A PATIENT-CENTERED APPROACH TO THE MANAGEMENT OF DEPRESSION

Transcription

1 Education Partner A PATIENT-CENTERED APPROACH TO THE MANAGEMENT OF DEPRESSION November 15, 212 Boston, Massachusetts

2 Session 3: A Patient-Centered Approach to the Management of Depression: Achieving and Maintaining Remission in the Primary Care Setting Learning Objectives 1. Develop strategies for effectively screening patients for depression within the boundaries of the primary care office visit. 2. Evaluate measurement-based care, specifically the APA guidelines, and strategies to address failure of initial antidepressant therapy. 3. Apply clinical data and guideline recommendations in creating an individualized, appropriate, and effective treatment plan. Sloan Manning, MD Adjunct Associate Professor University of North Carolina Chapel Hill, North Carolina Co-Director, Mood Disorders Clinic Moses Cone Family Practice Residency Greensboro, North Carolina Dr Manning is adjunct associate professor in the department of family medicine at the University of North Carolina at Chapel Hill. He also serves as co-director of the Mood Disorders Clinic at the Moses Cone Family Practice Residency in Greensboro, North Carolina. He earned his MD from the University of Mississippi Medical Center and completed his residency in family practice at Baptist Memorial Hospital in Gadsden, Alabama. He is board certified by the American Board of Family Practice, and is a member of both the American Academy of Family Physicians and the North Carolina Academy of Family Physicians. Dr Manning is the founding editor of The Primary Care Companion to The Journal of Clinical Psychiatry, and has authored or coauthored more than 5 letters, articles, and editorials in a variety of journals, including Archives of Family Medicine, Bipolar Disorders, Comprehensive Psychiatry, Journal of Affective Disorders, Journal of Clinical Psychiatry, North American Clinics of Psychiatry, and The Journal of Family Practice. He is also a reviewer for the Journal of Affective Disorders. His research interests include integrated somatic/mental health care systems in primary care, physician education in primary care psychiatry, and disorders of the bipolar spectrum, including their temperamental underpinnings and pharmacologic management. He was a member of the national coordinating council for the STABLE project, researching performance measures and quality improvement initiatives for bipolar treatment. Roger S. McIntyre, MD, FRCPC Professor of Psychiatry and Pharmacology Head, Mood Disorders Psychopharmacology Unit Toronto, Ontario, Canada Dr McIntyre is currently professor of psychiatry and pharmacology at the University of Toronto and head of the mood disorders psychopharmacology unit at the University Health Network, Toronto, Canada. He is involved in multiple research endeavors that primarily aim to characterize the association between mood disorders and medical comorbidity. This research involves elucidating metabolic adverse events associated with the use of psychotropic medications, the impact of medical comorbidity on the course of mood disorders, and the effect of glucose homeostasis on neurocognition. Dr McIntyre is a contributor to the Canadian Psychiatric Association (CPA) guidelines for the treatment of depressive disorders and the Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines for the management of bipolar disorder. He has published extensively in leading peer-reviewed journals and textbooks. Dr McIntyre is also a reviewer for many journals including the American Journal of Psychiatry, Biological Psychiatry, Journal of Clinical Psychiatry, and The New England Journal of Medicine, and serves as a grant reviewer for the National Institute of Mental Health. He completed his MD at Dalhousie University and did his psychiatry residency training and fellowship in psychiatric pharmacology at the University of Toronto. Session 3

