Addressing Depression in the Primary Care Setting

1. Addressing Depression in the Primary Care Setting Eunice Modilim Dave ngugi Nicole stoneback Laurie Timberlake 2018-2019 uncPrimecare UNC School of nursing

2. There is no point treating a depressed person as though she were just feeling sad, saying, ‘There now, hang on, you’ll get over it.’ Sadness is more or less like a head cold- with patience, it passes. Depression is like cancer. Barbara Kingsolver, The Bean Trees

3. what is Depression? • Sadness is a common, normal human emotion; but if it’s disproportional to events, and sustained over a significant period of time, sadness becomes pathological. • Depression is a complex brain-based illness with a primary characteristic of mood disturbance. • Excessive or distorted degree of sadness that manifests in behavioral, affective, cognitive and somatic symptoms. • It often has a precipitating event or situation, but sometimes occurs without a triggering stressor. • Depression interferes with daily functioning and goal achievement.

4. Etiology & Course • Etiological models for depression are largely diathesis-stress models in which stressful experiences trigger depression in vulnerable individuals. • Genetic, neurological, hormonal, immunological, and neuroendocrinological mechanisms appear to play a role in the development of major depression. • Many individuals may experience a single, major depressive episode following an acute stressor and recover with little implication for future vulnerability. • However, 50–80% of individuals who have one significant depressive episode will have recurrent episodes and intermittent subclinical symptoms. • The risk of recurrence progressively increasing with each episode of major depression. • The presence of co-occurring psychological and medical disorders exacerbates the clinical and social consequences of depression, and makes it more challenging to treat.

5. diagnostic Criteria According to the DSM-5, five or more of the following symptoms must be present during the same two week period and represent a change from previous functioning: • Depressed mood for most of the day ( feel sad, empty, hopeless) • Diminished interest or pleasure in activities • Weight loss or weight gain, or loss of appetite or increased appetite • Insomnia or hypersomnia • Fatigue or loss of energy nearly every day • Feelings of worthlessness or excessive guilt

6. Screening Tools Several evidence-based depression screening tools are available for use in rural primary care: • Patient Health Questionnaire (PHQ-9) • Patient Health Questionnaire (PHQ-2) • Beck Depression Inventory for Primary Care (BDI-PC) • Geriatric Depression Scale • Most of these instruments are easy to use and can be administered in less than five minutes • Patient Health Questionnaire (PHQ-9) is often most recommended for use in primary care (O’Byrne & Jacob, 2018) Providers should have full knowledge and awareness of the strengths and limitations of screening tools used in their clinical settings (O’Byrne & Jacob, 2018)

7. Cultural Considerations • Beliefs concerning cause of mental illness contribute to significant disparities in the utilization of mental health services among racial/ethnic minorities (Jimenez, Bartels, Cardenas, Dhaliwal, & Alegria, 2012) • African Americans, Asian Americans, and Latinos have differing beliefs regarding the cause of mental illness and its treatment when compared to non-Latino whites • Consider the attitudes and beliefs of older adults to include worry about additional treatments, concerns about cost, and difficulty with mobility (Vieira, 2014) • Stigma, lack of time, lack of trust in providers are among the barriers to disclosing depression symptoms (Keller, 2016). • Increased public education about behavioral health management in primary care as well as provider education for providing culturally competent care is needed.

8. Prevalence of Depression in Adult Population

9. Healthy people 2020 objectives • MHMD-4 Reduce the proportion of persons who experience major depressive episodes (MDEs) • MHMD-4.1 Reduce proportion of adolescents aged 12-17 who experience MDEs. • Baseline is 8.3 percent of adolescents aged 12 to 17 years experience MDEs (2008). Our target is 7.5 percent of adolescents which would represent a 10 percent improvement. • MHMD-4.2 Reduce proportion of adults aged 18 and older who experience MDEs. • Baseline is 6.5 percent adults experienced a MDE (2008). Our target is 5.8 percent of adults which would represent a 10 percent improvement.

