Depression Assessment and Management. John Kern MD Clinical Professor University of Washington

Transcription

1 Depression Assessment and Management John Kern MD Clinical Professor University of Washington

2 Handouts Antidepressant Treatment Flowchart Managing antidepressant nonresponse handouts 2

3 Diagnosis PHQ-9 Functional loss R/O bipolar SUD Minimal medical clearance 3

4 PRINCIPLES OF COLLABORATIVE CARE Population-Based Care Measurement-Based Treatment to Target Patient-Centered Collaboration Evidence-Based Care Accountable Care Principles University of Washington

5 TREATMENT TO TARGET DRIVES EARLY IMPROVEMENT In a recent retrospective study ( ) of over 7,000 patients: Usual primary care: 614 days Collaborative care program: 86 days Time to Remission for Depression with Collaborative Care Management in Primary Care: JAM Board Fam Med, 2016 Jan-Feb 5

6 ACCOUNTABILITY IN PRACTICE Pay-forperformance cuts median time to depression treatment response in half University of Washington Weeks Before P4P After P4P Unützer et al., 2012

7 RISK ASSESSMENT AT A DISTANCE PHQ-9 Follow-up Questions SAFE-T suicide assessment

8 PRINCIPLE: MEASUREMENT-BASED TREATMENT TO TARGET

9 Level 1: Citalopram ~30% in remission STAR-D SUMMARY REPEATED TREATMENT ATTEMPTS ARE PAR FOR THE COURSE, THEY SHOULD BE PART OF THE PLAN! Level 2: Switch or Augmentation ~50% in remission Level 3: Switch or Augmentation ~60% in remission Rush, 2007 Level 4: Stop meds and start new treatment ~70% in remission

10 COLLABORATIVE CARE VS CO-LOCATION Reduction in PHQ-9 scores: Functional differences: More frequent care manager contact Caseload review 35% 30% 25% 20% 15% 10% 5% 0% CoCM Co-Located Blackmore M et al,, Psychiatric Services in Advance (doi: /appi.ps )

11 PHQ-9 Over the last 2 weeks, how many days have you been bothered by any of the following problems? Not at All Several Days More than Half the Days 1. Little interest or pleasure in doing things Feeling down, depressed or hopeless Trouble falling asleep, staying asleep or sleeping too much Nearly Every Day 4. Feeling tired or having little energy Poor appetite or overeating Feeling bad about yourself or that you are a failure or have let yourself or your family down Trouble concentrating on things, such as reading the newspaper or watching television Moving or speaking so slowly that other people could have noticed. Or the opposite being so fidgety or restless that you have been moving around a lot more than usual Thoughts that you would be better off dead or of hurting yourself in some way If you checked off any problem on this questionnaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all Somewhat difficult Very Difficult Extremely difficult

12 UNDERSTANDING THE PHQ-9 SCORE Score Severity 0 4 No Depression 5 9 Mild Depression Moderate Depression 15 Severe Depression Are there safety concerns? If Question 9 is a score > 0, needs to be assessed for safety Is it depression? MDD: needs to have either Question 1 or Question 2 with a score of >2

13 SUICIDE PREVENTION IN THE PRIMARY CARE SETTING Suicide screening and evidence-based screening can be done efficiently by the collaborative care team using validated tools: Columbia-Suicide Severity Rating Scale (C-SSRS) Suicide Assessment Five-Step Evaluation and Triage (SAFE-T) A collaborative care team can put in place an efficient suicide risk response protocol that makes this difficult scenario MUCH EASIER for the PCP and clinic.