3 Faculty Financial Disclosure Statements The presenting faculty reports the following: Dr Manning has disclosed that he is a consultant for AstraZeneca, Eli Lilly, Lundbeck, PamLab LLC, and Takeda. He is also a member of the speakers bureaus for AstraZeneca and Eli Lilly. Dr McIntyre has disclosed that he is a consultant for AstraZeneca, Bristol-Myers Squibb, GlaxoSmithKline, Janssen-Ortho, Eli Lilly, Lundbeck, Merck, Organon, Pfizer, and Shire. He is a member of the speakers bureaus for AstraZeneca, Biovail, Bristol-Myers Squibb, Eli Lilly, Merck, and Pfizer and receives grant/research support from AstraZeneca, Eli Lilly, Janssen, Lundbeck, Pfizer, and Shire. Education Partner Financial Disclosure Statement The content collaborators at Creative Educational Concepts report the following: Joan B. Fowler, PharmD, BCPP-Vice-President, has no financial relationships to disclose. Nathan Hamilton, PharmD-Clinical Support, has no financial relationships to disclose. Ashley C. Lilly, MHA-Account Director, has no financial relationships to disclose. Suggested Reading List Gaynes BN, Rush AJ, Trivedi MH, et al. The STAR*D study: treating depression in the real world. Cleve Clin J Med. 28;75(1): Lam RW, Kennedy SH, Grigoriadis S, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults. III. Pharmacotherapy. J Affect Disord. 29;117(Suppl 1):S26-S43. McIntyre RS. When should you move beyond first-line therapy for depression? J Clin Psychiatry. 2;71(Suppl 1):16-2. Nelson JC, Papakostas GI. Atypical antipsychotic augmentation in major depressive disorder: a meta-analysis of placebocontrolled randomized trials. Am J Psychiatry. 29;166(9): Papakostas GI. Managing partial response or nonresponse: switching, augmentation, and combination strategies for major depressive disorder. J Clin Psychiatry. 29;7(Suppl 6): Perahia DG, Quail D, Desaiah D, et al. Switching to duloxetine from selective serotonin reuptake inhibitor antidepressants: a multicenter trial comparing 2 switching techniques. J Clin Psychiatry. 28;69(1):95-5. Szegedi A, Jansen W, van Willigenburg AP, et al. Early improvement in the first 2 weeks as a predictor of treatment outcome in patients with major depressive disorder: a meta-analysis including 6562 patients. J Clin Psychiatry. 29;7(3): Session 3

4 Session 3 :45 AM - 12: PM A Patient-Centered Approach to the Management of Depression: Achieving and Maintaining Remission in the Primary Care Setting Speakers: Sloan Manning, MD Roger S. McIntyre, MD, FRCPC Presenter Disclosure Information The following relationships exist related to this presentation: Dr Manning has disclosed that he is a consultant for AstraZeneca, Eli Lilly, Lundbeck, PamLab LLC, and Takeda. He is also a member of the speakers bureaus for AstraZeneca and Eli Lilly. Dr McIntyre has disclosed that he is a consultant for AstraZeneca, Bristol-Myers Squibb, GlaxoSmithKline, Janssen-Ortho, Eli Lilly, Lundbeck, Merck, Organon, Pfizer, and Shire. He is a member of the speakers bureaus for AstraZeneca, Biovail, Bristol-Myers Squibb, Eli Lilly, Merck, and Pfizer and receives grant/research support from AstraZeneca, Eli Lilly, Janssen, Lundbeck, Pfizer, and Shire. Off-Label/Investigational Discussion: In accordance with pmicme policy, faculty have been asked to disclose discussion of unlabeled or unapproved use(s) of drugs or devices during the course of their presentations. Drugs Referenced in Symposium A Patient Centered Approach to the Management of Depression: Achieving and Maintaining Remission in the Primary Care Setting Aripiprazole Bupropion Buspirone Citalopram Duloxetine Escitalopram Lithium Milnacipran Mirtazapine Nortriptyline Olanzapine Quetiapine Risperidone Sertraline Triiodothyronine Venlafaxine Please indicate the approximate number of patients that you see each week with depression 1. None 2. 1 to to to to to to Which of the following is a realistic goal for a patient undergoing treatment for MDD? 1. 75% reduction in depression score % reduction in depression score % reduction in depression score 4. <25% reduction in depression score 1

