1. PHQ-9 Severity and Screening Tests Predictive of Remission Outcomes at Six Months Kurt B. Angstman, MS MD Associate Professor John M. Wilkinson Assistant Professor Department of Family Medicine Mayo Clinic Rochester STFM Annual Spring Conference April 27, 2012

2. Conflicts of Interest We have no reportable conflicts of interest

3. Overview Background Hypothesis Study Design Results Conclusions

4. Background Depression is common in primary care Goal for treatment is remission Even by best of studies, up to 40% of diagnosed patients may have symptoms of persistent depression

5. Collaborative Care Management for Depression 2008-2011 Minnesota state wide collaborative – Care managers are employed by primary care – Oversight by Psychiatrist- 4 hours per week Review new patient intakes Review patients concerns, those not improving Medication management by PCP Six month remission rates range 49.32- 62.69% in re-measured patients – Angstman, KB, et al. “Age of Depressed Patient does not affect outcome in collaborative care management.” Postgraduate Medicine. 2011; 123(5):122-128.

6. Care Management 2008-2011 Successful program from many points of view – Clinical – Financial Spread from 1 clinic in March 2008 to 5 by March 2010 – By September 2011 2,543 patients enrolled 1,012 “graduated”

7. But… Even with successes, some patients still not able to achieve remission – PHQ-9 score< 5

8. Prior studies Initial depression severity (PHQ-9), anxiety symptoms (GAD-7) or abnormal screen for bipolar disorder (MDQ) – Inversely related to remission at six months Angstman, K.B., R.S. DeJesus, and J.E. Rohrer, Correlation between mental health co-morbidity screening and clinical response in collaborative care treatment for depression. Mental Health in Family Medicine, 2010. 7(3): p. 129-33. Angstman, K.B., et al., Age of depressed patient does not affect clinical outcome in collaborative care management. Postgraduate Medicine, 2011. 123(5): p. 123-45. Angstman, K.B., et al., Depression Remission after six months of collaborative care management: role of initial severity of depression in outcome. Mental Health in Family Medicine, 2012(Submitted for publication).

9. Hypothesis Routinely obtained baseline clinical and demographic variables would be identified that could predict patients who would have persistent depressive symptoms (PDS; PHQ-9 >=10) Once identified, a table of predictive probabilities for PDS at six months would be generated to allow clinical triage based on intake parameters.

10. Study Design Retrospective database study 1,419 patients diagnosed with depression or dysthymia and PHQ-9 >=10 Enrolled in collaborative care management Intake variables – PHQ-9, GAD-7, MDQ, AUDIT, Diagnosis (first episode or recurrent) – Age, gender, race, marital status Six month follow up PHQ-9

11. Baseline demographic and clinical variables of patients who were in collaborative care management for depression, by outcome at six months Remission (PHQ-9 <5) Mild depressive symptoms (PHQ-9 5–9) Persistent Depressive symptoms (PHQ-9 >=10) p-value N (%)731 (51.5%)358 (25.2%)330 (23.26%) Age Mean / (Std. Dev.) 43.3 (15.7) 42.3 (15.8) 40.8 (14.6) 0.056 Gender % Female 73.6%71.2%72.7%0.711 Race % White 92.2% 90.6%0.656 Marital Status % Married 63.0%58.8%52.8%0.008 Baseline diagnosis First episode of depression Recurrent major depression Dysthymia 424 (58%) 271 (37%) 36 (5%) 195 (54%) 139 (39%) 24 (7%) 135 (41%) 174 (53%) 21 (6%) 0.000

12. Baseline demographic and clinical variables of patients who were in collaborative care management for depression, by outcome at six months Remission (PHQ-9 <5) Mild depressive symptoms (PHQ-9 5–9) Persistent Depressive symptoms (PHQ-9 >=10) p-value Initial depression severity (PHQ-9) Moderate Depression Moderately-Severe Severe 387 (53%) 243 (33%) 99 (14%) 184 (52%) 116 (33%) 56 (16%) 93 (28%) 128 (39%) 109 (33%) 0.000 Initial anxiety (GAD-7) Asymptomatic Mild Moderate Severe 106 (15%) 200 (28%) 220 (31%) 176 (25%) 44 (13%) 84 (25%) 113 (34%) 96 (28%) 17 (5%) 57 (18%) 93 (30%) 145 (46%) 0.000 Initial MDQ screen Negative Abnormal Fully positive 439(64%) 229(33%) 21(3%) 174(52%) 138(42%) 20(6%) 121(39%) 152(49%) 35(11%) 0.000 Initial AUDIT score Below cut-off (<8) Hazardous drinking 662(94%) 45(6%) 299(90%) 34(10%) 275(87%) 41(13%) 0.002

