DEPRESSION MODULEIntegrating Population Health Inquiry Transforms (IPHIT)

Family Medicine

Northeast Education AfternoonJanuary 21, 2014,

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

DO YOU REMEMBER THIS SLIDE?

Notheast Education Afternoon

October 23, 2013

Top diagnoses at UW-Madison Family Medicine Residency clinics

Chronic condition

Belleville Northeast Verona Wingra

#1 Obesity Obesity Obesity Obesity

#2 Hyperlipidemia Depression Hyperlipidemia Depression

#3 Hypertension Smoking Hypertension Smoking

#4 Smoking Hyperlipidemia

Depression Hypertension

#5 Depression Hypertension Smoking Chronic back pain

Morbidity• According to the WHO (2004)

• depression is the 3rd most important cause of disease burden worldwide• 8th most important in low-income countries• 1st most important in middle- and high-income countries

• Estimated that by the year 2020• depression will be the 2nd 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

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

HEALTHY PEOPLE 2020Sample national targets

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

HealthyPeople.gov

NATIONAL DATA A bird’s eye view

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%

1 in 10 Americans over age 12 takes an antidepressant

Suicide rates by race/ethnicity

Suicide Rates Rise Sharply in U.S.By Tara Parker-PopesPublished: 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.

WISCONSIN DATA

Depression is even more prevalent in Wisconsin

• 8.4% of Wisconsin adults experienced major depression in 2009

• 15th highest rate of depression in the US

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.

Suicide trends in WI

DANE COUNTY

Suicide in Dane County

Healthydane.org

Healthydane.org

Gender Race/Ethnicity

NORTHEAST DATA

Patients with a depression diagnosis

N %Lower 95%

CIUpper 95%

CI

Belleville 856 14.9 14.0 15.8

Northeast 2036 21.5 20.7 22.3

Verona 2136 16.3 15.7 17.0

Wingra 1393 21.0 20.0 21.9

Depression is significantly more prevalent at Wingra and Northeast.

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

Northeast patientsN %

Lower 95% CI

Upper 95% CI

Gender Female 1407 26.7 25.5 27.9

Male 629 14.9 13.9 16.0

Age 12-17 years 42 7.0 4.9 9.0

18-34 years 554 22.5 20.8 24.1

35-64 years 1208 28.8 27.4 30.1

>65 years 231 28.6 23.6 29.5

Race/Ethnicity

White 1517 24.5 23.4 25.6

Black 270 17.5 15.6 19.4

Hispanic 67 15.0 11.7 18.4

Asian 72 12.0 9.4 14.6

Native Am 10 25.6 11.3 40.0

Other 100 15.4 12.6 18.1

Northeast patients

N %Lower 95%

CIUpper 95%

CI

Language

English 1972 21.8 21.0 22.7

Spanish 11 14.3 6.3 22.3

Hmong 21 10.4 6.2 14.6

Payor

Commercial 1107 19.6 18.6 20.7

Medicare 65+

185 26.0 22.8 29.2

Medicare <65

206 45.9 41.3 50.5

Medicaid 367 19.6 17.8 21.3

Uninsured 171 21.4 18.6 24.3

Utilization of health care services#

depressed patients

Avg office visits*

Avg urgent care visits*

Avg ER visits*

Avg inpatient

LOS*

Belleville 856 17.3 0.31 0.93 1.3

Northeast 2036 20.6 1 1.71 1.76

Verona 2136 17.1 0.9 1.18 1.31

Wingra 1393 22.8 0.86 2.24 2.23

* Last 3 years

# clinic patients

Avg office visits*

Avg urgent care visits*

Avg ER visits*

Avg inpatient

LOS*

All NortheastPatients

9470 12.6 0.75 0.86 0.98

Comorbidities

0 100 200 300 400 500 600 7000

10

20

30

40

50

60

30

30.9

42.9

39.2

49.7

34.2 33.335.7

41

34.8

44.2

35.1

Osteoporosis

29.7

53.852.4

# of patients with depression

% o

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ts w

ho

ha

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co

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de

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PHQ 9 data for the DFM

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

DISPARITIES DATA

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

ROOT CAUSESIncluding some social determinants

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)

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

POPULATION-LEVEL INTERVENTIONSdepression

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*

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