5 Which of the following is not an appropriate firstline switch in a patient who has failed an SSRI? 1. Escitalopram 2. Duloxetine 3. Buspirone 4. Mirtazapine 5. Bupropion Which of the following can most reliably be performed in the confines of the modern 15 minute office visit? 1. 9 item Patient Health Questionnaire item Hamilton Depression Rating Scale 3. Montgomery Asberg Depression Rating Scale 4. Quick Inventory of Depressive Symptomatology Self Report Which of the following statements is true regarding antidepressant response at 2 weeks? 1. Assessing response at two weeks likely does not yield clinically meaningful information 2. Symptom improvement at two weeks is highly predictive of overall treatment response 3. No symptom improvement at two weeks is highly predictive of overall treatment failure 4. Assessing for improvement at two weeks is only useful in severely depressed patients Learning Objectives 1. Develop strategies for effectively screening patients for depression within the boundaries of the primary care office visit. 2. Evaluate measurement based care, specifically the APA guidelines, and strategies to address failure of initial antidepressant therapy. 3. Apply clinical data and guideline recommendations in creating an individualized, appropriate, and effective treatment plan The Status Quo Physicians fail to recognize depression in 3 5% of patients Only 5% of patients receive minimally adequate pharmacologic treatment Less than % receive minimally adequate psychotherapy visits Healthy People 22: Mental Health Goals Several Healthy People 22 goals pertain to depression: Increase the proportion of primary care facilities that provide mental health treatment onsite or by paid referral Reduce the proportion of persons who experience major depressive episodes Increase the proportion of adults aged 18 and older with major depressive disorder (MDD) who receive treatment Increase depression screening by primary care providers Simon GE, et al. Gen Hosp Psychiatry. 22;24(4): Healthy People 22. Available at: objectiveslist.aspx?topicid=28. Accessed September

6 Challenging the Traditional Model The DIAMOND Model A plurality of trials have evaluated collaborative care models for depression Two 212 systematic reviews evaluated a total of 69 randomized trials of collaborative care 1,2 Consistently more effective than traditional model Higher response to treatment Higher remission rates Improved treatment adherence Improved quality of life and functional status DIAMOND Depression Intiative Across Minnesota, Offering a New Direction Designed by the Institute for Clinical Systems Improvement (ICSI) Payment redesign targeted to realign incentives DIAMOND model included 8 primary care practices; 7 health plans 1 Thota AB, et al. Am J Prev Med. 212;42(5): ; 2 Jacob V, et al. Am J Prev Med. 212;42(5): Pietruszewski P. Psychiatr Serv. 2;61(): The DIAMOND Model The DIAMOND Model Consists of four processes: Standardized assessment and monitoring (PHQ 9) Registry for tracking patients Stepped care for intensifying and changing treatment Measures to prevent relapse Introduces two new players: Care manager for follow up, coordination Consulting psychiatrist for recommendations Physician Patients 18 years of age with: Diagnosed dysthymia/mdd or PHQ 9 score Case Manager Screened for EtOHism, anxiety, bipolar disorder; Scenario and PMH gathered; Presented to psychiatrist weekly Psychiatrist Reviews weekly for recommendations Results in: no wait times to be seen, more patients seen per week, greater focus of resources, problems addressed in shorter timeframe Pietruszewski P. Psychiatr Serv. 2;61(): Pietruszewski P. Psychiatr Serv. 2;61(): The DIAMOND Model: Outcomes at Six Months Grand Challenges in Global Mental Health: The Burden of Depression % of Patients Achieving Remission Six month Remission 26% 8% 6% Primary Care Behavioral Health Clinics DIAMOND Clinics Care Model Pietruszewski P. Psychiatr Serv. 2;61(): Collins PY, et al. Nature. 211;475(7354):

