Why Treat Depression in Primary Care. A Real Case. Depression General Adult Prevalence, Under-recognition, and Under-treatment

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2 A Case Major Depressive Disorder: Improving Models for Care in the Primary Care Setting A 32 year old female without any past medical history presents with a month long history of sadness seeking help for depression Upon further question she further endorses a sense of anhedonia, insomnia, decreased energy, poor appetite, and an intermittent sense of hopelessness No anxiety, mania, or psychotic symptoms No alcohol or other drug use She is well known to you from years of health maintenance visits; you also care for her entire family (husband and two children) Her mother and two sisters all suffer from depression and have responded well to sertraline Examination reveals signs of depression What to do??? A Real Case A 54 year old male with a history of HTN, HLD, and lung cancer presents for a follow-up visit after a hospitalization for nausea, vomiting, and dehydration He verbalizes problems sleeping and a poor appetite Records indicate that he has lost 6kg recently It is only as he is ready to leave that his wife states that she is worried about him being depressed Upon further question he endorses symptoms of depression, anhedonia, hopelessness, and decreased energy along with poor concentration Now what??? Why Treat Depression in Primary Care We are already doing it! 70% of patients with depression initially present with a physical symptom 41% of antidepressants are prescribed by PCPs We are likely going to be doing more of it! 55% of all psychiatrists are older than 55 years of age In 2015, there were about 17,000 US medical school graduates who matched into a residency Only about 4% (774) entered psychiatry residencies in 2015 Simon GE et al. N Engl J Med : Wang PS, et al. Arch Gen Psychiatry 62: , Last accessed on 1/2/ Last accessed 1/2/2016. Depression General Adult Prevalence, Under-recognition, and Under-treatment Depression in Primary Care Under-recognition 50,371 patients were pooled across 41 studies 14 million Experience Depression The overall prevalence of depression (adjusted) was 19 5% (95% CI 15 7% to 23 7%) 7.2 million Treated 6.8 million Untreated Under-diagnosis Unable to access care Treatment refusal Stigma PCPs correctly identified depression 47 3% (95% CI 41 7% to 53 0%) However, diagnostic sensitivity varied greatly between individual studies, ranging from 6 6% to 78 8% Kessler RC, et al. JAMA. 2003;289(23): Mitchell AJ, et al. Lancet. 2009;22;374(9690):

3 Depression General Adult Prevalence, Under-recognition, and Under-treatment Mental Health in Primary Care Under-treatment Poor Adherence 3.2 million Adequately Treated 7.2 million Treated 14 million Experience Depression 4 million Inadequately Treated 6.8 million Untreated Lack of efficacy Adverse events Poor adherence Safety concerns Percentile Antidepressant Adherence Rates Months % Continuing Therapy Risks for Poor Adherence Reluctance to initiate treatment Experience of unanticipated side effects No recollection of being told that the AD needed to be continued for at least 6 months Kessler RC, et al. JAMA. 2003;289(23): Olfson M, et al. Am J Psychiatry. 2006;163(1): Mitchell AJ. Lancet. 2006;367(9528): Impact of Depression Financial Cost Impact of Depression Preventable Costs Annual Costs (Thousands) (n=859) 1-2 (n=616) 3-5 (n=659) 6-16 (n=423) Chronic disease score No depression Mild depression Moderate to severe depression The risk of hospitalization for ACSC associated with depression Incidence rate ratio (95% CI) Any ACSC 1.53 (1.51 to 1.54) Chronic ACSC Angina 1.52 (1.49 to 1.56) COPD/asthma 1.66 (1.62 to 1.70) exacerbation CHF exacerbation 1.09 (1.06 to 1.12) Diabetes-related 1.86 (1.80 to 1.93) HTN 1.30 (1.26 to 1.34) p<0.001 Note: Adjusted for demographics, socioeconomic factors, predisposing comorbidity, and substance use disorders Unützer J, et al. JAMA. 1997;277(20): ACSC- ambulatory care-sensitive conditions Davydow DS et al. BMJ Open Dec 2;5(12):e Impact of Depression Preventable Costs Impact of Depression Depression is Deadly: II Cumulative mortality with an acute coronary syndrome and major depressive disorder The risk of rehospitalization within 30 days for ACSC associated with depression Incidence rate ratio (95% CI) Same ACSC 1.21 (1.18 to 1.24) Another ACSC 1.19 (1.15 to 1.23) p<0.001 Note: Adjusted for demographics, socioeconomic factors, predisposing comorbidity, and substance use disorders RR Hazard ratio: % CI ( ) P<0.001 Davydow DS et al. BMJ Open Dec 2;5(12):e Ham-D- Hamilton Rating Scale for Depression Glassman AH, et al. Arch Gen Psychiatry. 2009;66(9):

