DEPRESSION IN PRIMARY CARE: An Overview. Jorge R. Petit, MD Quality Health Solutions

DEPRESSION IN PRIMARY CARE: An Overview Jorge R. Petit, MD Quality Health Solutions

Topics In this Session Overview Clinical Importance of Depression Types of Depression Phases of Depression Care Collaborative Care Treatment Options Considerations

CLINICAL IMPORTANCE OF DEPRESSION

Depression is a chronic illness It is a medical illness, not a character flaw Imbalance of chemicals, similar to DM It causes a wide range of symptoms and behaviors It is common and treatable Treatment may be long term, but is successful Stigma negatively affects treatment It causes serious family/social ramifications Annual cost of untreated depression is more than $43.7 billion in absenteeism, lost productivity, and direct treatment costs.

Major Depressive Disorder

Major Depressive Disorder

Depression is a Chronic Disease 15 years after recovery 85% of patients have experienced a recurrence Cumulative Probability of Recurrence 0 0.2 0.4 0.6 0.8 1.0 0 1 3 5 7 9 11 13 15 Years After Recovery

Depression negatively affects health & well being medical morbidity, mortality, and disability suicide risk tobacco, alcohol, and/or drug use risk of MI, CVA, DM healthcare utilization adherence to treatments (medical and psychiatric) function (home and work)

Depression is common 20-50% of patients with diabetes, CAD, Parkinson's, CVA, HIV/AIDS, asthma, and cancer have major depression: 15-23% of patients with MI develop major depression 14-23% of patients with stroke develop major depression 11-15% of patients with DM have major depression Depressed patients visit their primary care provider 3xs more often than patients who are not depressed.

Depression is under diagnosed and under treated Local perspective 2004 NYC HANES = 8%of New Yorkers had a diagnosis of depression at time of survey but only 37% were receiving clinically appropriate treatment. Even though there are over 25 FDA approved antidepressant medications and other treatments available!

Depression is under diagnosed and under treated Almost 10% of the US population are taking antidepressants. According to the AHRQ = 170 million prescriptions filled for antidepressants in 2005 70% are prescribed by non psychiatrists (general practitioners, family practitioners and internal medicine specialists)

Depression is under diagnosed and under treated BUT fewer than 50% are effectively treated Nearly ⅓ of antidepressant prescriptions are never filled. Nearly ½ of patients discontinue pharmacotherapy during the first month.

Antidepressant Adherence 100% 80% 60% 40% 20% 1 mo 28% stopped 4 mo 44% stopped 0% 0 1 2 3 4 Months Lin EH. Med Care 1995;33:67

Depression is under diagnosed and under treated BUT treatment is effective Over 30 50% of patients will have a complete response to initial treatment. 50 70% will require at least one change in treatment to get better.

TYPES OF DEPRESSION

Depressive Disorder Depression Primary Secondary Unipolar Bipolar Neuro Cardiac Sleep Apnea Substance Use

Depressive Disorders DSM 5 Depressive Disorders: Major Depressive Disorder Single episode Recurrent episode Persistent Depressive Disorder (Dysthymia) Premenstrual Dysphoric Disorder Substance/Medication Induced Depressive Disorder Depressive Disorder Due to Another Medical Condition

Depressive Disorders Diagnosis of Major Depressive Episode Five (5) or more of the following symptoms present during the same 2 week period and represent a change from previous functioning; at least one (1) of the symptoms is either depressed mood or loss of interest or pleasure. Symptoms must cause clinically significant distress or impairment in functioning. Cannot be due to the direct effects of a substance (drugs or medications) or a medical condition, such as hypothyroidism, nor occur within two months of the loss of a loved one.

