Strategies for Diagnosing and Treating Depressive Disorders in Primary Care

Transcription

1 Strategies for Diagnosing and Treating Depressive Disorders in Primary Care David Katerndahl, MD, MA University of Texas Health Science Center San Antonio, Texas

2 Speaker Disclosure Dr. Katerndahl has disclosed that he has no actual or potential conflict of interest in relation to this topic.

3 WHY ANOTHER DEPRESSION TALK? -Years Lived With Disability*- DISORDER 1990 Ranking 2010 Ranking % Change In Disability Major Depressive Disorder (MDD) % Dysthymia % *US Burden of Disease Collaborators, 2013

4 PRIMARY CARE TRENDS ( )* Mental health complaints Mental disorders Psychotropic medications Mental health severity Bipolar diagnosis >1 Mental disorder Antipsychotics *Olfson et al, 2014

5 PSYCHIATRIC CRITICISMS ABOUT FPs TREATMENT OF DEPRESSION FPs don t recognize it Criticisms Recognize symptoms but miss DSM diagnoses Recognize but do not label Recognition Rates Major Depression % Minor Depression 42-49%

6 PSYCHIATRIC CRITICISMS ABOUT FPs TREATMENT OF DEPRESSION FP s don t treat it appropriately Psychiatrists believe * Physicians too often treat sadness as a medical illness (20% agree) Undertreatment of depression is a more pressing problem than overtreatment of normal sadness (46% agree) *Lawrence et al, 2015

7 FPs Don t Treat It Appropriately Adequate antidepressants 55% Major Depression Completed therapy for Major Depression 55% for Psychotherapy 43% for Pharmacotherapy Received guideline-concordant care - 17% 1 general medical visit - 32% 1 mental health visit - 45%

8 OBJECTIVES By the end of this activity, the participant will be better able to: 1. Diagnose depressive disorders in patients. 2. Develop an individualized treatment plan, including pharmacological and nonpharmacological options. 3. Identify and manage patients at high risk for suicide.

9 CONTENT 1. Depression Symptom Diagnosis 1. Screening 2. Depressive Diagnoses 2. Management 1. General Measures 2. Pharmacotherapy 3. Psychotherapy 4. Individualized Therapy 5. Special Populations 3. Complications 1. Psychosis 2. Suicide 4. When To Refer

10 SCREENING Presentation in Primary Care (PC) Depressive symptoms Insomnia Fatigue Weight Change Dementia Sexual Dysfunction Vague Complaints (prior to suicide) Non-adherence

11 SCREENING -USPSTF Screening- 1. Recommends screening for MDD in adolescents aged years. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up (American Pediatrics Association too). 2. Recommends screening for depression in the general adult population, including pregnant and postpartum women. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.

12 SCREENING -Patient Health Questionnaire (PHQ-9)- } PHQ-2 3 = Positive KEY: 4 = None 5-9 = Mild = Moderate = Moderately Severe 20 =Severe

13 DEPRESSIVE DIAGNOSES -Symptom Diagnosis- Causes of depressed mood 1. Secondary Causes 2. Schizoaffective Disorder 3. Bipolar Disorder (Bipolar Depression) 4. Major Depressive Episode (MDE) 5. Persistent Depressive Disorder (Dysthymia) 6. Adjustment Disorder With Depressed Mood

14 DEPRESSIVE DIAGNOSES - Causes of Secondary Depression- ENDOCRINE Hypothyroidism Hyperparathyroidism Cushing s Syndrome Addison s Disease NEUROLOGIC CVA Seizures Huntington s Disease Wilson s Disease Multiple Sclerosis Parkinson s Disease Traumatic Brain Injury MALIGNANCY Paraneoplastic Syndromes Pancreatic Cancer INFECTIOUS HIV West Nile Virus Creutzfeldt-Jakob Disease Lyme Disease Neurosyphilis HCV VITAMIN DEFICIENCY Vitamin D Vitamin B12 Folate MEDICATIONS Antiepileptics Betablockers Steroids Interferon Isoretinoin Varenicline Does every depressed patient need labwork?

