Disclosures Management of Depression and Anxiety in I have nothing - PowerPoint PPT Presentation

3/12/2016 Disclosures Management of Depression and Anxiety in I have nothing to disclose the Primary Care Setting: Models of Integration and Treatment Approaches Melissa L. Nau, MD Assistant Clinical Professor, UCSF Objectives Case Examples Review the Collaborative Care model of integration Patient with multiple medical problems (HTN, CAD, � � DM2) who presents c/o depressive sx. Describe best practices for management of � depression in a primary care setting Describe best practices for management of anxiety Ptnt does not adhere to your treatment � � in a primary care setting recommendations despite saying he or she will. Review when to consult a psychiatrist or behavioral � health specialist Ptnt has a history of and current sx of anxiety. On � standing benzo x 2 years. Ptnt c/o new onset anxiety, wants treatment. � Patient has failed 2 antidepressant trials and is not � improving. 1

3/12/2016 Why treat depression in Burden of Mental Illness primary care? 10-15% pts in a Primary Care setting suffer from a � 1 in 4 Americans struggle with a mental health or � depressive disorder 1 substance use problem at some point in their lives. No 50% of depressed pts present with somatic family goes untouched. 1 � complaints rather than typical depressive symptoms 2 Behavioral health disorders cause nearly 25 % of all � � Insomnia, fatigue, HA, weight change disability worldwide. 1 � Anxiety, irritability, apathy Higher risk with comorbidities, worse prognosis 3 Depression alone accounts for 10% of health related � � disability. 1 Depression is treatable; untreated can � death � � Years Lost to Disability (YLD) from depression = � 3x diabetes; 8x heart disease; 40x cancer 1. Rait et al, Recent trends in the incidence of recorded depression in primary care. BJP 2009 2. Maske et al , Prevalence and correlates of DSM-IV-TR major depressive disorder, self-reported diagnosed depression and current depressive symptoms among adults in Germany, J Affect Disord. 2016 3. Van der Kooy et al. Depression and the risk for cardiovascular diseases: systematic review and meta 1. Murray C et al, Global Burden of Disease, Lancet, 2012 analysis. Int Geriatr Psychiatry. 2007 Depression and Medical Question Illness Cardiovascular disease � � Increased risk of CAD 1 � 4x mortality after MI, 3x more common post MI 2 � Depression before CABG doubles risk of death 3 Diabetes � � 2x higher odds of depression 4 � Earlier life depression doubles risk of DM 4 � Symptom severity � poorer diet, medication compliance, self-care; functional impairment 1. Wulsin et al, Do depressive symptoms increase the risk for the onset of CAD? A systematic quantitative review Psychosomatic medicine 2003 2. Lichtman et al, Depression and CHD recommendations for screening , referral, and treatment, Circulation, 2008 3. Blumenthal et al, Effects of treating depression…on clinical events after MI, JAMA, 2003 4. Lin et al, Relationship of depression and diabetes self-care, medication adherence, and • From Druss & Walker (2011) Mental Disorders and Medical Comorbidity preventive care, Diabetes care, 2004 • Based on the 2001–2003 National Comorbidity Survey Replication (NCS�R) 2

3/12/2016 Quality of Care Collaborative Care Model ~30 million people receive a prescription for a Primary Care Practice – Patient Centered Team � � psychiatric medication in primary care each year Care QUICK FACT: but only 25% improve 1 Only 30�50% of patients � Primary Care Physician have a full response to the � Patient first treatment plan. That means 50�70% of patients + Patients with serious mental illness die 20 years � need at least one change in earlier. Most have poor medical care. 1 treatment. � Behavioral Health Professional � Psychiatric Consultant Services are poorly coordinated 1 Outcome measures, Treatment Protocols, Evidence � � Based Population registry, psychiatric consultation � http://impact-uw.org 1. Unützer J, et al IMPACT Investigators. Improving Mood-Promoting Access to Collaborative Treatment Collaborative care management of late-life depression in the primary care setting: Aims.uw.edu a randomized controlled trial. JAMA. 2002 Key Points: Large Depression: Diagnosis burden/poor access Mental illness and substance use are major drivers � Familiarize yourself with DSM V criteria. � of disability & health care costs 1 Use the PHQ-2 to start… � <50% have access to effective specialty � ASK about suicidality (plan, intent, means) � mental health care 2 Consider: � Effective integration of behavioral health care can � � Dysthymia, Bereavement, Bipolar disorder , achieve: Psychosis � Better access to care � Substance use � Better health outcomes � Social situation/stressors � Lower cost � Comorbid disorders (medical and psychiatric) 1. Katon et al, Increased medical costs of a population-based sample of depressed elderly patients.Arch Gen Psychiatry. 2003 2. Grembowski et al Managed care, access to mental health specialists, and outcomes among primary care patients Get collateral, involve family if pt willing with depressive symptoms. J Gen Intern Med. 2002 � 3

3/12/2016 Principles Common presentations � Consider both: Multiple (more than five per year) medical visits � Multiple unexplained symptoms � Work or relationship dysfunction � � FUNCTIONAL IMPAIRMENT Dampened affect, weight changes, sleep disturbance, fatigue � Memory/other cognitive complaints: difficulty concentrating or � DURATION of episode � making decisions Irritable bowel syndrome � Poor behavioral follow-through w ADLs or tx recs � � Consider how other factors may be contributing NOTE: Medical issues should still be specifically addressed, � especially when new symptoms are reported. � Cultural competency! Medications that may lead Medical Conditions That Don’t forget to rule out… to Depressive Symptoms May lead to Depressive symptoms Baclofen Interferon Chronic Pain Biological causes � Barbiturates Levodopa � Chronic fatigue Benzodiazepines Methyldopa Dementia (e.g. neurodegenerative disorders � Thyroid function Cimetidine Metoclopramide � IBS � Obesity Ranitidine Opiates Drug toxicities and withdrawal � CVA, cancer, dementia � Delirium Clonidine Oral Endocrine disorders (e.g. thyroid) Contraceptives � Parkinson’s � Connective tissue diseases Cycloserine Propranolol Metabolic Disorders (e.g. anemia, malnutrition, electrolyte disturbance) Other � Digoxin Reserpine � Chronic pain Gonadotropin- Steroids Neoplasms � Substance Use releasing agonists Verapamil May exist as a co-morbid disease state � Shatzberg, Cole and DeBattista. Manual of Clinical Psychopharmacology, Fourth Edition. American Psychiatric Publishing, Inc.; 2015 4

3/12/2016 Low intensity Factors to consider when psychosocial choosing an interventions antidepressant Antidepressants NOT recommended as 1 st line in � recent onset, mild depression Patient preference � Nature of prior response to medication � So… what should we do? Relative efficacy and effectiveness � � � Individual guided self-help based on CBT principles Safety, tolerability, and anticipated side effects � � Computerized CBT (CCBT) Co-occurring psychiatric or general medical � � Structured group physical activity program conditions � Does ptnt need support from a trained practitioner? Potential drug interactions � � Monitor Half-life � Cost � RESILIENCE and HOPE � Adopted from APA practice guidelines 2010. Drug treatment of True or False? depression Discuss choice of drug w/ patient Antidepressants do not exert their effects for 2-4 Start antidepressant weeks No effect Effective Poorly tolerated 1. True Assess weekly Continue for 6�9 Switch to a for a further 1�2 months at full different 2. False weeks treatment dose antidepressant Poorly tolerated No effect Effective �or� No effect Switch to a different antidepressant Consult! Adapted from the Maudsley Prescribing Guidelines in Psychiatry, 2015 5