Mood Disorders in Primary Care

1. Mood Disorders in Primary Care Robert Kinney, PhD Psychologist, Center for Depression Research and Clinical Care Assistant Professor, UT Southwestern Medical Center Texas Primary Care and Health Home Summit November 9, 2017 Screening, Diagnosis & Treatment

2. https://youtu.be/1cwyuxKA0_M The Center for Depression Research and Clinical Care

3. The Depression Treatment Cascade Pence ,O’Donnell & Gaynes. Curr Psychiatry Rep. 2012 Aug; 14(4): 328–335.

4. The Facts About Depression • Depression is common: • 1 in 11 people will experience an episode this year. • 1 in 6 people will experience an episode during their lifetime. • 2% prior to 11 years of age • Approx. 7% in adolescence and adulthood • Depression starts early – average age of onset is 11-14 years • Females have twice the rate as males • Depression is genetic: • First-degree family members = 2 to 4 x higher risk • Depression is environmental: • Risk increases with • Adverse childhood experiences • Stressful life events • Illness

5. Mental Health • Depression affects young people: • 50% are diagnosed before the age 30. • 18 to 29 year olds are twice as likely to experience an episode of major depression as someone over the age of 60. • Depression is the most common complicating factor in illness. • Earlier age of onset leads to higher rates of recurrent episodes and worse functional outcomes. • One in five adolescents experience significant symptoms of emotional distress. • 10 - 15% of peds suffer from mental disorders, while ~18% of adults will have something go on this year. • Suicide is the second leading cause of death among 15-24 years worldwide. • Suicide is a “top ten” cause of death for ages 10-65+.

6. Depression is a Vast Challenge Substantial gaps exist • Causes – unknown • Prevention – to be discovered • Treatment – trial and error • Cure – elusive Understanding the genetic and biological causes will: • Improve outcomes • Prevent disease occurrence

7. Despite Advances in Treatment... • Less than 50% of people with depression receive treatment. • Only 1 of 3 patients treated for depression achieve short-term recovery. • No definitive tests identify which treatment is best for the patient.

8. Depression In Primary Care Because most youths in our nation are seen annually in primary care, primary care provides a major point of health system contact, is often the de facto site for behavioral health care, and provides opportunities to link youths to needed care for behavioral health problems. [1] It is possible to provide high quality treatment of depression in primary care settings with outcomes equal to those provided by specialty care [2, 3]. • Chevarley, 2001; Kolko & Perrin, 2014; Stancin & Perrin, 2014; Weersing, 2010 • Trivedi, M.H., et al., Am J Psychiatry, 2006. 163(1): p. 28-40. • Gaynes, B.N., et al.,.PsychiatrServ, 2009. 60(11): p. 1439-45.

9. Depression • WHO estimates that depressive disorders are the leading disability • MDD in primary care patients is common • Often goes undetected • Pediatric and primary care are the initial access point for patients • Shortage of behavioral health experts • 12.5% of your patients have it • Symptoms and severity are identical between primary care and specialty care • American Association of Pediatrics recommends beginning screening at 11 • US preventative Services Task force recommends screening and follow up beginning at 12 • Discovered that no harm is caused • Insufficient evidence for below the age of 12

10. Depression Statistics http://www.cdc.gov/nchs/data/databriefs/db07.htm

11. ? Theories of Depression

12. Major Depressive Disorder • Depressed/irritable mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful) • Decreased interest or pleasure in most activities, most of each day (a.k.a., anhedonia) • Significant weight change (5%) or change in appetite • Change in sleep: Insomnia or hypersomnia • Change in activity: Psychomotor agitation or retardation • Fatigue or loss of energy • Guilt/worthlessness: Feelings of worthlessness or excessive or inappropriate guilt • Concentration: Diminished ability to think or concentrate, or more indecisiveness • Suicidality: Thoughts of death or suicide, or has suicide plan • **one anchor + 4 additional; not due to medical condition or substance use for at least two weeks

13. Depressive Disorders • Major Depressive Disorder = 1 or more lifetime Major Depressive Episodes AND no history of manic or hypomanic episodes • Dysthymic Disorder = 2 or more years of depressed mood plus 2 or more other depressive symptoms • Can have both MDD and Dysthymic Disorder

14. DSM-5 DSM Criteria Rule Outs • Symptoms not attributable directly to • Effects of a substance/medication • Another medical condition • Symptoms do not represent normal bereavement (i.e., mild symptoms, duration less than 2 months, in direct response to loss/death of a loved-one) • Symptoms are not better explained by a primary psychotic disorder