14 COLUMBIA-SUICIDE SEVERITY RATING SCALE COLUMBIA-SUICIDE SEVERITY RATING Primary Care Screen SCALE with Triage (C-SSRS) Points SUICIDE IDEATION DEFINITIONS AND PROMPTS: Past month Ask questions that are in bold and underlined. YES NO Ask Questions 1 and 2 1) Wish to be Dead: Person endorses thoughts about a wish to be dead or not alive anymore, or wish to fall asleep and not wake up? Have you wished you were dead or wished you could go to sleep and not wake up? 2) Suicidal Thoughts: General non-specific thoughts of wanting to end one s life/commit suicide, I ve thought about killing myself without general thoughts of ways to kill oneself/associated methods, intent, or plan. Have you had any actual thoughts of killing yourself? If YES to 2, ask questions 3, 4, 5, and 6. If NO to 2, go directly to question 6. 3) Suicidal Thoughts with Method (without Specific Plan or Intent to Act): Person endorses thoughts of suicide and has thought of a least one method during the assessment period. This is different than a specific plan with time, place or method details worked out. I thought about taking an overdose but I never made a specific plan as to when where or how I would actually do it.and I would never go through with it. Have you been thinking about how you might do this? 4) Suicidal Intent (without Specific Plan): Active suicidal thoughts of killing oneself and patient reports having some intent to act on such thoughts, as oppose to I have the thoughts but I definitely will not do anything about them. Have you had these thoughts and had some intention of acting on them? 5) Suicide Intent with Specific Plan: Thoughts of killing oneself with details of plan fully or partially worked out and person has some intent to carry it out. Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? 6) Suicide Behavior Question Have you ever done anything, started to do anything, or prepared to do anything to end your life? Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn t swallow any, held a gun but changed your mind or it was grabbed from your hand, went to the roof but didn t jump; or actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc. Lifetime Past 3 Months If YES, ask: Was this within the past 3 months? Response Protocol to C-SSRS Screening (Linked to last item marked YES ) Item 1 Behavioral Health Referral Item 2 Behavioral Health Referral Item 3 Behavioral Health Consult (Psychiatric Nurse/Social Worker) and consider Patient Safety Precautions Item 4 Behavioral Health Consultation and Patient Safety Precautions Item 5 Behavioral Health Consultation and Patient Safety Precautions Item 6 Behavioral Health Consult (Psychiatric Nurse/Social Worker) and consider Patient Safety Precautions Item 6 3 months ago or less: Behavioral Health Consultation and Patient Safety Precautions

15 SUICIDE ASSESSMENT FIVE-STEP EVALUATION AND TRIAGE (SAFE-T)

16 ESTABLISH A DIAGNOSIS Identify & Engage Establish a Diagnosis Initiate Treatment Follow-up Care & Treat to Target Complete Treatment & Relapse Prevention University of Washington

17 BASIC DIFFERENTIAL DIAGNOSIS Mood Depression Mania/Hypomania Anxiety and Trauma Disorders Generalized anxiety Panic attacks PTSD OCD Psychosis Primary Secondary Substance Use Alcohol Illicit Prescription Organic Cognitive function Relevant medical history

18 PROVISIONAL DIAGNOSIS: HOW A TEAM CAN HELP Screeners filled out by patient Assessment by BHP/care manager and PCP Psychiatric consultant case review (or direct evaluation) Provisional diagnosis University of Washington

19 ASSESSMENT AND DIAGNOSIS IN THE PRIMARY CARE CLINIC Gather information Diagnosis can require multiple iterations of assessment and intervention Provide intervention Exchange information Advantage of populationbased care is longitudinal observation and objective data Generate a treatment plan University of Washington Start with diagnosis that is your best understanding and can adjust over time

20 WHY TO RULE OUT BIPOLAR DISORDER Poor response to antidepressant Risk of mania Assessment carried out by care manager

21 Depression Protocol Walkthrough 21

22 STEPPED DEPRESSION TREATMENT SSRI, SNRI, Bupropion Switch Medication, Switch Class, Augment with Bupropion, Mirtazapine Antipsychotic, TCA Other

23 CHOOSING ANTIDEPRESSANTS Prior treatment history in patient/family members Patient preferences Expertise of prescribing provider Side effect profile Safety in overdose (TCA) Drug-drug interactions

24 COMMON ANTIDEPRESSANT SIDE EFFECTS Short term: GI upset / nausea Jitteriness / restlessness / insomnia Sedation / fatigue Long term: Sexual dysfunction (up to 33%) Weight gain (5 10%)

25 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

26 EXERCISE 5 MANAGING ANTIDEPRESSANT NONRESPONSE 1. Failure to respond to 2 SSRI s What to do? 2.Depression responds but stopping because of sexual side effects Which med to choose? 3. Impatient patient not better 2 weeks after initiation of antidepressant. What to do?

27 QUESTIONS?