15 DEPRESSIVE DIAGNOSES -Schizoaffective Disorder*- A. MDE Concurrent With Schizophrenia A Symptoms ( 2 of following): 1. Delusions 2. Hallucinations 3. Disorganized speech 4. Grossly disorganized behavior 5. Negative symptoms B. Psychosis Without Depression (at least 2 weeks) *APA, 2013

16 DEPRESSIVE DIAGNOSES -Bipolar Depression*- A. History of manic / hypomanic episode ( 3): 1. Grandiosity 2. Decreased need for sleep 3. Talkativeness 4. Racing thoughts 5. Distractibility 6. Increase goal-directed activity 7. Excessive pleasurable activity despite consequences B. Current Major Depressive episode *APA, 2013

17 DEPRESSIVE DIAGNOSES -Major Depressive Episode*- A. 5 Symptoms present past 2-week period ( 1 either depressed mood or loss of interest / pleasure): 1. Depressed mood 2. Diminished interest or pleasure in activities 3. Weight loss or gain, or decrease or increase in appetite 4. Insomnia or excessive sleeping 5. Psychomotor agitation or retardation 6. Fatigue or loss of energy 7. Feelings of worthlessness or inappropriate guilt 8. Diminished ability to think or concentrate 9. Thoughts of death / suicidal ideation B. Significant distress / impaired functioning *APA, 2013

18 DEPRESSIVE DIAGNOSES -Differentiating MDD & Bipolar Depression- New Psychotropic Clinic Patients Seen In :* REFERRAL DIAGNOSIS DEPRESSION (n=126) BIPOLAR DISORDER (n=69) PSYCHOTROPIC CLINIC DX MDD / Dysthymia Bipolar Other Dx 89 (72%) 29 (24%) 5 (4%) 15 (22%) 51 (74%) 3 (4%) *Wang & Herman, 2013

19 DEPRESSIVE DIAGNOSES -Differentiating MDD & Bipolar Depression- New Psychotropic Clinic Patients Seen In :* PREDICTORS OF MISDIAGNOSIS Misdiagnosed Depression Misdiagnosed Bipolar Suicidal ideation Poorly responsive affect FH mental illness Personality disorder Lack of depressed mood Lack of FH mental illness Male gender *Wang & Herman, 2013

20 DEPRESSIVE DIAGNOSES -Differentiating MDD & Bipolar Depression- Misdiagnosed as MDD* Primary Care prevalence Probable lifetime Bipolar Disorder = 9.8% Past diagnosis among Bipolar patients Bipolar Disorder = 8% Depression = 80% Current MDD diagnosis= 47% Dilemma: Antidepressants Mania *Das et al, 2005

21 DEPRESSIVE DIAGNOSES -Differentiating MDD & Bipolar Depression- Improving Bipolar recognition Mood Disorder Questionnaire (MDQ) GROUP Sensitivity Specificity +LR -LR PC Depression 58% 93% 8.29 (moderate) 0.45 (small) Sensitivity greater for Bipolar 1 versus 2* Ask about history of manic symptoms: Every Patient 2-3 manic-specific questions (i.e.): 1. Decreased need for sleep 2. Grandiosity 3. Excessive pleasure involvement despite consequences * Miller et al, 2004

22 DEPRESSIVE DIAGNOSES -Differentiating MDD & Bipolar Depression- Distinguishing Bipolar Depression from MDD CHARACTERISTIC Bipolar Depression MDD Depressive Symptoms Sleep Appetite Psychomotor Mood Swings Associated Symptoms Age-of-Onset #Depressive Episodes Psychiatric Comorbidity FH Bipolar Treatment Response Induced Mania >2 Antidepressant Failures Increased Increased Retardation Hyper-to-Depressed Psychosis <25 Years 5 Episodes OCD, Social Phobia Yes + + Decreased Decreased Agitation Not Hyper Somatic >25 Years Current 6 Months --- No

