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Management of Depression in Primary Care

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Management of Depression in Primary Care University of Pittsburgh Management of Depression in Primary Care Ellen M Whyte, MD Medical Director, Psychiatric Services UPMC Benedum Geriatric Center Medical Director Integrated Behavioral Health – Primary Care DISCLOSURES Grant Support in last 12 months: Geriatric Workforce Enhancement Program (HRSA) U1Q HP028736 (PI: Schulz) Off-label use of medication will be discussed. 2 LEARNING OBJECTIVES Improve patient outcomes by identifying patients with major depression who require early psychiatric consultation. Improve patient outcomes by utilizing measurement based, stepped care medication management in the treatment of major depression. Improve skill in choosing and instituting pharmacotherapy for major depression. 3 PCP AS BEHAVIORAL HEALTH PROVIDERS Most behavioral health care in the US is delivered by the primary care provider. Ø National Comorbidity Survey (2001-2003), patients reported that they received BH treatment through 40% PCP^ (PCP only >> PCP + another BH provider) 26% Psychiatrist 21% non-physician Behavioral Health provider 9% Human Services Only 3% Complementary/Alternative Medicine ^ Patients followed by PCP: typically older, female, lower SES, rural 4 Wang et al 2006 MAJOR DEPRESSIVE EPISODE Must endorse Sadness/depressed mood and/or Loss of pleasure/anhedonia For at least 5 total symptoms • Impaired sleep • Poor concentration • Impaired appetite • Feelings of • Low energy worthlessness or guilt • Restlessness or looking ‘slowed • Thoughts of death or down’ suicidal thoughts At least 2 weeks duration, more days than not Causes distress or functional impairment 5 BENEFITS OF TREATMENT Ø Improved quality of life Ø Reduced risk Ø Mitigated disability Ø Improved medical outcomes Ø Decreased health care utilization 6 MAJOR DEPRESSIVE EPISODE Cardinal Episode in… Major Depressive Disorder Persistent Depressive Disorder (Dysthymia + Double Depression) Bipolar Disorder – Type I and Type 2 Schizoaffective Disorder Commonly Co-Morbid with… Personality Disorders Schizophrenia and Other Psychotic Disorders SuBstance ABuse Dementia (Neurocognitive Disorders) TBI, CVA, Parkinson’s Dz, other neurological disorders 7 MAJOR DEPRESSIVE EPISODE Cardinal Episode in… **Major Depressive Disorder Major Depressive Disorder with elevated suicide risk Persistent Depressive Disorder (Dysthymia + Double Depression) Bipolar Disorder – Type I and Type 2 Schizoaffective Disorder Commonly Co-Morbid with… Personality Disorders Schizophrenia and Other Psychotic Disorders Substance Abuse **Dementia (Neurocognitive Disorders) **TBI, CVA, Parkinson’s Dz, other neurological disorders 8 Maximizing Acute Treatment Outcomes for Depression Management in Primary Care IMPACT PROSPECT ------- STAR*D Texas Medication Algorithm Project 9 PHASES OF DEPRESSION TREATMENT Kupfer DJ. J Clin Psychiatry 1991. 10 Maximizing Acute Treatment Outcomes for Depression Management in Primary Care Measurement Based Care Stepped Care Collaborative Care 11 PHQ-9 * * 12 PHQ-9 Total Score Depressive Severity 1-4 Minimal Depression 5-9 Mild Depression 10-14 Moderate Depression 15-19 Moderately Severe Depression 20-27 Severe Depression PHQ-9 scores > 10 have a sensitivity of 88% and a specificity of 88% for Major Depressive Episode. 13 MEASUREMENT BASED CARE Use PHQ-9 to serially monitor response to treatment. PHQ-9 scores (as well as patient’s impression) determine next step of treatment. -------- Reflected in MIPS 371 “Depression Utilization of the PHQ-9 Tool” (q 4 months while treating depression) Flowsheet available in EPIC “PHQ-9 [1357]” 14 STEPPED CARE Medication Management is time focused and algorithm driven and leverages measurement based care. -- initiate treatment with simple medications (e.g., SSRI), but other choices may be reasonable. -- titrate to maximum tolerated doses of antidepressants quickly. -- patient status assessed at weeks 2,4,6,9,& 12 -- decision regarding continuation vs. change in medication regime every ∼ 6-8 weeks. 15 STEPPED CARE General Rule: After 6-8 weeks at a therapeutic dose of an antidepressant, assess response and adjust treatment plan.... After an additional 6-8 weeks, assess response and adjust treatment plan... Repeat until patient is ‘symptom free’ and enters Continuation Phase of Treatment. 