1. ©2015 MFMER | slide-1 PTSD: Worsening outcomes for comorbid depression… even with collaborative care management. Kurt B. Angstman, MS, MD Professor of Family Medicine Vice Chair for Education Mayo Clinic Rochester, Minnesota USA WONCA Europe Congress 16 June 2016

2. ©2015 MFMER | slide-2 Conflict of Interests Nothing to disclose

3. ©2015 MFMER | slide-3 Post-Traumatic Stress Disorder 12 month prevalence of 3.5% (U.S. general population) Lifetime prevalence of PTSD As high as 6-10% in civilian primary care 11-20% in Department of Veterans Affairs (VA) primary care settings Co-Morbid Depression Associated with a decreased likelihood of remission from depression Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. Jun 2005;62(6):617-627 Hegel MT, Unutzer J, Tang L, et al. Impact of comorbid panic and posttraumatic stress disorder on outcomes of collaborative care for late-life depression in primary care. Am J Geriatr Psychiatry. Jan 2005;13(1):48-58.

4. ©2015 MFMER | slide-4 Hypothesis Although our institution has seen significant improvement in depression management with collaborative care management (CCM): In Primary care patients diagnosed with depression and treated with CCM, that: A diagnosis of PTSD was associated with a decreased likelihood of remission of depressive symptoms at six months A diagnosis of PTSD was associated with a increased likelihood of persistent depressive symptoms at six months

5. ©2015 MFMER | slide-5 Methods Retrospective chart review study Using a depression registry Inclusion Criteria Adult CCM patients with: Diagnosis of major depression or dysthymia AND Initial PHQ-9 score of ≥ 10; March 2008 through June 30, 2013 with follow up through December 31, 2013; Automated query program to review EMR to identify the diagnosis of PTSD using ICD-9 code 309.81.

6. ©2015 MFMER | slide-6 Methods (continued) Exclusion criteria Diagnosis of Bipolar Disorder Treated with usual primary care Declined EMR review of chart for research

7. ©2015 MFMER | slide-7 Predictor Variables Patient Demographics (covariate/control variables): Age Gender Race/Ethnicity Marital status Clinical Characteristics: Diagnosis of PTSD documented in the EMR (ICD-9 code 309.81) Diagnosis of first episode or recurrent major depressive disorder or dysthymia Initial total scores (at enrollment): PHQ-9 (Patient Health Questionnaire – 9 items; depression) GAD-7 (General Anxiety Disorder – 7 items; anxiety) MDQ (Mood Disorder Questionnaire; symptoms of bipolar)

8. ©2015 MFMER | slide-8 Outcome Variables PHQ-9 at six months follow-up from CCM: Remission defined as: - PHQ-9 < 5 Persistent depressive symptoms (PDS) defined as: - PHQ-9 ≥ 10 Titov, Nickolai, et al. "Psychometric comparison of the PHQ-9 and BDI-II for measuring response during treatment of depression." Cognitive Behaviour Therapy 40.2 (2011): 126-136.

9. ©2015 MFMER | slide-9 Results 2,121 CCM patients with available follow up data 76 (3.6%) patients had a documented PTSD diagnosis PTSD prevalence similar to: Total CCM group (1 or more data points) n = 123 / 3,348: 3.7% Treatment as usual group n = 122 / 3,503: 3.6% 12-month U.S. prevalence rate of PTSD 3.5% Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. Jun 2005;62(6):617-627

10. ©2015 MFMER | slide-10 Results – Sample Characteristics % (n) Variable Patients with PTSD diagnosis (n = 76) Patients without PTSD diagnosis (n = 2,045) p-value Age 39.742.6.178 Gender: % female (n)72.4% (55)73.9% (1,511).871 Marital status: % married (n)39.5% (30)55.2% (1,129).010 Race: % white (n)89.5% (68)94.3% (1,929).128 Initial PHQ-9 mean: (min= 10, max = 27) 17.9 15.4<.001 Depression Diagnosis First Episode Recurrent Depression Dysthymia 34.2% (26) 52.6% (40) 13.2% (10) 51.6% (1,056) 41.1% (841) 7.2% (148).006 Initial Anxiety severity Asymptomatic/Mild (GAD-7 Score < 10) Moderate/Severe (GAD-7 Score ≥ 10) 26.3% (20) 73.7% (56) 37.5% (767) 62.5% (1,278).063 Initial Positive MDQ screen13.2% (10)8.7% (178).256

11. ©2015 MFMER | slide-11 Results Patients with PTSD diagnosis (N=76) Patients without PTSD diagnosis (N=2,045) p-value Remission from depression (PHQ-9 score < 5 at six months) 30.2% (23)55.6% (1,138) <0.001 Persistent Depressive Symptoms (PHQ-9 score ≥ 10 at six months) 51.3% (39)20.2% (414) <0.001 % (n)

12. ©2015 MFMER | slide-12 Multivariate Results – Association Between Demographic and Clinical Characteristics and Remission from Depressive Symptoms at Six Months Post-CCM in Primary Care Note. Only Adjusted Odds Ratio with 95% CI that do not include 1.0 are listed.

13. ©2015 MFMER | slide-13 Multivariate Results – Association Between Demographic and Clinical Characteristics and Persistent Depressive Symptoms at Six Months Post-CCM in Primary Care Note. Only Adjusted Odds Ratio with 95% CI that do not include 1.0 are listed.

14. ©2015 MFMER | slide-14 Summary of Results A documented PTSD diagnosis was associated with: Less likelihood of remission from depressive symptoms, compared to those without a documented PTSD diagnosis (consistent with hypothesis) Increased likelihood of persistent depressive symptoms, compared to those without a documented PTSD diagnosis (consistent with hypothesis)

15. ©2015 MFMER | slide-15 Strengths Large sample Longitudinal Primary care patients Pragmatic trial (‘real world’)

16. ©2015 MFMER | slide-16 Limitations Retrospective study No longitudinal comparison/control group Internal Validity PTSD diagnosis/comorbidity may be variable Available to what is in the EMR Possible heterogeneity of clinical characteristics Contact; Psychotropic Medications, etc. External Validity Single institution, so not sure if generalizable to other sites Different sociodemographic factors may have other impacts on outcomes

17. ©2015 MFMER | slide-17 Thank you! Contributors Kurt B. Angstman, MD Angstman.kurt@mayo.edu Alberto Marcelin, MD Cesar Gonzalez, PhD Tara Kaufman, MD Julie Maxson, BA Mark Williams, MD Questions?? Angstman, KB, Marcelin, A, Gonzalez CA, et al. The Impact of Posttraumatic Stress Disorder on the 6-Month Outcomes in Collaborative Care Management for Depression. J Prim Care Community Health. 2016 Mar 18. pii: 2150131916638329