Depressive Disorders 1. Depressed Mood (most of the day, nearly every day) either by subjective report or observations made by others 2. Loss of interest or pleasure in activities 3. Significant weight loss when not dieting (<5% body weight in 1 month) or appetite changes (increased or decreased) 4. Insomnia or hypersomnia 5. Psychomotor agitation or retardation 6. Fatigue or loss of energy 7. Feelings of worthlessness or excessive/inappropriate guilt 8. Decreased ability to think or concentrate, or indecisiveness 9. Recurrent thoughts of death or suicide

Depressive Disorders Persistent Depressive Disorder Used to be called = Dysthymia Less severe, but more chronic Chronic low grade depression Diagnosis Depressed mood for most of the day, for more days that not (or irritability in children/adolescents) for at least 2 years (or 1 year in children/adolescents)

Depressive Disorders Persistent Depressive Disorder Plus 2 additional symptoms while depressed: poor appetite or overeating insomnia or hypersomnia low energy or fatigue low self esteem poor concentration or difficulty making decisions feelings of hopelessness Never without symptoms for longer than 2 months at a time.

Depressive Disorder Persistent Depressive Disorder Persistent Depressive Disorder affects approximately 1.5 percent of the U.S. population age 18 and older in a given year. This figure translates to about 3.3 million American adults. The median age of onset of dysthymic disorder is 31.

Depressive Disorders Bipolar Depression or Manic Depression Bipolar disorder sometimes referred to as manic depression is a complex mood disorder that alternates between periods of clinical depression and times of extreme elation or mania. There are two subtypes of bipolar disorder: bipolar I and bipolar II. With bipolar I disorder, patients have a history of at least one manic episode with or without major depressive episodes. With bipolar II disorder, patients have a history of at least one episode of major depression and at least one hypomanic (mildly elated) episode.

Depressive Disorders Adjustment Disorder [Now under the Trauma and Stressor Related Disorders Section] Adjustment disorder is a short term condition that occurs when a person is unable to cope with, or adjust to, a particular source of stress, such as a major life change, loss, or event. People with adjustment disorders often have symptoms of depression, such as tearfulness, feelings of hopelessness, and loss of interest in work or activities, adjustment disorder is sometimes called "situational depression. Unlike major depression, however, an adjustment disorder is triggered by an outside stress and generally goes away once the person has adapted to the situation.

Other types Seasonal Depression (SAD) [with seasonal pattern] Seasonal depression, often called seasonal affective disorder or SAD, is a depression that occurs each year at the same time. It usually starts in the fall or winter and ends in spring or early summer. It is more than just "the winter blues" or "cabin fever." Psychotic Depression [with mood congruent or mood incongruent psychotic features] With psychotic depression, delusional thoughts or other symptoms of psychosis accompany the symptoms of depression. With psychotic depression, there's a break with reality. Patients with psychotic depression experience hallucinations and delusions. Postpartum Depression [with peripartum onset] As many as 75% of new moms get the "baby blues." But about one in 10 moms develop a more serious condition called postpartum depression. According to NIMH, postpartum depression is diagnosed when a new mother develops a major depressive episode within one month after delivery.

PHASES OF DEPRESSION CARE

Outcome Targets & Definitions Clinically significant improvement (CSI) 5 point decrease in PHQ 9 score Response 50% decrease in PHQ 9 score Remission PHQ 9 score < 5 for 3 months

Patient Health Questionnaire (PHQ 9) 9 item, self administered questionnaire Validated for diagnostic assessment Validated for follow up of outcomes Used to assess high risk, red flag patients Chronic illness Unexplained physical symptoms Appearing sad/stressed Loss of interest or pleasure

Patient Health Questionnaire (PHQ 9) Score indicates diagnosis and severity 0 4: Not clinically depressed 5 9: Mild depressive symptoms (adjustment disorder, dysthymic disorder) 10 14: Mild/moderate symptoms (major depression; 88% sensitivity and specificity) >14: Moderate/severe depression (major depression; 95% specificity)

Discussing Diagnosis with Patient Don t argue about whether or not patient has specific diagnosis focus on symptoms and symptom resolution Give hope! You don t have to feel this way This can be treated Educate patient about treatment in primary care Depression / anxiety medical conditions Effective treatments available

