January 28, 2016 Nelly burdette, psyD, IBH Consultant Universal Screening 101: Depression, Anxiety & Substance Use in Primary Care Care Transformation Collaborative of R.I. January 28, 2016 Nelly burdette, psyD, IBH Consultant

Objectives Describe importance of screening and rates of depression, anxiety and substance use in primary care Understand how to administer, score and interpret the following screening tools in primary care: PHQ9 (Depression) GAD7 (Anxiety) CAGE-AID (Alcohol and Substance Use)

Depression in Primary Care 18.8 million adults 9.5% of the U.S. population aged 18 years and older in a given year. 3 More than 80% of patients with depression have a medical comorbidity 5 PCPs detect major depression in 1/3 - 1/2 of patients 5 70-80% of antidepressants prescribed in primary care 5 Only 20-40% showing substantial improvement over 12 months 5

PHQ9 Purpose: dual purpose 9 item depression scale that can establish provisional depression diagnosis and grade depressive symptom severity Target Population: Adults age 18 and over Evidence: Validated for measuring depression severity; detecting and monitoring depression in primary care settings 4 Estimated Time: 2-5 min Administered by: Patient (self-report), Provider, Telephonically Intended Settings: Primary Care

PHQ9 Administration Ask the first two questions and continue with remaining questions if score > 3 Score > 3 = 83% sensitivity for major depression, 90% specificity 4 High rates of false positives when lowering cutoff to 2 1 Nine scored questions Total 27 points Each question having ranging from 0-3 All focusing on past 2 weeks Tenth question focuses on ADLs and is not scored 80% of patients within primary care would NOT have major depression with a cut-off on PHQ of 2 Sensitivity: True Positive Rate or in other words, probability of testing positive when disease present (So 17% chance of being missed for Major Depression) Specificity: True Negative Rate or in other words, individuals who are disease-free are correctly identified (So 10% chance of false-positive or being disease free but not indicated as such)

PHQ9 Administration

PHQ9 Scoring and Plan

PHQ9 Scoring and Plan

PHQ9 Repeat Administrations4 Detecting depression and initiating treatment are NECESSARY but often INSUFFICIENT steps to improve outcomes in primary care Monitoring clinical response to treatment is also CRITICAL. 5 point change correlates with a moderate effect size on multiple domains of health-related quality of life and functional status Total score of <10 = partial response and <5 = remission Repeat administrations allow for clinicians to assess: -medication noncompliance -increase appropriateness of increasing antidepressant dosage, or change or augment pharmacotherapy -or add behavioral health interventions IMPACT for Depression

Anxiety in Primary Care Occurs among 7-8% primary care patients8 and in general population 30% 9 Predominant presentation includes headaches or GI distress, not worry 8 Anxiety continues to be undertreated in primary care Adequate pharmacotherapy received < 20% Adequate psychotherapy received 14% Both pharmacotherapy and psychotherapy received by 5% TOTAL: Quarter of patients received adequate care 9 Risa Weisburg’s 2014 Study on adequacy of anxiety treatment in primary care Patients were MORE LIKELY to receive adequate care if they graduated college, were more impaired, earned less than $20,000 , had Medicaid/Medicare and had PTSD dx at intake. All ethnic minorities were LESS LIKELY to receive adequate care

GAD7 Estimated Time: 2-5 minutes Purpose :evaluate for presence and severity of anxiety in general practice, as well as monitoring change across time 7 Target Population: Adults age 18 and over Evidence 1: Panic Disorder - Sensitivity: 74% Specificity: 81% Social Anxiety Disorder - Sensitivity: 72% Specificity: 80% PTSD - Sensitivity: 66% Specificity: 81% Estimated Time: 2-5 minutes Administered by: Self-Report Intended Settings: Primary Care Sensitivity: True Positive Rate or in other words, probability of testing positive when disease present (So 26% chance of being missed for Panic Disorder) Specificity: True Negative Rate or in other words, individuals who are disease-free are correctly identified (So 19% chance of false-positive or being disease free but not indicated as such)

Copyright © 2015 American Medical Association. All rights reserved. From: A Brief Measure for Assessing Generalized Anxiety Disorder:  The GAD-7 Arch Intern Med. 2006;166(10):1092-1097. doi:10.1001/archinte.166.10.1092 Date of download: 12/29/2015 Copyright © 2015 American Medical Association. All rights reserved.

