1. 1 UW Health Depression Treatment Guideline Update Stevens S. Smith, Ph.D. Assistant Professor (CHS) Department of Medicine / General Internal Medicine Center for Tobacco Research and Intervention University of Wisconsin Medical School Primary Care Conference Presentation Wednesday, 28 September 2005

2. 2 Disclaimer I have received research support (but no consulting or speaking fees) from the following companies that market smoking cessation medications: SmithKline Beecham GlaxoSmithKline GlaxoSmithKline Elan Corporation, plc Elan Corporation, plc

3. 3 Learning Objectives Review of the revised UW Health practice guideline for treating depression in adults in primary careReview of the revised UW Health practice guideline for treating depression in adults in primary care Review of diagnostic issuesReview of diagnostic issues Role of primary care clinicians and behavioral health specialists in the treatment of depressionRole of primary care clinicians and behavioral health specialists in the treatment of depression Treatment planning for depressive disordersTreatment planning for depressive disorders

4. 4 58 year-old female; single, never-married; social services worker58 year-old female; single, never-married; social services worker Multiple medical conditions including hypertension, diabetes, CAD, hyperlipidemia; smoker; prior tx for alcoholism; has maintained sobriety for > 20 yearsMultiple medical conditions including hypertension, diabetes, CAD, hyperlipidemia; smoker; prior tx for alcoholism; has maintained sobriety for > 20 years At routine check with her primary care physician (PCP), the patient admits that she has felt mildly depressed for several years; she denies suicidal ideation but relates that she her main symptoms are “low self-esteem,” feeling tired much of the time, and feeling hopeless about the futureAt routine check with her primary care physician (PCP), the patient admits that she has felt mildly depressed for several years; she denies suicidal ideation but relates that she her main symptoms are “low self-esteem,” feeling tired much of the time, and feeling hopeless about the future Differential diagnosis rules out obvious medical or medication causes for the depression; substance abuse also ruled outDifferential diagnosis rules out obvious medical or medication causes for the depression; substance abuse also ruled out What is the probable diagnosis? How should her depression be treated?What is the probable diagnosis? How should her depression be treated? Case Study

5. 5 Depression in Primary Care General population estimates for major depression in the U.S. 1 :General population estimates for major depression in the U.S. 1 : - Lifetime prevalence: 16.2% - 12-month prevalence rate: 6.6% Prevalence of depression in adult primary care patients tends to be higher especially in the presence of chronic health problems 2Prevalence of depression in adult primary care patients tends to be higher especially in the presence of chronic health problems 2 Depression is associated with poor self-care and poor adherence to medical treatmentsDepression is associated with poor self-care and poor adherence to medical treatments Second only to hypertension as the most common chronic condition encountered in primary care settingsSecond only to hypertension as the most common chronic condition encountered in primary care settings 1 Kessler et al., JAMA 2003, 289:3095-3105; 2 Leon et al., Arch Fam Med 1995, 10:857-861

6. 6 Depression in Primary Care Primary care physicians are the gatekeepers of medical care including depressionPrimary care physicians are the gatekeepers of medical care including depression Primary care physicians (PCPs) outnumber psychiatrists 7 to 1; PCPs prescribe the majority of antidepressantsPrimary care physicians (PCPs) outnumber psychiatrists 7 to 1; PCPs prescribe the majority of antidepressants Outcomes for depression treatment of primary care patients do not differ for psychiatrists and primary care physicians 1Outcomes for depression treatment of primary care patients do not differ for psychiatrists and primary care physicians 1 Primary care physicians are increasingly prescribing antidepressants: in 1989, 2.6% of clinic visits versus 7.1% of visits in 2000 (National Ambulatory Medical Care Survey 2 )Primary care physicians are increasingly prescribing antidepressants: in 1989, 2.6% of clinic visits versus 7.1% of visits in 2000 (National Ambulatory Medical Care Survey 2 ) 1 Simon et al., Arch Gen Psychiatry 2001, 58:395-401. 2 Pirraglia et al., Primary Care Companion J Clin Psychiatry 2003, 5:153-157.

7. 7 UW Health: Treating Depression In Adults in Primary Care (2004) Update of the 2002 Depression Treatment GuidelineUpdate of the 2002 Depression Treatment Guideline Addresses identification and treatment of Major Depressive Disorder (also mentions Dysthymia and Adjustment Disorder with Depressed Mood with few details)Addresses identification and treatment of Major Depressive Disorder (also mentions Dysthymia and Adjustment Disorder with Depressed Mood with few details) Role of Primary Care ClinicianRole of Primary Care Clinician When to refer patients to Behavioral Health SpecialistWhen to refer patients to Behavioral Health Specialist Includes decision trees, medication tools, quick reference guideIncludes decision trees, medication tools, quick reference guide

8. 8 The UW Health Depression Workgroup

9. 9 Depression Guideline Sections 1.Suspect depression 2.Interview for key symptoms of depression 3.Involve Behavioral Health 4.Consider co-morbid disorders 5.Treatment plan 6.Section on post-partum depression 7.Useful tables on concurrent conditions, medication side effects, drug interactions, and dosage ranges + formulary info 8.Treatment monitoring flow-sheets

10. 10 Steps 1 & 2: Suspect & Diagnose Depression

11. 11 DSM-IV Disorders with Depression 1.Major Depressive Disorder (Mild, Moderate, Severe) 2.Dysthymia 3.Adjustment Disorder with Depressed Mood 4.Depressive Disorder Not Otherwise Specified 5.Mood Disorder Due to a Medical Condition 6.Substance-Induced Mood Disorder 7.Seasonal Affective Disorder 8.Post-Partum Depression 9.Others including Bipolar Disorder, Cyclothymia

12. 12 Guideline Step 1: Suspect Depression 1.Physical complaints – insomnia, fatigue, changes in appetite and/or weight 2.Functional impairments (work, relationships) 3.Risk factors: personal or family hx of depression, female, socially isolated, multiple medical problems, post-partum 4.Ask screening questions: “During the past two weeks, have you felt down, depressed or hopeless?” “During the past two weeks, have you felt little interest or pleasure in doing things?”

