Depression A Review For Primary Care. Marija Petrovic, MD

Transcription

1 Depression A Review For Primary Care Marija Petrovic, MD

2 Grand Rounds: 2/22/2017 Please sign the attendance sheet in the room to claim your credit. Kaiser Permanente South San Francisco has determined that the speakers (Dr. Petrovic, Dr. Austria, Dr. Russell) and the planning committee (Dr. Becker, Dr. Sheikh, Dr. Zheng, Dr. Liu, Dr. Jones, Rebecca Bayrer, Heather Miller) for this activity do not have any relevant financial relationships. Kaiser Permanente South San Francisco takes responsibility for the content, quality, and scientific integrity of this CME Activity. Kaiser Permanente does not endorse any brand-name products Kaiser January Foundation 25, 2017 Health Plan, Inc. For internal use only. 2

3 Goals Review Care Pathways and appropriate follow up for depression 1. Medications 2. Health Education Classes, BMS, KP.org/resources 3. Referral to Psychiatry

4 Statistics and Epidemiology for Depression and Suicide Depression is the world wide leading cause of disability. Per American Foundation for Suicide Prevention about 44,000 people committed suicide in Suicide was the 10 th leading cause for death in x more men than women committed suicide in 2015, that is about 7 men for every 9 suicides. Middle aged Caucasian men were at the highest risk for suicide, followed by Caucasian men older than 85.

5 Statistics and Epidemiology Per NIMH the data shows: 16.1 Million adults had an episode of Major Depressive Disorder in 2015, which equals 6.7 % of entire population Gender: Females >Males= 8.5% >4.7% Age groups: yrs: 10.3%, yrs: 7.5%, 50+ yrs: 4.8%

6 Risk Factors for Depression: Female Gender Ethnic groups: highest prevalence rate found in multi racial populations, 2 nd highest in Native Americans, 3 rd in Caucasians. Age: young adults carry highest prevalence rate for MDD in Medical problems such as cardiovascular problems, cancer, diabetes, asthma, neurological conditions such as epilepsy, Parkinson s and Multiple Sclerosis. Psychosocial factors such as social isolation in the elderly, and poverty. Family History

7 Nine Symptoms of Depression- Five are Needed for MDD Depressed mood Anhedonia Loss of energy, daily fatigue Significant weight loss or gain Feelings of worthlessness, guilt Insomnia or hypersomnia Psychomotor retardation or agitation Diminished concentration, indecisiveness Suicidal ideation

8 Different types of Depression Melancholic depression: predominantly insomnia, hopelessness, loss of appetite and sleep Atypical Depression: predominantly hypersomnia, increased appetite, heavy leaden paralysis of limbs Psychotic depression: mood congruent or mood noncongruent delusions or hallucinations Catatonic depression: mutism, catatonic stupor, bizarre movements, negativism Depression with anxious distress

9 Adult Outcome Questionnaire AOQ derived from DSM Consists of 3 parts PHQ: Patient Health Questionnaire- Depression GAD2: Generalized Anxiety GDS: Combined score of PHQ and GAD2

10 Severity Assessment using AOQ AOQ below 11: patient might have mild forms of anxiety or depression, patient may have another issue AOQ 11-20: Moderate distress, evaluate patient and discuss what the patient prefers (Health Ed, Therapy, BMS, life style modification or meds or combination of the above) AOQ 21-30: Indicates severe distress, evaluate patient and start medications for depression, refer to psychiatry AOQ 31-39: very severe distress, evaluate depression and suicidality, refer to psychiatry (call for phone consult with psychiatry)

11 Example Case: 45 y/o healthy female with new onset of depression after a relationship break up with these symptoms: Trouble falling asleep at night Weight loss of 5 lbs due to lack of appetite Feeling tired all the time Cannot focus at her job as a receptionist Feels it is her fault that boyfriend left her

12 Example Case: You think she might be suffering from her first depressive episode, so administer an AOQ in the office. The PHQ subscore comes back with 11, and the GAD is 5, so GDS total is 16. What is the most appropriate thing to say to the patient? A. I am not concerned about this, depression goes away on its own. Call me back in 3 months and let me know how things go. B. I feel we should start you on an antidepressant, how about Zoloft? C. Thank you for completing the questionnaire. I would like to ask you a few more questions and then we can talk about next steps, is that OK with you? I am not concerned about... 0% 0% 0% I feel we should start you.. Thank you for completing...

13

14 45 y/o depressed female with new onset of depression cont d Following a brief evaluation you diagnose her with MDD single, mild to moderate and offer her the following treatment plan: What is the correct answer? A. You discuss non pharmacological options with her like health education classes, referral to BMS and exercise. B. You recommend medical work up to rule out hypothyroidism. C. You offer to start her on a low dose of medication. D. All of the above. You discuss non pharmacol... 0% 0% 0% 0% You recommend medical wo.. You offer to start her on a... All of the above.