4 Impact of Depression Depression is Deadly: III Case I Rate (per 100,000) U.S. Suicide Rates (All rates are per 100,000 population) Year Last accessed 1/2/2016. Total Male Female Suicide (2014) 43,773 deaths 10 th ranking cause of death in US 2 nd ranking cause of death for young in US 3.4 :1 male to female ratio 147 people are exposed to each suicide with 18 suffering serious adverse effects Nonfatal Outcomes (2014) 1,069,325 attempts in the US (estimate) 25 attempts for every death (estimate) :1 for young 4:1 for elderly 3:1 female to male ratio Ms. S is a 62-year-old woman with PMHx significant for HTN and HLD who presents for evaluation of fatigue and depressed mood In addition to the above affective complaints the patient endorses little appetite, poor exercise tolerance, easy frustration, and impaired concentration A comprehensive review of symptoms reveals poor energy, headaches, minimal weight gain, constipation, and dry skin Vital signs reveal a mild asymptomatic bradycardia (58 bpm) HLD- Hyperlipidemia Case I (Continued) Pertinent findings on physical and mental status examinations A tired appearing, well-nourished female in NAD Psychomotor depression She denies psychotic symptoms and is without suicidal ideation She has no personal history of depression Family history of depression in her younger sister successfully treated with venlafaxine Drinks a glass of wine with dinner most nights Diagnosis of Major Depression Initial Evaluation Interview focused on establishing the diagnosis of major depression Five (or more) of the following have been present during the same 2-week period; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure Depressed mood Markedly diminished interest or pleasure Sleep disturbance Psychomotor agitation or retardation Fatigue or loss of energy Symptoms must cause impairment in social, occupational, or other important areas of function Assessment of suicidality Assessment of a history of mania or hypomania Feelings of worthlessness or excessive guilt Diminished ability to concentrate Recurrent thoughts of death, recurrent suicidal ideation, or suicide attempt NAD- No acute distress American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC Diagnosis of Major Depression Initial Evaluation Medical evaluation Requires a differential diagnosis and evaluation Scant empirical cost-benefit evidence to inform the laboratory work-up for depression U/A- Urinalysis RPR- Rapid plasma reagin LFTs- Liver function tests CBC and BMP TSH B 12 and Folate U/A, RPR, and LFTs Case I No pharmacotherapy or referrals are initiated CMP is entirely WNL A thyroid stimulating hormone (TSH) and a complete blood count (CBC) are ordered TSH: 9.9 uiu/ml ( ) WBC: 6.5 ( ) Hgb: 10.5 ( ) Hct: 37 (40-51) Platelets: 288 ( ) You subsequently order a repeat TSH along with a free thyroxine (ft4) TSH: 10.0 uiu/ml ( ) ft4: 0.22 ng/dl ( ) The patient is diagnosed with clinical primary hypothyroidism Levothyroxine (LT4) supplementation is initiated and the patient s affective and somatic signs and symptoms slowly resolve along with the patient s hypothyroid state

5 Diagnosis of Major Depression Differential Diagnosis Major Depression Treatment Options Medical Conditions (Partial List) Bipolar disorder Stroke Obstructive sleep apnea Anemia Organ failure (liver, kidney, lung, brain) Autoimmune disorder Thyroid abnormalities Adrenal insufficiency/cushings syndrome Electrolyte abnormalities Nutritional deficiencies HIV Cancer Medications and Substances (Partial List) Steroids Isotretinoin Beta-interferon Antiepileptic medications Benzodiazepines Reserpine Alcohol Mercury Metoclopramide Methyldopa Bromocriptine Psychotherapy Cognitive therapy Cognitive behavioral therapy (CBT) Interpersonal therapy Psychopharmacology Antidepressants Atypical antipsychotics Mood stabilizers Other potential therapies Electroconvulsive therapy (ECT) Transcranial magnetic stimulation (rtms) Vagal nerve stimulation (VNS) Deep brain stimulation (DBS) Exercise Bright light therapy Sleep deprivation Schulz PE, et al. Continuum(Minneap Minn). 