13. 13 Guideline Step 2: Interview for Key Symptoms of Major Depression 1.For DSM-IV diagnosis of Major Depressive Disorder, patient must have at least 5 of 9 symptoms including either depressed mood or anhedonia (loss of interest/pleasure) 2.Symptoms must have been present for at least 2 weeks

14. 14 Guideline Step 2: Interview for Key Symptoms of Dysthymia Chronic depressed mood for most of the days, for more days than not, for at least 2 yearsChronic depressed mood for most of the days, for more days than not, for at least 2 years Must not have gone for more than 2 months without experiencing two or more of the following symptoms:Must not have gone for more than 2 months without experiencing two or more of the following symptoms: - poor appetite or overeating - insomnia or hypersomnia - low energy or fatigue - low self-esteem - poor concentration or difficulty making decisions - feelings of hopelessness Significant distress or functional impairmentSignificant distress or functional impairment

15. 15 Guideline Step 2: Interview for Key Symptoms of Adjustment Disorder With Depressed Mood Development of emotional or behavioral symptoms in response to an identifiable stressor occurring within 3 months of the onset of the stressorDevelopment of emotional or behavioral symptoms in response to an identifiable stressor occurring within 3 months of the onset of the stressor Marked distress beyond expected response to stressor or significant functional impairment Not bereavement Symptoms do not persist > 6 months after stressor ends

16. 16 Guideline Step 3: Consider Referral to Behavioral Health Specialist (BHS) 1.Same day consultation with or evaluation by psychiatrist: - suicidality with safety concerns; assaultiveness or homicidal intentions; psychosis; severe functional impairment 2.Consider non-emergent/non-urgent referral to BHS: - psychiatric co-morbidity (e.g., OCD, eating disorders) - suicidal thoughts or angry with others (no clear plan) - alcohol or substance abuse (special referral to AODA tx) - psychotic depression (refer to psychiatry) - pregnancy (refer to psychiatry) - diagnostic uncertainty - poor response to antidepressant (refer to psychiatry)

17. 17 Relative Degree of Involvement of PCPs and Behavioral Health Specialists (BHS) None SubthresholdSimpleComplex Severe PCP BHS in SpecialtySettings Type of Problem/Disorder BHS in Primary Care Settings PCP

18. 18 Guideline Step 4: Consider Co-Morbid Disorders 1.Is depression secondary to a medical condition? 2.Is depression secondary to medication? 3.Is depression secondary to alcoholism or substance use? 4.Are there other psychiatric disorders that may be masked by depression such as anxiety, OCD, phobias, or eating disorders? 5.Is the patient experiencing normal bereavement (lasting up to 2 months)?

19. 19 Guideline Step 5: Treatment Plan 1.Objectives of treatment: - Reduction and elimination of depressive signs and symptoms - Restoration of premorbid functioning - Relapse prevention 2. Modes of treatment: - psychotherapy alone - medication - medication and psychotherapy - ECT 3. Patient education - medication compliance - nature and course of depression - importance of follow-up appointments

20. 20 Guideline Step 5: Treatment Plan

21. 21 Phases of Depression Treatment Kupfer DJ. J Clin Psychiatry. 52(5s):28-34,1991. Treatment Phases Relapse Recurrence Recovery AcuteContinuationMaintenance Syndrome Symptoms Remission Response No Depression

22. 22 1. Acute phase - first 12 weeks of treatment: - Patient should be seen a minimum of 3 times (at least once with prescriber) - After resolution of depression, patient can be seen about every 4-12 weeks 2.Continuation phase – next 6-9 months - Patient should remain on medication for at least 6 months after resolution of symptoms - Patient must be symptom-free for 6-9 months before discontinuing medication/treatment 3.Maintenance phase – 1 year to lifetime (if needed) Guideline Step 5: Treatment Plan

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24. 24 Primary care physician referred the patient to a psychologist for evaluation and treatmentPrimary care physician referred the patient to a psychologist for evaluation and treatment Psychiatric Diagnoses:Dysthymic DisorderPsychiatric Diagnoses:Dysthymic Disorder Tobacco Use Disorder Treatment:Initial medication – fluoxetineTreatment:Initial medication – fluoxetinePsychotherapy Medication changed to bupropion XL after 2 years Patient is continuing in treatment (medication and psychotherapy)Patient is continuing in treatment (medication and psychotherapy) Case Study

25. 25 Depression Guideline Sections Revisited 1.Suspect depression 2.Interview for key symptoms of depression 3.Involve Behavioral Health 4.Consider co-morbid disorders 5.Treatment plan 6.Section on post-partum depression 7.Useful tables on concurrent conditions, medication side effects, drug interactions, and dosage ranges + formulary info 8.Treatment monitoring flow-sheets