Medical Care of Vulnerable and Underserved Populations: Advanced Cases in Anxiety and Depression Disclosures The speakers have no disclosures. Lisa Ochoa-Frongia, MD Christina Mangurian, MD, MAS L. Elizabeth Goldman, MD, MCR Margo Pumar, MD Overview of Workshop Objectives Review challenges in underserved populations Split into small groups to discuss cases Groups come together to review cases Audience questions Conclusions Objectives Understand challenges in diagnosing and treating anxiety and depression in underserved and vulnerable populations Review best practices Learn how to differentiate between different anxiety disorders Review management of treatment refractory depression 1
What best describes your training? Challenges in Underserved and Vulnerable Populations A. Resident B. Nurse Practitioner C. Physician s Assistant D. General Internist or Family Practitioner E. Psychiatrist F. Allied Health Professional 3% 62% 29% 3% R e s i d e n t N u r s e P r a c t i t i o n e r P h y s i c i a n s A s s i s t a n t G e n e r a l I n t e r n i s t o r F a m... 3% 0% P s y c h i a t r i s t A l l i e d H e a l t h P r o f e s s i o n a l Homelessness Poverty Food insecurity Language barriers Violence/crime Medical complexity Contributors to anxiety, depression Health disparities Immigrants Unemploymen t Trauma history Uninsured Standard treatment PLUS services Case 1: Mr. M ID/CC: 32 year-old Spanish-speaking man presenting to primary care with anxiety. HPI: Patient reports significant anxiety. At times so distressed by his symptoms that he thinks he might be better off dead. Numerous recent visits to the ER for chest pain, anxiety, negative cardiac workup. Recent heavy alcohol use and some recreational cocaine use in past. PMH: GERD Case 1: Mr. M Medications: Started paroxetine 20 mg two weeks ago, but does not want to continue since making him sleepy during day, not helping anxiety. Family history: father w/ anxiety, depression. No history of suicide attempts in family. Social history: Moved from Mexico 2 years ago, lives with father. Works in construction. 2
Case 1: Questions What is your behavioral differential diagnosis for Mr. M s anxiety? What instruments, testing, or additional questions could help you clarify his diagnosis? Case 1: Questions After being given additional information by your facilitator, what are your treatment recommendations for Mr. M? How would your treatment differ if he had a history of trauma? Are you concerned about suicide risk? How do you assess this? Anti depressants and Sedation Different patients have different responses Paroxetine generally most sedating SSRI Mirtazapine, Trazodone also very sedating, often used for insomnia Citalopram, escitalopram less sedating/neutral Fluoxetine more activating SNRIs (venlafaxine), bupropion more activating Suicide Risk Assessment Patients who died by suicide were over twice as likely to have PCP visit in month preceding death compared to psychiatrist (45% vs 20%) SAFE-T: Suicide Assessment Five-step Evaluation and Triage 3
Suicide Risk Assessment: SAFE T Case 1 Teaching Points Prior to initiating SSRI/SNRI, screen for symptoms/episodes of mania, trauma history Consider sedating vs. activating SSRI/SNRI Assess suicide risk in patients with SI SSRIS for anxiety: start low and go slow Adjunctive medications to bridge patient to SSRI effect: propranolol, hydroxyzine, BZDs Case 1 Teaching Points Continued Titrate to maximum SSRI dose as tolerated/until symptoms remit Track patient symptoms with a validated tool Switch to a different SSRI if no response to first at maximal dose by 6-8 weeks Case 2: Mrs. D ID/CC: 70 year-old woman with depression, MMP. Mrs. D s depression worsening, very low motivation. Has gained 9 pounds since last visit and back pain worsening. PHQ-9 score is 20. Stopped seeing therapist. PMH: CAD, DM-2, HTN, obesity and chronic low back pain w/sciatica. Treat minimum 6-8 months after sx remit When stopping anti-depressants, taper 4
Case 2: Mrs. D Medications: sertraline 200mg, aspirin, benazepril, carvedilol, atorvastatin, metformin, glipizide, gabapentin, acetaminophen Previously on citalopram for 3 years, stopped working, switched to escitalopram which failed, now on sertraline x 1 year. Case 2: Questions What is the most likely diagnosis of Mrs. D? Why? What would you do to treat her? Why? If you decide to cross-taper her to venlafaxine, how would you do this? Social history: widowed, lives alone, facing eviction Case 2 Teaching Points Definition of treatment-resistant depression: MDD not responding to at least two appropriate courses of antidepressants Algorithm for treatment-resistant depression: STAR-D If PCP comfortable with treating resistant depression, follow algorithm, otherwise refer Simplified STAR*D Algorithm for Treatment of Depression SSRI SNRI Bupropion Step 1 Switch OR Cont. and Augment: Buspar, Bupropion, CBT Switch to Mirtazapine, TCA OR Augment: SGA (Abilify, Seroquel), T3, Lithium, Stimulant Based on STAR D, 2008. Each of these with an 8 week trial at an adequate/tolerated dose. Bupropion, venlafaxine should be prescribed in sustained/extended release. 5
Case 2 Teaching Points Continued Be aware of other conditions: choose medications that might kill two birds with one stone. Depression or anxiety with chronic pain: TCAs, SNRIs Gabapentin and pregabalin also w/anxiolytic effects Anxiety + psychosis: quetiapine has some evidence for off-label use Depression or anxiety with insomnia: mirtazapine When To Refer to Psychiatry When diagnosis is not clear Serious mental illness Depression with psychotic features When medications indicated are beyond PCP s scope of practice (mood stabilizers, antipsychotics) Summary: Advanced Cases in Anxiety and Depression Importance of screening patients for anxiety, depression, using validated tools Keep in mind evidence-based algorithms Follow best practices in medication prescribing Advocate for increased integration of behavioral health Ensure providers in your clinic understand how to refer to behavioral health providers Questions? 6