Treating Chronic Illness in the PCMH Handout - Depression. A. Guidelines. 1. Control of Symptoms:
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1 Treating Chronic Illness in the PCMH Handout - Depression A. Guidelines A quick note on diagnosis: Note: For a major depressive episode a person must have experienced at least five of the nine symptoms (depressed mood & SIGECAPS) below for the same two weeks or more, for most of the time almost every day, and this is a change from his/her prior level of functioning. One of the symptoms must be either (a) depressed mood, or (b) loss of interest. 1. Control of Symptoms: SIGE-CAPS (sleep, interest, guilt, energy-concentration, appetite, psychomotor, suicide) Discuss drug and alcohol use (not mentioned in SIGE-CAPS) Expect response to treatment in 1-4 weeks but maximal response may take 8-12 weeks. Assure complete remission & then treat for 9-12 months. With recurrent depression, will likely require lifelong treatment. Tools like Becks or PHQ 9 allow more accurate measurement of treatment response. 2. Pharmacotherapy: Serotonin: (SSRI) sertraline (zoloft), citalopram (celexa), escitalopram (lexapro), fluoxetine (prozac), paroxetine (paxil). Serotonin trazadone (desyrel) Norepinephrine, Dopamine: (Tricyclics) amitriptyline (elavil) Setotonin, Norephinephrine: (SNRI) venlaflaxine (effexor), duloxetine (cymbalta). Serotonin, Norepinephrine: (Tetracylics) mirtazapine (remeron) Serotonin, Norepinephrine, Dopamine: buproprion (welbutrin) All are equal in efficacy (more or less) Sertraline stands out in metanalysis of 119 studies (Lancet 2009) efficacy, tolerability, price Citalopram stands out because of large study in primary care (STAR D trial) Q1: Prior response to treatment in patient or family Q2: Trouble sleeping vs excessive sleepiness: tricyclics & mirtazapine (-) vs buproprion & fluoxetine (+) Q3: Pain: amitriptyline (TCA) & cymbalta Q4: Smoke: buproprion Side effects & Cautions Amitriptyline (TCA): cardiac arrhythmia, overdose potential Caution with teens, caution with mania Always discuss sexual side effects (consider buproprion as alternative) 3. Non pharmacologic treatment: Cognitive behavioral therapy equal to meds (even better in combination with meds) Electroconvulsive therapy (ECT) St. John s Wort: Evidence is inconsistent but favors efficacy. Treatments with unknown effectiveness: Acupuncture, psychological treatment in severe depression, exercise.
2 B. Application of Guidelines to the Unique Situation of the Patient Reflections on the Patient Recording using FLIP camera: Reflection #1: Addressing sexual dysfunction and alcohol use is important in patients with depression. I addressed both topics and was pleased with the way I introduced the topic: I was not pleased that I did not follow up on statement by patient that he felt not perfect but good. What does group think? How could I have followed up? I was not pleased that I did not follow up and explore relationship more and how he defines desire. I left interview knowing relatively little about his social context. What questions should I have asked? Refelction #2: Informed decision making is a key part of patient centered care. I offered him choices on what to do with medication. I liked that he was able to articulate the choice he made. I was less pleased with how I presented options. Does the group think I needed to provide patient with more details to make a choice? C. Systems Issues in the Practice that Influence Care: Depression is a stigmatized and often under-recognized chronic illness. System improvement efforts (NCQA, CCNC etc) have traditionally focused on illnesses such as diabetes, HTN, CHF. But depression deserves more focus as we improve systems Is expensive - $ 90 billion with $60 billion in indirect costs Diagnosis if often inaccurate (30%) and inventories help Many patients are not adequately treated, with <50% follow up Many patients stop taking medication prematurely (70% discontinuation at 180 days) - Managed care 2005 Current situation in our practice: Practice recognizes the importance of depression as chronic illness. Beck Inventories in file cabinets of individual physicians. Patient handouts on depression available. Medicaid Provider Provider Portal provides information on medication adherence for Medicaid patients. Care Managers available to help patients with depression. No template in electronic health record that prompts screening or follow up. No registry or systematic tracking of patients. Recommendations 1. Extend care to nurses: Depression on problem list flags patient on check in. Patient is given an inventory to complete while waiting. Ideally, on hand held device so information is available to physician electronically before entering room 2. Manage patients proactively through use of registry: Use registries of patients with diagnosis of depression Review claims data for pharmacy and contact patients who have gaps in fill 3. Measure success with PDSA cycle Completion of inventories is measured, feedback provided to team, and modifications made to improve completion rates.