2015;21(3); Pharmacologic - Antidepressants Between 1999 and 2012 in the United States The percentage of adults treated with an antidepressant medication increased from 6.8% to 13.0% SSNRI: 0.4% 2.0% SSRIs: 4.3% 8.5% The percentage who underwent psychotherapy declined Top 4 selling classes of medications in 2009 in the U.S. 1. Antipsychotics ($14.6 billion) 2a. Acid reflux medications ($13.6 billion) 2b. Lipid regulators ($13.6 billion) 3. Antidepressants ($9.9 billion) Kantor ED, et al. JAMA. 2015;314(17): Olfson M, et al. Arch Gen Psychiatry. 2009;66(8): Last accessed 1/2/2016. Pharmacologic - Antidepressants Antidepressants through the generations 1 st generation (MAOIs and TCAs) Increase extracellular monoamines, either through inhibition of catabolism or inhibition of reuptake 2 nd generation (SSRIs) Increase selectivity to reduce side effects No clear benefit in efficacy 3 nd generation (SNRIs, mirtazapine, bupropion, serotonin modulators) Back to multiplicity of action Multiple neurotransmitters Multiple mechanisms of action Multiple receptor sites No clear benefit in efficacy Case II Case II Linda is a 42 year old woman with a PMHx significant for depression, HTN, and breast cancer (ER/PR +) who presented with complaints of anhedonia, tearfulness, little appetite, insomnia, hopelessness, impaired concentration No symptoms of mania or psychosis She also endorses escalating symptoms of depression for >8 weeks A comprehensive review of symptoms reveal stable weight, headaches, decreased libido, and fatigability She is afebrile and the remainder of the vital signs are WNL Pertinent findings on physical and mental status examinations Psychomotor depression and little eye contact Tearful, but no anxiety or psychosis She is without suicidal ideation She was treated for depression with paroxetine in college with good results There is no family history of depression Does not drink alcohol Current medication(s): Tamoxifen and propranolol

6 Pharmacokinetic Adverse Effects Inhibitors May lead to toxicity of a substrate May lead to loss of efficacy if a metabolite is the active agent Inducers May lead to a loss of efficacy if the substrate is the active agent Pharmacokinetic Adverse Effects CYP3A4 Inhibitors Fluoxetine Paroxetine Nefazodone CYP3A4 Substrates Diazepam Zolpidem Fentanyl Macrolide antibiotics Cyclosporine Ca Channel Blockers Pharmacokinetic Adverse Effects Case II CYP2D6 Inhibitors Fluoxetine Paroxetine Sertraline Bupropion Duloxetine CYP2D6 Substrates TCAs Tramadol Oxyocodone Propranolol Tamoxifen Escitalopram was chosen as the best option of the choices provided It is of the same class of antidepressants that had worked previously for the patient - SSRIs It does not cause significant inhibition or induction of CYP2D6 that may complicate the patient s current pharmacotherapy She was started on10mg qd and at 4 weeks reported a partial response and a lack of adverse effects She was titrated to 20mg qd and achieved remission of major depression Pharmacodynamic Adverse Effects Norepinephrine Serotonin Dopamine Histamine-1 antagonism -1 antagonism Muscarinic antagonism Anxiety Sympathomimetic effects Sexual side effects GI disturbances Serotonin syndrome Psychomotor activation Anxiety Nausea Sedation Weight gain Postural hypotension and dizziness Blurred vision Urinary retention and constipation Cognitive impairment Tricyclic antidepressants (TCAs) Names Tertiary: imipramine & amitriptyline Secondary: desipramine & nortriptyline Primary mechanism Block the presynaptic monoamine reuptake pump, thereby increasing the amount of monoamines in the synaptic cleft Therapeutic levels have been established for some Amitriptyline (combined amitriptyline plus metabolite nortriptyline) 80 to 200 ng/ml Nortriptyline 50 to 150 ng/ml Overdose risk 10 day supply can be fatal Nelson, JC. Tricyclic and tetracyclic drugs. In: The American Psychiatric Publishing Textbook of Psychopharmacology, 4th ed, Schatzberg, AF, Nemeroff, CB (Eds), American Psychiatric Publishing, Washington, DC p.263.