Depression Clinical Practice Guidelines Acute treatment phase Goal: Relieve symptoms, identify the right medication, optimize dose Duration: 1 3 months Continuation of therapy phase Goal: Resolve depressive episode, prevent relapse Duration: 4 6 months Long term maintenance phase Goal: Prevent relapse Duration: 3 months 5 years depending on # of lifetime episodes and comorbid

COLLABORATIVE CARE

Collaborative Care Partnership between: 1) Primary Care Provider (PCP) and practice 2) Care Management 3) Collaborating Mental Health Specialist Key features: Integration of depression screening (and management) tools and routines into standard care Periodic quantitative feedback about the patient's response to treatment from the care manager to the clinician via the PHQ 9 Closer relationships between the primary care team and /behavioral health specialists, including informal psychiatric advice when needed from a psychiatrist The psychiatrist also provides weekly supervisory support for the care manager Source: http://www.depression primarycare.org/organizations/component_model/

Evidence for CC Success RESPECT MacArthur Initiative Cluster randomized controlled trial 60% response to treatment and 37% remission at 6 months, compared to 47% and 27% in usual care practices 3 Primary Care Provider IMPACT Study Randomized clinical trial of collaborative care intervention for elderly patients Showed significant improvements in symptoms and functionality at 6 months, 12 months, and 2 years 1 DIAMOND Initiative Adapted IMPACT program for general population setting and studied outcomes Patient Registry Care Manager Stepped Care Approach Relapse Prevention Screening/ Monitoring Consulting Psychiatrist 64% response to treatment and 44% remission at 6 months; 72% response and 52% remission at 12 months 2 1 The IMPACT Program: A team approach to depression care that gets dramatic results. John A. Hartford Foundation. 2 Jaeckels, N. and Trangle, M. DIAMOND: Origin, Context & Future. ICSI presentation, Oct. 2009. 3 Dietrich, A. et al., Re engineering systems for the treatment of depression in primary care: Cluster randomised controlled trial. British Medical Journal, 2004. doi: 10.1136/bmj.38219.481250.55.

Collaborative Care Partnership between primary care provider (PCP), care manager, and consulting psychiatrist Integration of care manager and consulting psychiatrist into PCP based care team Coordination of services and tracking progress carried out by care manager Primary Care Provider Care Manager Psychiatrist SCREEN all patients for depression using the PHQ 2 ASSESS all patients screening positive with the PHQ 9 DIAGNOSE depression or other related condition if present TREAT patients as indicated ADVISE PCP on differential diagnosis and treatment plan EDUCATE patients/behavioral Activation SUPPORT self management and medication adherence ASSESS treatment progress with the PHQ 9 COORDINATE referrals and care services CONSULT by phone on difficult cases re: differential diagnosis and treatment plan REVIEW cases with team periodically RECOMMEND assessment by psychiatrist as indicated

TREATMENT OPTIONS

Treatment Options During the Acute Phase 1. Watchful Waiting 2. Psychotherapy 3. Antidepressant medication 4. Psychotherapy + medication

Treatment Option #1: Watchful Waiting Many depressions remit spontaneously Watchful Waiting is an acceptable treatment plan Initial treatment of choice for minor depression Variable intensity of Watchful Waiting Low (mild depression): repeat PHQ 9 only Moderate (moderate depression): includes behavioral goals (e.g., exercise)

Treatment Option #2: Psychotherapy Effective in: Mild to moderate depression Adjunct to antidepressants Not effective (as 1 st line) in: Severe depression Barriers Previous negative experience Nervous about first counseling experience Worried about stigma Family has negative bias Believes counseling is not helping

Treatment Option #3: Pharmacotherapy Effective in: Major depressive Disorder Chronic depression Not recommended for: Minor depression Barriers Beliefs (e.g., Medicine can t help feelings ) Stigma (e.g., I should be able to do this myself ) Cost Family has negative bias

