Part 1: Depression Screening in Primary Care

Transcription

1 Part 1: Depression Screening in Primary Care Toni Johnson, MD Kristen Palcisco, BA, MSN, APRN MetroHealth System

2 Objectives Part 1: Improve ability to screen and diagnose Depression in Primary Care Increase ability to use PHQ-2 and PHQ-9 tools in Primary Care

3 Why screen for depression in primary care?

4 Depression Facts -- Epidemiology Lifetime prevalence of 10-24% in women and 5-12% in men 19 million Americans diagnosed each year 151 million people affected worldwide 2 nd leading cause of disability by 2020 Depressive disorders are 2-fold more prevalent in patients with diabetes, CAD, HIV, and stroke Depression associated with 2x increase in risk of type 2 diabetes Depression associated with 64% increase in risk of CAD Untreated symptoms of depression exacerbate chronic illness

5 Depression in Primary Care <5% of clinical instruction for 20-33% of primary care practice Only 30-50% of patients with depression are recognized by PCPs Only 50% of patients with depression receive treatment New England Journal of Medicine March; 354 (12)

6 Challenges for Depression Screening in Primary Care Provider time Provider knowledge about depression Responding to score on screening tool Appropriate treatment (antidepressant) Provider concern about suicide risk and liability Provider concern about ability to refer to Psychiatry or to receive timely direction (curbside consultation)

7 Depression Screening Recommended

8 Better Health Greater Cleveland Recommendations Every adult with diabetes, heart failure or hypertension at least once a year for depression using the Patient Health Questionnaire (PHQ-2/PHQ-9). All patients who screen positive for depression will be provided with appropriate diagnosis, treatment, and follow-up. Eligible patients with an established diagnosis of depression should have follow-up monitoring using the PHQ-9 at least annually.

9 Depression Screening: Tool The Patient Health Questionnaire: PHQ-2 and PHQ-9 The PHQ-9 is a screening tool studied in the primary care setting (3000 primary care patients and 3000 OB/GYN patients) Used to screen and monitor treatment for Major Depression Contains 9 items, with scores ranging from 0-3 (depending on frequency of symptoms which reflects severity) #9 asks about death/ suicide thinking Includes item #10, to measure the impact severity of symptoms on work, home life, and relationships

10 PHQ-2 (Patient Health Questionnaire-2) It is the first 2 questions of the PHQ-9 asked as yes/ no Inquires about the frequency of depressed mood and anhedonia (lack of interest or pleasure) over the preceding 2 weeks The PHQ-2 is a first step in screening and is not for diagnosis or monitoring Patients who screen positive (i.e. answer yes to either question) should be evaluated further with a PHQ-9 to determine whether they meet criteria for a depressive disorder diagnosis

11 (PHQ-9)Patient Health Questionnaire 9 Over the last 2 weeks, how often have you been bothered by any of the following problems? Not at all, Several days, More than half the days, Nearly every day: 1. Little interest or pleasure in doing things 2. Feeling down, depressed, or hopeless 3. Trouble falling or staying asleep, or sleeping too much 4. Feeling tired or having little energy 5. Poor appetite or overeating 6. Feeling bad about yourself or that you are a failure or have let yourself or your family down 7. Trouble concentrating on things, such as reading the newspaper or watching television 8. Moving or speaking so slowly that other people could have noticed? Or the opposite being so fidgety or restless that you have been moving around a lot more than usual. 9. Thoughts that you would be better off dead or of hurting yourself in some way. =Total Score: If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all (score = 0) Somewhat difficult (score = 1) Very difficult (score = 2) Extremely difficult (score = 3) Scoring Totals: 1-4 = Minimal 5-9 = Mild = Moderate = Moderately Severe =Severe Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues

12 Screening for suicidality in primary care The PHQ-9 (question #9) asks about suicidal thoughts Screening tools (PHQ-9) do not predict which patients with suicidal thoughts will actually attempt suicide Positive response should proceed to questions about intention and plan

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14 Best Practice Alert in Epic For Providers

15 BPA Smartset for Providers

16 PHQ-9 Sample Workflow

17 Diagnosis of Depression

18 Phases of Major Depressive Disorder

19 Major Depressive Disorder (commonly referred to as Major Depression or Depression) DSM IV Criteria Depressed mood or anhedonia (loss of interest/ pleasure) every day, all day for at least 2 weeks At least 4 additional symptoms: Sleep changes Fatigue Appetite or weight changes Psychomotor agitation or retardation Helplessness Hopelessness (excessive guilt) Difficulty concentrating or making decisions Recurrent thoughts of death or suicide Significant functional impairment (in occupational, educational, social/ relationship areas of life) Rule out other cause such as substances or general medical

20 Recurrence of Depression Recurrence of episode of depression is 50-85% after 1st episode. Risk of recurrence increases with each successive depressive episode. Untreated episodes are associated with treatment resistant recurrence. Schneider RK and Levenson JL. ACP

21 Depressive episode of Bipolar Disorder? Bipolar disorder has either manic or hypo-manic episodes in addition to major depressive episodes. Patients with bipolar disorder may present in the depressive phase with symptoms that appear to be major depression. Bipolar depression requires different treatment than major depression. The Mood Disorder Questionnaire (MDQ) can provide clues to bipolar disorder but is not a diagnostic tool. You can find the MDQ at BETTERHEALTHCLEVELAND.ORG

22 DSM-IV Criteria for Mania Abnormally and persistently elevated, expansive or irritable mood for at least 1 week. At least 3 symptoms listed (4 symptoms if mood is only irritable): Distractibility Irresponsibility: Involvement in pleasurable activities with high potential for painful consequences Grandiosity or inflated self-esteem Flight of ideas or reports racing thoughts Increase in activity level (goal-directed) or psychomotor agitation Decreased need for sleep Talkative: pressured to keep talking Significant functional impairment (occupational, social, relationships, educational, recreational) Rule out other cause such as substances, or general medical

23 Screening for Mania or Hypomania Has there ever been a period of 4 days or more when you were feeling so good, high, excited, or hyper that you:..did not need to sleep (for long)?..made illogical (impulsive) decisions you later regretted?..did things you normally would not do (spending, sexual, high risk)?..got into trouble (legal or social)?..had family or friends worried, irritated with you?..had a doctor tell you that you were manic or bipolar? Not related to substance use or medical condition

24 Some Medical Mimics or Causes of Exacerbation of Mood Disorders (Depression and Bipolar) Endocrinopathies (hypo- or hyperthyroidism) Substance use/abuse/dependence Medications (opiates, corticosteroids, hormonal therapies, interferon/ chemotherapy, stimulants, antidepressants) Chronic viral infections (HIV, Hep C) Liver disease Neurological diseases (Parkinson s, Multiple Sclerosis, seizure disorders, dementias)

25 End of Part One

26 Thank You! Questions or Comments? Toni Johnson, MD Kristen Palcisco, BA, MSN, APRN 26

27 Toolkit Availability A hardcopy of our Behavioral Health Toolkit is available for any Better Health Greater Cleveland member practice at no charge. E-copies also are available. Please contact Bonnie at or bhollopeter@metrohealth.org