7 Tricyclic Antidepressants Pharmacology m-ach receptors -1 receptors 5HT reuptake TCA Blockade of cardiac fast Na channels NE reuptake H1 receptors Selective Serotonin Reuptake Inhibitors (SSRIs) Primary mechanism Block the presynaptic serotonin reuptake pump, thereby increasing the amount of serotonin in the synaptic cleft Affect other neurotransmitters to different degrees All share certain properties Hepatically metabolized Relatively safe in overdose Generic Name Usual Daily Dose Generic Name Usual Daily Dose Citalopram 20-40mg/d Paroxetine 10-50mg/d Escitalopram 10-20mg/d Sertraline mg/d Fluoxetine 10-60mg/d Selective Serotonin Reuptake Inhibitors Pharmacology Antagonism of m-ach receptors Antagonis m of -1 receptors Blockade of cardiac fast Na channels 5-HT reuptake SRI Antagonis m of H1 receptors Inhibition of NE reuptake Inhibition of DA reuptake Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) Names Venlafaxine/Desvenlafaxine Serotonin (5HT) reuptake inhibitor at low dose Dual action (5HT/NE) reuptake inhibitor at higher doses Duloxetine Dual action (5HT/NE) reuptake inhibitor across dose range Levomilnacipran NE>5HT reuptake inhibition Some other potential indications Chronic MSK pain, neuropathic pain, and fibromyalgia Generic Name Usual Daily Dose Generic Name Usual Daily Dose Venlafaxine mg/d Duloxetine 30-60mg/d Desvenlafaxine mg/d Levomilnacipran mg/d Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) Pharmacology m-ach receptors -1 receptors 5HT reuptake SNRI Blockade of cardiac fast Na channels NE reuptake H1 receptors Bupropion Mechanism Norepinephrine (NE) and dopamine (DA) reuptake inhibition Properties Minimal sedation Weight neutral SR formulation FDA-approved for nicotine dependence Contraindicated in patients with a history of seizures or eating disorders Generic Name Bupropion Usual Daily Dose mg/d

8 Bupropion Pharmacology m-ach receptors -1 receptors Blockade of cardiac fast Na channels 5HT reuptake Bupropion NE reuptake H1 receptors DA uptake Mirtazapine Mechanism Presynaptic alpha-2 NE blocker Postsynaptic 5HT2 and 5HT3 blocker Antihistaminic Minimally anticholinergic Side effects Sedation Weight gain Theoretically the antihypertensive effects of clonidine may be negated Case III Serotonin Modulators Primary mechanism Block the presynaptic serotonin reuptake pump, thereby increasing the amount of serotonin in the synaptic cleft They are agonists, partial-agonists, or antagonists at various serotonin receptors All share certain properties Hepatically metabolized Minimal weight gain Relatively safe in overdose Generic Name Vilazodone Vortioxetine Usual Daily Dose 10-40mg/d 10-20mg/d A 26 year old male with a PMHx significant for obesity and depression presents urgently to the office with complaints of restlessness, shivering, and diarrhea of less than 24 hours duration He reports that he has had a cold recently and had, earlier in the day, taken an over-the-counter cough and cold medication Vital signs revealed tachycardia (110bpm) and a temperature of 38 o C Pertinent positives on physical examination include diaphoresis, dilated pupils, and hyper-reflexia Choice of antidepressant is largely based on the following factors Patient preference Nature of prior response to medication Patient and patient s family Safety, tolerability, and anticipated side effects Co-occurring psychiatric or general medical conditions properties of the medication Pharmacodynamic (neurotransmitters) Pharmacokinetic (half-life, metabolism, excretion) Cost Pharmacologic Acute Phase Evidence Treating Acute-Phase Major Depressive Disorder Outcome Strength of Evidence Findings Comparative efficacy Quality-of-life Onset of action Moderate Moderate Moderate Results from direct and indirect comparisons indicate that clinical response and remission rates are similar among secondgeneration antidepressants Consistent results indicate that the efficacy of second generation antidepressants regarding quality of life does not differ among drugs Consistent results suggest that mirtazapine has a statistically significantly faster onset of action than citalopram, fluoxetine, paroxetine, and sertraline Whether this difference favoring mirtazapine can be extrapolated to other second-generation antidepressants is unclear Most other trials do not indicate a faster onset of action of a particular second-generation antidepressant compared with another Gartlehner G, et al. Ann Intern Med. 2011;155(11):