15 45 y/o female with depression opted out of meds and other recs--now 3 weeks later feeling worse Next steps: Schedule an urgent phone session and administer AOQ ASAP: GDS is now 24, with PHQ 16. What do you do next? A. Start her on Wellbutrin 150mg SR 1 tablet in the morning. B. Zoloft 50mg at bed time and increase in 1 week to 100mg at bed time, and refer her to BMS therapist. C. Evaluate her for substance use disorders and life style issues. D. All of the above. Start her on Wellbutrin % 0% 0% 0% Zoloft 50mg at bed time and... Evaluate her for substance u.. All of the above.

16

17 45 y/o female with depression feels much happier after 30 days on Zoloft 100mg a day, and her GDS went down to 4. What is the correct answer? A. You update her diagnosis to MDD in full remission. B. You encourage her to continue with the medication and therapy and ask her to follow up in 3 months. C. After 3 months, she cancels and sends you a friendly , stating she feels very good and thanks you. You write back and ask her to follow up with another AOQ in 6 months time. D. All of the above. You update her diagnosis t... 0% 0% 0% 0% You encourage her to contin.. After 3 months, she cancels a.. All of the above.

18 45 y/o female with depression worse after remission Patient calls you after 6 month and reports that her depression got worse again in the last 1 month, after some conflict with her family. Her total AOQ is 30 this time and she confesses to you that she has occasional death wishes (with answer 9 being 2). You diagnose her with MDD severe and recurrent type. She assures you that she would not hurt herself because of her faith as a devout Catholic and she feels that the meds worked before. She assures you that she would call 911 if her mood gets worse.

19 Cont d What is the most important thing to do next? A. Call the DOD and refer the patient to the psychiatrist for an urgent appointment. B. You provide her with a phone number for the suicidal hotline. C. You call her brother, whom she is close to, to watch over her till she sees the psychiatrist in 2 days. D. You encourage her to get more sleep and eat regularly. Call the DOD and refer the p... 0% 0% 0% 0% You provide her with a pho.. You call her brother, whom... You encourage her to get mo..

20

21 Treatment modalities Pharmacological Interventions : Fluoxetine Sertraline Bupropion Venlafaxine XR Mirtazapine

22 Treatment Modalities Non Pharmacological: Communicate compassionate understanding of your patient s feelings, provide encouragement, and try to instill hope. Encourage patients to engage in positive activities such as cleaning the house, doing chores, going to work, talking to friends, seeking help and support from family and friends, taking breaks or rest. Encourage healthy life style such as avoid overeating or under-eating, get some physical activity each day, get adequate sleep. Address any other contributing factors: medical problems, domestic abuse.

23 Treatment modalities Crisis intervention: We as physicians need to be aware of the potential for suicide in all patients, so ask if you have any suspicion. Normalize help seeking behaviors. Advise patients to call 911 or seek help via Emergency Room if suicidal or homicidal. Or call suicide hotline for San Francisco or National Suicide Prevention Life Line Be aware that many patients who commit suicide will never say anything to anyone, but often have seen a doctor in the last 30 days prior to suicide.

24 References Kaplan and Sadock Textbook of Psychiatry 2007 Edition Pocket Book Guide to the DSM 5 by Nussbaum NCHS Data Brief No 206 June 2015 from US Department of Health and Human Services National Center of Disease Control Diagnostic Statistical Manual 5 th Edition as provided by Psychiatry Online.Org Innovative Psychological Treatments for Depression by Steven Hollen, PhD, Christopher Williams, MD Focus Journal Vol 14, No2, Spring 2016 Adjunctive Therapy with Second Generation Antipsychotics: The new standard for treatment resistant depression by Michael Thase, MD Focus Journal Vol 14, No 2 Spring 2016 Deconstructing Diabetes and Depression: Clinical Context, Treatment Strategies and New Directions by Jonathan Gregory MDBAsc, Joshua Rosenblatt MD Bsc, Roger Mcintyre, MDFRCP Focus Journal Vol 14, No 2 Spring 2016 Cognitive Dysfunction in Major Depressive Disorder: Assessment, Impact and Management by Trisha Chakrabarty, MD, George Hadijpavluo, MDMA, Raymond Lam MD Focus Journal Vol14, No 2 Spring 2016 Major Depressive Disorder: New Clinical, Neurobiological and Treatment Perspectives by David Kupfer et all Focus Journal Vol14, No 2, Spring

25 February 21, 2017 Please sign the attendance sheet in the room to claim your credit. Please complete the Online Survey: This survey will be ed to participants and will close within 10 days of the date the was sent Kaiser Foundation Health Plan, Inc. For internal use only. 25