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University of Pittsburgh
Management of Depression in Primary Care
Ellen M Whyte, MDMedical Director, Psychiatric Services
UPMC Benedum Geriatric CenterMedical Director
Integrated Behavioral Health – Primary Care
DISCLOSURES
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Grant Support in last 12 months:Geriatric Workforce Enhancement Program (HRSA) U1Q HP028736 (PI: Schulz)
Off-label use of medication will be discussed.
LEARNING OBJECTIVES
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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.
PCP AS BEHAVIORAL HEALTH PROVIDERS
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Most behavioral health care in the US is delivered by the primary care provider.
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 provider9% Human Services Only3% Complementary/Alternative Medicine
Wang et al 2006
^ Patients followed by PCP: typically older, female, lower SES, rural
MAJOR DEPRESSIVE EPISODEMust endorseSadness/depressed mood and/or Loss of pleasure/anhedonia
For at least 5 total symptoms
At least 2 weeks duration, more days than notCauses distress or functional impairment
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• Impaired sleep• Impaired appetite• Low energy• Restlessness or looking ‘slowed
down’
• Poor concentration • Feelings of
worthlessness or guilt• Thoughts of death or
suicidal thoughts
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BENEFITS OF TREATMENT
Improved quality of life Reduced risk Mitigated disability Improved medical outcomes Decreased health care utilization
MAJOR DEPRESSIVE EPISODE
Cardinal Episode in…Major Depressive DisorderPersistent Depressive Disorder (Dysthymia + Double Depression)Bipolar Disorder – Type I and Type 2Schizoaffective Disorder
Commonly Co-Morbid with…Personality DisordersSchizophrenia and Other Psychotic DisordersSubstance AbuseDementia (Neurocognitive Disorders)TBI, CVA, Parkinson’s Dz, other neurological disorders
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MAJOR DEPRESSIVE EPISODE
Cardinal Episode in…**Major Depressive DisorderMajor Depressive Disorder with elevated suicide riskPersistent Depressive Disorder (Dysthymia + Double Depression)Bipolar Disorder – Type I and Type 2Schizoaffective Disorder
Commonly Co-Morbid with…Personality DisordersSchizophrenia and Other Psychotic DisordersSubstance Abuse**Dementia (Neurocognitive Disorders)**TBI, CVA, Parkinson’s Dz, other neurological disorders
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Maximizing Acute Treatment Outcomes for Depression
Management in Primary Care
IMPACTPROSPECT
-------STAR*D
Texas Medication Algorithm Project
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PHASES OF DEPRESSION TREATMENT
Kupfer DJ. J Clin Psychiatry 1991.
Maximizing Acute Treatment Outcomes for Depression
Management in Primary Care
Measurement Based Care
Stepped Care
Collaborative Care11
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PHQ-9
**
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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
PHQ-9 scores > 10 have a sensitivity of 88% and a specificity of 88% for Major Depressive Episode.
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]”
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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.
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STEPPED CAREGeneral 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.
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STEPPED CAREGeneral 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
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STEPPED CAREGeneral Rule: After 6-8 weeks…assess response and adjust treatment plan.
IMPLICATION: Response based on
Change in PHQ-9 scores
Patient’s subjective report
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STEPPED CAREFull Response = PHQ-9 demonstrates nearly 100% resolution or symptoms and patient reports ‘back to normal’.
RECOMMENDATIONS:
Pt exits ACUTE treatment
Pt enters CONTINUATION treatment
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STEPPED CARENon-Response = PHQ-9 ↓ by < 30% and/or patient is reporting little to no change
RECOMMENDATIONS:
Switch antidepressants
Examples: SSRI SSRI (Limit to 2 SSRI trials)
SSRI SNRI
SSRI or SNRI Mirtazapine (Remeron)
SSRI or SNRI Bupropion (Wellbutrin)
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STEPPED CAREPartial Response = PHQ-9 ↓ by > 30% and/or patient is reporting improvement
RECOMMENDATIONS: Watchful waiting for patients reporting near complete
resolution of symptoms. Dose increase (if possible) to maximum dose
(e.g., sertraline 50mg 200mg/d; mirtazapine 30mg 45mg)
Augmentation with a 2nd medication with different mechanism of action
Examples: SSRI/SNRI + bupropion SSRI/SNRI + mirtazapine SSRI/SNRI + atypical antipsychoticSSRI/SNRI + lithium
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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.
