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Management of Depression in the Primary Care Setting Alan L. Podawiltz, D.O., M.S. Chair, Psychiatry and Behavioral Health www.jpsbehavioralhealth.org.

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Presentation on theme: "Management of Depression in the Primary Care Setting Alan L. Podawiltz, D.O., M.S. Chair, Psychiatry and Behavioral Health www.jpsbehavioralhealth.org."— Presentation transcript:

1 Management of Depression in the Primary Care Setting Alan L. Podawiltz, D.O., M.S. Chair, Psychiatry and Behavioral Health

2 Learning Objectives After your participation in this session you should be able to: DESCRIBE the epidemiology of depressive disorders. DESCRIBE symptoms of depressive disorders. DIFFERENTIATE/DIAGNOSE the characteristics of depressive disorders DESCRIBE drugs and medical illnesses that may induce depression DESCRIBE physiologic abnormalities caused by psychotropic medications: DESCRIBE common adverse effects of psychotropic agents DESCRIBE strategies to assist the compliance of patients with recommended treatment. –Impact of illness on activities of daily living, –Early development –Access to diagnosis and treatment –Cultural influence on illness

3 Biopsychosocial Affect BehaviorCognition Environment

4 Biopsychosocial Affect Behavior Cognition Environment

5 Major Depressive Disorder Lifetime prevalence in women: 21.3% 1 Lifetime prevalence in men: 12.7% 1 Most prevalent in women between onset of menstruation and menopause 2 1.Kessler RC et al. Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Arch Gen Psychiatry. 1999;56(7): Cohen LS et al. H. Diagnosis and management of mood disorders during the menopausal transition. Am J Med. 2005;118 Suppl 12B:93-97.

6 Risk of Depression by Age & Sex Kessler R, et al. J Affect Disord. 1993; 29:85-96.

7 Comorbidity and Depression 72.1% of those with lifetime MDD and 64% of those with 12-month MDD have at least one additional mood disorder Primarily anxiety disorder, substance abuse disorder, or impulse control disorder Kessler RC et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA. 2003;289(23):

8 Major Depressive Disorder (MDD) One or more major depressive episodes Absence of any history of manic, mixed, or hypomanic episodes Relapsing and remitting Episodes may last months or, more rarely, years Half of all episodes fully remit within 6 to 12 months with or without treatment Up to 20% of those who experience an initial episode may develop chronic depression After an initial episode, the patient is predisposed to additional episodes which become more severe and last longer Moore DP, Jefferson JW. Mood Disorders. In: Moore & Jefferson: Handbook of Medical Psychiatry, 2nd ed. Philadelphia: Mosby; 2004

9 Depression Very common Associated with significant dysfunction Under diagnosed Often chronic or recurrent Commonly present with other GMC Highly treatable Multiple safe and effective treatments are available

10 Major Depressive Disorder Relapsing and remitting course May eventually become chronic Minimum duration ≥ two weeks Clear distinction between episodes and inter- episodic function Often well or at least much better between episodes

11 Two Questions Over the last two weeks: 1.Have you felt down, depressed, or hopeless? (Mood) 2.Have you felt little interest or pleasure in doing things? (Interest)

12 A “yes” to either question is a positive initial screen for depression… Two-Steps for Depression Screening Over the past 2 weeks have you felt down, depressed, or hopeless? Over the past 2 weeks have you felt little interest or pleasure in doing things? Probe deeper, be proactive, engage in conversation about mood and changes in behavior 24% - 40% of patients with positive screen receive MDD diagnosis Others may have dysthmia, subsyndromal depressive disorders, anxiety, PTSD, substance abuse, panic disorder, or grief disorder Step One: Two-Question Depression Screen Step Two: If Screen is Positive… US Preventive Services Task Force. Screening for depression: recommendations and rationale. Ann Intern Med. 2002;136(10):

13 Visual Screening Tool Ask the patient to point to the face that best represents how she/he has felt in the past 2 weeks. Depression in Women Series, PACE, 2007

