1. Depression in Primary Care: Decision Support for Chronic Care Model
Steven Cole, MD
Professor of Psychiatry
Stony Brook University Health Center

2. OUTLINE
The problem
Assessment
Engagement
Management

3. 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

4. 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)

5. 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:

6. 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

7. 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:

8. 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

9. 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

10. IMPACT OF MENTAL DISORDERS: COSTS OF DEPRESSION
Annual
Costs
($)
Depressed
Non depressed
Simon G, Am J Psychiatry. 1995

11. 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

12. ASSESSMENT Types of depression Symptoms PHQ-9 Suicide assessment
Co-morbidity (Anxiety)
Bipolarity

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

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

15. DEPRESSED MOOD Hallmark 1
Neither necessary, nor sufficient
Can be misleading
Beware of asking the question, “Are you depressed?”

16. ANHEDONIA Hallmark 2 Loss of interest or pleasure
May be most useful hallmark
Ask, “What do you enjoy doing?”

17. PHYSICAL SYMPTOMS Hallmark 3
Sleep disturbance
Appetite or weight change
Low energy or fatigue
Psychomotor changes

18. PSYCHOLOGICAL SYMPTOMS Hallmark 4
Low self-esteem or guilt
Poor concentration
Suicidal ideation or persistent
thoughts of death

19. 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

20. 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

21. 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

22. 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

23. Oxman, 2003

24. 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

25. INTERPRETING THE PHQ: ASSESSMENT AND SEVERITY
Count numerical values of symptoms
not clinically depressed
mild depression
moderate depression
88%sensitivity, 88%specificity (MDD)
>14 severe depression

26. 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…?”

27. 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.

28. 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:
Magee WJ, et al. Arch Gen Psychiatry. 1996;53:
Roy-Byrne PP, et al. Br J Psychiatry. 2000;176:
Kessler RC, et al. Arch Gen Psychiatry. 1995;52:
Weissman MM, et al. J Clin Psychiatry. 1994;55(suppl):5-10.
Bleich A, et al. Br J Psychiatry. 1997;170:
Depression
37%
(SAD + MD)
OCD
27% (OCD + MD)

29. 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

30. 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”

31. 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

32. MANAGEMENT Referral Three phases of depression
Outcome targets/definitions
Treatment selection
Medications
Office counseling

33. REFERRAL Suicidality Psychosis Bipolarity Chemical dependency
Personality disorder

34. 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

35. 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

36. 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

37. 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:
Thase ME, et al. Am J Psychiatry. 1992;149:
Judd LL, et al. J Affect Disord. 1998;59:
Miller IW, et al. J Clin Psychiatry. 1998;59:
Simon GE, et al. Gen Hosp Psychiatry. 2000;22:
Druss BG, et al. Am J Psychiatry. 2001;158:
Frasure-Smith N, et al. JAMA. 1993;270:
Penninx BW, et al. Arch Gen Psychiatry. 2001;58:
Rovner BW, et al. JAMA. 1991;265:
1. Paykel ES, et al. Psychol Med. 1995;25:
2. Thase ME, et al. Am J Psychiatry. 1992;149:
3. Judd LL, et al. J Affect Disord. 1998;59:
4. Miller IW, et al. J Clin Psychiatry. 1998;59:
5. Simon GE, et al. Gen Hosp Psychiatry. 2000;22:
Druss BG, et al. Am J Psychiatry. 2001;158:
Frasure-Smith N, et al. JAMA. 1993;270:
Penninx BW, et al. Arch Gen Psychiatry. 2001;58:
Rovner BW, et al. JAMA. 1991;265:

38. TREATMENT SELECTION: CONSIDER FOUR OPTIONS
Watchful waiting
Psychotherapy
Antidepressant medication
Combination therapies

39. 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)

40. 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

41. PHARMACOTHERAPY Effective major depression
chronic depression (dysthymia)
Equivocal
minor depression

42. 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

43. 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.

44. 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)

45. 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

46. RECURRENCE BECOMES MORE LIKELY WITH EACH EPISODE OF DEPRESSION
>50%
First
episode1,2
Second
episode2
≈70%
Third +
episode2,3
80%-90%
Risk recurrence (%) following recovery during long-term follow-up*
1. Judd LL, et al. Am J Psychiatry. 2000;157:
2. Mueller TI, et al. Am J Psychiatry. 1999;156:
3. Frank E, et al. Arch Gen Psychiatry. 1990;47:

47. 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

48. 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”