10. The state of Current practice in primary care • Prevalence of Depression among adult patients in primary care: 5% - 13% (Lakkis & Mahmassani, 2015). • After anxiety disorders, depression is the most common mood disorder with 1/3 to 1/2 adults receiving treatment that is managed by primary care providers (PCPs; Lakkis & Mahmassani, 2015). • Many patients go undiagnosed or undertreated at the PCP level, as providers lack training or lack time to recognize and treat mental health disorders (Mulvaney-Day, 2018). With average appointment times of 13 minutes, this is not surprising (Wolfe & Hopko, 2008). While the US Preventive Services Task Force (USPTF) encourages depression screening at each appointment (Siu et al., 2016), only 2.29% of community-based practices screen (Harrison et al., 2010).

11. The Current state, continued • Why do so few primary care providers screen and treat depression? • Reasons may include lack of available follow-up resources or availability of referral providers, lack of reimbursement incentives, continuing education requirements, and lack of clear treatment guidelines (Harrison et al., 2010; Mulvaney-Day, 2018). In addition, PCPs often lack familiarity with newer antidepressants, their dosages and appropriate durations of treatment. While many patients prefer psychotherapy over pharmacotherapy, the most cost-effective approach in the traditional practice is for the primary care provider to prescribe medications as few providers are equipped to provide psychotherapy (Wolfe & Hopko, 2008).

12. Risks of current treatment practice • Lack of PCP training to treat or augment mild to moderate depression with CBT or other evidence-based psychotherapeutic approach (Wolfe & Hopko, 2008). • Inadequate initial medication dosing, duration of treatment, and choice of initial antidepressants. • Lack of appropriate medication titration to therapeutic range or confidence to switch antidepressants when first-line medication does not lead to remission. • Risk of the patient’s death, as depression – while treatable – is a potentially fatal illness and the second leading cause of death in the second and third decades of life (Bachmann, 2018).

13. Current Guidelines • The American Psychiatric Association (APA) Practice Guideline for Treatment of Patients with Major Depressive Disorder, Third Edition (2010) • When selecting an initial treatment modality, consider the following: • Severity of symptoms • Presence of co-occurring disorders or psychosocial stressors • Biological, psychological, and environmental factors contributing to the current episode of depression • Patient preference • Prior treatment experiences

14. Treatment Modalities Consider Pharmacotherapy if: Consider Psychotherapy if: Prior positive response to psychotherapy Significant psychological factors, psychosocial stressors, or interpersonal difficulties Mild to moderate severity of illness Patient preference • Prior positive response to an antidepressant • Moderate to severe symptomatology • Significant sleep or appetite disturbances or agitation • Patient preference

15. Pharmacotherapy • Selective Serotonin Reuptake Inhibitors (SSRIs) are first line treatment • The most widely prescribed class of antidepressants Selection is based on: • Side effect profile • Client-specific symptoms • Medication interactions • Cost • Client or family’s previous responses to antidepressants American Psychiatric Association. (2010). Treating major depressive disorder: a quick reference guide. American Psychiatric Association: Washington, DC, 1-28.

16. When to Refer & Referral Process • Create contact for mental health providers and establish a clear, standard office protocol for referral • Refer to a mental health professional if: • Patient is not responding to treatment • Patient is suicidal • Be empathetic and use sensitive approach when explaining the need and process for referral • Explain what to expect and provide as much information as possible about the provider you are referring the patient to. • If possible, schedule the referral appointment with patient present in the office, encouraging patient’s involvement • Involve family members in the referral discussion when feasible to help ease frustration and improve compliance

17. Integrated Care Approach • Integrated care improves depression outcomes in primary care patients, and can improve outcomes for general medical illnesses • Availability of clinicians with appropriate training and expertise to perform • Depression screening • Psychiatric-focused assessments • Psychotherapy • Antidepressant • Initiation • Titration • Monitoring

