Managing Depression Effectively: What we think we know may not be true The many ways care can be organized, can be inadequate, and many things we know about depression and its treatment that may not be true

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Managing Depression EffectivelyWhat we think we
know may not be trueThe many ways care can be
organized, can be inadequate, and many things we
know about depression and its treatment that may
not be true

• Paul Block, PhD
• Director, Psychological Centers
• Paul.Block_at_PsychologicalCenters.com

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Software Screen
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Todays Speaker
Paul Block, PhD Director, Psychological
Centers Paul.Block_at_PsychologicalCenters.com
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Why depression?

• Depression is associated with more severe (and
  costly) medical problems, less effective medical
  treatment, higher health care costs
• Disability (2 impact on DALYs)
• Treating depression in patients with historically
  high medical expenditures reduced medical cost
  from 13.28 to 6.75 per day
• Depression impedes long-term rehabilitation and
  recovery, and increases length of hospital stay
  and re-hospitalization by as much as a factor of
  three
• Disability-adjusted life years

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Why depression?

• Association of depression/anxiety
• with the top chronic diseases
• (diabetes, heart disease, cancer, etc.)
• Disease-related biological causes of depressive
  symptoms, esp. CNS and endocrine disorders
• Behavioral causes of depressive symptoms, inc.
  adjusting to illness, limits of rewarding
  activities, interference with roles
• Diagnostic difficulty
• Overlapping symptoms lead to over-diagnosis
• Under-diagnosis is far more common

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Why depression?

• Results of comorbid depression
• Reduced quality of life
• 2x restriction of activities and lost work days
• 50-100 higher health care spending
• Increased morbidity (worse medical outcomes)
• Increased mortality

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Costs of mental illness

• Work performance is affected by
• decreased productivity (presenteeism)
• increased absenteeism
• increased industrial accidents
• higher rates of termination and turnover
• increased rates of disability and worker
  compensation claims

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Costs of mental illness

• 15 of total corporate profits nationally
• (671 billion per year) are lost to behavioral
  problems
• based on American Psychological Association
  reports of costs to employers due to depression,
  anxiety disorders, substance abuse, and stress,
  compared to Presidents annual report of total
  U.S. economic activity

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Costs of mental illness

• Social effects of mental illness or substance
  abuse include
• increased likelihood of relying on welfare
• increased criminal activity
• increased violence
• homelessness
• family disruption and
• breakup

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Ways to organize care in medical settings

• Models of management of depression in primary
  care, where most depression is found and treated
  
• (with descriptions of each)
• Referral to specialty care
• Case/care management
• Primary Care Behavioral Health
• Co-location
• Integration

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Ways for care to be inadequateGeneral

• Primary Care Behavioral Health
• missed referrals
• Screening, but self-report?
• missed diagnoses
• (e.g., 20 MDE BPD)
• which services are typically accessed
• (meds, not therapy)
• incomplete care

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Ways for care to be inadequateMedication

• Medication management
• Wrong patient
• Wrong problem
• Wrong medicine
• Too little
• Too short
• Not enough
• follow up
• Not combined with other interventions

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Ways for care to be inadequateBehavioral health

• Primary Care Behavioral Health and
• patient preference (vs. providers skill)
• Do patients prefer if health behavior focus is
  built in to all care as opposed to identified as
  an individual need (stigma)?
• Do patients seen by a behavioral clinician to
  work on health behavior prefer to see the same
  clinician for mental health treatment?
• (hub and spoke model)

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Ways for care to be inadequateIdentification

• Importance of screening vs.
• referral only
• Typical PHQ2, maybe PHQ9, BAI3, rarely complete
  screening or screening of all patients
• Is full behavioral/mhsa screening impractical?
• PC development of 1 page screener
• How to manage identified concerns
• (PCP time)
• Truly accessible resources

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Ways for care to be inadequateTargets

• Focus on depression only
• Anxiety disorders more common than depression
• Substance abuse (SBIRT)
• Health behaviors
• Estimate that 50 of deaths are preventable,
  related to health behavior
• Obesity responsible for 10 of
• health costs, increasing to 20
• Smoking

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Ways for care to be inadequatePopulation

• Specific details of safety net populations and
  providers, inc. access to adequate care
• Low income populations and people from ethnic
  minority groups that are over-represented in
  Medicaid have
• significantly higher behavioral health needs
• more often ineffectively-addressed
• dramatically increased healthcare costs
• Good news until 2014, only population fairly
  sure to be covered

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Ways for care to be inadequate

• Specific details of safety net populations and
  providers, inc. access to adequate care
• Increasing use of behavioral health services by
  Medicaid patients alone dramatically reduced
  costs in the population-based "Hawaii Project"
  including
• 38 lower costs for patients without chronic
  illnesses
• 18 for patients with chronic illnesses
• 15 for substance abusers
• among high users of medical services, significant
  total cost reductions through use of even brief
  psychological interventions

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Things we know about depression(that arent
necessarily true)Role of medication

• Combined treatment is
• better (maybe for teens)
• Severe depression responds
• better to medications than
• to therapy
• Its better not to use meds
• Patient preference is primary
• (vs. professional recommendations)

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Newer medications are better than older
medications

• Antidepressants may cause mild and often
  temporary side effects in some people, but they
  are usually not longterm.
• Newer antidepressants have fewer side effects.
• For all classes of antidepressants, patients must
  take regular doses for at least three to four
  weeks before they are likely to experience a full
  therapeutic effect.