Acute Phase: Medication Guidelines Elicit patient commitment (i.e., personal action plan) Start with SSRI (citalopram) or new agent Arrange early follow up after initial visit (within 1 3 weeks) Repeat PHQ 9 at every follow up (every 1 2 months) Increase dose of antidepressant every 2 4 weeks up to maximum dose or until remission Sources: www.ahrq.gov; www.depression primarycare.org; American Psychiatric Association

Continuation Phase After Acute Phase, assess treatment response at every follow up: If response is adequate (patient achieves full remission): Continue follow up with PHQ 9 administration and treatment Form relapse prevention plan If response is inadequate (partial or no response): Consult psychiatrist Formulate secondary treatment plan and implement with psychiatric oversight (as needed) Sources: www.ahrq.gov; www.depression primarycare.org; American Psychiatric Association

Continuation Phase Continuation therapy is intended to prevent relapse, that is, to suppress the symptoms of a current depressive episode from which the patient has not fully recovered. Usually, continuation therapy lasts 4 to 6 months after a patient has responded in the acute phase of treatment. After completion of Continuation Phase, consider maintenance treatment

Preventing Recurrence Risk of recurrence becomes more likely with each episode of depression > 50% after 1 st recurrence 70% after 2 nd recurrence 80 90% after 3 rd recurrence 1 Judd LL et al. Am J Psychiatry, 2000; 157:1504 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.

Preventing Recurrence If patient s response to treatment is insufficient, or does not respond at all: Assess adherence Re evaluate diagnosis Adjust dosage Change/augment antidepressant Consider switch to or add dual action agent Consider psychotherapy Refer for expert consultation

Discussing Treatment Options Review all treatment options available Psychotherapeutic interventions Behavioral Activation, Problem Solving Treatment, Cognitive Behavioral Treatment, etc. Medications Discuss pros and cons of each option

Discussing Treatment Options The treatment that WORKS is the best one Person centered care means selecting treatments based on client preference, not clinician preference Be unbiased when offering treatment options Be eclectic: One size fits few Supporting whole person treatment is important This may include medication therapy You can support medication therapy within scope of practice Ask questions and collect information Support patient being informed and active in plan

Non Medication Treatment Options Support Self Management/Wellness Activity Scheduling (pleasant activities) Physical activity / exercise Psychotherapies Cognitive behavioral therapy (CBT) Problem solving Treatment (PST) Interpersonal psychotherapy Individual Group Family Marital/Couples

Pharmacotherapy Prior response and/or treatment history in patient/ family members Patient preferences Expertise of prescribing provider Side effect profile Safety in overdose: 10 days of a TCA can be a lethal overdose Availability and costs Drug drug interactions

Pharmacotherapy Key principles Use adequate doses for an adequate amount of time. Start slow and work with side effects but titrate to an effective dose as needed. Change medication if not effective Usually after 8 10 weeks Current evidence does not warrant the choice of one second generation AD over another on the basis of differences in efficacy and effectiveness. Other differences with respect to onset of action and adverse events may be relevant for the choice of a medication.

Antidepressants SSRIs Citalopram (Celexa ) Escitalopram (Lexapro ) Fluoxetine (Prozac ) Fluvoxamine (Luvox ) Paroxetine (Paxil ) Sertraline (Zoloft ) SNRIs Duloxetine (Cymbalta ) Venlafaxine (Effexor XR ) Desvenlafaxine (Pristiq ) Levomilnacipran ER (Fetzima ) Mirtazapine (Remeron ) Bupropion (Wellbutrin )*

Antidepressants Trazodone (Oleptro ) and Nefazadone (Serzone ) TRICYCLICS and TETRACYCLICS Desipramine (Norpramin ) Nortryptaline (Pamelor ) MAOIs Phenelzine (Nardil ) Tranylcypromine (Parnate ) Isocarboxazid (Marplan ) Selegeline (Eldepryl ) Vilazadone (Viibyrd ) Vortioxetine (Brintellix )

CONSIDERATIONS

Considerations: Side Effects Short term: GI upset / nausea Jitteriness / restlessness / insomnia Sedation / fatigue Long term: Sexual dysfunction (up to 33%) Weight gain (5 to 10%)

Considerations: Side Effects Common side effects in all SSRIs (>10 %): GI distress (nausea, diarrhea),insomnia, restlessness, agitation, fine tremor, headache, dizziness, sexual dysfunction. SNRI side effects: GI distress (nausea, diarrhea), insomnia, restlessness, agitation, fine tremor, headache, dizziness, constipation, decreased appetite, sexual dysfunction. Small risk of elevation of blood pressure at higher doses => check BP.