7 Multidimensionality of Mood Disorders Relative Risk of Cardiovascular and Overall Mortality from the Nurses Health Study Migraine Personality disorders Pain disorders ADHD Diabetes mellitus Mood Disorder Impulse control Cardiovascular Anxiety disorders Obesity Eating disorders Substance abuse The prevalence and epidemiology of psychiatric and medical comorbidities in mood disorders is high Stress sensitive medical disorder prevalent Cardiometabolic disorders most common specific cause of premature mortality Cardiovascular Mortality N=78,282 (aged yrs) Overall Mortality McIntyre RS, et al. Hum Psychopharmacol. 24;19(6): Pan A, et al. Arch Gen Psychiatry. 211;68(1):42 5. Adiposity, Inflammation and Depression Increased Inflammation Predicts Higher HAM D Scores & Treatment Resistance HAM D Correlation of IL 6 and HAM D scores r=.38, P= IL 6 (pg/ml) IL 6 (pg/ml) IL 6 vs. Treatment Response P<.1 P<.1 P<.5 controls responsive refractory IL 6=interleukin 6; HAM D=Hamilton Rating Scale for Depression Shelton RC and Miller AH. Prog Neurobiol. 2;91(4): Yoshimura R, et al. Prog Neuropsychopharmacol Biol Psychiatry. 29;33(4): Body Mass Index: Impact on Antidepressant Response Response to antidepressant treatment according to weight status. Mean Hamilton Depression test (HAM D) rating scores and SEMs for 5 weeks after hospitalization (left) in normal body mass index (BMI) and high BMI patients and (right) in normal BMI, overweight, and obese patients CBT & Inflammation: Symptom, and Neurobiological Marker Improvement Change in IL 6 HAM D score 29 BMI BMI > admission week 1 week 2 week 3 week 4 week 5 HAM D score BMI 25 25< BMI 3 BMI >3 13 admission week 1 week 2 week 3 week 4 week Pg/mL Effect size (UC CBT vs UC)=.61 Change in CRP Effect Effect Size size (UC CBT vs vs UC)= UC)=.85 SEM=specific event memory Kloiber S, et al. Biol Psychiatry. 27;62(4): CRP = C reactive protein; CBT= cognitive behavioral therapy CABG = coronary artery bypass graft Doering LV, et.al. Altern Ther Health Med. 27;13(3):

8 Remission is the Goal Remission is the Goal % Reduction in Score Remission >75% Response 5% 74% Partial Response 25% 49% Nonresponse <25% % Reduction in Score Remission >75% APA MDD Treatment Guidelines: The goal of acute phase treatment Response for major depressive 5% 74% disorder, insofar as possible, Partial is to Response achieve remission 25% and 49% a return to full functioning and quality of life. Nonresponse <25% Remission also defined as attainment of a virtually asymptomatic status (17 item Hamilton Depression Rating Scale [HDRS] score 7) for at least two consecutive weeks. Frank E, et al. Arch Gen Psychiatry. 1991;48(9): ; McIntyre R, et al. J Psychiatry Neurosci. 22;27(4): Remission also defined as attainment of a virtually asymptomatic status (17 item Hamilton Depression Rating Scale [HDRS] score 7) for at least two consecutive weeks. American Psychiatric Association. Practice Guidelines for the Treatment of Patients with Major Depressive Disorder, 3 rd Edition. 2. Definition of Outcomes Response (without remission) 5% decrease in baseline depression scores Remission HAM D score 7 (also referred to as HDRS) QIDS SR score 5 QIDS SR=Quick Inventory of Depression Symptomology Self Report Trivedi MH, et al. Am J Psychiatry. 26;163(1):28 4. IDS C 3 total score Measurement Based Care Leads to Better Outcomes vs. Usual Care Prospective trial evaluating clinical outcomes for patients with MDD (N=35) receiving algorithm guided treatment or treatment as usual Baseline IDS C 3 : 3 item Inventory of Depressive Symptomatology Clinician Rated Scale Months Treatment as usual (N=175) Algorithm guided treatment (N=175) Trivedi MH, et al. Arch Gen Psychiatry. 24;61(7): Causes of Non Remission in Major Depressive Disorder Evidence Based Treatment Options Failure to establish the diagnosis Absence of measurement based care Complex illness presentations Absence of early improvement SSRIs (fluoxetine, paroxetine, etc) SNRIs (duloxetine, venlafaxine) NRIs (bupropion) 5HT 2 antagonists (trazodone) Atypical antipsychotics (aripiprazole, quetiapine, etc) Noradrenergic antagonist (mirtazapine) TCAs (amitriptyline, nortriptyline, etc) MAOIs (phenelzine) 5