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Medication details

• The most popular types of antidepressant
  medications are selective serotonin reuptake
  inhibitors (SSRIs)
• SSRIs include
• fluoxetine (Prozac),
• paroxetine (Paxil)
• citalopram (Celexa),
• sertraline (Zoloft)
• escitalopram (Lexapro-
• ? esp. effective in agitated or bipolar
  depression)
• fluvoxamine (Luvox)
• Common side effects
• Headacheusually temporary and will subside.
• Nauseatemporary and usually shortlived.
• Insomnia and nervousness (often subside over time
  or if dose is reduced).
• Agitation (feeling jittery or restless).
• Sexual problemsmen and women, including reduced
  sex drive, erectile dysfunction, delayed
  ejaculation, or inability to have an orgasm.

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Medication details

• Serotonin and norepinephrine reuptake inhibitors
  (SNRIs) include
• venlafaxine (Effexor)
• duloxetine (Cymbalta)
• desvenlafaxine (Pristiq)
• Common side effects similar to SSRIs
• In high doses, sweating and dizziness
• Norepinephrine and dopamine reuptake inhibitor
• Bupropion (Wellbutrin)
• No sexual side effects (at high doses can
  increase seizure risk)

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Medication details

• Older classes of antidepressants, such as
  tricyclics and monoamine oxidase inhibitors
  (MAOIs)
• MAOIs
• Food and medicinal restrictions (tyramine, found
  in many cheeses, wines and pickles, and some
  medications including decongestants)
• Tricyclic antidepressants (e.g., Amitriptyline,
  Doxepin, Imipramine, Desipramine, Nortriptyline)
  significant side effects include
• Dry mouth
• Constipation
• Bladder problems emptying the bladder may be
  difficult, and urine stream may not be as strong
  as usual
• Sexual problemsside effects are similar to those
  from SSRIs.
• Blurred vision.
• Drowsiness during the day.
• Low blood pressure (especially on standing
  quickly)

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Medication details

• Augmentation strategies
• FDA Warning on Antidepressants
• 4 of adolescents and young adults taking
  antidepressants thought about or attempted
  suicide (no suicides occurred), compared to 2 of
  those receiving placebos.
• Prompted the 2005 FDA "black box" warning label,
  extended in 2007 to include young adults up
  through age 24
• Emphasizes that patients of all ages taking
  antidepressants should be closely monitored,
  especially during initial weeks of treatment.
• Benefits of antidepressant medications
  outweigh their risks to children and
  adolescents with major depression and anxiety
  disorders (even in terms of suicide risk).

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Things we know about depression (that arent
necessarily true) Psychotherapy

• Cognitive Behavioral Therapy (CBT) and
  Interpersonal Therapy (IPT) are the best
  behavioral treatments
• Is CBT gt IPT?
• BT, BMT, SCT, MT, ACT, others
• (even psychodynamic treatments)
• Main issue to consider may be
• relapse, more than recovery

Gerald Klerman and Myrna Weissman
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Things we know about depression(that arent
necessarily true)Modifying the team

• Case management is optimal
• (e.g., Diamond, IMPACT, PRISM-E)
• but vs. alternatives, inc. on-site integration?
• Acceptance of referrals (43, 49-52 with case
  management, 71-80 on-site)

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Things we know about depression(that arent
necessarily true)Relapse

• Depression is a relapsing disorder
• (14.3 who receive EBT given the very loose
  definition, even lower who receive relapse
  prevention)
• EBT requires 14 sessions, not 1-3, 6, 8, or 12
• Formulation
• Treatment to full remission to reduce
• risk of relapse

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Things we know about depression(that arent
necessarily true)Comorbidity

• Comorbidity predicts lower recovery
• Substance abuse
• Trauma
• Personality disorder
• Undiagnosed comorbidity
• misdiagnosis
• Combined treatments

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Things we know about depression(that arent
necessarily true)Role of primary care

• Primary care manages most depressions
• 50 are identified
• 30 of those identified receive
• guideline-based care
• 90 receive meds
• only
• Specialty care is
• much better
• receiving EBT

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Things we know about depression(that arent
necessarily true)PCP expertise

• PCPs cant manage medications
• MCPAP
• CHC experiences
• Therapist diagnosis
• and consultation

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What would adequate care look like?

• Individualized
• Whole-person
• Integrated
• Actually provided
• Flexible
• Complete
• Relapse Prevention

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Recommendations

• Screening
• Evaluation
• Collaboration
• Design of treatment
• Management of care
• LPHC full integration

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LPHC
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Questions / Discussion
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