23 DEPRESSIVE DIAGNOSES -Persistent Depressive Disorder (Dysthymia)*- A. Depressed mood for 2 years B. Presence, While Depressed, Of 2 Of Following: 1. Poor appetite or overeating 2. Insomnia or hypersomnia 3. Low energy or fatigue 4. Low self-esteem 5. Poor concentration or difficulty making decisions 6. Feelings of hopelessness C. During 2-year period, person never without symptoms in criteria A & B for > 2 months at a time *APA, 2013

24 DEPRESSIVE DIAGNOSES -Persistent Depressive Disorder (Dysthymia)- Can have Psychosis and Suicide Consider checking TSH & Vitamin D levels Treatment CONTROVERSY: Psychotherapy <> Antidepressants? Combined (Medication + Cognitive Behavioral Therapy) Exercise Adjunctive* St. John s Wort? *Melrose 2017

25 DEPRESSIVE DIAGNOSES -Adjustment Disorder With Depressed Mood*- A. Emotional or behavioral symptoms in response to identifiable stressor occurring within 3 months of onset of stressor B. Symptoms do not represent Normal bereavement (> 1 year) C. Once stressor ended, symptoms do not last > 6 months *APA, 2013

26 MANAGEMENT -Goals & Monitoring- Goal(s) of treatment Suicide prevention Role functioning Monitoring Comorbidity Substance abuse Panic & Generalized Anxiety Disorders Suicide Treatment Response Patient Health Questionnaire (PHQ-9) Visit Frequency

27 # Off Label General Measures MANAGEMENT -Treatments- Education Real Disorder Neurotransmitters? Treatability Need for Compliance Exercise Aerobic (3x weekly, moderate intensity, 9 weeks)* Diet Limiting Caffeine Inositol (2 gm 3x daily) St. John's Wort Pharmacotherapy NSAIDs (Celecoxib # ) Less Depression but Heterogeneity** Antidepressants ± Augmentation Psychotherapy *Stanton & Reaburn, 2014 **Kohler et al, 2014

28 ANTIDEPRESSANTS -Equally Effective- MEDICATION SELECTED Selective Serotonin Reuptake Inhibitor (SSRI)* Fluoxetine Paroxetine Sertraline Citalopram / Escitalopram Serotonin/Norepinephrine Reuptake Inhibitor (SNRI) Venlafaxine XR* / Desvenlafaxine Duloxetine Levomilnacipram Vilazodone Vortioxetine * = First-Line Agent ** = May Go Higher? MINIMAL EFFECTIVE DOSE (mg) / / MAXIMUM DOSE (mg) ** 40 / / **

29 ANTIDEPRESSANTS MEDICATION SELECTED Tricyclic Antidepressant (TCA)* Amitriptyline Doxepin Nortriptyline Desipramine Selective Antagonist/Reuptake Inhibitor (SARI) Trazodone Nefazodone** Mirtazapine Bupropion XL* Monoamine Oxidase Inhibitor (MAOI) Selegiline Patch MINIMAL EFFECTIVE DOSE (mg) MAXIMUM DOSE (mg) * = First-Line Agent ** = Hepatotoxicity

30 ANTIDEPRESSANTS Additional Considerations Pharmacogenetics Polygenic / inconsistent benefit Mirtazapine vs. SSRI Mirtazapine faster onset?* TCA vs SSRI (PC)** TCA SSRI NNT 4 6 NNH NNT = Number Needed To Treat NNH = Number Needed To Harm Low-Dose TCA = High-Dose TCA Inpatient Depression: TCA > Others*** *Thase et al, 2010 **Arrol et al, 2005 ***Barbui et al, 2004

31 ANTIDEPRESSANTS Prescribing Facts Start with medication with Prior +Response Poor Adherence (number of doses) Timing (AM-PM) Switching between antidepressants (from fluoxetine) Combining Antidepressants Except: Serotonergic MAOIs Stopping Them Flu-Like Withdrawal Symptoms If non-fluoxetine Antidepressant > Minimal effective dose Methods 1. Weekly Downgrade 2. Switch to Fluoxetine & Discontinue