14 Recommended Instruments QIDS: Quick Inventory of Depressive Symptomatology (http://www.ids-qids.org) PHQ-9: Patient Health Questionnaire-9 (www.phqscreeners.com) Both instruments are… Validated Quickly and easily administered and scored Available to download Available in English and Spanish Helpful for initial screening AND evaluation of treatment response

15 SIGECAPS - Changes in sleep pattern - Changes in interests or activity - Feelings of guilt or increased worry - Changes in energy - Changes in concentration - Changes in appetite - Psychomotor disturbances - Suicidal ideation SIGECAPSSIGECAPS

16 Major Depressive Disorder Core symptoms: SIGECAPS Depressed mood (sad, down, blue) AND/OR Reduced interest or pleasure (I) Somatic symptoms: Change in appetite (A) Change in sleep pattern (S) Reduced energy level (E) Psychomotor agitation/retardation (P) Cognitive symptoms: Poor concentration/easy distraction (C) Inappropriate guilt/self reproach (G) Thoughts of death, dying, suicide (S) 5 out of 9 for at least two weeks

17 The Suicide Question If an adult, child, or adolescent says, “I want to kill myself, or I'm going to commit suicide” Always take this statement seriously and immediately seek assistance from a qualified mental health professional People often feel uncomfortable talking about death. However, asking the adult, child, or adolescent whether he or she is depressed or thinking about suicide can be helpful. Rather than putting thoughts in the person's head, such a question will provide assurance that somebody cares and will give the person the chance to talk about problems

18 U.S. Suicides 11th leading cause of death 8th leading cause of death for males 19th leading cause of death for females 1.3% deaths suicide 29% heart diseases 23% malignant neoplasms 6.8% cerebrovascular disease

19 Suicide Risk Screening MeasureSuicide Risk Screening QuestionsScore Ideation Have you had thoughts of taking your own life 1 Plans Have made any plans to take your life? 1 Means Do you have access to the tools or situation to take your life according to your plan? 1 Intent Do you intend to commit suicide? When? 1 History Have you ever tried to take your own life? 1 Total Depression in Women Series, PACE, 2007

20 Suicide Risk Assessment ScoreSuicide RiskTreatment Recommendation 0Low Risk Follow Up as needed 1-2Moderate Risk Assess suicide risk at each visit. Refer as needed 3-5High Risk Implement protective measures and emergent management Depression in Women Series, PACE, 2007

21 Explore the Differentials Depressive Disorders Psychiatric – Major Psychoses – Adjustment D/O w/ depression – Bereavement (up to 2 months) General Medical – Hypothyroidism = classic rule-out – Post-CVA, Post-MI – Ca of head of pancreas Substance-Related – Alcohol abuse, cocaine/amphetamine withdrawal – Rx meds: steroids, b-blockers, a-methyldopa

22 Comorbid Medical Conditions Asthma 1 Pain 2 Arthritis 1 Cardiovascular disease 1 Stroke 3 Diabetes 1 Obesity 1 1.Chapman DP et al. The vital link between chronic disease and depressive disorders. Prev Chronic Dis. 2005;2(1):A14. 2.Gureje O et al. A cross-national study of the course of persistent pain in primary care. Pain. 2001;92(1-2): Gillen R et al. Depressive symptoms and history of depression predict rehabilitation efficiency in stroke patients. Arch Phys Med Rehabil. 2001;82(12):

23 Substances Related to Sexual Dysfunction Antidepressants Lithium Sympathomimetics  and  - adrenergic antagonists Anticholinergics Antihistamines Anti-anxiety agents Alcohol Opioids Hallucinogens Cannabis Barbiturates Sedative hypnotics

24 Sexual Dysfunction and Antidepressants Selective Serotonin Reuptake Inhibitors (SSRIs) Increases serotonin levels in both sexes Decreases sex drive Impairs orgasm 5HT2A Agonist Tricyclic Antidepressants (TCAs) Drying of mucosal membranes Reduction of lubrication Stimulation of 5HT2A receptors Inhibits erection and ejaculation