Considerations: Side Effects Consult with pharmacist / team psychiatrist Are side effects physical or psychological? Short term strategies Wait and support (e.g., GI side effects of SSRIs) Adjust medication timing (e.g., take sedating meds at bedtime) Consider temporary dose reduction Treat side effects (if drug effective) Change to a different antidepressant Change to or add PST PC

Considerations: Side Effects Activating Fluoxetine (Prozac ) Citalopram (Celexa ) Sertraline (Zoloft ) Venlafaxine (Effexor ) Bupropion (Wellbutrin ) Sedating Paroxetine (Paxil ) Fluvoxamine (Luvox ) Mirtazepine (Remeron ) Nefazadone (Serzone ) Trazadone

Considerations: Discontinuation Syndrome Most frequent with paroxetine (short elimination ½ life and no active metabolite) Least frequent with fluoxetine (long ½ life of parent compound and active metabolite) Physical Symptoms = dizziness, nausea, vomiting, lethargy, fatigue, flu like symptoms (aches, chills), sleep disturbance Psychological Symptoms = anxiety, irritability Emerges 1 3 days after discontinuation IMPORTANT = slow taper of short acting agents

Considerations: Black Box Warning FDA public health advisory in 2004 and then Black Box Warning re: increased suicidality risk in children, adolescents and young adults < 25 years old Management: Depression associated with increased suicide risk Suicide assessment warranted if Question 9 on PHQ is scored Weigh risk vs. benefit Observe all patients for clinical worsening

Considerations: Orgasmic Dysfunction 25 33% of SSRI treated patients Change to Bupropion Mirtazapine Augment with Bupropion SR 100mg PO BID Buspirone 15mg PO BID to 30mg PO BID

Considerations: Problems Early in Treatment Non adherence Medical and psychiatric comorbidity Side effects Unmasking bipolar disorder Activation and suicidal ideation Incomplete response

Considerations: What if Patients Don t Improve? Is the patient adhering to treatment? Is the dose high enough? See max dose guidelines Is the diagnosis correct?? Bipolar depression? Medical conditions (hypothyroidism, sleep apnea, pain)? Meds: steroids, interferon, hormones? Withdrawal: stimulants, anxiolytics Are there untreated comorbid conditions / life stressors?

Medication Adherence 20% to 30% medication prescriptions never filled consistently Medication not continued as prescribed in about 50% of cases, especially long term therapies Rates of medication adherence drop after first six months Only 51% of Americans treated for hypertension are adherent to their long term therapy About 25% to 50% of patients discontinue statins within one year of treatment initiation

Determinants Provider Factors Communication skills Knowledge of health literacy issues Lack of empathy Lack of positive reinforcement Number of comorbid conditions Number of medications needed per day Types or components of medication Amount of prescribed medications or duration of prescription

Determinants Physical Patient related Psychological Condition and therapy related Complexity of medication Frequent changes in regimen Treatment requiring mastery of certain techniques Unpleasant side effects Duration of therapy Lack of immediate benefit of therapy Medications with social stigma

Determinants Economic Health insurance Medication cost Social Limited English proficiency Inability to access or difficulty accessing pharmacy Lack of family or social support Unstable living conditions

What Can you Do to Overcome These Challenges? Communication is key! Effective interventions Measure medication adherence

General Office Strategies for Optimizing Adherence Provide rationale for use Careful attention to side effects Address fear of dependence and loss of control Enlist family/spousal support Address concerns in relation to patient s or significant other s prior experience with medication Increase contact with brief phone check ins Specific instructions (take regardless of symptom change, don t stop on own) Use symptom scale (e.g., PHQ 9)