18. References American Psychiatric Association. (2010). Treating major depressive disorder: a quick reference guide. American Psychiatric Association: Washington, DC, 1-28. American Psychiatric Association. (2013). Diagnostic And Statistical Manual of Mental Disorders DSM-5. Arlington, VA : American Psychiatric Association. Bachmann, S. (2018). Epidemiology of Suicide and the Psychiatric Perspective. International Journal Of Environmental Research And Public Health, 15(7), 1425. doi: 10.3390/ijerph15071425 Gaynes, B. N. (2017). Unipolar depression in adult primary care patients and general medical illness: Evidence for the efficacy of initial treatments. Retrieved from: https://www.uptodate.com/contents/unipolar-depression-in-adult-primary-care-patients-and-general-medical-illness-evidence-for-the-efficacy-of-initial-treatments Gelenberg, A. J., Freeman, M. P., Markowitz, J. C., Rosenbaum, J. F., Thase, M. E., Trivedi, M. H., & Schneck, C. D. (2010). Practice guideline for the treatment of patients with major depressive disorder third edition. The American Journal of Psychiatry, 167(10), 1. Harrison, D., Miller, M., Schmitt, M., & Touchet, B. (2010). Variations in the Probability of Depression Screening at Community-Based Physician Practice Visits. The Primary Care Companion To The Journal Of Clinical Psychiatry, 12(15). doi: 10.4088/pcc.09m00911blu Jimenez, D., Bartels, S., Cardenas, V., Dhaliwal, S., & Alegria, M. (2012). Cultural beliefs and mental health treatment preferences of ethnically diverse older adult consumers in primary care. The American journal of Geriatric Psychiatry , 20, 533-542. https://doi.org/10.1097/JGP.0b013e318227f876 Johnson, K., & Vanderhoef, D. (2016). Psychiatric-Mental Health Nurse Practitioner. Silver Spring : American Nurses Association .

19. References Keller, A. (2016). Disclosure of depression in primary care: A qualitative study of women’s perceptions. Women’s Health Issues, 26, 529-536. https://doi.org/10.1016/j.whi.2016.07.002 Lakkis, N., & Mahmassani, D. (2014). Screening instruments for depression in primary care: a concise review for clinicians. Postgraduate Medicine, 127(1), 99-106. doi: 10.1080/00325481.2015.992721 Mental Health and Mental Disorders | Healthy People 2020. (2018). Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/mental-health-and-mental-disorders/objectives Mulvaney-Day, N., Marshall, T., Downey Piscopo, K., Korsen, N., Lynch, S., & Karnell, L. et al. (2017). Screening for Behavioral Health Conditions in Primary Care Settings: A Systematic Review of the Literature. Journal Of General Internal Medicine, 33(3), 335-346. doi: 10.1007/s11606-017-4181-0 O’Byrne, P., & Jacob, J. D. (2018). Screening for depression: Review of the Patient Health Questionnaire-9 for nurse practitioners. Journal of the American Association of Nurse Practitioners, 30, 406-411. https://doi.org/10.1097/JXX.0000000000000052 Siu, A., Bibbins-Domingo, K., Grossman, D., Baumann, L., Davidson, K., & Ebell, M. et al. (2016). Screening for Depression in Adults: US Preventive Services Task Force Recommendation Statement. JAMA, 315(4), 380. doi: 10.1001/jama.2015.18392 Vieira, E. (2014). Depression in older adults: Screening and referral. Journal of Geriatric Physical Therapy , 37, 24-30. https://doi.org/10.1519/JPT.0b013e31828df26f Wolf, N., & Hopko, D. (2008). Psychosocial and pharmacological interventions for depressed adults in primary care: A critical review. Clinical Psychology Review, 28(1), 131-161. doi: 10.1016/j.cpr.2007.04.004