25 CVD and Depression Patients with cardiovascular disease (CVD) more likely to experience depression 1 Patients with depression 1.6 times more likely to develop coronary artery disease (CAD); even more likely with MDD 1 Also 4 times more likely to experience a myocardial infarction (MI) 1 Post-MI patients with depression less likely to follow lifestyle changes 2 1.Pratt LA et al. Depression, psychotropic medication, and risk of myocardial infarction. Prospective data from the Baltimore ECA follow-up. Circulation. 1996;94(12): Ziegelstein RC et al. Patients with depression are less likely to follow recommendations to reduce cardiac risk during recovery from a myocardial infarction. Arch Intern Med. 2000;160(12):

26 Depression and Diabetes Depression twice as prevalent in those with diabetes More prevalent in women with diabetes than in men with diabetes Anderson RJ et al. The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care. 2001;24(6):

27 Depression and Obesity 65% of the US population is overweight or obese More obese women than men (54% vs. 46%) 1 BMI ≥30 in women associated with nearly 50% increase in lifetime prevalence of depressive disorders 2 1.Ogden CL et al. Prevalence of overweight and obesity in the United States, JAMA. 2006;295(13): Chapman DP et al. The vital link between chronic disease and depressive disorders. Prev Chronic Dis. 2005;2(1):A14.

28 Practice Recommendation Screen patients with any chronic health condition for depression, especially patients with diabetes, cardiovascular disease, or chronic pain. US Preventive Services Task Force. Screening for depression: recommendations and rationale. Ann Intern Med. 2002;136(10): AAFP Approved source: Institute for Clinical Systems Improvement Website: Strength of Evidence: Grade A (randomized, controlled trials)

29 Study of Women’s Health Across the Nation (SWAN) Depression risk highest in: Early or late perimenopause Using hormone therapy (OR=1.30 – 1.71) Late vs. early perimenopause Bromberger JT et al. Depressive symptoms during the menopausal transition: The Study of Women's Health Across the Nation (SWAN). J Affect Disord. 2007

30 Harvard Study of Moods and Cycles Nearly twofold increased risk of depression in women entering perimenopause (OR=1.8) Hot flushes associated with greater risk of MDD (OR=2.2) Cohen LS et al. Diagnosis and management of mood disorders during the menopausal transition. Am J Med. 2005;118 Suppl 12B:93-97.

31 Mood, Emotion, Cognitive function Motivation Sex Appetite Aggression Anxiety Irritability Energy Interest Impulsivity Drive Norepinephrine Serotonin Dopamine Major Neurotransmitters

32 Role of Serotonin in the CNS Serotonin influences a wide variety of brain functions Mood Sleep Cognition Sensory perception Temperature regulation Nociception (e.g., migraine headache) Appetite Sexual behavior Kaplan HI, Sadock BJ. In: Synopsis of Psychiatry: Behavioral Sciences,Clinical Psychiatry, 8th ed Hardman JG, et al. In: Goodman & Gilman’s The Pharmacological Basis of Therapeutics, 9th ed Nemeroff C. Scientific American. June 1998;42-49.

33 Role of Dopamine in the CNS Dopamine modulates various brain functions Mood Cognition Motor function Drive Aggression Motivation Kaplan HI, Sadock BJ. In: Synopsis of Psychiatry: Behavioral Sciences,Clinical Psychiatry, 8th ed Hardman JG, et al. In: Goodman & Gilman’s The Pharmacological Basis of Therapeutics, 9th ed

34 Role of Norepinephrine in the CNS Norepinephrine plays an important role in the brain affecting Mood Learning and memory Regulation of sleep-wake cycle Regulation of hypothalamic-pituitary axis Regulation of sympathetic nervous system Kaplan HI, Sadock BJ. In: Synopsis of Psychiatry: Behavioral Sciences,Clinical Psychiatry, 8th ed Nemeroff C. Scientific American. June 1998; Frazer A. J Clin Psychiatry. 2000;61(suppl 10)25-30.