Interventions S Simplify the regimen I Impart knowledge M Modify patient beliefs and behavior P Provide communication and trust L Leave the bias E Evaluate adherence

S Simplify the Regimen Adjust timing, frequency, amount, and dosage Match regimen to patient s activities of daily living Recommend taking all medications at the same time of day Avoid prescribing medications with special requirements Investigate customized packaging for patients Encourage use of adherence aids Consider changing the situation vs. changing the patient

I Impart Knowledge Focus on patient provider shared decision making Keep the team informed (physicians, nurses, and pharmacists) Involve patient s family or caregiver if appropriate Advise on how to cope with medication costs Provide all prescription instructions clearly in writing and verbally Suggest additional information from Internet if patients are interested Reinforce all discussions often, especially for low literacy patients

M Modify Patient Beliefs and Behavior Empower patients to self manage their condition Ensure that patients understand their risks if they don t take their medications Ask patients about the consequences of not taking their medications Have patients restate the positive benefits of taking their medications Address fears and concerns Provide rewards for adherence

P Provide Communication and Trust Improve interviewing skills Practice active listening Provide emotional support Use plain language Elicit patient s input in treatment decisions

L Leave the Bias Understand health literacy and how it affects outcomes Examine self efficacy regarding care of racial, ethnic, and social minority populations Develop patient centered communication style Acknowledge biases in medical decision making Address dissonance of patient provider, race ethnicity, and language

E Evaluating Adherence Self report Ask about adherence behavior at every visit Periodically review patient s medication containers, noting renewal dates Use biochemical tests measure serum or urine medication levels as needed Consider using medication adherence

Key Educational Messages for Patients Antidepressants only work if taken every day Antidepressants are not addictive Benefits from medication appear slowly Continue antidepressants even after you feel better Mild SE are common and usually improve over time If you re thinking about stopping the medication, call me first The goal of treatment is to complete remission; sometimes it takes a few tries

Is Patient at Maximum Therapeutic Dosage? Fluoxetine Paroxetine Escitalopram Citalopram Sertraline Venlafaxine Desvenlafaxine Duloxetine Bupropion SR Mirtazapine Nortriptyline Despramine 60mg 60mg 20mg 60mg 200mg 300mg 100 mg 60mg 450mg 60mg 125mg (check serum level) 200mg (check serum level)

Good Reasons to Stop a Medication Intolerable side effects Dangerous interactions with necessary medications The medication was not indicated to start with (e.g., bipolar depression) Medication has been at maximum therapeutic dose without improvement for 4 8 weeks

Dose Increase: Practical Approaches Definition = use of doses higher than those considered standard for a given antidepressant Rationale Increase chance of obtaining adequate blood levels in rapid metabolizers Obtain a different neurochemical effect (e.g.: going from relatively selective serotonergic effect at lower doses to a dual action effect at higher doses)

Dose Increase: Practical Approaches Gradual increasing the dose by 50 100% Wait at least 4 weeks before deciding whether the strategy works If no side effects are present, consider increasing further Blood levels may be informative (even with SSRIs or other newer agents)

Switching: Practical Approaches Gradual taper one agent while starting new one Side effects of new drug may be intensified by the concurrent presence of 1 st agent Start low and go slow with new agent Consider possible drug drug interactions Wash outs are necessary with MAOIs

Antidepressant Summary There are over 25 FDA approved antidepressants Each is effective in ~ 40 50% of patients It may take several trials until an effective medication is identified Patients need support during this time (work with care manager)

Antidepressant Summary If medications are not effective after 8 10 weeks at a therapeutic dose Is patient taking medication as prescribed? Consider substance abuse, bipolar disorder, anxiety disorders, cognitive impairment. Ask every patient about suicidal ideation Consult with team psychiatrist and change treatment (medications, other somatic treatments, psychotherapy)