Disclosures Medical Care of Vulnerable and Underserved Populations: - PowerPoint PPT Presentation

3/12/2016 Disclosures Medical Care of Vulnerable and Underserved Populations: Advanced Cases in Anxiety and The speakers have no disclosures. Depression Lisa Ochoa-Frongia, MD Christina Mangurian, MD, MAS L. Elizabeth Goldman, MD, MCR Margo Pumar, MD Overview of Workshop Objectives � Objectives � Understand challenges in diagnosing and treating anxiety and depression in � Review challenges in underserved underserved and vulnerable populations populations � Review best practices � Split into small groups to discuss cases � Learn how to differentiate between � Groups come together to review cases different anxiety disorders � Audience questions � Review management of treatment � Conclusions refractory depression 1

3/12/2016 What best describes your Challenges in Underserved and Vulnerable Populations training? Medical Resident A. Homelessness Health disparities complexity Nurse B. 62% Poverty Immigrants Contributors to Practitioner Food insecurity Unemploymen anxiety, Physician’s C. t Assistant Language Trauma depression 29% barriers history D. General Internist or Family Violence/crime Uninsured 3% 3% 3% Practitioner 0% Psychiatrist Resident Physician’s Assistant Psychiatrist E. Nurse Practitioner General Internist or Fam... Allied Health Professional Allied Health F. Professional Standard treatment PLUS services Case 1: Mr. M Case 1: Mr. M � ID/CC: 32 year-old Spanish-speaking man � Medications: Started paroxetine 20 mg two presenting to primary care with anxiety. weeks ago, but does not want to continue since making him sleepy during day, not � HPI: Patient reports significant anxiety. At helping anxiety. times so distressed by his symptoms that he thinks he might be better off dead. Numerous � Family history: father w/ anxiety, depression. recent visits to the ER for chest pain, anxiety, No history of suicide attempts in family. negative cardiac workup. Recent heavy alcohol � Social history: Moved from Mexico 2 years ago, use and some recreational cocaine use in past. lives with father. Works in construction. � PMH: GERD 2

3/12/2016 Case 1: Questions Case 1: Questions � What is your behavioral differential � After being given additional information diagnosis for Mr. M’s anxiety? by your facilitator, what are your treatment recommendations for Mr. M? � What instruments, testing, or additional questions could help you clarify his � How would your treatment differ if he diagnosis? had a history of trauma? Are you concerned about suicide risk? � How do you assess this? Anti�depressants and Suicide Risk Assessment Sedation � Different patients have different responses � Patients who died by suicide were over twice as likely to have PCP visit in month preceding � Paroxetine generally most sedating SSRI death compared to psychiatrist (45% vs 20%) � Mirtazapine, Trazodone also very sedating, often used for insomnia � SAFE-T: Suicide Assessment Five-step � Citalopram, escitalopram less sedating/neutral Evaluation and Triage � Fluoxetine more activating � SNRIs (venlafaxine), bupropion more activating 3

3/12/2016 Suicide Risk Assessment: Case 1 Teaching Points SAFE�T � Prior to initiating SSRI/SNRI, screen for symptoms/episodes of mania, trauma history � Consider sedating vs. activating SSRI/SNRI � Assess suicide risk in patients with SI � SSRIS for anxiety: “start low and go slow” � Adjunctive medications to “bridge” patient to SSRI effect: propranolol, hydroxyzine, BZDs Case 1 Teaching Points Case 2: Mrs. D Continued � Titrate to maximum SSRI dose as � ID/CC: 70 year-old woman with depression, tolerated/until symptoms remit MMP. Mrs. D’s depression worsening, very low motivation. Has gained 9 pounds since last visit and back pain worsening. PHQ-9 score is � Track patient symptoms with a validated tool 20. Stopped seeing therapist. � Switch to a different SSRI if no response to � PMH: CAD, DM-2, HTN, obesity and chronic low first at maximal dose by 6-8 weeks back pain w/sciatica. � Treat minimum 6-8 months after sx remit � When stopping anti-depressants, taper 4

3/12/2016 Case 2: Mrs. D Case 2: Questions � What is the most likely diagnosis of Mrs. D? � Medications: sertraline 200mg, aspirin, benazepril, carvedilol, atorvastatin, metformin, Why? glipizide, gabapentin, acetaminophen � What would you do to treat her? Why? � Previously on citalopram for 3 years, stopped working, switched to escitalopram which failed, � If you decide to cross-taper her to venlafaxine, now on sertraline x 1 year. how would you do this? � Social history: widowed, lives alone, facing eviction Simplified STAR*D Algorithm Case 2 Teaching Points for Treatment of Depression � Definition of treatment-resistant depression: Step 1 Step 1 Switch to Switch to SSRI SSRI MDD not responding to at least two Mirtazapine, Mirtazapine, Switch OR Switch OR appropriate courses of antidepressants SNRI SNRI TCA OR TCA OR Cont. and Cont. and Bupropion Bupropion � Algorithm for treatment-resistant depression: Augment: Augment: Augment: Augment: STAR-D SGA (Abilify, SGA (Abilify, Buspar, Buspar, Seroquel), Seroquel), Bupropion, Bupropion, T3, Lithium, T3, Lithium, � If PCP comfortable with treating resistant CBT CBT Stimulant Stimulant depression, follow algorithm, otherwise refer • Based on STAR�D, 2008. • Each of these with an 8 week trial at an adequate/tolerated dose. • Bupropion, venlafaxine should be prescribed in sustained/extended release. 5

3/12/2016 Case 2 Teaching Points When To Refer to Continued Psychiatry � Be aware of other conditions: choose � When diagnosis is not clear medications that might “kill two birds with one stone.” � Serious mental illness � Depression or anxiety with chronic pain: TCAs, SNRIs � Depression with psychotic features � Gabapentin and pregabalin also w/anxiolytic effects � When medications indicated are beyond PCP’s � Anxiety + psychosis: quetiapine has some scope of practice (mood stabilizers, evidence for off-label use antipsychotics) � Depression or anxiety with insomnia: mirtazapine Summary: Advanced Cases Questions? in Anxiety and Depression � Importance of screening patients for anxiety, depression, using validated tools � Keep in mind evidence-based algorithms � Follow best practices in medication prescribing � Advocate for increased integration of behavioral health � Ensure providers in your clinic understand how to refer to behavioral health providers 6