15. Suicide Risk • 10th leading cause of death in the US • 2nd leading cause of death for teens • Boys are the fastest growing subset • Highest in rural areas • 1 in 7 people with MDD will attempt suicide at some point in their life • Risk is 8 times higher in untreated MDD compared to those who received treatment • More attempts in females • More completions in males • Risk for future suicide attempt • Unresolved major depression • History of a past suicide attempt

16. Screening and Assessment • Several tools out there • Mood and Feeling Questionnaire (MFQ - 32 Items)*free • Patient Health Questionnaire (PHQ2 and PHQ9 - 2 and 9 items respectively)*free • mirrors the diagnostic criteria • Available in many languages • Beck Depression Inventory (BDI – 21 items)*$120 for 25 forms and a manual • Children’s Depression Inventory (CDI- 28 items) *$267 for a manual and 25 forms • A little younger • Semi-Structured Clinical Interview: Open ended questions, can be structured around the screener- rule out the other mood disorders; duration; keep an open mind; watch for behavioral cues; look for clinically significant impairment; be patient and stay calm; test your judgement; share your thoughts; address safety concerns and document

17. Treatments Lifestyle Adaptions Diet Light (SAD) Omega 3 Sleep Exercise (150 minutes) Psychotherapy CBT Behavioral Activation Interpersonal Psychotherapy Psychopharmacology SSRIs Black Box Warning Impact Atypical Mood Stabilizers Treatment Resistant Depression

18. VitalSign6 Our Model

19. 17. Trivedi, MH, et al VitalSign6 • https://youtu.be/uXWYg_Wj1z4 • Key components: • Patient screening and education • A comprehensive Measurement Based Care treatment protocol • Utilizes self-report measures • Monitors symptom severity, associated symptoms, side effects, and adherence • Clinical Decision Support • Electronic data capture to provide rapid and comprehensive reports • Decreased reliance on additional or outside personnel

20. VitalSign6 • VitalSign6 will allow providers potentially to satisfy six of the “Clinical Quality Measures”: • Screening for clinical depression • Utilization of the PHQ-9 tool • MDD diagnostic evaluation • Antidepressant medication management • Depression remission at 6 months • Depression remission at 12 months

21. Patient Health Questionnaire (PHQ9)

22. VitalSign6 Goal1 • Implementation of routine, evidence-based depression screening. Integration into clinical practice of a scientifically validated, measurement-based care (MBC) program for the treatment of depression for patients who screen positive. Goal2

23. Available Measures • Standard Measures: • Adolescent PHQ-9 • GAD-7 • PFIB-S (Pain Frequency, Intensity, and Burden Scale) • SUS (Substance Use) or MAST (Alcohol)/DAST (Drug) • ASRM (Altman Self-Rating Mania) • CAST-SR (Concise Associated Symptom Tracking Scale)(Symptom severity) • Physical Activity • Optional Measures: • CHRT (Suicide Assessment) • ADHD • FIBSER (side effects severity) • PAQ (Patient adherence to medication)

24. Training • To ensure that clinic staff and providers can speak to why their clinic is now screening for and managing depression in-house • Ensure baseline understanding knowledge of MDD • Administer the VS6 screening and assessment tools to patients • Properly screen and document clinical decisions and follow-up choices in VS6 • Demonstrate and implement MC • There are three formal trainings: • Overview of Depression • Introduction to MBC • Application Training

25. Consultation Opportunities • Formal and informal educational opportunities delivered by the Consulting Clinicians and Clinic Coordinators once the clinics have started screening • Patient Rounds to review patients in treatment for depression • Phone consultations with a consulting clinician • Monthly Teleconferences

26. VitalSign6 PROJECT SUMMARY August 18, 2014 – March 1, 2018 Total Screened Patients: 40,362 Remission Rate with at least 1 follow-up visit *4,189 of patients with a positive screen, were confirmed to have a depressive diagnosis 37%

27. Pediatric Primary Care Clinics August 18, 2014 – March 1, 2018

28. VitalSign6 Remission Rates Remission Rates at Select VitalSign6 Clinics (Patients with at least one follow-up visit) The Depression Treatment Cascade in Primary Care 59.0% 26.6% 38.8% 20.0% Our Goal was 5% remission; With VitalSign6, we have reached a higher rate.

