1. 11 Clarifying Diagnosis and Monitoring Recovery: Self Report Mental Health Scales can Help! Dr. Margie Oakander Sunridge Primary Mental Health Clinical Associate Professor University of Calgary

2. 2 Disclosure: Dr. Margie Oakander Advisory Board or Committee: Astra Zeneca, Biovail, GlaxoSmith Kline, Janssen, Lilly, Lundbeck, Otsuka, Pfizer, Valeant, Wyeth Honouraria or other fees: Astra Zeneca, Biovail, Bristol Myers Squibb, Janssen, Lundbeck, Lilly, Otsuka, Pfizer, Shire, Wyeth, Valeant Research: GlaxoSmithKline, Lilly, Lundbeck, Pfizer, Wyeth CME Development: Canadian Psychiatric Association University of Calgary

3. 3 70-year-old male 35-year-old female Let’s Start with the many faces of major depression + Depressed mood + Hypersomnia + Increased appetite / weight + Psychomotor retardation + Difficulty making decisions + Suicidal ideation - Marked loss of interest / pleasure - Insomnia - Decreased appetite / weight - Psychomotor agitation - Impaired concentration - Inappropriate guilt DSM-IV criteria

4. 4 DSM 5 Major Depressive Disorder ● Depressed mood ● Loss of interest or pleasure ● Significant changes in weight and/or appetite ● Insomnia or hypersomnia ● Psychomotor agitation or retardation ● Fatigue or loss of energy ● Feelings of worthlessness or excessive/inappropriate guilt ● Diminished ability to think or concentrate, or indecisiveness ● Recurring thoughts of death or suicide, including plans and attempts American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5 th edition 2013.

5. 5 DSM 5 Criteria: SIGGE-CAPS Mnemonic S—Suicidal preoccupation I—Interest/pleasure (  ) G—Gain/lose weight G—Guilty feelings E—Energy (  ) C—Concentration A—Affect (  mood) P—Psychomotor retardation S—Sleep disturbance DSM-5 major depressive disorder: 5 of 9 symptoms x 2 weeks Diagnostic and Statistical Manual of Mental Disorders, 5 th Edition. 2013.

6. 6 Most frequent conditions leading to short-term and long-term disability in Canada Respondents, % n=87 Note: Respondents were asked to select the top three conditions. The Conference Board of Canada. 2013. Most frequent conditions leading to short-term and long-term disability in Canada according to employers

7. Lopez et al. Lancet 2006;26:1747-57. Ischemic heart disease Cerebrovascular disease Unipolar depressive disorders Alzheimer's & other dementias Respiratory cancers Adult-onset hearing loss COPD Diabetes mellitus Alcohol use disorders Osteoarthritis % of total DALYs lost Top 10 Conditions in High-Income Countries Global Burden of Disease Study COPD: chronic obstructive pulmonary disease; DALY: disability-adjusted life-year

8. 8 Mental illness carries a huge burden to society ●Is more than 1.5 times that of ALL cancers ●Is more than 7 times that of ALL infectious diseases ●Contributed to loss of 600,000 health-adjusted life years (HALYs) ●Included the top 5 conditions with highest impact on life and health: –Depression –Bipolar disorder –Alcohol use disorders –Social phobia –Schizophrenia The burden of mental illness and addictions in Ontario: Health-adjusted life years (HALYs): A combination of years lived with less than full function and years lost to early death. Ratnasingham S, et al. Institute for Clinical Evaluative Science, 2012.

9. Considerations for Measurement-based Care (MBC) How many people would consider…  Treating diabetes without measuring and following a patient’s HbA1c?  Prescribing an antihypertensive and not measuring a patient’s BP? Measurement-based care (MBC) provides specific and objective information on which to base clinical decisions and should therefore enhance quality of care and treatment outcomes. Rush J. et al., Psychiatric Times. Vol. 26 No. 9, 2009

10. Why don’t clinicians use scales to measure outcome when treating depressed patients? How often do you use a rating scale to monitor the course of treatment for depression? Why not? Please indicate all that apply. Zimmerman & McGlinchey, J Clin Psychiatry 2006. Survey of 314 psychiatrists attending a CME conference in 2006 and 2007. Reason (N=248) % Do not believe it would be clinically helpful. 28 Do not know what scale to use. 21 Takes too much time. 34 Too disruptive to practice. 19 Wasn’t trained to use them. 34 Percent

