Changing the Landscape for Depression Treatment in NYC

1. Changing the Landscape for Depression Treatment in NYC Judy Stein, LMSW, MS Co-Director of Depression Initiative NYC Department of Health and Mental Hygiene February 28, 2006

2. Outline Take Care New York DOHMH Depression Initiative Geriatric Depression Prevalence Suicide Risk factors Depression and Chronic Disease Depression in Primary Care

3. Outline Depression Screening Depression Management IMPACT Study Bronx Geriatric Depression Pilot Project DOHMH Depression Initiative Projects

4. Take Care New York (TCNY) A health policy that prioritizes actions to help individuals, health care providers and New York City as a whole to improve health Sets an agenda for 10 key areas for intervention Addresses preventable causes of illness/death Focuses on undeserved communities with disproportionately high disease burden to reduce health disparities

5. 10 Steps to a Healthier New York 1. Have a regular doctor or other health care provider 2. Be Tobacco-Free 3. Keep your Heart Healthy 4. Know your HIV Status 5. Get Help for Depression 6. Live Free of Dependence on Alcohol and Drugs 7. Get Checked for Cancer 8. Get the Immunizations You Need 9. Make Your Home Safe and Healthy 10. Have a Healthy Baby

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7. TCNY # 5 Depression can be treated. Talk to your doctor or a mental health professional.

8. TCNY # 5 TCNY Goal: Increase by 10% the number of people treated for depression in NYC by 2008 Baseline: 37% of New Yorkers with depression were receiving mental health treatment (NYCHANES, 2004)

9. DOHMH Depression Initiative Depression initiative seeks to: Increase access to treatment by reducing stigma through public education about depression and how to access treatment Address Depression among high risk groups (elderly, perinatal, DPHO regions) Assist primary care physicians (PCPs) with implementing depression screening and management in primary care practice DOHMH provides training and technical assistance to PCP on how to incorporate depression screening and management into their practicesDOHMH provides training and technical assistance to PCP on how to incorporate depression screening and management into their practices

10. Depression in Older Adults Of the nearly 35 million Americans age 65 and older, an estimated 6.5 million have a depressive illness Depression in the elderly is often untreated confusion with other illnesses, ie. dementia expectation that depression is normal part of aging stigma Unrecognized and untreated geriatric depression has fatal consequences, ie. suicide, non-suicide mortality

11. Depression and Suicide Of those with MDD, close to 50% report feelings of wanting to die, 33% consider suicide and 8.8% report a suicide attempt (NCS-R) Comprising only 13 percent of the U.S. population, individuals age 65 and older accounted for 18 percent of all suicide deaths in 2000 Highest rate of suicide in the US is among older white men Of those who commit suicide, many reach out for help from their primary care doctor---20% see a doctor the day they die, 40% the week they die, and 70% in the month they die

12. Risk Factors for Geriatric Depression Family or personal history of depression Living alone, social isolation Recent bereavement Presence of other illnesses Presence of chronic or severe pain Damage to body image (from amputation, cancer surgery, or heart attack) Fear of death Use of certain meds or a combination of meds Substance abuse Past suicide attempt (s)

13. Geriatric Depression and Chronic Disease Symptoms of clinical depression can be triggered by other chronic illnesses common in later life, such as Alzheimer’s disease, Parkinson’s disease, heart disease, cancer and arthritis.

14. Depression and Chronic Disease Depressive disorders are associated with increased prevalence of chronic diseases Depressive disorders tend to precipitate chronic disease Chronic disease exacerbates symptoms of depression Seven out of 10 office visits to a primary care doctor concern chronic diseases.

15. Depression & Medical Comorbidities Not surprisingly, depression has been found to occur in a significant number of patients with other medical conditions.3,5-14Not surprisingly, depression has been found to occur in a significant number of patients with other medical conditions.3,5-14

16. Implications of Comorbid Depression Patients with chronic medical conditions and concomitant major depression have poorer outcomes: Increased somatic symptoms, eg, multiple pain complaints Excess functional disability Increased morbidity/mortality Increased healthcare utilization and costs Poor self-care Decreased adherence to treatment regimens Higher drug interaction potential due to polypharmacy Some potential implications of depression coexisting or comorbid with a general medical illness include increased somatic symptoms, excess functional disability, increased morbidity/mortality, and increased healthcare utilization/costs. Patients’ self-care may be poor and their adherence to treatment regimens may decrease.15 Additionally, there is a greater potential for drug interactions in these patients due to polypharmacy.16Some potential implications of depression coexisting or comorbid with a general medical illness include increased somatic symptoms, excess functional disability, increased morbidity/mortality, and increased healthcare utilization/costs. Patients’ self-care may be poor and their adherence to treatment regimens may decrease.15 Additionally, there is a greater potential for drug interactions in these patients due to polypharmacy.16

17. Depression in Primary Care

18. Depression in Primary Care

19. Depression in Primary Care

20. Detection of Depression: Why Screen and Manage in primary care? Primary care is the 1st line of defense = To find people who may be depressed or at risk for depression who don’t know it Screening for depression in the primary care setting improves detection rates US Preventative Service Task Force (USPSTF) recommends screening adults for depression in clinical practices that have systems in place for accurate diagnosis, effective treatment, and follow-up. Only 50% of those referred to specialty mental health practitioners complete more than one visit