GAD7 Scoring and Plan Cognitive-behavioral and SSRI/SNRI agents are effective in reducing symptoms in up to 50% of patients 8 If a 50% or more decrease in treatment does not occur within 3 months of treatment, different or adjunctive treatment should be offered 8

Substance Use in Primary Care6 22.5 million persons older than 12 years meet criteria for substance abuse or dependence < 20% of PCPs described themselves as very prepared to identify alcoholism or illegal drug use More than 50% of patients with substance use disorders said their PCP did nothing to address their substance abuse.

CAGE-AID Purpose: Assesses likelihood and severity of alcohol and drug use; modified from CAGE Target Population: Adults aged 18 years and older Evidence: One or more yes responses has sensitivity of 0.79 and specificity of 0.77; Two of more yes responses has sensitivity of 0.70 and 0.85. 2 Estimated Time: 1 minute Length: 4 yes/no questions Intended Settings: Primary care

CAGE AID

CAGE-AID Scoring and Interpretation6 Annals of Family Medicine (2013) recommends any use of substance as hazardous, then categorizing substance abuse and substance dependence

Resources PHQ and GAD Language Translation Options http://www.phqscreeners.com IMPACT for Depression, Evidence-Based Collaborative Care in Primary Care Setting http://impact-uw.org/

Final Thoughts Screening for behavioral health does NOT equate to a behavioral health diagnosis. Workflows should be in place to connect patients with positive screens to IBH providers for treatment. Not “One and Done”; follow-up screenings should measure progress and allow for evidence to make changes to treatment options

References Arroll, B., Goodyear-Smith, F., Crengle, S., Gunn, J., Kerse, N., Fishman, T., Falloon, K., Hatcher, S. (2010). Validation of PHQ-2 and PHQ-9 to Screen for Major Depression in Primary Care Population. Annals of Family Medicine, 8 (4): 348-353. Brown, R.L. and Rounds, L.A. (1995). Conjoint screening questionnaires for alcohol and other drug abuse: criterion validity in a primary care practice. Wisconsin Medical Journal, 94(3): 135-40. Egede, L. E. (2007). Failure to Recognize Depression in Primary Care: Issues and Challenges. Journal of General Internal Medicine, 22(5), 701–703. Kroenke K, Spitzer R. (2002). The PHQ-9: A New Depression Diagnostic and Severity Measure. Psychiatry Annals. 32: 509-515. Mitchell J, Trangle M, Degnan B, Gabert T, Haight B, Kessler D, Mack N, Mallen E, Novak H, Rossmiller D, Setterlund L, Somers K, Valentino N, Vincent S. Institute for Clinical Systems Improvement. Adult Depression in Primary Care. Updated September 2013. Shapiro, B., Coffa, D., McCance-Katz, E.F. (2013). A primary care approach to substance misuse. American Family Physician. 88 (2): 113-21. Spitzer RL, Kroenke K, Williams JW, Löwe B. (2006). A Brief Measure for Assessing Generalized Anxiety Disorder: The GAD-7. Archives Internal Medicine. 166(10):1092-1097. Stein, M.B and Sareen, J. (2015). Generalized Anxiety Disorder. New England Journal of Medicine. 373(21): 2059-2068. Weisberg, R.B., Beard, C., Moitra, E., Dyck, I., Keller, M.B. (2014). Adequacy of Treatment Received by Primary Care Patients with Anxiety Disorders. Depression Anxiety. 31 (5): 443-450.