11. Rosenbluth M et al., The Canadian Journal of Diagnosis, June 2011 Does Measurement-based Care Help Guide Treatment? Canadian Practice Reflective Audit Results * Physicians may have changed more than one part of a patient’s treatment regimen, therefore, percentages do not equal 100%. % of Patients 67% of Primary Care and 77% of psychiatrists made changes to treatment regimens

12. A Quick Look at the Scales PHQ-15 GAD-7 PHQ-9

13. What makes a scale useful to clinicans and patients? Validated Sensitive to change Brief enough to allow routine administration Preferably patient rated Easy to administer and require minimal training  PHQ -9 (for Major Depressive Disorder)  GAD-7 (for Generalized Anxiety)  Sheehan Disability Scale (For Functionality)  PHQ-15 (for Physical Symptoms)  BC-CCI (for Cognitive Complaints)  PHQ -9 (for Major Depressive Disorder)  GAD-7 (for Generalized Anxiety)  Sheehan Disability Scale (For Functionality)  PHQ-15 (for Physical Symptoms)  BC-CCI (for Cognitive Complaints)

14. When Time Is Limited… The 30 second PHQ-2 depression screen: Kroenke et al. Med Care 2003;41:1284-94 Cut-off score of 3 Sensitivity = 83%, specificity = 92% for MDD Over the past 2 weeks, how often have you been bothered by any of the following items? Not at All Several Days More Than Half the Days Nearly Every Day 1. Little interest or pleasure in doing things0123 2. Feeling down, depressed or hopeless0123 Practical Screening Tool

15. Patient Health Questionnaire- PHQ 9 Self-rated scale is the “HbA1c” of depression. Designed specifically for primary care. Highly sensitive and specific for the diagnosis of depression. Useful in monitoring treatment response TOTAL SCOREDEPRESSION SEVERITY 1-4Minimal Depression 5-9Mild Depression 10-14Moderate Depression 15-19Moderately-severe Depression 20-27Severe MDD PHQ-9 is adapted from PRIME MD TODAY, developed by Drs Robert L. Spitzer, Kurt Kroenke, and Janet B.W. Williams. Copyright ©1999 Pfizer Inc

16. 16 Treatment options based on the PHQ9 score ScoreSeverityProposed Treatment Plan 0 – 4None-minimalNone 5 – 9MildWatchful waiting; repeat at follow-up 10 – 14ModerateConsider psychotherapy and/or pharmacotherapy 15 – 19Moderately SevereConsider pharmacotherapy and/or psychotherapy 20 – 27SevereInitiate pharmacotherapy and, if severe impairment, or actively suicidal consider consultation +/- admission to psychiatry

17. GAD: DSM-IV Diagnostic criteria Excessive anxiety and worry (apprehensive expectation) occurring more days than not for at least 6 months, about a number of events or activities (such as work, school performance) The individual finds it difficult to control the worry.

19. Screening Questions for GAD Are you by nature a worrier? Do you worry more than other people? What do you worry about? Does the worry interfere with your life?

20. GAD-7 For Scoring Symptom Severity In GAD Spitzer RL. Arch Intern Med 2006;166:1092-1097. following problem? Feeling nervous, anxious, on edge

21. Generalized Anxiety Disorder - GAD-7 Spitzer RL. Arch Intern Med 2006;166:1092-1097. TOTAL SCOREProvisional Diagnosis 0-4Minimal anxiety 5-9Mild anxiety 10-14Moderate anxiety 15-21Severe anxiety Self rated Specific for GAD but useful to detect an anxiety disorder in depression Can be used to monitor treatment progress *GAD-2 is the first 2 questions of the GAD-7

22. Substance/Medication-Induced Anxiety Disorder Examples of Substances that can cause anxiety: Alcohol Caffeine Cannabis Phencyclidine Other Hallucinogens Inhalant Opioid Sedative, hypnotic or anxiolytic Amphetamine Cocaine

23. How Patients with Depression & Anxiety Initially Present to Primary Care Physicians Most people with psychological problems go to their family doctor with a physical complaint rather than recognizing that they have a form of mental distress. If patient presents with somatic symptoms instead of psychological symptoms the diagnosing of depression or anxiety is much less Presentation Physician Diagnosis of Depression or Anxiety Disorder 83% 22% 77% 17% Kirmayer LJ, et al. Somatization and the recognition of depression and anxiety in primary care. Am J Psychiatry 1993;150:734-41. Somatic Symptoms Psychological Symptoms

24. 0-12-34-56-8≥9 Strong Correlation Between Number of Physical Symptoms and Prevalence of Psychiatric Disorders The more physical complaints there are, the more likely there is a psychiatric problem. Kroenke K, et al. Arch Fam Med 1994;3:774-9.