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ACUTE TREATMENT- BASELINEPatient with elevated PHQ-9 score (including mood/anhedonia)
Assess suicide risk thoughts that life is not worth livingdesire 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
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ACUTE TREATMENT- BASELINEClarify diagnosis
Screen for maniaScreen for substance abuseScreen for psychosis (“what has been worrying you recently”)
Review prior depression tx and family hx of tx informs medication choices
Assess for medical contributions to depressionThyroid function Sleep apnea HypercalcemiaVit B12/ Vit D Pancreatic CA
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SCREEN FOR HISTORY OF MANIAAll 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’)
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ACUTE TREATMENT
Pharmacotherapy + Adjunct Meds
Psycho-Education
Support/Encouragement
Psychotherapy
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PHARMACOTHERAPY-GENERAL PRINCIPLES
All antidepressants are equally effectiveCannot predict which medication will work for a particular patient
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
Especially venlafaxine, paroxetine
Age alone does not dictate medication dosing
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ANTIDEPRESSANTS
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SSRI*Prozac (fluoxetine)Luvox (fluvoxetine)Paxil (paroxetine)*Zoloft (sertraline)Celexa (citalopram) Lexapro (escitalpram)Viibryd+ (vilazodone)Brintellix++ (vortioxetine)
SNRIEffexor (venlafaxine)Pristiq (desvenlafaxine)*Cymbalta (duloxetine)Fetzima (levomilnacipran)
ATYPICAL*Remeron (mirtazapine)Wellbutrin (buprorion)
+ 5HT1A partial agonist; ++5HT3antagonist & 5HT1A agonist
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
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ANTIDEPRESSANTS
SSRI: Fluoxetine, paroxetine, fluvoxamine-avoid in elderly d/t CYP inhibitionCitalopram - monitor QTc above 20mg/dSertraline - 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
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Psycho-EducationKey points• People can and do get better: Treatment works!• Medication compliance is important; slow onset of benefit• Side effects occur early & are usually transient; can be
managed• Three stages of treatment (Acute + Continuation +/- Maintenance)
• Role of psychotherapy• Importance of behavioral activation (little steps)• Importance of good sleep hygiene
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PSYCHOTHERAPY
Appropriate as treatment, without medications, for mild depression and as an adjunct to medication in moderate to severe cases.
Structured, brief psychotherapies are preferred and more likely to be reimbursed by insurance companies.
Likely needs to be de-mystified for patients. Safe place to tell your storySafe place to consider your optionsLearn skills to manage depression/anxiety
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BRIEF STRUCTURED PSYCHOTHERAPIESCognitive Therapy (CBT): Identify and correct core beliefs that lead to and/or reinforce depression; alter behaviors that lead to and/or reinforce depression.
Problem Solving Therapy (PST): Reduce learned helplessness by teaching an explicit process of solving problems. Includes 6 problem solving steps plus behavioral activation.
Interpersonal Therapy (IPT): Focus on 1 of 4 areas associated with depression -- grief, role transitions, role disputes, interpersonal deficits that lead to isolation.
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DEPRESSION MANAGEMENT
Recommendations are for contact at a minimum at2, 4, 6, 9, 12 weeks during acute treatment.
• monitor side effects• monitor/encourage compliance• monitor response• re-assess suicide risk
Goal is complete resolution of symptoms residual symptoms predict recurrence of depressive
episode36
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PHASES OF TREATMENT
Kupfer DJ. J Clin Psychiatry 1991.