35 Undertreatment Evidence 1/3 discontinued medication Lewis, et al. 50% received no follow-up visit More than 1/3 had not refilled antidepressant Lin, et al. Fewer than half had adequate treatment for their depression Simon, et al. 1.Lewis E, et al. Patients' early discontinuation of antidepressant prescriptions. Psychiatr Serv. 2004;55(5): Lin EH et al. Low-intensity treatment of depression in primary care: is it problematic? Gen Hosp Psychiatry. 2000;22(2): Simon GE et al. Treatment process and outcomes for managed care patients receiving new antidepressant prescriptions from psychiatrists and primary care physicians. Arch Gen Psychiatry. 2001;58(4):

36 Patient Adherence Patients are often reluctant to engage in therapy. 1 More than half of patients treated for depression in primary care practices stopped drug treatment within 3 weeks. 2 Why?? Weren’t told how long it would take to feel better Weren’t warned about side effects Weren’t told I needed to continue once I felt better 2 1.Hirschfeld RM et al. The National Depressive and Manic-Depressive Association consensus statement on the undertreatment of depression. JAMA. 1997;277(4): Stimmel GL. How to counsel patients about depression and its treatment. Pharmacotherapy. 1995;15(6 Pt 2):100S-104S.

37 Antidepressant Warnings All patients being treated with antidepressants for any indication should be monitored closely for: Clinical worsening Suicidality Unusual changes in behavior Monitor these patients especially during the initial few months of a course of drug therapy, or at times of dose changes, either increases or decreases. Antidepressant Use in Children, Adolescents, and Adults

38 Practice Recommendation Base a choice of antidepressant on the patient’s prior response, patient and clinician preference, potential side effects, and cost. Choose any class of antidepressant as a first- line treatment for MDD. Ask patients from different ethnic groups about their treatment preference for MDD. AAFP Approved source: National Guideline Clearinghouse.

39 Maintenance Patients with one lifetime episode of MDD who achieve remission on antidepressants should continue to take them for another 6 to 12 months. Patients with two or more episodes should be maintained an additional 15 months to 3 years. Patients with chronic MDD or MDD with concurrent dysthymia should be continued on antidepressants an additional 15 to 28 months after the acute phase treatment. Kaiser Permanente Care Management Institute. Depression clinical guidelines.

40 Practice Recommendation Follow up with patients on antidepressants for MDD: At least once within the first month At least once more 4 to 8 weeks after the first contact Assess for adherence, side effects, suicidal ideation, and response. AAFP Approved Source: National Guideline Clearinghouse. Strength of evidence: Consensus-based. A practice is recommended based on the consensus or expert opinion of the Guideline Development Team.

41 Practice Recommendation Advise patients that: Most people need to be on antidepressant medication for at least 6 months. It may take 2 to 6 weeks to see any improvement. It is very important to take the medication as prescribed, even after they start feeling better. They should not stop taking the medication without calling the provider first. Changing the dose or dose schedule can help manage side effects. AAFP Approved Source: Institute for Clinical Systems Improvement.

42 Steps for Choosing an Effective Antidepressant 1.Recognize that some antidepressants may be more effective in certain populations even though most are generally of equal effectiveness. 2.Ask about personal or family history of treatment with antidepressants, particularly about side effects. 3.Consider the burden of side effects, particularly weight gain and sexual side effects in midlife women. 4.Consider drug-drug interactions with other medications the patient is taking or may take. 5.Consider the potential lethality of the antidepressant in the case of an overdose. 6.Use antidepressant side effects for efficacy. Moore DP, Jefferson JW. Mood Disorders. In: Moore & Jefferson: Handbook of Medical Psychiatry, 2nd ed. Philadelphia: Mosby; 2004.

43 Treatment Recommendation Base a choice of antidepressant on the patient’s prior response, patient and clinician preference, potential side effects, and cost. AAFP Approved Source: National Guideline Clearinghouse. Strength of evidence: Consensus-based. A practice is recommended based on the consensus or expert opinion of the Guideline Development Team.