9 Other Treatment Options Non Drug Therapy/Procedures Buspirone Folate Inositol Lamotrigine Lithium Melatonin Omega 3 fatty acids Pindolol Psychostimulant (e.g., modafinil) S adenosyl methionine (SAM e) St. John s wort Testosterone Thyroid hormone Acupuncture Deep brain stimulation (DBS) Electroconvulsive Therapy (ECT) Light therapy Psychosurgery Psychotherapy Transcranial Magnetic Stimulation (TMS) Vagus Nerve Stimulation (VNS) Tools to Assess Response & Remission CANMAT Recommendations for Incomplete Response to an Initial Antidepressant Measure Time to complete (mins) Patient/ clinician rated Symptoms 9 item Patient Health Questionnaire (PHQ 9) <3 Patient 17 item Hamilton Depression Rating Scale (HDRS 17) 3 Patient or clinician Beck Depression Inventory (BDI) 5 Patient Montgomery Asberg Depression Rating Scale (MADRS) 15 Patient or clinician Quick Inventory of Depressive Symptomatology Self Report (QIDS SR) 5 Patient or clinician Toronto 7 item Hamilton Depression Rating Scale (HDRS 7) NA Clinician Sheehan Disability Scale (SDS) 1 2 Patient or clinician First line switch Duloxetine Escitalopram Milnacipran* Mirtazapine Sertraline Venlafaxine First line add on Aripiprazole Lithium Olanzapine Risperidone Download: PHQ 9 at primarycare.org and HAM D 7 at McIntyre RS. J Clin Psychiatry. 2;71(Suppl1):16 2. CANMAT=Canadian Network for Mood and Anxiety Treatments *Not FDA approved for treating depression Lam RW, et al. J Affect Disord. 29;117(Suppl 1):S26 S43. Treatment Strategies Options Optimization Augment the treatment regimen with a nonantidepressant agent Combine the initial antidepressant with a second antidepressant Switch to a different antidepressant (within class or across classes) Optimization Adequate adherence 2% of TRD is attributable to nonadherence underestimate 1/3 of patients are nonadherent to antidepressant therapy Adequate dose Adequate duration Papakostas GI. J Clin Psychiatry. 29;7(Suppl 6): TRD=treatment resistant depression Souery D, et al. Eur Neuropsychopharmacol. 1999;9(1 2):83 91; Nemeroff CB. J Clin Psychiatry. 23;64(Suppl 18):

10 Options Optimization Augmentation Combination Switching Treatment Strategies Are We Reassessing Too Late? Early Improvement at 2 Weeks Predicts Response Early improvement at week 2 (N=4284) 53% Went on to have a stable response Stable response No stable response No improvement at week 2 (N=2263) 89% Did NOT go on to have a stable response Lack of improvement in first 2 weeks of treatment may indicate that changes in management should be considered Early Improvement: 2% score reduction from baseline on the HDRS 17 within 2 weeks of treatment Follow up response determined at wk 4 8 Papakostas GI. J Clin Psychiatry. 29;7(Suppl 6): Szegedi A, et al. J Clin Psych. 29;7(3): Case #1: Debbie 35 year old WF Works in call center for major credit card company Medical History: HTN (HCTZ 25 mg QD), seasonal allergic rhinitis Social History: +Tobacco (1/2 ppd), +EtOH (1 2 beers/wk) Family History: Son (ADHD), mother (treated with antidepressants), sister (substance abuse in high school) Psychiatric History: Onset of depressive symptoms at age 25 after husband s affair; now divorced x 6 yrs Previously has taken four antidepressants: Paroxetine (max dose 2 mg; weight gain, sexual adverse effects; duration of tx=4 6 months) Bupropion (max dose 15 mg; headache, agitation) Escitalopram (currently on 2 mg x 3 months; experiencing mild orgasmic delay) Case: Debbie Diagnosis Debbie: MDD Difficult to treat Failed three separate pharmacologic approaches Bipolar disorder ruled out Most difficult symptoms: Insomnia Irritability Case: Approach to Treatment for MDD Make diagnosis Choose reasonable intervention Follow through with intervention Measurement based approach with: Set visit schedule Regular monitoring of symptom improvement, side effects, medication adherence Set dose titration and treatment algorithm Use of critical decision points 7

