Depression Screening and Management Elizabeth Klein, MD FAAFP Jennifer Herber, MD Providence Family Medicine Residency Milwaukie Oregon

Goals and Objectives Discuss the importance of Depression and Depression Screening in Family Medicine Review PHQ-9, Mood Disorder, CAGE and Suicide Risk forms in Logician Discuss treatment options, adding meds - when and how - through case discussion and use of the electronic health record

What are your goals? How to better document depression and depression treatment? How to make depression screening and treatment happen in your clinic? How to better treat depression to remission? ????

Questions for you How common is depression in the general population? 5,10 or 20%? How common is depression in primary care clinics? 10, 15 or 30%? T/F - Lost years of healthy life due to depression is 2nd only to ischemic heart disease. T/F - Suicide is in the top 10 causes of death in USA.

Major Depression: DSM-IV Criteria >5 of the following symptoms QD x 2+ weeks Essential symptoms (must have at least 1) depressed mood anhedonia Physical symptoms changes in sleep change in appetite or weight fatigue change in psychomotor activity Psychological symptoms feelings of guilt or worthlessness difficulty in thinking, concentrating or making decisions recurrent thoughts of death and/or suicidal plans or attempts

Other Mood Disorders Dysthymia Minor depression Bipolar disorder Common co-existing behavioral health disorders anxiety substance abuse ADD

Major Depression – The Facts Common, Chronic, Costly >10% of the general population has major depression (women > men) 15-35% of nursing home patients 20-30% of primary care patients 24-46% of hospitalized medically ill patients 4.9-17.1% lifetime prevalence Common comorbidity of other medical diseases

Major Depression –Chronic untreated disease often lasts months-years even with treatment, recurrent episodes are common

Major Depression – Costly Costly: untreated > treated disease  direct and indirect costs $44 billion annually in US > healthcare utilization and costs > disability and time lost from work worsens medical outcomes post CVA and MI DM cancer lost yrs of healthy life 2nd only to ischemic heart dz suicide among top 10 causes of death in the US US Preventive Services Task Force

Depression in Primary Care Majority of patients present to PCPs Only 50-70% recognition in primary care high volume of patients time limitations in visits w/ competing issues lack of resources to assist w/ dx, tx, and f/u inadequate reimbursement/carve-outs concern for overdiagnosis “rationalized” depression stigma of depression

Depression in Primary Care Underrecognition (continued) may present differently in 1o care chief complaint of depression is rare complicated by multiple somatic complaints suspect high utilizers self-described lack of expertise “subjective” nature of diagnosis Underrecognition  undertreatment

Lack of Adequate Treatment Despite prevalence and impact on pt lives, major depression is undertreated 50% screened 25% receive initial treatment 12.5% receive adequate treatment 5% continue for >6 months National Institute of Mental Health Patients with depression have 20X risk of suicide compared to normal

Importance of Screening Recommendation to screen adults for depression to enhance detection need systems to ensure accurate diagnosis, effective treatment and follow-up insufficient evidence to recommend for/ against routine screening of children and adolescents USPSTF

Importance of Screening Screening also provides objective information assists with diagnosis – DSM-IV criteria assignment of severity improves documentation higher level of coding/billing code: V79.0 (depression screening) can guide treatment decisions beneficial in follow-up level of response dose titration achievement of remission

Our Choice… PHQ-9 Primary Care Evaluation of Mental Disorders (PRIME-MD) Patient Health Questionnaire - Depression Subscale 9 patient self-administered, 9 item survey assesses DSM-IV criteria & evaluates severity scored continuously to monitor response 81% sensitivity, 92% specificity, 85% overall accuracy, 55% PPV after 2-question screen validated across many primary and tertiary care populations Journal of Family Practice 2003;52:118-26 JAMA 2002;287:1160-70 Journal of General Internal Medicine 2007; 22: 1596-1602

Who Should Be Screened? Risk factors: economic hardships/unemployment stressful events, loss chronic illness h/o abuse or trauma 1st degree relative w/ mood disorder female caretaking responsibilities Risk factors alone are not predictive

Approaches for Patient Identification All new pts and with preventative visits Chronically ill Post-MI or CVA Pts w/ HTN, asthma, COPD, DM Pts w/ somatic complaints High utilizers Pts w/ dysthymia or minor depression

Logician Encounter Form PHQ-9 Related screening tools Patient History Suicide Risk CAGE Questions Grief Reaction Mood disorders questionnaire Scoring instructions Common ICD-9 codes

Special Features Self-calculating scores Links to problem and med lists Direct flow into patient’s flowsheet

Depression Screening

Training Document

Logistics Initial screening questions (y/n) “Over the last 2 weeks, have you been bothered by... 1) Little interest or pleasure in doing things?” 2) Feeling down, depressed or hopeless?” If one or both positive, then give PHQ-9 MA can hand out and enter results into EMR

Groups

Case-Based Learning Judith, Case #1 49 yo female, PHQ 17 What are the issues? What do you advise? Do you switch or add medication? Do you use the depression self-care handout? Discuss f/u. By phone and in clinic?

Judith at 2 week follow-up “I love Lexapro.” PHQ went from 17 to 4 What are the treatment options? What are your treatment recommendations? When do you recommend follow-up?

Debra, Case #2 39 yo with worsening depression and anxiety on Prozac PHQ 21, Mood Disorder 11 What are the issues? What are the options for treatment? What do you recommend and why? When do you schedule follow-up?

Debra at 2 week follow-up PHQ 14, down from 21 What are your treatment options? What do you recommend? Do you use the Depression Self-Care Action Plan handout? How do you communicate with counselors? When do you recommend follow-up?

Lisa, Case #3 Anxiety and tummy pain, disliked Zoloft PHQ 14 What are the issues? What are the treatment options? Remember non-medicinal options for treatment of anxiety and depression. When do you advise follow-up?

Lisa at 3 week follow-up PHQ went from 14 to 3 What are the treatment options? Why do you see this patient back in 2-3 weeks? How long should she be treated with medication?

Larry, Case #4 56 yo with hx of meth abuse, s/p anoxic brain injury. Tried bupropion, fluoxetine, duloxetine – no remission PHQ 18 What are the issues? What are the options for treatment? What do you recommend and why?

Larry at 3 week follow-up PHQ went from 18 to 15, overall feeling more functional. What are the treatment options? When do you see this patient for f/u? How long should he be treated with medication?

Use Your Resources PHQ-9, Mood Disorder, Suicide Risk Use the handouts on the EMR Use RN support Collaborate with counselors Check in with your patients regarding counseling and self-care

Depression Screening and Management Depression screening on vitals form Nurse follow up of PHQ >18 or after medication initiation Depression phone follow-up at 3 days and 2 weeks Close follow-up and med management Depression self-care and counseling

Future Depression screening is best in an integrated program Depression screening on our Diabetic Registry Depression Registry Better access to mental health providers Better medications with fewer side effects We have only just begun . . .