9 Antidepressant Medication Potential Adverse Effects In efficacy trials, an average of 63% of patients experienced at least one adverse event during treatment GI disturbances (diarrhea, nausea) Dizziness Dry mouth Fatigue Headache Sexual dysfunction Tremor Weight gain Sweating Overall, second-generation antidepressants caused similar adverse events The frequency of specific events differ among antidepressants Antidepressant Medication Potential Adverse Effects Weight Gain Effect of AD on Weight Change (after >4m of Treatment) Medication Mean diff (Kg) 95% CI (Kg) P Paroxetine 2.73 (0.78 to 4.68) Mirtazapine 2.59 (-0.23 to 5.41) 0.07 Amitriptyline 2.24 (1.82 to 2.66) < Citalopram 1.69 (-0.97 to 4.34) NS Nortriptyline 1.24 (-0.51 to 2.59) NS Duloxetine 0.71 (-0.23 to 1.65) NS Escitalopram 0.65 (-0.97 to 4.34) NS Sertraline (-1.25 to 1.42) NS Fluoxetine (-1.04 to 0.43) NS Bupropion (-2.37 to -1.37) < Gartlehner G, et al. Ann Intern Med Dec 6;155(11): Serretti A, et al. J Clin Psychiatry 2010;71(10): Depression Treatment Goals Phases of Treatment The goals for depression treatment 1. Achieve remission 2. Restore optimal functioning 3. Prevent relapse 4. Minimize (or manage) treatment side effects Acute Phase 2-3 months Treatment goal is complete remission of symptoms Continuation Phase 4-9 Months Treatment goal is to prevent relapse of depression episode Maintenance Phase >1 year Treatment goal is to prevent a the occurrence of another episode of depression Davidson JR. J Clin Psychiatry. 2010;71(suppl E1) Kupfer DJ. J Clin Psychiatry. 1991;52 Suppl: Phases of Treatment STARD Trial Medication Algorithm Acute Phase 2-3 months Goal is remission Ensure treatment has been administered for a sufficient duration and dose 4 8 weeks are needed to determine responsiveness to a specific intervention Generally, no treatment should continue unmodified if there has been no symptomatic improvement after 1 month Considerations for treatment modification include Maximizing current treatment Switching medications Augmentation Citalopram Switch: bupropion SR, sertraline, or venlafaxine ER Augment: bupropion SR or buspirone Switch: mirtazapine or nortriptyline Augment: lithium or T3 Switch: Tranylcypromine or mirtazapine + venlafaxine ER Gelenberg AJ, et al. Practice guidelines for the treatment of patients with major depressive disorder. Third Edition. American Psychiatric Association Rush, A.J, et al. Am J Psychiatry. 2006;163:

10 STARD Trial Remission Rates STARD Trial Remission and Intolerance Rates Citalopram Switch: bupropion SR, sertraline, or venlafaxine ER Augment: bupropion SR or buspirone Switch: mirtazapine or nortriptyline Augment: lithium or T3 Overall Acute Remission Rates (QIDS-SR) 37% 31% 14% Citalopram Switch: bupropion SR, sertraline, or venlafaxine ER Augment: bupropion SR or buspirone Switch: mirtazapine or nortriptyline Augment: lithium or T3 Overall Acute Remission Rates (QIDS-SR) 37% 31% 14% Overall Intolerance Rates 16% 19% 26% 4 Switch: Tranylcypromine or mirtazapine + venlafaxine ER 13% 4 Switch: Tranylcypromine or mirtazapine + venlafaxine ER 13% 39% Rush, A.J, et al. Am J Psychiatry. 2006;163: Rush, A.J, et al. Am J Psychiatry. 2006;163: STARD Trial A Better More Real-World Trial? More than 82% of STARD participants overall would be ineligible for antidepressant registration trials 14% excluded for being older than 65 years of age 15% ineligible because their depression too mild 20% ruled out due to another medical condition(s) 21% of women would have been denied participation because they did not use birth control Phases of Treatment Continuation Phase 4-9 months For patients who achieve remission continue the medication for 4 9 months The same dose used during the acute phase to achieve remission should be utilized during the continuation phase, if tolerated Monitor for relapse, utilizing Patient Family Assessment tools (PHQ-9) Preskorn SH, et al. Journal Psychiatric Pract. 