25. TOTAL SCORE SEVERITY OF SOMATIC SYMPTOMS 5-9Low 10-14Moderate 15-20HIgh Brief, self-rated somatic symptom scale Useful for screening somatization as well as monitoring somatic symptom severity. Strong correlation between PHQ15 and functional status, disability days and symptom related difficulty. Kroenke K et al. The PHQ 15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med. 2002 Mar-Apr, 64(2):258-66 The Somatic Symptom Scale – PHQ-15

26. 26 Patient language to describe cognitive symptoms ATTENTIONMEMORY PSYCHOMOTOR SPEEDEXECUTIVE FUNCTION CONFUSED INADEQUATE OVERWHELMED CONFUSED INADEQUATE OVERWHELMED Tired / lethargic Slow motion Forgetful Loss of short-term memory Concentration Lack of focus Indecisive Procrastinate Not listening Attention Lacking confidence Lose train of thought Brain is cloudy Patients use a diverse range of language to describe their cognitive symptoms Some terms are specific to an individual domain, whereas others encompass multiple domains of cognitive dysfunction 26 Qualitative market research with patients (July 2011) on patients in Canada and Europe, conducted by H. Lundbeck A/S

27. 27 Mini-Mental State Exam (MMSE) and the Montreal Cognitive Assessment (MoCA) ●Common bedside tests to assess cognitive impairment ●Not very sensitive for milder degrees of cognitive impairment seen in depression

28. British Columbia Cognitive Complaints Inventory (BC-CCI) 6 item scale that measures perceived cognitive problems. Brief, self-rated, easy to incorporate clinically, ensures standardized cognitive assessment Sensitive to cognitive complaints in patients with depression Can be used to monitor change over time Should be used in conjunction with a depression rating scale eg PHQ-9 TOTAL SCORE SEVERITY OF PERCEIVED COGNITIVE SYMPTOMS 0-4Broadly normal 5-8 “mild” cognitive complaints 9-14 “moderate” cognitive complaints 15-18 “severe” cognitive complaints Iverson GL, Lam RW, Rapid screening for perceived cognitive impairment in major depressive disorder, Ann Clin Psychiatry, 2013 May; 25(2) 135-40

29. The Sheehan Disability Scale- SDS Sheehan DV. The Anxiety Disease. New York. Charles Scribner and Sons, 1983. 10-point self-rated scale Assists clinician to monitor function in 3 domains - work, social and family functioning Uses visuospatial, numeric and verbal descriptive anchors Reflects change over time with effective treatment SCORING No recommended cut-off score; change- over-time useful in monitoring response Clinicians should pay attention to patients with scores over 5 in any domain

30. 30 Prepared in response to an unsolicited request – Not for further distribution Arizona Sexual Experience Scale (ASEX)  The Arizona Sexual Experience Scale (ASEX) is designed to assess five major global aspects of sexual dysfunction: Drive Arousal Penile erection/vaginal lubrication Ability to reach orgasm Satisfaction from orgasm  All of these are domains most commonly impaired by psychotropic dugs  Items are rated 1-6; higher scores = greater dysfunction  Sexual dysfunction is defined as: ASEX total score  19 or 1 item  5 or 3 items  4 ASEX, Arizona Sexual Experience Scale McGahuey CA et al. J Sex Marital Ther. 2000;26(1):25-40.

