Antidepressant Medication Therapy in Primary Care July 25, 2013

Transcription

1 New York State Collaborative Care Initiative Antidepressant Medication Therapy in Primary Care July 25, 2013

2 Presenter Building on 25 years of Research and Practice in Integrated Mental Health Care Anna Ratzliff, MD, PhD Associate Director of Education Division of Integrated Care and Public Health University of Washington

3 Case Patient is a 23yo female presenting for initial intake for depression. She was referred to you by her PCP. She has been depressed for 6 months with increased isolation, missing days of work and no longer engaged with friends. She has no substance use history. She denies bipolar symptoms. She denies anxiety symptoms. You diagnose her with MDD Integrated care planning!

4 Principles of Effective Integrated Behavioral Health Care Patient Centered Team Care Collaboration not co location Team members have to learn new skills Population Based Care Patients tracked in a registry: no one falls through the cracks Measurement Based Treatment to Target Treatments are actively changed until the clinical goals are achieved Evidence Based Care Treatments used are evidence based Accountable Care Providers are accountable and reimbursed for quality of care and clinical outcomes, not just the volume of care provided

5 Treatment Planning Patient, PCP & Care Manager all involved in making the treatment plan Treatment plans individualized because patients differ in Medical comorbidity Psychiatric comorbidity Prior history of depression and treatment Current treatments Treatment preferences Treatment response

6 Discussing Treatment Options Review all treatment options available Psychotherapeutic interventions Behavioral Activation, Problem Solving Treatment, Cognitive Behavioral Treatment, etc. Medications Discuss pros and cons of each option

7 The Advantages of Integrating Opportunity Time Different relationship Skills Engaging patients Assessing patients Supporting patients

8 Case Continued Patient initially chose Behavioral Activation. Client has now met with you for several sessions and making some progress in therapy, but she is still missing work and having trouble working on therapy goals. After you consulted with your consulting psychiatrist, a recommendation for sertraline has been made. PCP has written a prescription for an antidepressant but the client is hesitant to fill it.

9 Discussing Treatment Options The treatment that WORKS is the best one Person centered care means selecting treatments based on client preference, not clinician preference Try to be unbiased when offering treatment options Be eclectic: One size fits few Medication therapy is not right for everyone Psychotherapy is not right for everyone; Different therapies Supporting whole person treatment is important This may include medication therapy You can support medication therapy within scope of practice Ask questions and collect information Support patient being informed and active about all aspects of treatment plan

10 Antidepressants 101

11

12 Major Depression Medication Treatment SSRI Fluoxetine/Prozac Sertraline/Zoloft Citalopram/Celexa Escitalopram/Lexapro Paroxetine/Paxil Fluvoxamine/Luvox SNRI Venlafaxine/ Effexor Duloxetine/Cymblta Other Newer: Bupropion / Wellbutrin / Zyban, Mirtazapine / Remeron Older: TCA (Amitriptyline, Nortriptyline ) MAOI Common Augmentation Buspirone /Buspar Antipsychotic medications (ex. Abilify or Seroquel)

13 Choosing Antidepressants Prior treatment history in patient/family members Patient preferences Expertise of prescribing provider Side effect profile Safety in overdose 10 days of a TCA can be a lethal overdose Availability and costs Drug drug interactions

14 Anxiety Antidepressants SSRI SNRI Benzodiazepines Lorazepam / Ativan Xanax/ Alprazolam Clonazepam / Klonopin Other Prazosin Buspirone Hydroxazine

15 Bipolar Depression Antipsychotics Seroquel Lithium ANTI DEPRESSANTS Lamictal Depakote

16 Managing Misconceptions What concerns about medications do clients / patients tell you about?

17 Taking a medication history History Bring in bottles of current medications Ask for list of past medications What has been your experience with medications? Helped? Side effects? Assess adherence How are you taking this medication? Most people miss doses. How many times do you think you missed a dose of medication in the last week? How do you remember to take your medications? Ask about concerns How is this medication working for you? What has improved? Anything worse? Quantify. Any side effects? What, when, how much do they bother you? Do you think this medication is helping you reach your goals?

18 Common Side Effects for SSRI/SNRIs Short term: GI upset / nausea Jitteriness / restlessness / insomnia Sedation / fatigue Long term: Sexual dysfunction (up to 33%) Weight gain (5 10%)

19

20 Response Rates Antidepressant response ~5O 60 % Real world effectiveness ~28%

21 Patient Education About Antidepressants Anticipate Reinforce Patient concerns about medications Side effects (these can be managed) Problems with adherence Do not stop medications without talking to prescriber May need continuation or maintenance treatment to prevent relapse

22 Case Continued First 4 weeks of treatment She has started the antidepressant, but still struggled with compliance. She had some improvement and had met some smaller BA goals.

23 Antidepressant Adherence 100% 80% 60% 40% 20% 1 mo 28% stopped 4 mo 44% stopped 0% Months Lin EH. Med Care 1995;33:67

24 What s missing? Behavior Change Specialists Enhancing medication adherence Support behavioral change

25 Optimizing Adherence Provide rationale for use Careful attention to side effects Counter demoralization (CM) Address fear of dependence and loss of control Enlist family/spousal support (CM) Address concerns in relation to patient s or significant other s prior experience with medication (CM) Increase contact with brief phone check ins (CM) Specific instructions (take regardless of symptom change, don t stop on own) Use symptom scale (e.g., PHQ 9) (CM)

26 What if Patients Don t Improve? Is the patient adhering to treatment? Is the dose high enough? See max dose guidelines Is the diagnosis correct?? Bipolar depression? Medical conditions (hypothyroidism, sleep apnea, pain)? Meds: steroids, interferon, hormones? Withdrawal: stimulants, anxiolytics Are there untreated comorbid conditions / life stressors?

27 Case Continued After 8 weeks Client has now taken an antidepressant and has improved symptoms. After 6 months Client comes in asking about discontinuing medications. She has been actively engaged with BA and making good progress on her goals.

28 Good Reasons to Stop a Medication Intolerable side effects Dangerous interactions with necessary medications The medication was not indicated to start with (e.g., bipolar depression) Medication has been at maximum therapeutic dose without improvement for 4 8 weeks

29 When and How to Stop Antidepressants? Treat all adults for 9 18 months after initial response Treat those at high risk for relapse for 2 years or longer; Some may need lifetime treatment Maintenance treatment should be at full dose Make a relapse prevention plan Taper antidepressants slowly to avoid discontinuation syndrome TEAM EFFORT!

30 Case Continued Client did well tapering off medication and continuing BA. Client returned to PCP for ongoing care!

31 Antidepressant Summary There are over 30 FDA approved antidepressants Each is effective in ~ 40 50% of patients Use adequate doses for an adequate amount of time It may take several trials until an effective medication is identified Patients need support during this time (work with care manager) If medications are not effective after 8 10 weeks at a therapeutic dose Is patient taking medication as prescribed? Consider substance abuse, bipolar disorder, anxiety disorders, cognitive impairment. Ask every patient about suicidal ideation Consult with team psychiatrist and change treatment (medications, other somatic treatments, psychotherapy)

32 The Advantages of Integrating Opportunity Time Different relationship Skills Engaging patients Assessing patients Supporting patients