Treatment of Anxiety and Depression in Primary Care (Mobile Accessible)

1. Treatment of Anxiety and Depression in Primary Care (Mobile Accessible) Presented by: Dr. Edward Post

2. Purpose • The purpose of this training is to help Primary Care Providers (PCPs) treat anxiety and depression

3. Learning Objectives • Engage PCPs in delivering care for anxiety and depression in all settings • Identify the role of behavioral strategies in managing anxiety and depressive symptoms • Make appropriate use of psychotherapies and medication treatments for anxiety and depression • Recognize common adverse effects and advantages to specific antidepressants

4. Treatment of Anxiety and Depression in Primary Care Patients

5. A Whole Person Approach • Anxiety and depression impact upon health behaviors, adherence, and medical illness • Patient concerns should be seen within a biopsychosocial model • Anxiety and depressive symptoms occur along a spectrum of severity, and clinical measures should match both non-specific (e.g., exercise) and specific treatments (e.g., targeted behavioral therapies and medication) to the problem and to patient preferences

6. Case Vignette #1 Ms. Turner is a 27 year-old OEF/OIF Veteran. During her visit, she shares that, since her military discharge 2 months ago, she is having trouble adjusting to life at home. She reports conflicts with her husband and family and she is worried about finding a job. In the past two months, she has been on edge, has had difficulty concentrating, and reports trouble falling asleep.

7. Clinical Impression • Present circumstances and facts are consistent with normal reactions to post-deployment reintegration (not out of proportion to what is expected after a significant life stressor) • Close attention is appropriate to monitor these concerns, in case prolonged or disproportionate symptoms develop

8. Management Goals • Normalize experience • Improve ability for self-management • Provide early intervention now to avoid further decline in functioning / increase of symptoms

9. Management Strategies – How Do We Do This? • Education regarding normal and potential problem circumstances and expectations • Behavioral interventions to improve self-care • Avoid caffeine, excessive alcohol, or drug abuse • Regular exercise • Purposeful scheduling of enjoyable activities • Support groups involving self and/or family as needed • Web-based self-management resources • e.g., http://www.afterdeployment.org/web/guest • Case management for specific challenges • Job search / Vocational rehabilitation

10. Case Vignette #2 Ms. Turner, a 27 year-old OEF/OIF Veteran, subsequently returns for a follow-up visit 4 months later. She has not found a job and reports that her family relationships have worsened, despite trying some of the things recommended at her last visit. Her difficulty sleeping and anxiety have gotten worse. In the past six months, she reports spending a lot of time worrying and having difficulty concentrating, and that she’s “stressed out.”

11. Clinical Impression – Rule Out • Rule out hyperthyroidism • TSH is negative • Rule out substance use disorder • No history of alcohol or drug abuse • Criteria for an anxiety disorder are met

12. Management Options • Further questioning or referral to evaluate for PTSD • Continue previous behavioral interventions and self-management strategies as appropriate • Psychotherapy • e.g., Cognitive-behavioral Therapy

13. Management Options - Medication • Trial of medication therapy for anxiety • Lower doses of an SSRI can be effective • e.g., citalopram 10mg qd, consider increase to 20mg at week 2 during a 6- to 8-week trial; consider trazodone PRN for sleep in addition to education on sleep hygiene • Benzodiazepines not first-line treatment • Use with caution, due to intermittent withdrawal/worsened anxiety, reinforcement of situational use and dependence

14. Case Vignette #3 During his appointment, Mr. Smith, an 86-year-old World War II Veteran, reports difficulty coping with the death of his wife 4 months ago. He notes trouble sleeping, doesn’t enjoy things like he used to, and states: “I just can’t get going like I used to. It’s hard to find meaning for my life now.”

15. Clinical Impression - Symptoms • Bereavement with mild depressive symptoms

16. Management Strategies • Education regarding normal and problem circumstances and realistic framing of expectations for recovery • Scheduling enjoyable activities • Engagement with family and/or existing social network • Bereavement support group • Supportive counseling (therapist/counselor/clergy) • Likely includes review of patient’s past coping strategies • Consideration of short-term use of an antidepressant • e.g., mirtazapine 15mg qhs for 3-6 months

17. Case Vignette #4 Mr. Howell is a 59 year-old male with osteoarthritis, diabetes and hypertension who was laid off 6 weeks ago from his manufacturing job. He notes during his PCP visit that in the past three weeks he has not been feeling well. He is sleeping much more than usual but still has little or no energy most days. He notes his mood is “OK”, but is bothered by the occasional anxiety about his financial future. He denies hopelessness, or past or present suicidal ideation. PHQ-9 score is 8.

