Depression in Primary Care: Decision Support for Chronic Care Model Steven Cole, MD Professor 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, alcoholism  risk of MI, CVA, DM  adherence to medical therapy  function (home and work)  achievement (education, work)

Frazure-Smith, JAMA 1993;270:1819-1825 Depressed (n=35) Nondepressed (n=187) Cox Hazard Ratio = 5.74 p=0.0006 Frazure-Smith, JAMA 1993;270:1819-1825

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, 2003 Groot et al Psychosom Med 2001 Van Tilburg et al Psychosom Med 2001

GLOBAL BURDEN OF DISEASE: WORLD HEALTH ORGANIZATION 2020 Ischemic heart disease Unipolar major depression Road traffic accidents Cerebrovascular disease Chronic obstructive pulmonary disease Lower respiratory infections 1990 Lower respiratory infection 2 Conditions arising during the perinatal period 3 Diarrheal diseases Unipolar major depression Ischemic heart disease Vaccine-preventable disease Murray & Lopez, WHO: Global Burden of Disease, 1996; Michaud, JAMA, 2001

IMPACT OF MENTAL DISORDERS: COSTS OF DEPRESSION Annual Costs ($) 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

Major depression TYPES OF DEPRESSION Chronic depression (dysthymia) Minor depression adjustment disorder depressive disorder nos

MAJOR DEPRESSION Four Hallmarks: Depressed mood Anhedonia Physical symptoms Psychological symptoms

DEPRESSED MOOD Hallmark 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

Depressed mood or anhedonia 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 1999 Kroenke K et al, Medical Care, 2003 Kroenke K et al, J Gen Int Med, 2001

Oxman, 2003

USE OF THE PHQ-9 Universal screening/ or High-risk, ‘red flag’ patients* Chronic illness Unexplained physical complaints sleep disorder, fatigue Patients who appear sad Recent major stress or loss

INTERPRETING THE PHQ: ASSESSMENT AND SEVERITY Count numerical values of symptoms 0-4 not clinically depressed 5-9 mild depression 10-14 moderate depression 88%sensitivity, 88%specificity (MDD) >14 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 56% (Panic + MD) 48% (PTSD + MD) Panic Specific Phobia 42% (phobia +MD) PTSD SAD 62% (GAD + MD) GAD Key Point There is a high incidence of comorbidity between anxiety disorders and depression Background Anxiety disorders are frequently comorbid with depression Rates of lifetime comorbidity with major depression among patients with lifetime diagnoses of anxiety disorders in epidemiologic surveys range from approximately one third to more than two thirds of cases1-5 Rates of comorbidity in clinical populations would likely be higher than these estimates from community populations. Compare, for example, the rates reported by Kessler et al4 (from the National Comorbidity Survey) with those of Bleich et al6 (from a clinical population) References Wittchen HU, et al. Arch Gen Psychiatry. 1994;51:355-364. Magee WJ, et al. Arch Gen Psychiatry. 1996;53:159-168. Roy-Byrne PP, et al. Br J Psychiatry. 2000;176:229-235. Kessler RC, et al. Arch Gen Psychiatry. 1995;52:1048-1060. Weissman MM, et al. J Clin Psychiatry. 1994;55(suppl):5-10. Bleich A, et al. Br J Psychiatry. 1997;170:479-482. Depression 37% (SAD + MD) OCD 27% (OCD + MD)

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 activity Racing 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 T ell – provide basic information about illness A sk – about concerns/beliefs (cognitive/emotional) C are – develop rapport; respond to emotions C ounsel – provide information relevant to concerns and explanatory model T ailor – 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 Remission Recovery Normal Relapse Recurrence Response Relapse > 50% STOP Rx Symptom Severity 65 to 70% STOP Rx Acute Phase (3 months+) Continuation Phase (4-9 months) Maintenance Phase (years) Time 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

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 Failure to achieve remission can be associated with many negative health and psychosocial outcomes Potential consequences of failing to achieve remission include: Increased risk of relapse and treatment resistance1-3 Continued psychosocial limitations4 Decreased ability to work and decreased workplace productivity5,6 Increased cost for medical treatment6 Sustained depression can worsen morbidity/mortality of other conditions7-9 Sources: Paykel ES, et al. Psychol Med. 1995;25:1171-1180. Thase ME, et al. Am J Psychiatry. 1992;149:1046-1052. Judd LL, et al. J Affect Disord. 1998;59:97-108. Miller IW, et al. J Clin Psychiatry. 1998;59:608-619. Simon GE, et al. Gen Hosp Psychiatry. 2000;22:153-162. Druss BG, et al. Am J Psychiatry. 2001;158:731-734. Frasure-Smith N, et al. JAMA. 1993;270:1819-1825. Penninx BW, et al. Arch Gen Psychiatry. 2001;58:221-227. Rovner BW, et al. JAMA. 1991;265:993-996. 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. Druss BG, et al. Am J Psychiatry. 2001;158:731-734. Frasure-Smith N, et al. JAMA. 1993;270:1819-1825. Penninx BW, et al. Arch Gen Psychiatry. 2001;58:221-227. Rovner BW, et al. JAMA. 1991;265:993-996.

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 *no generic available at present time 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 Start with SSRI or new agent Elicit commitment to take medication regularly (self-management plan) Early follow-up (1-3 weeks) Increase dose every 2-4 weeks (to 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 Inadequate Drop of 1 point, no change or increase Consider change in plan: increase dose or change medication; increase intensity of SMS, psychotherapy Possibly Inadequate Drop of 2-4 points from baseline No treatment change needed. Follow-up monthly until remission, then every 6 months. Adequate Drop of  5 points from baseline or PHQ < 5 Treatment Plan Treatment Response PHQ-9 Adapted from Oxman, 2002

RECURRENCE BECOMES MORE LIKELY WITH EACH EPISODE OF DEPRESSION >50% First episode1,2 Second episode2 ≈70% Third + episode2,3 80%-90% 0 20 40 60 80 100 Risk recurrence (%) following recovery during long-term follow-up* 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.

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 ENGAGEMENT “TACCT” Reflection, Legitimation, Support, Partnership, Respect ENGAGEMENT “TACCT” SELF-MANAGEMENT SUPPORT UB-PAP (ultra-brief personal action planning) 5 A’s OFFICE PSYCHOTHERAPY “BATHE” “SPEAK”