11 Are We Reassessing Too Late? Early Improvement at 2 Weeks Predicts Response Early improvement at week 2 (N=4284) 53% Went on to have a stable response Stable response No stable response No improvement at week 2 (N=2263) 89% Did NOT go on to have a stable response Lack of improvement in first 2 weeks of treatment may indicate that changes in management should be considered Early Improvement: 2% score reduction from baseline on the HDRS 17 within 2 weeks of treatment Follow up response determined at wk 4 8 Treating Depression in the Real World Remission, not response, is the goal Should first treatment fail, either switching or augmenting is reasonable For most patients, remission requires repeated trials of sustained, vigorously dosed antidepressant medication Likelihood of remission substantially decreases after two adequate treatment trials, suggesting need for more complicated regimens and psychiatric consultation Szegedi A, et al. J Clin Psych. 29;7(3): Gaynes B, et al. Cleve Clin J Med. 28;75(1): Strategies for Refractory Depression STAR*D Treatment Strategies and Options Switch to a different antidepressant (within class or across classes) Augment the treatment regimen with a nonantidepressant agent Combine the initial antidepressant with a second antidepressant Psychosocial Intervention Manual Based Therapy (e.g., Cognitive Behavioral Therapy) Family Focused Therapy (FFT) Psychoeducation/Bibliotherapy Others BUP SR SERT CIT: citalopram CT: cognitive therapy BUS: buspirone BUP SR: bupropion sust. rel. Li: lithium MIRT: mirtazapine NTP: nortriptyline SERT: sertraline T 3:triiodothyronine TCP: tranylcypromine VEN XR: venlafaxine ext. rel. SWITCH VEN XR SWITCH MIRT TCP NTP Citalopram CT BUP SR SWITCH LEVEL 1 CT + CIT SWITCH VEN XR Li + BUP SR, SERT, VEN XR, or CIT MIRT + VEN XR CIT + BUP SR LEVEL 2A AUGMENT AUGMENT T 3 + BUP SR, SERT, VEN XR, or CIT LEVEL 4 CIT + BUS LEVEL 3 LEVEL 2 Papakostas GI. J Clin Psychiatry. 29;7(Suppl 6): Adapted from Warden D, et al. Curr Psychiatry Rep. 27;9(6): STAR*D Cumulative Remission Rates STAR*D Clinical Study Results Remission Rates (HAM D 17 7) Cumulative Remission Rates (%) % 63% 57% 33% Level 1 Level 2 Level 3 Level 4 Gaynes B, et al. Cleve Clin J Med. 28;75(1): Level 2 Level 1 (1 failure) 11.9 weeks 8 weeks 3 Mono Augm 2 Low Mono Level 3 (2 failures) 14 weeks Level 4 (3 failures) 14 weeks Mono = monotherapy Augm = combination treatment McGrath P, et al. Am J Psychiatry. 26; Rush A, et al. Am J Psychiatry. 26; Nierenberg A, et al. Am J Psychiatry. 26; Trivedi M, et al. Am J Psychiatry. 26; Trivedi M, et al. N Engl J Med. 26. Augm Treatment Resistance Mono Augm Mono High 8