13. Odds ratio of persistent depressive symptoms six months after diagnosis of depression, utilizing all baseline intake variables Odd Ratio95% C.I.p-value Age0.9930.984-1.0010.096 Sex MaleReference Female1.0340.738-1.4500.845 Race Non-whiteReference White0.8130.677-9.760.027 Marital Status Not marriedReference Married0.7730.584-1.0250.073 Baseline diagnosis First episode of depressionReference Recurrent major depression1.5311.249-1.8770.000 Dysthymia1.6020.893-2.8740.114

14. Odds ratio of persistent depressive symptoms six months after diagnosis of depression, utilizing all baseline intake variables Odd Ratio95% C.I.p-value Initial depression severity (PHQ-9) ModerateReference Moderately severe1.7501.184-2.5870.005 Severe2.3201.643-3.2750.000 Initial anxiety symptoms (GAD-7) AsymptomaticReference Mild1.4151.272-1.5760.000 Moderate1.7261.144-2.6040.009 Severe2.2621.294-3.9540.004 Initial MDQ screen NegativeReference Abnormal1.3711.037-1.8130.027 Full-positive1.9801.042-3.7630.037 Initial AUDIT score Below cut-off (<8)Reference Hazardous drinking1.5840.911-2.7530.103

15. Adjusted probability of persistent depression in collaborative care at six-month follow-up, by intake levels of GAD-7, Diagnosis, PHQ-9, and MDQ* Notes: *Probabilities (shown here as percents) are based on multivariate regression estimates, adjusted for age, sex, race (white/other), and marital status (married/other); regression used inverse-probability weights to account for attrition and clustering to adjust standard errors for site effects.

16. Anxiety (GAD-7) Asymptomatic (<=4) Mild (5-9) Moderate (10-14) Severe (>=15) First Episode Depression MDQ Negative Depression severity (PHQ- 9) Moderate (10-14)6.18.410.112.8 Moderately severe (15-19)10.213.916.420.4 Severe (>=20)13.117.520.525.2 MDQ Abnormal Depression severity (PHQ- 9) Moderate (10-14)8.211.213.316.7 Moderately severe (15-19)13.518.021.125.9 Severe (>=20)17.122.526.131.5 MDQ Full-Positive Depression severity (PHQ- 9) Moderate (10-14)11.415.418.122.4 Moderately severe (15-19)18.324.027.733.4 Severe (>=20)22.829.433.639.8

17. Anxiety (GAD-7) Asymptomatic (<=4) Mild (5-9) Moderate (10-14) Severe (>=15) Recurrent Major Depression MDQ Negative Depression severity (PHQ-9) Moderate (10-14)9.112.314.618.3 Moderately severe (15-19)14.819.723.028.0 Severe (>=20)18.724.428.233.9 MDQ Abnormal Depression severity (PHQ-9) Moderate (10-14)12.016.119.023.4 Moderately severe (15-19)19.225.129.034.7 Severe (>=20)23.930.634.941.2 MDQ Full-Positive Depression severity (PHQ-9) Moderate (10-14)16.421.725.230.5 Moderately severe (15-19)25.432.536.943.3 Severe (>=20)31.138.843.550.1

18. Conclusions Four clinical factors remain independent predictors for persistent depressive symptoms six months after diagnosis and enrollment into collaborative care management – PHQ-9 (moderate, moderately severe or severe) – GAD-7 (asymptomatic, mild, moderate or severe) – MDQ (negative, abnormal or positive) – Diagnosis of first or recurrent episode of depression

19. Conclusions Predictive probabilities for persistent depression symptoms range from: – 6.1%: A patient with the diagnosis of first episode of moderate major depression and negative screening tests for GAD-7 and MDQ – 50.1%: A patient with recurrent severe major depression, severe anxiety symptoms and an positive MDQ screen Future studies evaluating clinical use would be indicated

20. Questions? angstman.kurt@mayo.edu wilkinson.john@mayo.edu Angstman KB, Shippee ND, MacLaughlin KM, Rasmussen NH, Wilkinson JM, Williams MD, Katzelnick DJ. “Factors predictive of persistent depressive symptoms despite six months of collaborative care management”. General Hospital Psychiatry. Submitted for publication. THANK YOU!