32 AUGMENTATION DRUGS -Non-Antidepressants That Help Antidepressant Response- Proven Augmentation Drugs # Lithium Buspirone Nonselective Betablockers Levothyroxine Atypical Antipsychotics (aripiprazole NOT off-label) Folate Scopolamine Stimulants (Dextroamphetamine & Modafinil better augmentation than antidepressant)* # Off Label *McIntyre et al, 2017

33 STEPPED CARE -STAR*D Study- Primary Care & Psychiatry Outpatients Screened (N = 4,790) Refused Consent/Ineligible (N = 1,680) Non-Psychotic Depression (HAM-D 14) (N = 3,110) Lost To Follow-Up (N = 234) Response To Citalopram (N = 2,876) Responded/Left Study (N = 1,437) Level 2 Treatment (N = 1,439) Switch Medication (N = 727) Added Medication (N = 565)

34 STEPPED CARE -STAR*D Study- Citalopram Max 60 mg X 12 weeks Change to Sertraline Change to Bupropion Change to Venlafaxine Add Bupropion Add Buspirone Which Had Best Response Rate?

35 RECOMMENDED STEPS Start SSRI No Response MDD Remits Partial Response Switch SSRI Change to NSRI or Add Different Antidepressant

36 PSYCHOTHERAPY General # Sessions / week important (2+ > 1)* Effective Methods All effective in PC** Depression-focused Psychotherapy Cognitive Behavioral Therapy (CBT) - Online & computer-based Interpersonal Psychotherapy Psychodynamic Therapy Problem-Solving Therapy Comparing Effectiveness*** Supportive < Others Session Duration 90+ minutes CBT Best <90 minutes Behavioral Activation Best *Cuijpers et al, 2013 **Linde et al, 2015 ***Braun et al, 2013

37 COLLABORATIVE CARE MODEL (CCM) CCM = Behavioral Integration Into Practice* Components 1. Case Management & Follow-Up 2. Provider Communication (Education, Specialist Advice, Guidelines) 3. Motivational Interviewing & Brief Psychotherapy 4. Community Resources 5. Screening 6. Goal Setting Improved Outcomes Particularly: Follow-Up, Provider Communication, Psychological Intervention Fewer Symptoms, Improved MH-QOL PC Depressed Patients > 60 y/o Without Baseline Cardiovascular Disease** 48% Decreased Risk Of CV Event (NNT=6) *Gerrity 2016 **Stewart et al, 2014

38 MANAGEMENT -Combined Therapy- Psychotherapy + Antidepressant > Psychotherapy Alone Moderate Depression ONLY* Problem-Solving Therapy (PST) + Antidepressant > PST Alone** *demaat et al, 2007 **Gellis & Kenaley, 2008

39 BEWARE OF THE LITERATURE! -EXAMPLE: Escitalopram vs Citalopram- META-ANALYSIS: Conclusion = Escitalopram better for MDD (especially severe)* 4 RCTs NO DIFFERENCE within individual studies Sponsors of individual studies? Drug company sponsored meta-analysis (Escitalopram distributor in Europe) Effect Sizes 5x larger in drug company studies** *Auquier et al, 2003 **IOM, 2011

40 BEWARE OF THE LITERATURE! -Limitations Of Psychiatric Guidelines (CPGs)- 1. Poor quality & Primary Care applicability STUDY: Schizophrenia 24 CPGs from 18 Countries Mean Total Quality Score = 37 / 96 STUDY: Depression 45 CPGs in UK Wide Range in Quality 2. Conflicts of interest of preparers not reported 3. Conflicting Guidelines - Differ in Recommendations 1,3 1 Giebel et al, Littlejohns et al, Saddichha & Chaturvedi, 2014