44 Follow-Up Considerations In The First Three Months WeekTreatment Actions 2 Check patient compliance to medication usage. Assess for adherence, side effects, suicidal ideation, and patient response. Adjust, as appropriate, medication and dosage. 4 Re-check patient compliance to medication usage. Assess for adherence, side effects, suicidal ideation, and patient response. 6Adjust, as appropriate, medication and dosage Monthly communication with patient; Patients Appointments every 3rd or 4th week; Further Medication or Medication Dosage Adjustments; Goal: Remission

45 Other Options Include... Combine antidepressants and psychotherapy Increase dose of initial antidepressant Combine treatment with SSRI and low-dose desipramine (monitoring for TCA toxicity) Switch to different antidepressant of same or different class Augment with low-dose (300–600 mg/day) lithium in consultation with psychiatrist Switch from psychotherapy to antidepressants, or antidepressants to psychotherapy Kaiser Permanente Care Management Institute. Depression clinical practice guidelines. Accessed May 2, 2007.

46 APA Practice Guidelines for the Treatment of Psychiatric Disorders. Treatment Goal The goal of treatment with antidepressant medication in the acute phase is the remission of major depressive disorder symptoms

47 Follow Up after Initial Treatment Follow up with patients on antidepressants for MDD: Individualize visit frequency for each patient Patient’s starting or switching to a new RX should be seen every two weeks until stable Patient’s at increased risk for suicidality or self-injury seen more frequently Contact all patients in early phase of treatment to assess for suicidality or self-injury Assess response with validated tool Texas Medication Algorithm Project (TMAP) Treatment of Major Depressive Disorder Clinician’s Manual-

48 Maintenance 50% of MDD patients will experience recurrence after initial episode without long-term treatment 3< episodes – maintain AD therapy as preventative Duration varies depending on risk factors from 1 year to lifetime Consider maintenance after 2 episodes for patients with high risk factors, PTSD, co-morbid anxiety, chronic depression or serious personality disorder Increased stressors may warrant longer maintenance Weilburg JB, O'Leary KM, Meigs JB, Hennen J, Stafford RS. Evaluation of the adequacy of outpatient antidepressant treatment. Psychiatr Serv. 2003;54(9): Texas Medication Algorithm Project (TMAP) Treatment of Major Depressive Disorder Clinician’s Manual-

49 Continuation Continuation bridges remission to recovery Patients who remit should continue RX at least 6-9 months after remission at same dosage at which response was achieved Visits every 3 months Texas Medication Algorithm Project (TMAP) Treatment of Major Depressive Disorder Clinician’s Manual-

50 Rush AJ, et al. J Clin Psychiatry. 1997;58(suppl 13): Thase ME, et al. Am J Psychiatry. 1999;60(suppl 22):3-6. Trivedi M et al. Am J Psychiatry. 2006;163(1): Increasing the Likelihood of Remission Measurement-based care Optimize dose/extend trial Selection of antidepressant Role of adherence Pharmacologic adjuncts Role of psychotherapy

51 Adherence to Treatment Having depression generally increases the risk of nonadherence three to four-fold Hispanic patients may be less likely to comply with antidepressant treatment than whites To improve adherence: Understand the patient’s model of the illness Identify social and financial barriers to adherence Address patient concerns about the medication Discuss patient understanding about treatment and ability to follow through (i.e. health literacy) Lewis-Fernandez R et al; JABEFP; 2005:18; ; Wagner GJ et al. Psychiatr Serv. 1998;49(2):239-40; Harman JS et al. Psychiatr Serv. 2004;55(12): ; Sleath B et al. Compr Psychiatry. 2003;44(3):

52 If Initial Treatment Ineffective Medication trial should last 8-12 weeks If no side effects or tolerability issues, increase dosage every 2-3 weeks until Remission achieved Max dose achieved Side effects limit titration Combine antidepressants and psychotherapy Combine antidepressants or consider augmentation trial Considering tailoring your treatment for specific sub- populations (e.g., elderly, midlife women etc). Texas Medication Algorithm Project (TMAP) Treatment of Major Depressive Disorder Clinician’s Manual- Kaiser Permanente Care Management Institute. Depression clinical practice guidelines.