29. Depressed Patients Application

30. Foundations of Empathy • Listening! • Stop talking • Avoid interrupting • Show interest • Nonverbals • Don’t jump to conclusions • Avoid why questions • Avoid closed questions • Active Listening

31. Problem Solving v. Listening • Rapport and Trust Building • Foundational Skills • Nonverbals • Listening • Active listening • Reflection • Paraphrasing • Asking questions • Confirming understanding • Empathy • Using group dynamics • Patience • Homesickness • De-escalating frustrated patients

32. Attitudes for Good Communication Open-mindedness- willing to look at alternatives Genuineness- real and authentic Acceptance- not tolerance Humility- humble, modest, not the authority A note about expectations (high expectations set the tone- same with low expectations)

33. Rapport and Trust Building • Avoid touch • Make good eye contact • Encourage the client to do the same • Be aware of your nonverbals- • Get on the level of the ct • Be aware of personal space • Voice intonation and tone • Facial expressions

34. Rapport and Trust Building • Communicate Acceptance and open-mindedness • Ex- I could see why you would feel that way • Ex - I may react in the same way! • Ex - That would be so frustrating! • Empathy • Not sympathy or over-identification • A sense of understanding • I hear you • I’m sorry that I didn’t follow through • I’m sorry to hear that • It sounds like you are struggling • Avoid saying “I understand” and “get over it”

35. Foundations of Empathy • Active Listening • Reflecting- not just words • Mirroring: parroting content as well as the emotional message; restating the words and feelings of the client • Paraphrasing: using your own words to restate the message (content and feelings) • So You are saying…. • I heard… • If I heard you right, you are saying… • What I heard you saying was….

36. How to Respond Empathically 1. Listen 2. Take a second to think/pause 3. Condense and paraphrase • Be short • Content • Feelings • Be specific • Check for feedback • When in doubt, use a stock statement • “You feel _____ because of _____”

37. Application Frank is a 12 year old boy that you have been working with for several weeks. He’s quiet and you don’t know much about him. While in session with Frank, he states that he “sometimes wished [he] weren’t here”. What do you do?

38. Call somebody!!!!!! • Know your policy • Maintain safety • Call the appropriate team • Call Crisis number • Ask for mobile crisis assessment • DO NOT leave the client alone • Do not assume that it was “just a threat” Don’t be a hero Don’t use your gut

39. Helpful Information Was there a treat? What was said? Is there a text or note or social media post? Is there a plan? Was there an attempt? Reported hopelessness/no reason for living Seeing or hearing things that aren’t there? Odd beliefs (I’m G-d or Everyone is out to get me or aliens are speaking to me through my pudding) Intent Ideation

40. Some Do’s and Don’ts • Be direct • Use the word suicide • Be non-judgmental • Be supportive • STAY CALM • Call for help • Minimize access to potentially harmful objects/substances • Call 911 (if already attempted) • Call MHMR or 911 for further assessment • Don’t agree to keep a secret • Don’t dare the client • Don’t ask why • Leave the client alone • Let’s talk about this one • Special relationships • Try to counsel or argue with the client • Blame yourself • Offer ways to fix it Do Don’t

41. Helpful Things to Say/Do “You’re not alone.” “How can I best support you right now?” “I care and want to help.” “I’m here for you.” Be yourself- the right words are often unimportant Listen Be patient Offer hope

42. FAQ’s • Why should I screen? • AAP • US Preventative Task Force • What if someone starts crying in my office? • If I ask questions, am I going to increase my liability? • Will screening make someone depressed? • US preventative task force • QUESTIONS?

43. References • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association. • Burger, J.M. (2015). Personality. Boston, M.A. Cengage. • Brennanm J.F. (2003). History and systems of psychology. Upper Saddle River, N.J.: Pearson. • Mukherjee, S. (April 19, 2012). Post- Prozac Nation: The science and history of treating depression. Retrieved from http://www.nytimes.com/2012/04/22/magazine/the-science-and-history-of-treating-depression.html • Pence, B. W., O’Donnell, J. K., & Gaynes, B. N. (2012). The depression treatment cascade in primary care: a public health perspective. Current psychiatry reports, 14(4), 328-335. • Rush, A. J., Trivedi, M. H., Wisniewski, S. R., Nierenberg, A. A., Stewart, J. W., Warden, D., ... & McGrath, P. J. (2006). Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR* D report. American Journal of Psychiatry, 163(11), 1905-1917. • U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Mental Health. (2015). Depression (NIH Publication No. 15-3561). Bethesda, MD: U.S. Government Printing Office. https://www.nimh.nih.gov/health/publications/depression-what-you-need-to-know/index.shtml • World Health Organization. (1996). Diagnostic and management guidelines for mental disorders in primary care: ICD-10. Chapter 5, Primary care version.

44. Thank You Robert Kinney, PhD Psychologist, Center for Depression Research and Clinical Care Assistant Professor, Department of Psychiatry UT Southwestern Medical Center 214-648-3763 Robert.kinney@utsouthwestern.edu