31. 31 Prepared in response to an unsolicited request – Not for further distribution Arizona Sexual Experiences Scale (ASEX) How strong is your sex drive? 1 Extremely Strong 2 Very Strong 3 Somewhat Strong 4 Somewhat Weak 5 Very Weak 6 No Sex Drive How easily are you sexually aroused? 1 Extremely Easily 2 Very Easily 3 Somewhat Easily 4 Somewhat Difficult 5 Very Difficult 6 Never Aroused Male: Can you easily get and keep an erection? / Female: How easily does your vagina become moist? 1 Extremely Easily 2 Very Easily 3 Somewhat Easily 4 Somewhat Difficult 5 Very Difficult 6 Never How easily can you reach an orgasm? 1 Extremely Easily 2 Very Easily 3 Somewhat Easily 4 Somewhat Difficult 5 Very Difficult 6 Never Reach Orgasm Are your orgasms satisfying? 1 Extremely Satisfying 2 Very Satisfying 3 Somewhat Satisfying 4 Somewhat Unsatisfying 5 Very Unsatisfying 6 Can’t Reach Orgasm For each item, please indicate your OVERALL level during the PAST WEEK, including TODAY. ASEX, Arizona Sexual Experience Scale McGahuey et al. J Sex Marital Ther. 2000;26(1):25-40.

32. 32 Evaluating Comorbidity 32 Beck Depression Inventory HAMD-7 PHQ-9 MDD MDQ Bipolar Disorder Fear Questionnaire GAD-7 Hamilton Anxiety Scale GAD Substance Abuse and Dependence Scale Substance Use Disorder Adult ADHD Self-Report Scale (ASRS) ADHD

33. Hirschfeld RM, et al. Am J Psychiatry. 2000;157(11);1873-75. Patient self-assessment screening tool for a broad diagnosis of the bipolar spectrum according to DSM-IV criteria 13 questions covering hypo/mania symptoms, clustering of symptoms, and impaired functioning Criteria for a diagnosis within the bipolar spectrum:  7 positive questions + clustering of symptoms + moderate-to-severe impairment 9 out of 10 correctly identified (specificity) 7 out of 10 ruled out (sensitivity) Mood Disorder Questionnaire “ … useful screening instrument ”

34. Lifecycle of ADHD Hyperactive as child Drop out of school Job performance Parent Relationship Issues Alcohol/Substance Abuse Accidents 34

35. When to Screen? Patients presenting with: Major Mood and Anxiety D/O (including poor response to treatment) Drug abuse or drug dependence Family history or children with ADHD Poor school performance as a child (not reaching potential) Frequent job changes or moving often Frequent driving infractions Higher number of accidents than average population Forgetfulness (missed appointments, trouble with adherence to medications) History of maternal smoking during pregnancy 35

36. Questions for Suspected ADHD McIntosh D, Kutcher S, Binder C, et al. Neuropsychiatr Dis Treat. 2009. Anything positive – move to Step 2 Anything positive – move to Step 3 36 Do you currently have substantial difficulties with forgetfulness, attention, impulsivity or restlessness that are interfering with your relationships or your success at work? Have you ever been diagnosed with ADHD? Do you have a family history of ADHD (siblings, children, parents or extended family)? Did you have any difficulty in school? Did you daydream or have difficulty paying attention? Did you get your homework done on time? Were you disruptive? Have you ever been diagnosed with ADHD? Do you have a family history of ADHD (siblings, children, parents or extended family)? Did you have any difficulty in school? Did you daydream or have difficulty paying attention? Did you get your homework done on time? Were you disruptive? Complete ASRS & Complete Diagnostic Interview

37. The Adult ADHD Self-Report Scale (ASRS-V1.1 )1 Symptom Checklist A checklist of 18 questions about symptoms that are based on the diagnostic criteria for ADHD from the DSM-IV Developed in conjunction with the World Health Organization and the Workgroup on Adult ADHD. 1. ASRS-v1.1 Screener COPYRIGHT ©2003 World Health Organization (WHO). Reprinted with permission of WHO. All rights reserved. 37

38. Remission Not officially defined; varies between studies (e.g., HAM-D <7-10) Functional Recovery Outcomes were here Outcomes are now here Ideal outcome should be here Defining Treatment Goals Adapted from: Nierenberg & DeCecco. J Clin Psychiatry 2001;62 (Suppl 16):5-9. Response 50% improvement in a validated depression rating scale from baseline (e.g., HAM-D)

39. Defining “remission” from a patient’s perspective Factors identified as very important, in rank order: 1.Presence of positive mental health (e.g. optimism, vigour, self-confidence) 2.Feeling like your usual, normal self 3.Return to usual level of functioning at work, home or school 4.Feeling in emotional control 5.Participating in, and enjoying, relationships with family and friends 6.Absence of symptoms of depression Zimmerman et al. Am J Psychiatry 2006; 163:148-150

40. Thanks! Q&A Time!