18. Clinical Impression – Fatigue • Rule out medical causes for fatigue • CBC and TSH are normal • Adjustment disorder and possible minor depression

19. Management Strategies • Education regarding potential symptom progression yet realistic framing of expectations for recovery • Scheduling enjoyable activities • Engagement with family and/or existing social network • Exercise • Supportive counseling (therapist/counselor/clergy) • Likely telephone care management to assess progress and monitor (‘watchful waiting’) for any symptom progression to Major Depressive Disorder

20. Case Vignette #5 Mr. Howell returns for office follow-up in 3 months. Two telephone contacts in the 6 weeks after the prior visit showed no change; however, he now reports no improvement in previous symptoms and now depressed mood and little interest in previously pleasurable activities on most days for the past 4 weeks. PHQ-9 score = 18. He has gained 10 pounds since losing his job, and reports his blood sugars are often in the 180-240 range. He denies thoughts of suicide, but states that in some ways he really doesn’t care what happens to him anymore. He denies any risky activities or firearms in the home.

21. Clinical Impression – Major Depression • Major depressive disorder with hopelessness • Impact on medical conditions and health behaviors (diabetes, weight/physical activity)

22. Management Options – Behavioral Interventions • Continue previous behavioral interventions and self-management strategies as appropriate • Close monitoring for symptom progression including suicidal ideation, and progress of treatment • Psychotherapy • Can be used as monotherapy if depression is not severe, or in combination with medication treatments • Patient may be resistant to referral

23. Management Options – Medication Therapy • Medication therapy for depression • Education regarding antidepressant medication is essential • Timing of benefits; side effects and risks; medication interactions • Consider uptitration as indicated and adequate length of trial (6 weeks) of a single agent is important • Telephone care management can facilitate process

24. Antidepressant Options • SSRIs • Citalopram: start 10-20mg qd; target 20-60mg/d • Sertraline: start 50-100mg qd; target 100-200mg/d • Fluoxetine: start 10-20mg qd; target 20-60mg/d • Paroxetine: start 10-20mg qhs; target 20-60mg/d • Common side effects: transient nausea at initiation; somnolence or anxiety; gastrointestinal disturbances; headache; erectile dysfunction • Rare but important side effects: agitation or suicidal ideation, serotonin syndrome

25. Antidepressant Options (cont’d) • SNRIs (caution with hypertension) • Venlafaxine (extended release): start 37.5-75 mg qd; target 150-300mg/d • Duloxetine: start 20-30 mg qd; target 30-120 mg/d • Other agents • Bupropion (sustained action): start 100-150 qam; target 200-450mg/d (caution if seizure risk) • Mirtazapine: start 15 qhs; target 15-45 mg/d

26. Duration of Medication Treatment • Treatment should be tailored to individual patients, including consideration of comorbidities and patient preferences • First episode: at least 6 months after initial remission of symptoms is achieved • Many antidepressants should be tapered when discontinuing • Multiple episodes: consider long-term or indefinite maintenance antidepressant treatment, given risk of relapse

27. Challenges • Patient factors: • Cultural norms may influence not only discussion of symptoms but also preferences for treatment • Practice factors: • Rural settings: access to consultative and/or referral resources • Urban settings: role responsibility around referral management and follow-up may be unclear between multiple providers

28. Summary You should now be able to: • Provide appropriate behavioral strategies for anxiety and depression in primary care settings • Recognize the role of psychotherapy and medication treatment for anxiety and depression • Identify appropriate initial dosing, trial duration, and answers to common patient questions for medication treatment of anxiety and depression in primary care

29. Contact Information • Dr. Edward Post: Edward.Post@va.gov • Ms. Pat Dumas: Patricia.Dumas@va.gov • Dr. Kimberly Arlinghaus: Kimberly.Arlinghaus@va.gov • Dr. Jennifer Patterson: Jennifer.Patterson@va.gov