16 STEPPED CARE General Rule: After 6-8 weeks at a therapeutic dose of an antidepressant…. IMPLICATION: Titrate to maximum tolerated (therapeutic) antidepressant dose quickly. Sertraline start at 12.5-25mg/d (↑to 50mg over 1-3 weeks) Duloxetine start 30mg/d x 7 days, then↑ 60mg/d [or start 20mg/d x 7 d then ↑ 40mg (renal)] Mirtazapine start at 15mg/hs x 1-2 weeks, then↑30mg/hs 17 STEPPED CARE General Rule: After 6-8 weeks…assess response and adjust treatment plan. IMPLICATION: Response based on Ø Change in PHQ-9 scores Ø PatIent’s subjectIve report 18 STEPPED CARE Full Response = PHQ-9 demonstrates nearly 100% resolution or symptoms and patient reports ‘back to normal’. RECOMMENDATIONS: Ø Pt exits ACUTE treatment Ø Pt enters CONTINUATION treatment 19 STEPPED CARE Non-Response = PHQ-9 ↓ by < 30% and/or patient is reporting little to no change RECOMMENDATIONS: Ø Switch antidepressants Examples: SSRI à SSRI (Limit to 2 SSRI trials) SSRI à SNRI SSRI or SNRI à Mirtazapine (Remeron) SSRI or SNRI à Bupropion (Wellbutrin) 20 STEPPED CARE Partial Response = PHQ-9 ↓ by > 30% and/or patient is reporting improvement RECOMMENDATIONS: Ø Watchful waiting for patients reporting near complete resolution of symptoms. Ø Dose increase (if possible) to maximum dose (e.g., sertraline 50mg à 200mg/d; mirtazapine 30mg à 45mg) Ø Augmentation with a 2nd medication with different mechanism of action Examples: SSRI/SNRI + bupropion SSRI/SNRI + mirtazapine SSRI/SNRI + atypical antipsychotic SSRI/SNRI + lithium 21 Discuss psychotherapy as treatment option MOA = mechanism of action PROSPECT Algorithm STEPPED CARE: General Rule: After 6-8 weeks at a therapeutic (max) dose of an antidepressant, assess response and adjust treatment plan.... Repeat until patient is ‘symptom free’ and enters Continuation Phase of Treatment… or refer to psychiatry after failure of 2 – 4 treatment trials. 24 ACUTE TREATMENT- BASELINE Patient with elevated PHQ-9 score (including mood/anhedonia) Assess suicide risk à thoughts that life is not worth living desire for death (e.g., “wish I would not wake up”) *suicidal ideation ^suicide plan (including giving away possessions, etc) ^suicide intent reasons for living (protective factors) *risk factors (e.g., substance abuse, interpersonal loss) history of suicide attempt ^requires emergency assessment; *consider emergency assessment 25 ACUTE TREATMENT- BASELINE Clarify diagnosis Screen for mania Screen for substance abuse Screen for psychosis (“what has been worrying you recently”) Review prior depression tx and family hx of tx à informs medication choices Assess for medical contributions to depression Thyroid function Sleep apnea Hypercalcemia Vit B12/ Vit D Pancreatic CA 26 SCREEN FOR HISTORY OF MANIA All antidepressants can trigger a mania in patients with bipolar disorder who are not on a mood stabilizer. Patients tend not to remember their manias as ‘problematic’ especially early in the disease. Screening For Mania: • Mood Disorder Questionnaire (MDQ) • Bipolar Type I (mania) >> Bipolar Type II (hypomania) • In primary care, sensitivity 0.58 & speciFicity 0.93 • Ask about a unique period (lasting 4+ days) of • Increased energy • Increased activity +/- decreased sleep • Increased selF – conFidence (can lead to ‘reckless behavior’) • Abnormal elevated/irritable mood (not ‘normal selF’) 27 ACUTE TREATMENT Pharmacotherapy + Adjunct Meds Psycho-Education Support/Encouragement Psychotherapy 28 PHARMACOTHERAPY- GENERAL PRINCIPLES All antidepressants are equally effective Cannot predict which medication will work for a particular patient Ø Genetic testing can predict side effect burden. Side effects appear early & are usually transient Choose medication based on tolerability, utility of a side effect, or history of response (patient or family) Avoid abrupt discontinuation of antidepressants Ø Especially venlafaxine, paroxetine Age alone does not dictate medication dosinG 29 ANTIDEPRESSANTS SSRI SNRI *Prozac (fluoxetine) Effexor (venlafaxine) Luvox (fluvoxetine) Pristiq (desvenlafaxine) Paxil (paroxetine) *Cymbalta (duloxetine) *Zoloft (sertraline) Fetzima (levomilnacipran) Celexa (citalopram) ATYPICAL Lexapro (escitalpram) *Remeron (mirtazapine) + Viibryd (vilazodone) Wellbutrin (buprorion) Brintellix++ (vortioxetine) + ++ 5HT1A partial agonist; 5HT3antagonist & 5HT1A agonist 30 ANTIDEPRESSANTS Common to All: Risk of Hypomania/Mania SSRI: nausea, diarrhea, ↑ bleeding, hyponatremia (SIADH), serotonin syndrome (rare), sexual SE SNRI: same as SSRIs plus orthostatic hypotension, hypertension, exacerbate closed angle glaucoma Bupropion: activation/anxiety, insomnia, tremor, seizure^ (1/1000) [low incidence weight gain and sexual SE] Mirtazapine: sedation (at lower doses), weight gain, ↑ triglycerides, [low incidence hyponatremia and sexual SE] ^SR/XL versions better tolerated, lower sz incidence 31 ANTIDEPRESSANTS SSRI: Fluoxetine, paroxetine, fluvoxamine-avoid in elderly d/t CYP inhibition Citalopram - monitor QTc above 20mg/d Sertraline - competes with warfarin - protein binding SNRI: Duloxetine - renal dosing; pain benefit Venlafaxine – likely pain benefit; + orthostatic BP, HTN risk, significant withdraw syndrome Bupropion: weight neutral; tremor, sz risk, anxiety Mirtazapine: helps with sleep; + weight gain 32 Psycho-Education Key points • People can
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