Medical Management of Depression

1. Medical Management of Depression Public Health Detailers’ Training NYC Department of Health and Mental Hygiene Jorge R. Petit, MD Associate Commissioner, Bureau of Program Services

2. Overview Depression management Types of antidepressants Choosing an antidepressant PCP concerns: suicide risk, misdiagnosis of bipolar PHQ9 as a monitoring tool Treatment algorithm

3. Overview Acute, Maintenance, Continuation Phases Ongoing monitoring Referral to Psychiatry Involvement of non-physician staff

4. Depression Management Once a diagnosis has been made, effective management in primary care includes: Medication management (Pharmacotherapy) Patient education Self management support Ongoing monitoring, including monitoring of concurrent psychotherapy

5. Pharmacotherapy: Types of Meds Selective serotonin uptake inhibitors (SSRIs) Other newer antidepressants (norepinephrine plays a key role) Tricyclic antidepressants (not considered a first-line antidepressant) MAO Inhibitors (rarely used by primary care physicians)

6. SSRIs Citalopram (Celexa) Escitalopram (Lexapro) Fluoxetine (Prozac) Paroxetine (Paxil, Paxil CR) Setraline (Zoloft) Duloxetine (Cymbalta)

7. SSRIs Potential side effects: GI (N/V, diarrhea) Activation/insomnia Sexual Dysfunction Neurological (headaches, etc) Weight changes Serotonin syndrome Drug Interactions (MAOIs)

9. Dopamine-norepinephrine reuptake inhibitor Buproprion (Wellbutrin SR, Wellbutrin XL) Potential side effects: Neurological/seizures Insomnia GI upset Psychotic symptoms

10. Norepinephrine serotonin neurotransmission enhancer Mirtazapine (Remeron) Potential side effects Sedation Dry mouth Weight gain Increase serum cholesterol

11. Serotonin-norepinephrine reuptake inhibitor Venlafaxine (Effexor XR) Potential side effects: Similar side effect profile to SSRIs, including N/V, sexual dysfunction, and activation Possible dose-related increase in BP

13. Tricyclics As effective as newer agents Side effects potentially more dangerous: dry mouth, constipation, bladder problems, sexual dysfunction, blurred vision, dizziness, drowsiness and increased heart rate. Cheaper-especially generic forms May be good for selected patients

15. Choosing an antidepressant In general, no particular antidepressant is more effective than another Choice should be based on: Family history of response Safety and side effect profiles Ease of use Consider symptom profile/presence of comorbidities, ie. anxious, obsessive compulsive cost

16. 1st line antidepressants All categories mentioned with the exception of trycyclics, MAOs 1st line antidepressants have these factors in common: Once a day dosing (ease of use aids compliance) Favorable side-effect profile (also aids compliance) Safety in overdose Broad efficacy for mood disorders

17. 1st line antidepressants Using these better tolerated, newer meds can: prevent the need for complicated titration-allowing for a quicker response improve compliance Lead to fewer office visits Result in less overall cost

18. Suicide Risk FDA Public Health Advisory March, 2004: possible risk of worsening depression and suicidality in patients taking antidepressants Done in reaction to reports of suicidal ideation and attempts in treatment of major depression in pediatric patients. Black box warning for children / adolescents September, 2004

19. FDA Public Health Advisory Points out the need to closely monitor patients receiving antidepressants for worsening and suicidality especially at beginning of treatment and with changes in dosage Also need to instruct patients and families to be alert for worsening or suicidal thoughts and to immediately report such symptoms

20. Misdiagnosis of Bipolar Patients Potential risks from antidepressants May induce mania or hypomania Can cause rapid cycling Requires mood stabilizer (e.g. lithium or valproic acid) before brief use of antidepressant Generally need psychiatry consultation or referral

21. Quantifies the severity of depression (gives a number) Provides measurement over the time which aids in assessing effectiveness of chosen treatment course Follow-up PHQ9s should be conducted every month in person or over the phone PHQ-9 as a monitoring tool

22. Remission Goal of treatment: full remission (absence of symptoms) Monitoring with the PHQ9 can assist in the process of achieving full remission A score of 5 or less on the PHQ9 = full remission Once remission is achieved, patient should remain on the current dose of medication for 6-9 months to prevent relapse

23. Treatment Algorithm Decision support tool PCPs can use to manage depression Assists with monitoring of medication and psychotherapy over all phases of treatment Provides timeframes for effective monitoring Pocket size version available

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25. Phases of Treatment Acute Continuation Maintenance

26. Acute Phase Usually 6-12 weeks Effective treatment response is usually obtained in this phase--initial remission

27. Continuation Phase Usually 6-9 months Residual symptoms can continue to impair patients and complicate co-morbid medical illness Patients are prone to relapse during this phase Important to continue full therapeutic dose during this phase

28. Maintenance Phase >9 months If 1st episode, meds should be tapered and discontinued If recurrent episode, long term maintenance should be considered, generally at the therapeutic dose established in acute phase

29. Maintenance Phase Other factors that would extend a course of antidepressant treatment include: patient preference illness severity and related disability when affected

30. Important for practices to have some sort of system in place for monitoring Close follow up by telephone and or visits until stable Severity tool (PHQ-9) to assess progress Titrate dose for total remission Ongoing Monitoring

31. Ongoing Monitoring Maintain effective dose for 4 to 9 months (continuation phase) Monitor for early signs of recurrence Consider maintenance therapy

32. Consider referral to psychiatrist if:

33. Requires specialized treatment (MAO inhibitors, ECT) Deteriorates quickly Has unclear diagnosis Consider referral to psychiatrist if:

34. To Locate a Psychiatrist American Psychiatric Association Answer Center: apa@psych.org or (888) 35-PSYCH LIFENET (accessible 24/7): 1-800-LIFENET (800-543-3638) or call 311 and ask for LIFENET

35. Patient Education Key to promoting compliance with the treatment plan, patient becomes partner in care Dispels negative perceptions/addresses stigma that may contribute to non-adherence If patients know what to expect will be less likely to discontinue meds prematurely

36. Patient Education Compare depression to other treatable medical illnesses to help patients feel less stigmatized Inform patients that antidepressant medication helps correct imbalances in brain chemicals Educate about medication options Effectiveness, onset of action, potential adverse side effects All patients should be cautioned not to expect immediate symptom relief may need to take antidepressants for as long as 6 weeks before they experience benefits

37. Key Educational Messages For patients starting antidepressant meds: Antidepressants only work if taken every day Antidepressants are not addictive Benefits from meds appear slowly Continue meds even after you feel better

38. Key Educational Messages For patients starting antidepressant meds, cont: Mild side effects are common and usually improve with time Some medications must be stopped gradually. Always consult a doctor before changing, reducing, or stopping a drug regimen. The goal of treatment is complete remission; sometimes it takes a few tries.

39. Use of Non-physician and Support Staff Many of the monitoring and education functions important in the care of depressed patients can be handled by support staff, including: Administration/scoring of PHQ to monitor symptoms Providing educational materials Explaining care plan, what to expect, side effects

40. Scheduling follow-up visits Assisting with referral process Care management active patient follow-up through regularly scheduled phone contacts or visits Use of Non-physician and Support Staff