1. DEPRESSION MODULE Integrating Population Health Inquiry Transforms (IPHIT) Family Medicine Northeast Education Afternoon January 21, 2014,

2. IPHIT Education Modules - topics 8 rotating modules (four/year) maternal/child health depression obesity cardiovascular disease and diabetes prevention/wellness chronic pain asthma/COPD tobacco/AODA

3. DO YOU REMEMBER THIS SLIDE? Notheast Education Afternoon October 23, 2013

4. Top diagnoses at UW-Madison Family Medicine Residency clinics Chronic condition BellevilleNortheastVeronaWingra #1Obesity #2HyperlipidemiaDepressionHyperlipidemiaDepression #3HypertensionSmokingHypertensionSmoking #4SmokingHyperlipidemi a DepressionHypertension #5DepressionHypertensionSmokingChronic back pain

5. Morbidity According to the WHO (2004) depression is the 3 rd most important cause of disease burden worldwide 8 th most important in low-income countries 1 st most important in middle- and high-income countries Estimated that by the year 2020 depression will be the 2 nd leading cause of disability worldwide, trailing only ischemic heart disease Mental health disorders are the leading cause of disability in the US and Canada leading to more the 25% of all years of life lost to disability and premature mortality

6. 15 leading causes of death in the US 2010 1. Diseases of heart (heart disease) 2. Malignant neoplasms (cancer) 3. Chronic lower respiratory diseases 4. Cerebrovascular diseases (stroke) 5. Accidents (unintentional injuries) 6. Alzheimer’s disease 7. Diabetes mellitus (diabetes) 8. Nephritis, nephrotic syndrome and nephrosis (kidney disease) 9. Influenza and pneumonia 10. Intentional self-harm (suicide) 11. Septicemia 12. Chronic liver disease and cirrhosis 13. Essential hypertension and hypertensive renal dis­ ease (hypertension) 14. Parkinson’s disease 15. Pneumonitis due to solids and liquids

7. HEALTHY PEOPLE 2020 Sample national targets

8. HealthyPeople.gov Mental Health and Mental Disorders (MHMD)

9. HealthyPeople.gov

10. NATIONAL DATA A bird’s eye view

11. Prevalence of Current Depression* Among Persons Aged ≥12 Years, by Age Group and Sex — United States 2007–2010 National Health and Nutrition Examination Survey * Current depression was determined based on responses to the Patient Health Questionnaire, which asks about symptoms of depression during the preceding 2 weeks. Depression was defined by a score of ≥10 out of a possible total score of 27. † 95% confidence interval Lifetime prevalence of depression is 16.5% 12 month prevalence of severe depression is 2%

12. 1 in 10 Americans over age 12 takes an antidepressant

13. Suicide rates by race/ethnicity

14. Suicide Rates Rise Sharply in U.S. By Tara Parker-Popes Published: May 2, 2013 From 1999 to 2010, the age- adjusted suicide rate for adults aged 35–64 years in the United States increased significantly by 28.4%, from 13.7 per 100,000 population to 17.6 (p<0.001). More people now die of suicide than in car accidents, according to the Center for Disease …In 2010 there were 33,687 death from motor vehicle crashes and 38,364 suicides.

15. WISCONSIN DATA

16. Depression is even more prevalent in Wisconsin 8.4% of Wisconsin adults experienced major depression in 2009 15 th highest rate of depression in the US

17. In 2006… Among those ages 18-40 years, suicide was the second most common cause of death, following unintentional injuries. Each suicide death was estimated to affect the life of six other people. This means nearly 4,000 Wisconsin residents were affected by a loved one’s suicide. There were 5,277 hospitalizations and 4,143 emergency department visits due to self-harm. Many who make suicide attempts never seek professional care immediately after the attempt. These hospitalizations and emergency department visits resulted in over $64 million dollars in hospital charges. Forty-five percent of suicides were by firearm.