3 Beck's Depression Inventory: (the scoring scale is at the end of the questionnaire) 0 I do not feel sad. 1 I feel sad 2 I am sad all the time and I can't snap out of it. 3 I am so sad and unhappy that I can't stand it. 0 I am not particularly discouraged about the future. 1 I feel discouraged about the future. 2 I feel I have nothing to look forward to. 3 I feel the future is hopeless and that things cannot improve. 0 I do not feel like a failure. 1 I feel I have failed more than the average person. 2 As I look back on my life, all I can see is a lot of failures. 3 I feel I am a complete failure as a person. 0 I get as much satisfaction out of things as I used to. 1 I don't enjoy things the way I used to. 2 I don't get real satisfaction out of anything anymore. 3 I am dissatisfied or bored with everything. 0 I don't feel particularly guilty 1 I feel guilty a good part of the time. 2 I feel quite guilty most of the time. 3 I feel guilty all of the time. 0 I don't feel I am being punished. 1 I feel I may be punished. 2 I expect to be punished. 3 I feel I am being punished. 0 I don't feel disappointed in myself. 1 I am disappointed in myself. 2 I am disgusted with myself. 3 I hate myself. 0 I don't feel I am any worse than anybody else. 1 I am critical of myself for my weaknesses or mistakes. 2 I blame myself all the time for my faults. 3 I blame myself for everything bad that happens. 0 I don't have any thoughts of killing myself. 1 I have thoughts of killing myself, but I would not carry them out. 2 I would like to kill myself. 3 I would kill myself if I had the chance. 0 I don't cry any more than usual. 1 I cry more now than I used to. 2 I cry all the time now. 3 I used to be able to cry, but now I can't cry even though I want to. 0 I am no more irritated by things than I ever was. 1 I am slightly more irritated now than usual. 2 I am quite annoyed or irritated a good deal of the time. 3 I feel irritated all the time.
4 I have not lost interest in other people. 1 I am less interested in other people than I used to be. 2 I have lost most of my interest in other people. 3 I have lost all of my interest in other people. 0 I make decisions about as well as I ever could. 1 I put off making decisions more than I used to. 2 I have greater difficulty in making decisions more than I used to. 3 I can't make decisions at all anymore. 0 I don't feel that I look any worse than I used to. 1 I am worried that I am looking old or unattractive. 2 I feel there are permanent changes in my appearance that make me look unattractive 3 I believe that I look ugly. 0 I can work about as well as before. 1 It takes an extra effort to get started at doing something. 2 I have to push myself very hard to do anything. 3 I can't do any work at all. 0 I can sleep as well as usual. 1 I don't sleep as well as I used to. 2 I wake up 1-2 hours earlier than usual and find it hard to get back to sleep. 3 I wake up several hours earlier than I used to and cannot get back to sleep. 0 I don't get more tired than usual. 1 I get tired more easily than I used to. 2 I get tired from doing almost anything. 3 I am too tired to do anything. 0 My appetite is no worse than usual. 1 My appetite is not as good as it used to be. 2 My appetite is much worse now. 3 I have no appetite at all anymore. 0 I haven't lost much weight, if any, lately. 1 I have lost more than five pounds. 2 I have lost more than ten pounds. 3 I have lost more than fifteen pounds. 0 I am no more worried about my health than usual. 1 I am worried about physical problems like aches, pains, upset stomach, or constipation. 2 I am very worried about physical problems and it's hard to think of much else. 3 I am so worried about my physical problems that I cannot think of anything else. 0 I have not noticed any recent change in my interest in sex. 1 I am less interested in sex than I used to be. 2 I have almost no interest in sex. 3 I have lost interest in sex completely.
5 INTERPRETING THE BECK DEPRESSION INVENTORY Now that you have completed the questionnaire, add up the score for each of the twenty-one questions by counting the number to the right of each question you marked. The highest possible total for the whole test would be sixty-three. This would mean you circled number three on all twenty-one questions. Since the lowest possible score for each question is zero, the lowest possible score for the test would be zero. This would mean you circles zero on each question. You can evaluate your depression according to the Table below. Total Score Levels of Depression 1-10 These ups and downs are considered normal Mild mood disturbance Borderline clinical depression Moderate depression Severe depression over 40 Extreme depression A PERSISTENT SCORE OF 17 OR ABOVE INDICATES THAT YOU MAY NEED MEDICAL TREATMENT. IF YOU HAVE ANY CARDIAC CONCERNS, PLEASE CONTACT CARDIOVASCULAR INTERVENTIONS, P.A. at 40
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It is the policy of health plans affiliated with Centene Corporation that Seroquel XR is medically necessary when the following criteria are met:
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Anxiety. Definition. Sometimes anxiety results from a medical condition that needs treatment. Whatever form of anxiety you have, treatment can help.
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Criteria for Probable Diagnosis: 1. Meets criteria for core symptoms of the disorder. 2. Meets all but one, or a minimum of 75% of the remaining criteria required for the diagnosis 3. Evidence of functional