41 RECENT GUIDELINE RECOMMENDATIONS - Adult Depression In Primary Care - Screening: Screen All Adults Using Standardized Instrument Diagnosis: Use DSM-5 To Diagnose Treatment MDD: Consider Combining Pharmacotherapy With Psychotherapy If Cannot: Mild-Moderate Start Psychotherapy Severe Start Pharmacotherapy Dysthymia: Start With Pharmacotherapy? Comprehensive Care Collaborative Care Model: Recommended In Primary Care Education & Engagement: Establish Therapeutic Alliance Follow-Up: Maintain Follow-Up *Trangle et al, 2016

42 RECENT GUIDELINE RECOMMENDATIONS - Treatment of Patients With MDD - Psychiatric Management Establish therapeutic alliance Thorough diagnostic assessment Evaluate safety Evaluate quality-of-life Enhance adherence Patient education Acute Phase Mild-Moderate: Start Antidepressant OR Psychotherapy Severe: Start Antidepressant WITH Psychotherapy Continuation Phase Discontinuance after 4-9 months 3 rd relapse needs maintenance *APA, 2010

43 INDIVIDUALIZING THERAPY Demographics Age Gender Symptomatology Sleep Appetite Comorbidities - Other Medications PSYCHIATRIC -Suicidality -Substance Abuse -Anxiety MEDICAL -Obesity -Hypertension -Seizures -Pregnancy -CAD -Sexual Dysfunction -Migraines -GERD -COPD -Chronic pain -Cirrhosis -Renal Failure

44 INDIVIDUALIZING THERAPY CONDITION Use Avoid Gender -Female (childbearing) -Male Symptomatology Insomnia Poor Appetite Drug Interactions Fluconazole / Macrolides Methadone / Ziprasidone Tramadol Psychiatric Comorbidity Suicidality Attention Deficit Disorder Anxiety Sertraline Bupropion? Mirtazapine, TCA Mirtazapine Bupropion SSRI, NSRI, TCA, Mirtazapine, MAOI Paroxetine Trazodone, TCA? Bupropion Bupropion TCAs,Citalopram TCAs,Citalopram SSRIs / NSRIs? TCA Bupropion

45 INDIVIDUALIZING THERAPY -Medical Comorbidities- CONDITION Use Avoid Cardiovascular Hypertension Coronary Artery Disease Endocrine Obesity Sexual Dysfunction Neurology Seizures Migraines Gastroenterology GERD Cirrhosis Chronic Pain Renal Failure SSRI Bupropion Bupropion Fluoxetine, TCA Sertraline, Citalopram, Nortriptyline Duloxetine, TCA Venlafaxine TCA Mirtazapine, SSRI (paroxetine) SSRI (paroxetine), NSRI Bupropion TCA Fluoxetine NSRI

46 INDIVIDUALIZING THERAPY -Special Populations- CHILDREN Often psychosocial cause Start with psychotherapy Antidepressants? Suicide risk? Fluoxetine = First Choice

47 # Off Label INDIVIDUALIZING THERAPY -Special Populations- ELDERS Medications: Start at ½ minimal effective dose Antidepressants > Placebo* No difference in antidepressant response ** No TCAs Urinary retention if BPH Worsen constipation CV Risk Orthostatic Dementia risk SSRIs In Elders Sertraline best studied 25% Hyponatremia risk Comorbid Dementia Poor SSRI response *Roose & Schatzberg, 2005 **Kok et al, 2012 ***Gerson et al, 1999 Methylphenidate # (if rapid response needed) Psychotherapy: CBT, Behavioral & Psychodynamic Therapy > Placebo***

48 MANAGEMENT SUMMARY -Depressive Disorders- MANAGEMENT Primary Secondary Other Schizoaffective Disorder Antipsychotics + Antidepressants Bipolar Disorder Mixed Depression Antipsychotics Mood Stabilizers Quetiapine Olanzapine + Fluoxetine Lurasidone Psychotherapy? Major Depressive Disorder Psychotherapy / Antidepressants Augmentation Inositol Dysthymia Psychotherapy? Antidepressants? Antidepressants? Adjustment Disorder Psychotherapy