2015;21: Gelenberg AJ, et al. Practice guidelines for the treatment of patients with major depressive disorder. Third Edition. American Psychiatric Association Phases of Treatment Risk of Relapse and Recurrence Maintenance Phase >12 months Goal is to prevent future episodes of depression (i.e., recurrence) Determine individual risk factors for recurrence Requires a collaborative and open discussion with patient and others The same dose used during the acute and continuation phases should be utilized, if tolerated Monitor for recurrence (PHQ-9) Gelenberg AJ, et al. Practice guidelines for the treatment of patients with major depressive disorder. Third Edition. American Psychiatric Association Residual symptoms increase the risk of an early relapse or recurrence of major depressive The risk of recurrence after one episode of major depression 20% will recur within the first 6 months >50% will have at least one lifetime recurrence Most often within the first 2-3 years The risk of recurrence increases with each subsequent episode of major depression by 16% Lifetime maintenance should be seriously considered for patients with >3 episodes of major depression Mueller TI, et al. Am J Psychiatry 1999; 156 (7): Solomon DA, et al. Am J Psychiatry 2000; 157 (2):

11 Phases of Treatment American College of Physicians Discontinuation Phase Several weeks Goal is to prevent the discontinuation syndrome Gradual taper the antidepressant over at least several weeks Longer taper for medications with short half-lives (paroxetine and venlafaxine IR) Monitor the patient for recurrence of depression Gelenberg AJ, et al. Practice guidelines for the treatment of patients with major depressive disorder. Third Edition. American Psychiatric Association Qaseem A, et al. Ann Intern Med. 2008;149(10): Recommendation 1 The American College of Physicians recommends that when clinicians choose pharmacologic therapy to treat patients with acute major depression, they select second-generation antidepressants on the basis of adverse effect profiles, cost, and patient preferences Grade: strong recommendation; moderate quality evidence American College of Physicians American College of Physicians Recommendation 2 The American College of Physicians recommends that clinicians assess patient status, therapeutic response, and adverse effects of antidepressant therapy on a regular basis beginning within 1-2 weeks of initiation of therapy Grade: strong recommendation; moderate-quality evidence Recommendation 3 The American College of Physicians recommends that clinicians modify treatment if the patient does not have an adequate response to pharmacotherapy within 6-8 weeks of the initiation of therapy for major depressive disorder Grade: strong recommendation; moderate-quality evidence Qaseem A, et al. Ann Intern Med. 2008;149(10): Qaseem A, et al. Ann Intern Med. 2008;149(10): American College of Physicians Depression Treatment Recommendation 4 The American College of Physicians recommends that clinicians continue treatment for 4-9 months after a satisfactory response in patients with a first episode of major depressive disorder. For patients who have had 2 or more episodes of depression, an even longer duration of therapy may be beneficial Collaborative Care Coordinated care management which provides patient-orientated and guideline-based management to patients at the primary care level It is originally conducted on depressive patients Model has diversified to patients with other chronic illnesses Grade: strong recommendation; moderate-quality evidence Qaseem A, et al. Ann Intern Med. 2008;149(10):