PHASES OF DEPRESSION TREATMENT
Acute Phase: From onset of treatment to resolution of ALL symptoms. [If medically ill, resolution of depressed mood, anhedonia, low self esteem, passive death wish/suicidal thoughts.]
Continuation Phase: patients advised to remain on medications for 6-9 months AFTER resolution of ALL symptoms; followed by slow taper and discontinuation.
Maintenance Phase: Prevention of recurrence after 6-9+ months symptom free.
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PROGNOSISMajor depression is a recurrent illness but full inter-episode remission is the norm.
~ 60% of patients who have one episode of majordepression will have a 2nd episode.
~ 90% of patients who have 3 episodes of majordepression will have a 4th episode.
~ 2/3 of patients have full recovery between episodes.
~ 1/3 of patients have partial recovery between episodes and are at high risk for recurrence.
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If first lifetime episode, uncomplicated… taper & discontinue antidepressant after completion
of continuation phase (at least 6 months of ‘wellness’).
If 3rd or more lifetime episode [or at least one episode with significant suicidality and/or functional impairment]… indefinite continuation of ‘full dose’ antidepressant
regime.
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MAINTENANCE TREATMENT - ADULTS
APA Practice Guidelines for Depression2000
Maximizing Outcomes in Depression ACUTE TREATMENT
Measurement Based Care
Stepped (time sensitive) Care
Collaborative Care
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Collaborative Care Model
Collaborative Care Management of Late-Life Depression in Primary Care Setting
Patients: N = 1,801; 60 + years oldInclusion Criteria:
MDE (17%), Dysthymia (30%) or both
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IMPACT STUDY
Unutzer et al 2002
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IMPACT Results
Unutzer et al 2002
IMPACTN=906
Usual CareN=895
Any Antidepressant Use 73% 57.2%Any Psychotherapy or specialty BH visit 42.7%1 15.6%
Any Antidepressant or Psychotherapy 82.3% 61%
Response 44.7% 19.2%Remission 25% 8.3%All differences statistically significant1 30% received PST-PC; 11% met with study psychiatrist
Prevention of Suicide in Primary Care Elderly: Collaborative Trial
Patients: N = 578; 60 + years oldInclusion Criteria:
CES-D > 20CES-D < 20 (5% random sample)CES-D < 20 + prior hx of depression
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PROSPECT STUDY
Bruce et al 2004
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PROSPECT ResultsProspect
N=320Usual Care
N=278
Any Antidepressant Use 66.3%^ 44.2%Psychotherapy Only 15%^ 1.3%Any Antidepressant and Psychotherapy 6.8% 13.6%
Response @ 4-8-12 mo 43%^-46%^-52% 29%-36%-42%
Remission @ 4-8-12 mo 48%^-50%-55% 34%-44%-53%
Bruce et al 2004
^differences statistically significant
UPMC Behavioral Health CareUPMC Western Psychiatric Hospital
Supports for Primary Care Providers
INTEGRATED BEHAVIORAL HEALTH SERVICE
OPTIMUM STUDY
TELEPHONIC PSYCHIATRIC CONSULTATION
GREAT-MH EVALUATION-REFERRAL PROGRAM
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Collaborative Care-lite Model, started March 2015
Goal: Improve Behavioral Health access for patients w/o current BH providers by partnering with PCPs
Short –Term Model of Care: 6-10 months
Ages 18+
All diagnoses are eligible, including depression, anxiety, stress-management, etc.