49 COMPLICATIONS -Psychosis- NOT ALL PSYCHOSES ARE SCHIZOPHRENIA! Schizophrenia / Schizoaffective Bipolar Disorder Psychotic Depression Posttraumatic Stress Disorder (PTSD) CNS Pathology Determine Source - ASK: Mood-Congruence? Bizarre Nature? Treat Psychosis if: Hallucinations Commands, Scary, Disabling Delusions Paranoia Always Medications Antipsychotics ONLY Effective Treatment Psychotic Depression Antidepressant +Antipsychotic > Antidepressant Alone* *Farahani & Correll, 2012

50 COMPLICATIONS -Suicidality- Lifetime risk of suicide in untreated depression = 2-15% (primarily recurrent MDD) 1 PHQ-9 Question 9 : 1-year suicide risk doubles with each response increase 2 Benzodiazepines Risk Acting on suicidal thoughts Lethal with alcohol BLACK BOX WARNING: Adolescents & Young Adults 3 Association between antidepressant use & suicidality controversial 4,5 1 American Association of Suicidology 2 Simon et al, Nischal et al, Nischal et al, Pompili et al, 2010

51 COMPLICATIONS -Suicidality- Suicide Risk Assessment* Presence: Suicidal / homicidal ideation Psychotic symptoms (especially command hallucinations) Severe Anxiety History: Substance abuse Serious prior attempts / gestures Access: Family history / recent suicide exposure Planned means of suicide & access to means Lethality of means *APA Practice Guideline

52 COMPLICATIONS -Suicidality- Immediate referral to psychiatry emergency department Currently suicidal Method Planned + Access to means Rehearsal

53 COMPLICATIONS -Suicidality- Suicide Prophylaxis NO SUICIDE CONTRACT! Only Lithium proven to prevent Valproate? Clozapine? Schizophrenia Schizoaffective Disorder Electroconvulsive Therapy (ECT)? Depression Omega-3-Fatty Acids? Posttraumatic Stress Disorder

54 MDD COURSE & RECURRENCE Course Remission = No Symptoms 2 Months Typical Resolution < 1 year (3-12 months) Treat until Symptom-Free 4-9 Months Recurrence MDD = MDE + Recurrence Higher relapse risk with each subsequent recurrence Lifelong antidepressant after 2 nd relapse

55 WHEN TO REFER TO PSYCHIATRY Psychiatrists believe 2.5% patients too severe for PCP to treat Crisis Care / Psych Emergency Department: Actively Homicidal / Suicidal Psychiatry Referral Patient s Request Chronically Suicidal / Homicidal Active Substance Abuse Numerous Psychiatric Hospitalizations If you feel unsafe Needing treatments beyond your ability to order ECT Clozapine Needing treatments beyond your comfort / training Dissociative Identity Disorder

56 TAKE-HOME POINTS Rarely present complaining of key features (sadness / anhedonia) Depressed Mood Diagnosis MAKE THE DIAGNOSIS! Major Depressive Disorder All antidepressants (except trazodone) equally effective Antidepressant choice based on side effects & comorbidity Suicidal patients present within 1 month prior to attempt Monitor & Adjust Always ask about suicidality Can antidepressant be stopped?

57 FINAL TIPS 1. Diagnosis 1. Spend time to make CORRECT diagnosis 2. Screening questions you ask EVERY depressed patient 1. Grandiosity? 2. Decreased NEED for sleep? 3. Excessive pleasure involvement despite consequences? 2. Monitoring 1. ALWAYS ask about suicidality 2. Follow-up 1-2 weeks after NEW psychotropic given 3. Check Status 4. Either: 1. PHQ-9 2. Questioning

58 3. Treatment FINAL TIPS 1. Don t undertreat! 2. Get comfortable with 2 SSRIs (especially Sertraline) 3. Choose once-a-day dosing if possible! 4. Adults with Attention Deficit Disorder, treat other disorders that affect concentration BEFORE starting stimulants 5. Can antidepressant be discontinued? 4. Psychiatric Referral 1. Chronic or recurrent homicidal / suicidal ideation 2. Prior psychiatric hospitalizations