12 Remission Rates in STAR*D Level 1 Citalopram STAR*D: Level 2 Medication Switch Citalopram to Bupropion SR, Sertraline, or Venlafaxine XR 5 47% 5 % Patients % 33% HRSD 17 QIDS SR % 26% 18% 27% 25% 25% HRSD 17 QIDS SR 16 Response Remission Bupropion SR Sertaline Venlafaxine XR N=2,876 HRSD 17 response not reported Trivedi MH, et al. Am J Psychiatry. 26;163(1):28 4. N=727 P=Not significant among groups Rush AJ, et al. N Engl J Med. 26;354(12): Non STAR*D evaluated Medication Switch SSRI to Duloxetine STAR*D: Level 2 Switch Cognitive Therapy Versus Medication P.1 vs. baseline 36% 37% Direct Switch Taper Switch Although not included in the STAR*D framework, CANMAT recommendations include duloxetine as a first line switch Study at left included switches from any SSRI to duloxetine Remission measured via changes in HRSD 17 scores HRSD 17 QIDS SR 16 31% 28% 27% 25% Graph at left shows CBT vs. all Level 2 pharmacotherapy strategies (augmentation and switch) Results were similar between both groups Pharmacotherapy groups achieved remission faster, but had a side effect burden Duloxetine CBT Medication Strategies N=168 P=Not significant between groups Perahia DG, et al. J Clin Psych. 28;69(1):95 5. N=122 P=Not significant among groups Thase ME, et al. Am J Psychiatry. 27;164(5): STAR*D: Level 3 Medication Switch Mirtazapine or Nortriptyline STAR*D: Level 4 Medication Switch Tranylcypromine or Mirtazapine Combined With Venlafaxine XR % 8% 2% 12% HRSD 17 QIDS SR % 14% 14% 16% HRSD 17 QIDS SR 16 Mirtazapine Nortiptyline Tranylcypromine Venlafaxine XR + Mirtazapine N=235 P=NS among groups Fava M, et al. Am J Psychiatry. 26;163(7): N=9 P=NS among groups McGrath PJ, et al. Am J Psychiatry. 26;163(9):

13 STAR*D: Level 2 Medication Augmentation Bupropion SR or Buspirone Non STAR*D Evaluated Augmentation Adding Atypical Antipsychotics to SSRIs % 39% 3% 33% HRSD 17 QIDS SR 16 Remission OR: 2. (95% CI )** Discontinuation for Adverse Events OR: 3.91 (95% CI )** NNT = 9 NNH = 17 Remission rate 3.7% vs. 17.2% for placebo Adverse event discontinuation rate 9.1% vs. 2.3% for placebo Augmentation with an atypical antipsychotic is also a first line CANMAT strategy not evaluated in STAR*D Meta analysis at left includes trials of augmenting initial SSRI failure with select* atypicals Remission measured via changes in HDRS 17 scores N=656 P=NS among groups Bupropion SR Buspirone Trivedi MH, et al. N Engl J Med. 26;354(12): *AAs 16 Trials; include 3,48 olanzapine, patients risperidone, quetiapine, aripiprazole **P<.1 Atypical antipsychotic (AA) vs. placebo Nelson JC, Papakostas G. Am J Psychiatry. 29;166(9): STAR*D: Level 3 Medication Augmentation Lithium or Triiodothyronine Summary and Conclusions % 15% Lithium* 25% 23% Triiodothyronine HDRS 17 QIDS SR 16 Depression is under recognized and undertreated in current primary care practice Adequate screening can be performed within the confines of the modern office visit Remission is an achievable treatment goal Early (2 week) follow up may predict response Algorithm guided care improves patient outcomes *Lithium group had significantly higher d/c rates; N=142; P=NS among groups for efficacy Nierenberg AA, et al. Am J Psychiatry. 26;163(9): Which of the following is a realistic goal for a patient undergoing treatment for MDD? Post test 1. 75% reduction in depression score % reduction in depression score % reduction in depression score 4. <25% reduction in depression score

14 Which of the following is not an appropriate firstline switch in a patient who has failed an SSRI? Which of the following can most reliably be performed in the confines of the modern 15 minute office visit? 1. Escitalopram 2. Duloxetine 3. Buspirone 4. Mirtazapine 5. Bupropion 1. 9 item Patient Health Questionnaire item Hamilton Depression Rating Scale 3. Montgomery Asberg Depression Rating Scale 4. Quick Inventory of Depressive Symptomatology Self Report Which of the following statements is true regarding antidepressant response at 2 weeks? 1. Assessing response at two weeks likely does not yield clinically meaningful information 2. Symptom improvement at two weeks is highly predictive of overall treatment response 3. No symptom improvement at two weeks is highly predictive of overall treatment failure 4. Assessing for improvement at two weeks is only useful in severely depressed patients Questions & Answers? 11