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INTEGRATED BEHAVIORAL HEALTH SERVICE
INTEGRATED BEHAVIORAL HEALTH SERVICE
Phone/email if unsure evaluation is indicated
Enter EPIC Order
Evaluation with Behavioral Health Specialist (LCSW)
Brief therapy with Behavioral Health Specialist
Short-term treatment completed
Back to PCP
PCP identifies need
Psychiatric Input Phone In person
Refer to specialty or community
services
Integrated Providers INTEGRATED BEHAVIORAL HEALTH SERVICE
Location Therapists Psychiatrist
CMI Hampton L. Bonavita & A. ZajacsUmang Shah, MD
(Em Ketterer MD for RFP patients)
CMI Absolute Justin Miller
CMI Steel City Sarah Johnson
RFP Aspinwall -----
Emily Ketterer, MD
RFP Millvale Rebecca Weiss
RFP Penn Hills Kirsten Yaggi
CMI VFM Natrona Ben Fisher
Partners-in-Health Rachel Porterfield
CMI White Oak Ingrid Edwards
Ellen Whyte, MD
CMI Bethel Park Kathleen Dzura
Solano Ayesha Crawford
Health Center Assoc (Oakland) Ben Fisher
CMI Monroeville x Danielle Thorpe
CMI Squirrel Hill x Connie Crain
BH Specialist Experience (Jan-June 2019)4,516 patient visits
30% visits were for new patients
48% of new patients do not return: Referral for specialized treatment Conflict with work hours/transportation Patient choice Only wanted medication recommendations
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INTEGRATED BEHAVIORAL HEALTH SERVICE
When older patients don’t respond to two antidepressant trials, what should be the next step in treatment?Collaborative care approach:Patients stay with their primary care provider.Research assessors measure outcomes and reports to PCPs.Geriatric psychiatrists provide recommendations to the PCP based on a
standard algorithm (bupropion, venlafaxine, aripiprazole, lithium, nortriptyline)Patients can do the entire study by phone.
OPTIMUM StudyOptimizing Depression Tx in Older Adults
Collaborative Care Model
OPTIMUM StudyOptimizing Depression Tx in Older Adults
• Principle Investigator Jordan Karp MD• Inclusion
– Age > 60– Major Depression– Failed > 2 trials of antidepressant meds
• Exclusion– Dementia– Parkinson’s Disease
If patient is interested in hearing more about the study, email study group through EPIC In Basket at P_TRD.
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Geriatric Psychiatric Evaluation & Referral Program
Pilot Project, funded through University of Pittsburgh Department of PsychiatryEligible Patients
Aged 60+Any Mental Health or Cognitive ConcernConsult letter to PCPReferral to research studies or clinical services
Marie Anne Gebara MD, leadLocations: UPMC Primary Care – White Oak & HamptonScheduling: 412 523-3261
SELECTED REFERENCESPHQ-9Kroenke K, Spitzer RL, Williams JB: The PHQ-9 Validity of a Brief Depression Severity Measure. J Gen Intern Med. 2001 Sep; 16(9): 606–613.
MDQHirschfield RMA, et al: Development and validation of a screening instrument for bipolar spectrum disorder: The Mood Disorder Questionnaire. American Journal of Psychiatry, 2000, 157: 1873-1875
Hirschfield RMA. The Mood Disorder Questionnaire: A simple, paitent-rated screening instrument for Bipolar Disorder. Journal of Clinical Psychiatry Primary Care Companion 2002, 4:9-11
Hirschfield RMA, et al: Screening for Bipolar Disorder in patients treatment for depression in a family medicine clinic. JABFP 2005, 18:233-239
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SELECTED REFERENCES
COLLABORATIVE, MEASUREMENT BASED, STEPPED CAREBruce et al. Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: a randomized controlled trial. JAMA.2004 Mar 3;291(9):1081-91 [PROSPECT]
Unutzer et al. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA.2002;288(22):2836-45. [IMPACT]
Trivedi MH, Rush AJ, Crismon ML, et al. Clinical results for patients with major depressive disorder in the Texas Medication Algorithm Project. Arch Gen Psychiatry. 2004;61:669-680. [TEXAS]
Trivedi MH, Rush AJ, Wisniewski SR, et al. Evaluation of outcomes with citalopram for depression using measurement-based care in STAR*D: implications for clinical practice. Am J Psychiatry. 2006;163:28-40. [STAR*D]
American Psychiatric Association Practice Guideline for the Treatment of Patients With Major Depressive Disorder, Third Edition, originally published in October 2010.
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THANK YOU!
Questions?
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