18. Suicide trends in WI

19. DANE COUNTY

20. Suicide in Dane County

21. Healthydane.org

22. GenderRace/Ethnicity

23. NORTHEAST DATA

26. Patients with a depression diagnosis N% Lower 95% CI Upper 95% CI Belleville85614.914.015.8 Northeast203621.520.722.3 Verona213616.315.717.0 Wingra139321.020.021.9 Depression is significantly more prevalent at Wingra and Northeast.

27. Adjusted for age, gender, race/ethnicity, payer category and language

28. Northeast patients N% Lower 95% CI Upper 95% CI GenderFemale140726.725.527.9 Male62914.913.916.0 Age12-17 years427.04.99.0 18-34 years55422.520.824.1 35-64 years120828.827.430.1 >65 years23128.623.629.5 Race/Ethnic ity White151724.523.425.6 Black27017.515.619.4 Hispanic6715.011.718.4 Asian7212.09.414.6 Native Am1025.611.340.0 Other10015.412.618.1

30. Northeast patients N% Lower 95% CI Upper 95% CI Language English197221.821.022.7 Spanish1114.36.322.3 Hmong2110.46.214.6 Payor Commercial110719.618.620.7 Medicare 65+ 18526.022.829.2 Medicare <65 20645.941.350.5 Medicaid36719.617.821.3 Uninsured17121.418.624.3

31. Utilization of health care services # depressed patients Avg office visits* Avg urgent care visits* Avg ER visits* Avg inpatient LOS* Belleville85617.30.310.931.3 Northeast203620.611.711.76 Verona213617.10.91.181.31 Wingra139322.80.862.242.23 * Last 3 years # clinic patients Avg office visits* Avg urgent care visits* Avg ER visits* Avg inpatient LOS* All Northeast Patients 947012.60.750.860.98

32. Comorbidities

33. PHQ 9 data for the DFM

34. Missing information We do not have suicide data Think about PHQ documentation

35. DISPARITIES DATA

36. Depression disparities Sex the prevalence of depression is about 2x higher in females than in males Race Native Americans are about twice as likely as white to experience depression in their lifetime the lifetime incidence of depression is about 18% for whites and about 10% for blacks however, the chronicity and functional impairment is greater for blacks compared with whites Age in community surveys, adults 65 and older have a lower prevalence of depression compared with younger adults however, older adults with a greater burden of medical illness have a depression prevalence similar to younger adults LGBTQ 2.5 times more likely to carry a mental health disorder than heterosexuals Those rejected from their families were 8.4 times more likely to attempt suicide and have 5.9 times more likely to be depressed

37. ROOT CAUSES Including some social determinants

38. Risk factors for depression individual risk factors genetics female sex early puberty substance abuse family parental depression poor parenting parent-child conflict parental abuse marital conflict or divorce single-parent household (for girls only)

39. Risk factors for depression school and peers poor grades peer rejection stressful life events entering new social context with decrease in social support neighborhood and community low socio-economic status stressful community events

40. POPULATION-LEVEL INTERVENTIONS depression

41. Interventions to prevent depression? What do we mean by prevention, anyway? Gerald Caplan “Principles of Preventive Psychiatry” – 1964 primary prevention secondary prevention tertiary prevention Robert Gordon – 1983 universal prevention offered to the full population, likely to provide benefit to all targeted prevention targeted to subpopulations identified to be at elevated risk indicated prevention indicated for specific individuals who are identified as having particular vulnerability based on individual assessment but who are currently asymptomatic *

42. further reading IOM report 2009 - Preventing Mental, Emotional, and Behavioral Disorders Among Young People - Progress and Possibilities http://books.nap.edu/openbook.php?record_id=12480 stats on US depression http://www.nimh.nih.gov/statistics/1mdd_adult.shtml paper on youth prevention from UW Extension http://www1.cyfernet.org/prog/teen/94-youthfut9.html Healthiest Wisconsin progress report 2009 http://publichealthcouncil.dhs.wi.gov/shp/mentalreport09.pdf Healthy Wisconsin 2020 mental health summary http://www.dhs.wisconsin.gov/hw2020/pdf/mentalhealth.pdf Dane Co health report 2013 http://www.publichealthmdc.com/documents/HealthDC-2013status.pdf