DEPRESSION IN MEDICAL SETTINGS: STRATEGIES FOR INTEGRATION

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DEPRESSION IN MEDICAL SETTINGS STRATEGIES FOR
INTEGRATION

• Steven Cole, MD
• Professor of Clinical Psychiatry
• S.U.N.Y. Stony Brook Health Sciences Center
• Rural Quality Program Conference, Office of Rural
  Health Policy
• Health Resources Services Administration
• September 1, 2009

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DEPRESSION IN MEDICAL PATIENTS IS COMMON

• 20-50 of patients w/diabetes, CAD, PD, MS, CVA,
  asthma, cancer... (etc) have MD
• Prevalence varies by illness, pathophysiology,
  severity, and research methodology
• Depressed patients visit PCPs 3x more often than
  patients not depressed

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DEPRESSION IS SIGNIFICANT

• Increased morbidity and mortality in medical
  conditions
• Increased utilization
• Increased costs
• 4th leading cause of disability worldwide (2nd in
  2020)

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GLOBAL BURDEN OF DISEASE WORLD HEALTH
ORGANIZATION

• 1990
• Lower respiratory infection
• 2 Conditions arising during the perinatal
  period
• 3 Diarrheal diseases
• 4 Unipolar major depression
• 5 Ischemic heart disease
• 6 Vaccine-preventable disease

• 2020
• Ischemic heart disease
• Unipolar major depression
• Road traffic accidents
• Cerebro-vascular disease
• Chronic obstructive pulmonary disease
• Lower respiratory infections

Murray Lopez, WHO Global Burden of Disease,
1996 Michaud, JAMA, 2001
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Depressed (n35)
Nondepressed (n187)
Cox Hazard Ratio 5.74 p0.0006
Frazure-Smith, JAMA 19932701819-1825
Circulation 199591999-1005
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DEPRESSION IN CARDIAC DISEASE

• ? risk of hypertension ? CVA ? CAD
• ? death risk after MI (controlling for other
  risks)
• ? HPA activation
• ? sympatho-medullary activity
• ? platelet aggregation ? HR variability
• Musselman et al Archives Gen Psych 1998
• van Kanel et al Psychosom Med 2001

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DEPRESSION IN DIABETES

• ? non-adherence
• ? GHb
• ? retinopathy? neuropathy? nephropathy
• ? macrovascular complications (CAD, etc)
  
• Groot et al Psychosom Med 2001
• Van Tilburg et al Psychosom Med 2001

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UNDER-RECOGNITION/UNDERTREATMENT

• 30-70 of depression missed
• 50 stop medication in 3 months
• 50 of treated patients in primary care remain
  depressed after 1 year

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PATIENT HEALTHQUESTIONNAIRE (PHQ)

• 9-item, self-administered questionnaire
• Validated for diagnostic assessment
• Validated for follow-up of outcomes
• Clinically significant depression
  (CSD) PHQ 10 or
  greater

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Oxman, 2003
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SCORING THE PHQ DIAGNOSTIC ASSESSMENT

• Count numerical values of symptoms
• 0-4 not clinically depressed
• 5-9 mild depressive symptoms or...
• adjustment disorder
• dysthymic disorder
• 10-14 mild/moderate depression
• CSD (88 sens/spec for major depression)
• gt14 mod/severe depression

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USE OF THE PHQ

• Assess high-risk, red flag patients
• Chronic illness
• Unexplained physical complaints
• Patients who appear sad/ stressed
• Patients who have lost interest or pleasure in
  their lives

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MANAGEMENT GUIDELINES I Acute Phase

• Start with medication or psychotherapy
• Elicit commitment to take medication or attend
  therapy regularly (action plan)
• Arrange early (1-3 week) follow-up
• Repeat PHQ every 1-2 months
• Re-evaluate treatment every month depending on
  PHQ score (adjust meds adjust therapy)

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OUTCOME TARGETS DEFINITIONS

• Clinically significant improvement (CSI)
• 5 point decrease in PHQ score
• Response
• 50 decrease in PHQ score
• Remission
• PHQ score lt5 for three months

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SELF-MANAGEMENT SUPPORT

• Integrate SMS into routine care in all visits
• Three minute goal-setting (SMS)
• Goal 1 Are you willing to take this every day?
• What is your confidence on a 1 to 10 scale that
  you will actually take the medicine every day?
• Goal 2 To make sure the medicine is working, we
  need to see you again (or talk by phone) in a
  week or so.
• What is your confidence that you will make it
  for this visit (or phone call) that we agreed
  to?
• Chart Note
• PAP agrees to take meds regularly (cl 8)
• PAP agrees to return for visit in 2 weeks
  (cl7)

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Early Steps in Depression Care

• Activities in the Six Components of the Care
  Model
• Dan Ford, MD

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Unique Aspects of Depression

• Depression is a chronic relapsing condition (like
  asthma)
• Depressive symptoms closely linked with function
  in time
• Diagnosis and monitoring based on self-report,
  not labs or exam (telephone is ideal)

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Unique Aspects of Depression

• Depression itself may interfere with patients
  self-care planning
• Overly pessimistic about effectiveness of
  treatment
• Difficulty monitoring oneself and making decisions

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Unique Aspects of Depression

• Social stigma
• Health personnel have varying degree of comfort
  with depression
• Largest gulf between primary care providers and
  specialists in depression
• Depression care may be reimbursed/funded at lower
  level than other chronic conditions

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Where should you start?
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First Steps Depression Self Management

• Examine the patient handouts provided (e.g.
  Depression Self-Action Plan)
• Try these materials out with a sample of patients
  and determine how they might have to be adapted
  for patients with chronic medical conditions

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First Steps Decision Support

• Identify one or two local mental health
  specialists to help support your depression
  treatment program (medications and psychotherapy)
• Let cluster directors know if not successful
• Develop a suicide protocol
• Train staff in suicide assessment
• Establish referral protocols

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First Steps Clinical Information Systems

• Learn how to enter PHQ scores in registry
• Learn how to interpret longitudinal PHQ scores
  for patients
• Maximize efficiency in data entry

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First Steps Delivery System Design

• Identify one person on team to be the champion
  for depression care
• Integrate depression education into other programs

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First Steps Organization of Health Care

• Identify what resources will be needed for the
  depression care program
• Identify and address any objections from senior
  leaders and staff members to expanding care to
  depression
• Common barriers include 1) our patients do not
  want to address depression 2) somatic care is
  more important 3) we do not have the right
  staff 4) our patients need help with social and
  economic issues, not depression

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First Steps Community

• Begin to identify community resources for
  patients with depression
• Local
• National
• National Depressive and Manic-Depressive
  Association www.ndmda.org
• National Mental Health Association www.nmha.org

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8 Early Steps

• 1. Identify a mental health specialist
• 2. Develop a suicide protocol
• 3. Develop initial antidepressant guidelines
• 4. Integrate SMS (ultra-brief personal action
  plan) into clinical practice/select a SMS tool

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Eight early steps

• 5. Administer the PHQ to two patients suspected
  to have depression
• 6. Initiate antidepressant protocol and
  ultra-brief PAP/SMS tool
• 7. Repeat PHQ at one month and two months
• 8. Review results with team - PDSA