21. Depression Screening: PHQ2

22. Depression Screening: PHQ2 Valid and practical tool for depression screening in busy medical settings Sensitivity: 83% for Major Depression Specificity: 92% for major Depression

23. The Patient Health Questionnaire (PHQ-9)

24. Quantifies the severity of depression (gives a number) Provides measurement over time Available in multiple languages (Spanish, Chinese, Russian, Creole, Bengali, Korean) Strong evidence of reliability and validity: Sensitivity = 88% for Major Depression Specificity = 88% for Major Depression The Patient Health Questionnaire (PHQ-9)

25. Why use the PHQ9? Specific advantages of the PHQ9 are: Shorter than other depression rating scales Can be administered in person, by telephone, or self-administered Facilitates diagnosis of major depression Provides assessment of symptom severity Proven effective in geriatric population (Loewe B, et al, 2004 Medical Care) Well validated and documented in a variety of populations

27. Scoring the PHQ 9 Scorecard for Severity Determination: Total Score: Depression Severity: 1-4 Minimal Depression 5-9 Mild Depression 10-14 Moderate Depression 15-19 Moderately Severe Depression 20-27 Severe Depression

28. Consider referral to mental health specialist if:

29. Requires specialized treatment (MAO inhibitors, ECT) Deteriorates quickly Unclear diagnosis For referral resources: Call 1-800 LIFENET/ (800) 543-3638 or 311 and ask for LIFENET Consider referral to mental health specialist if:

30. Depression Management Patient education: -Compare depression to other treatable medical illnesses to help patients feel less stigmatized -Provide information about treatment options (medications--including effectiveness, onset of action, and potential adverse side effects and psychotherapy) -Support staff, other professional staff can play a role Treatment: -Type of treatment recommended depends on the type of symptoms, the severity of symptoms and the patient’s personal preferences -Combined treatment with antidepressants and psychotherapy is recommended as first line treatment for patients with severe major depressive disorder Patient education: -Compare depression to other treatable medical illnesses to help patients feel less stigmatized -Provide information about treatment options (medications--including effectiveness, onset of action, and potential adverse side effects and psychotherapy) -Support staff, other professional staff can play a role Treatment: -Type of treatment recommended depends on the type of symptoms, the severity of symptoms and the patient’s personal preferences -Combined treatment with antidepressants and psychotherapy is recommended as first line treatment for patients with severe major depressive disorder

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32. Depression Management Self-Management Emphasize the patients central role in managing their illness use of effective SMS strategies, ie. assessment, goal setting, action planning, problem-solving, and follow-up organize internal and community resources to provide ongoing self management support to patients The individual’s ability to manage the symptoms, treatment, physical and social consequences, and lifestyle changes inherent in living with a chronic condition. The individual’s ability to manage the symptoms, treatment, physical and social consequences, and lifestyle changes inherent in living with a chronic condition.

33. Self-Management

34. Self Management:

35. Three Component Model Prepared primary care physician Mental health specialist support Care manager National IMPACT Study (Improving Mood-Promoting Access to Collaborative Treatment for Late-Life Depression) PHQ9 screening and Three Component Model used with older adults 1801 depressed older adults from 8 diverse health care systems in 5 states participated

36. Impact Study Results IMPACT participants were more likely than usual care patients to Receive antidepressants or psychotherapy according to treatment guidelines Report high satisfaction with depression care Experience a substantial improvement in depressive symptoms Experience improvements in health related functional impairment and quality of life

37. Bronx Depression Screening and Management Pilot Project DOHMH collaboration with MHANYC and DFTA 6 month duration, began 1/06 Project seeks to educate seniors and senior center staff about depression identify depressed seniors refer seniors for assessment and treatment provide supportive follow-up contact

38. Bronx Depression Screening and Management Pilot Project Target population: Bronx Seniors in CDs 1-6 Attend DFTA senior centers (24 centers) Participate in SOS case management program (200 seniors) Voluntary participants

39. Bronx Depression Screening and Management Pilot Project Interactive educational workshops Depression Bingo Screening sessions with PHQ9 Referrals for those who score 10 or above Care manager follow-up contacts Educational information to approx. 200 Bronx-based PCPs

40. Bronx Depression Screening and Management Pilot Project Current Data: 62 seniors screened 12 seniors scored above 10 on PHQ9 3 seniors scored 20-27 14 seniors made follow-up contact with a PCP 2 seniors made follow-up contact with a mental health professional

41. Bronx Depression Screening and Management Pilot Project Next steps: Meeting with mental health providers in the Bronx Continue to meet with PCPs in the Bronx Future considerations: Follow-up with PHQ9 at senior centers Follow-up with Bronx PCPs to evaluate changes in practice

42. DOHMH Depression Initiative Projects CHI Health Bulletin DPHO Detailing Campaign Public Education Campaign

44. DOHMH Depression Initiative Projects

45. Final Note Seniors are a population at high risk for depression Geriatric Depression is inadequately identified and undertreated, despite serious consequences Depression Screening with the PHQ9 in primary care can have a significant impact on this growing public health problem DOHMH Depression Initiative staff can assist primary care MDs with implementing depression screening and management