PHQ-9 Severity and Screening Tests Predictive of Remission Outcomes at Six Months Kurt B. Angstman, MS MD Associate Professor John M. Wilkinson Assistant.

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Presentation transcript:

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

Conflicts of Interest We have no reportable conflicts of interest

Overview Background Hypothesis Study Design Results Conclusions

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

Collaborative Care Management for Depression 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 % 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):

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

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

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, (3): p Angstman, K.B., et al., Age of depressed patient does not affect clinical outcome in collaborative care management. Postgraduate Medicine, (5): p 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).

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.

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

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) 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

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%) 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%) 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%) Initial AUDIT score Below cut-off (<8) Hazardous drinking 662(94%) 45(6%) 299(90%) 34(10%) 275(87%) 41(13%) 0.002

Odds ratio of persistent depressive symptoms six months after diagnosis of depression, utilizing all baseline intake variables Odd Ratio95% C.I.p-value Age Sex MaleReference Female Race Non-whiteReference White Marital Status Not marriedReference Married Baseline diagnosis First episode of depressionReference Recurrent major depression Dysthymia

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 severe Severe Initial anxiety symptoms (GAD-7) AsymptomaticReference Mild Moderate Severe Initial MDQ screen NegativeReference Abnormal Full-positive Initial AUDIT score Below cut-off (<8)Reference Hazardous drinking

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.

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) Moderately severe (15-19) Severe (>=20) MDQ Abnormal Depression severity (PHQ- 9) Moderate (10-14) Moderately severe (15-19) Severe (>=20) MDQ Full-Positive Depression severity (PHQ- 9) Moderate (10-14) Moderately severe (15-19) Severe (>=20)

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) Moderately severe (15-19) Severe (>=20) MDQ Abnormal Depression severity (PHQ-9) Moderate (10-14) Moderately severe (15-19) Severe (>=20) MDQ Full-Positive Depression severity (PHQ-9) Moderate (10-14) Moderately severe (15-19) Severe (>=20)

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

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

Questions? 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!