53 Thase ME, et al. Am J Psychiatry. 1997;58(suppl 13): Nierenberg AA, et al. J Clin Psychiatry. 1999;60(suppl 22):7-11. Thase ME. J Clin Psychiatry. 1999;60(suppl 22):3-6. Factors that Predispose to Incomplete Remission Chronicity Medical co morbidity Older age Axis I or II co morbidity Severity Inadequate treatment

54 Nierenberg AA, et al. J Clin Psychiatry. 1999;60(suppl 22):7-11. Thase ME. J Clin Psychiatry. 1999;60(suppl 22):3-6. Consequences of Failing to Achieve Remission Increased risk of relapse Continued psychosocial limitations Continued impairments at work Worsened prognosis of Axis III disorders Increased utilization of medical services Sustained elevation of suicide and substance abuse risks Increased risk of treatment resistance

55 In-Office Therapeutic Approaches to Management of Depression Supportive Treatment - Identify and reinforce positive behaviors and coping mechanisms that patient has used in the past or is using now “Even though you’ve felt lousy, you have gone to work everyday and done what you need to do. That shows a lot of resilience”. “Let’s think about ways you’ve handled situations like that in the past and see how you can apply those skills you already have”.

56 Aiding the Patient in Problem Solving Problem Solving – Most depressed individuals feel overwhelmed by their emotions and their problems. Help patient identify current psychosocial stressors and help patient formulate coping strategy. Don’t focus on significant interpersonal problems or large life issues. Steps in Problem Solving 1.Identify stressors - “What things going on in your life bother you most right now?” 2.Focus on specific behavior – “You told me you feel bad because you can’t get anything done around the house and it is a mess. If you could do one thing around the house to help you feel like you are handling things better, what would you do?” 3.Break behavior down to manageable components – “That huge pile of laundry seems really overwhelming. It would take more energy than you have to do 10 loads of laundry. How about starting by sorting some of it, maybe one basket of laundry. Then tomorrow you may feel like throwing one load in the laundry.”

57 Problem Solving Steps in Problem Solving Cont’d 4.Guarantee success don’t define failure – “It may be difficult to get that load of laundry started. Even talking about it like we are doing and having a plan to get started is a great step. When I see you next week we’ll see how things are going.” 5.Reinforce successive approximations – “Being able to sort that laundry shows you’ve come a long way since I first saw you.” 6.Assess barriers to change – “When you walked into the laundry room and saw the basket of sorted laundry, what do you think kept you from putting it in the washer?” 7.Reframe barriers – “The thought of folding all that laundry seemed like too much. Remember when even the thought of sorting it was overwhelming but then you were able to do that. Maybe folding it while you are watching Desperate Housewives would make it easier.” 8.Reinforce success and apply process to another problem – “Doing the laundry shows that you are really starting to get better. Is there another thing around the house that’s bothering you

58 Helping Patients with Mild Depression SPEAK Schedule – taking control by planning and organizing to counteract avolitional state Pleasurable Activities – engaging in one pleasurable activity a day to counteract anhedonia Exercise – increasing activity even slightly increases sense of control and has positive physical benefits Assertiveness – engaging in small acts that set limits and express own feelings reflects positively on sense of self Kind Thoughts About Oneself – positive self talk can negate effects of negative/irrational self perceptions John Christensen, Ph.D., Oregon Health Sciences University

59 About the Virtual Guidance Program Telephonic clinical guidance with a behavioral health clinical team member Evidence based protocols and guidelines Online reference library of behavioral health education materials Educational opportunities. Diagnostic Recommendations and Treatment planning Call , or visit ww.JPSBehavioralHealth.org for more information and to access a free virtual consultation for your


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