalopram Celexa 10 qam x 1 wk, then 20qAM Buproprion SR Wellbutrin SR 150 qam x 1 wk, then 100 BID 40 qam 60 qam 40 qam 60 qam 150 BID 200 BID Buproprion XL Wellbutrin XL 150 mg qam 300 mg qam 450 mg qam Nortriptyline Aventyl mg qhs mg qhs 150 mg qhs

13 ROLE of Diabetes Care Assistants To be determined but many ideas in the making: Continue to enter data from returned PHQ-9s PHQ-9 return to front desk: -extra paper to hand in vs. placing PHQ-9 on back of visit planner Likely will continue to provide diabetes education for all PHQ-9s 10 (MD will notify DCAs at visit) Role of follow-up phone call after positive score yet to be determined Role outside of PHQ-9 will remain unchanged

14 Plan: Spread the word Educate RNs Venue: Staff meeting Date: November 12 Mode: PowerPoint Subject: New process Educate providers Venue: Pre-clinic conference Date: To be determined Subject: New process Diagnosis and treatment of depression

15 RN Presentation Goals: Provide motivation to implement changes in clinic practice in order to improve quality of diabetic care. Explain reason for changes. Introduce new RN responsibilities.

16 Outcome measures RN Presentation Is this mode of education effective? Administer informal survey post-presentation: Do you feel comfortable with our new clinic procedure for depression screening after this presentation? Is this mode of communication effective? Suggestions for changes? How often do RNs hand the patient a PHQ-9 after a positive screen? To be measured in the next two months by tracking visit planners.

17 Pre-clinic conference Two existing pre-clinic conferences that teach diagnosis and treatment of depression, respectively, were revised and combined. Emphasis was placed on: Efficiently screening for depression and suicidality Guidelines for initiating treatment How to adjust treatment for nonresponders or partial responders Our new clinic procedure.

18 Pre-clinic conference: Learning objectives 1. Know the current recommendations regarding screening adults for depression 2. Identify the diagnostic criteria for major depression 3. Recognize the importance of identifying depression in patients with underlying chronic diseases, such as diabetes and coronary artery disease 4. Learn the new process for identifying and treating depression in diabetic patients at our clinic. 5. Be able to initiate rational anti-depressant therapy 6. Be able to recognize when psychiatric consultation is indicated

19 Pre-clinic conference: Case CASE ONE: Mrs. Smith is a 53-year-old female with a history of diabetes, for which she takes metformin. She is obese with a BMI of 39 and she has a history of CAD. She presents for a scheduled routine visit at the UNC Internal Medicine Clinic. 1. How common is depression? Should she be screened for depression? If so, why?. CASE ONE, CONTINUED: Per our new clinic protocol to screen all diabetic patients for depression, the RN screens Mrs. Smith using the point-score PHQ-2 questionnaire. The patient scores 3 points. 2. How do you interpret the score?

20 CASE ONE, CONTINUED: Mrs. Smith s PHQ-2 score 3 prompts the RN to hand her a PHQ-9 questionnaire for selfadministration. It is now your responsibility to score the PHQ-9 and act appropriately based on the score. 3. How does the PHQ-9 compare to the DSM-IV criteria for MDD? How do you score the PHQ-9? 4. What will you do if she scores: a. 8 b. 13 c. 19 CASE ONE, CONTINUED: Mrs. Smith s PHQ-9 score is Having concluded that this patient is depressed, how important is it to ask specific questions about suicidality? What will you do if she is suicidal?

21 CASE ONE, CONTINUED: Mrs. Smith denies suicidal ideation. For a variety of reasons, Mrs. Smith is hesitant to start pharmacotherapy. 6. What is your next step? CASE ONE, CONTINUED: Your words of wisdom reassure Mrs. Smith, and she agrees to start pharmacotherapy. 7. What is your choice of treatment? What barriers to treatment do you anticipate, and how can you overcome them? When will you see her back?

22 CASE ONE, CONTINUED: You start Celexa (10 mg qam for 1 week, then 20 mg qam), and Mrs. Smith returns to clinic 6 weeks later as directed. She reports that she has been taking Celexa as prescribed, and she is feeling a little better. 8. What can you do to quantitatively measure change in depressive symptoms? How can you adjust her medication regimen? When should you consider referral to a psychiatrist? CASE ONE, CONTINUED: Mrs. Smith s PHQ-9 score is now 14. You choose to increase her dose of Celexa to the maximum recommended dose of 40 mg QD. She returns to clinic 4 and 8 weeks later, and again, the PHQ-9 is administered; she scores 4 and 3, and states she is no longer depressed. 9. Are you done treating Mrs. Smith?

23 How to spread the word to Options: attendings? Presentation at Thursday division meeting, outlining both our clinic process and the approach to treatment that we recommend to our residents. attending version of pre-clinic conference to all attendings for their perusal Other suggestions?

24 Educating providers: Outcome measures Is this mode of education effective? Administer informal survey post-conference or post-division meeting: Do you feel comfortable with our new clinic procedure for depression screening after this case discussion? Are you comfortable with diagnosis of major depression after this case discussion? Are you comfortable with initiation of anti-depressant therapy? Is this mode of communication effective? Suggestions for changes?

25 Further changes? Incorporate the following prompt into the provider section of the visit planner: PHQ-9 (circle one)? Administered NEEDS ACTION If administered, PHQ-9 score? Not Administered If PHQ-9 15, which action was taken (circle one)? Started Rx Optimized dose Changed agent Added second agent Psychiatry referral Other

26 Outcome measures (To be measured in future projects) 1) % of +PHQ-2s getting full PHQ-9s to the MD 2) # of +PHQ-9s appropriate treatment (education +/- medication and follow up phone calls) 3) Improved comfort in residents dealing with depression. (survey vs. proof in the data??) 4) Decreased number of +PHQ-2s for returning diabetics ~6 months into the change

27 Thanks to: - Kim Young-Wright - Anne Whitney - Dr. Tom Miller