12 What is Collaborative Care? Collaborative care (CC) is a systematic approach to the management of depression and/or other medical conditions disorders in medical settings It provides patients with specialty-level care within the context of their primary medical treatment through the use of a team-based approach Three core components 1. Systematic identification of patients with relevant psychiatric disorders via screening 2. Delivery of interventions by a team Patient Primary care provider Specialty physicians Nonphysician care managers 3. Treat-to-target approach based on careful monitoring of patient outcomes Rating scales Registry Screening Proposed New Recommendations USPSTF Depression in Adults: Screening 2016 (Proposed) Population Recommendation Grade General adult population, including pregnant and postpartum women The USPSTF 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. Last accessed 1/1/2016. B Screening - Instruments _Screening Instruments (PHQ-9) Depression Rating Scales Self-Report Test Beck Depression Inventory-II (BDI-II) Patient Health Questionaire-9 (PHQ-9) Patient Health Questionaire-2 (PHQ-2) Center for Epidemiologic Studies Depression Scale, Revised (CESD-R) Quick Inventory of Depressive Symptoms (QIDS-16) Geriatric Depression Scale (GDS) Edinburgh Postnatal Depression Scale (EPDS) Clinician-Administered Test Hamilton Depression Rating Scale (HAM-D) Montgomery-Asberg Depression Rating Scale (MADRS) PHQ-9 Scoring Key PHQ-9 Score Depression Severity 0-4 Minimal 5-9 Mild Moderate Moderately Severe Severe Kroenke K, et al. J Gen Intern Med. 2001;16(9): Screening Possible Flow The Real Case Part I Identify Need to Screen for Depression in Patient Population PHQ-2 PHQ-9 A 54 year old male with a history of HTN, HLD, and lung cancer presents for a follow-up visit after a hospitalization for nausea, vomiting, and dehydration He verbalizes problems sleeping and a poor appetite Records indicate that he has lost 6kg recently Physical examination is remarkable for notable muscle wasting and frailty Mental State Examination is normal, but he is obviously clinically depressed

13 The Real Case Part I (Continued) PHQ-9 indicates moderate depression (score of 13) You ask about depression He endorses multiple affective and neurovegatative symptoms of depression that have been present for over 2 months Detailed laboratory studies, including thyroid function tests, are all within normal limits You diagnose depression and initiate escitalopram You finish clinic early and make it home to dinner (on time) The Real Case Part II The patient meets with the care manager 1 week later, endorses multiple symptoms of depression, admits to not taking escitalopram She educates the patient and recommends continuation of escitalopram Fred s case is discussed at the weekly team meeting with the PCP, care manager, and psychiatrist since he is a new case Psychiatrist agrees with the initial choice of escitalopram After 8 weeks on a therapeutic dose of escitalopram serial PHQ-9 scores show minimal improvement (9-12), and he endorses intermittent nausea, poor appetite, and weight has dropped another 3 kg The Real Case Part II Case discussed with consulting psychiatrist due to failed medication trial Which antidepressant is most appropriate in this case? Mirtazapine Amitriptyline Nortriptyline Bupropion Continue with escitalopram The Real Case Part II The consulting psychiatrist recommended mirtazapine, due to the medications pharmacodynamic characteristics Serotonergic and noradrenergic properties may help treat the major depression 5-HT3 antagonism may help control the patient s complaint of nausea Histaminergic properties may help improve the patient s appetite and insomnia The Real Case Part III Conclusions Care manager is in contact with Fred every other week Repeat screening at 3-6 months done during medical follow-up indicates remission of depression (PHQ-9 scores of 2 and 3) Care manager discussed rationale for continued AD treatment with mirtazapine Sleeping well, appetite improved, and weight trending up Care manager contacts the patient via phone q3 months for next 12 months Monitor adherence, adverse effects, education, recurrence PCP, care manager, and psych in communication verbally and EMR Fred remains in remission from depression and is gaining weight Your high school senior just got a full scholarship to college Your CGCAHPS scores are in the 99% percentile Depression is common Untreated depression is associated with multiple adverse consequences Depression is poorly recognized in primary care, but tools exist to add in the diagnosis and management Depression is treatable and the goal of that treatment should be complete remission of depressive symptoms