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 - PowerPoint PPT Presentation

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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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Title: 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

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

Software Screen
Todays Speaker
Paul Block, PhD Director, Psychological
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
  • Disability-adjusted life years

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

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

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

Costs of mental illness
  • 15 of total corporate profits nationally
  • (671 billion per year) are lost to behavioral
  • 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

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

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

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

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

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)

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

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

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

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"
  • 38 lower costs for patients without chronic
  • 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

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)

Newer medications are better than older
  • 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.

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
  • 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.

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)

Medication details
  • Older classes of antidepressants, such as
    tricyclics and monoamine oxidase inhibitors
  • 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

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).

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
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)

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
  • EBT requires 14 sessions, not 1-3, 6, 8, or 12
  • Formulation
  • Treatment to full remission to reduce
  • risk of relapse

Things we know about depression(that arent
necessarily true)Comorbidity
  • Comorbidity predicts lower recovery
  • Substance abuse
  • Trauma
  • Personality disorder
  • Undiagnosed comorbidity
  • misdiagnosis
  • Combined treatments

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

Things we know about depression(that arent
necessarily true)PCP expertise
  • PCPs cant manage medications
  • CHC experiences
  • Therapist diagnosis
  • and consultation

What would adequate care look like?
  • Individualized
  • Whole-person
  • Integrated
  • Actually provided
  • Flexible
  • Complete
  • Relapse Prevention

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

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