Paul Block, PhD Director, Psychological Centers Paul.Block@PsychologicalCenters

1. Managing Depression Effectively:What we think we know may not be trueThe many ways care can be organized, can be inadequate, and many things we know about depression and its treatment that may not be true Paul Block, PhD Director, Psychological Centers Paul.Block@PsychologicalCenters.com

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3. Today’s Speaker Paul Block, PhD Director, Psychological Centers Paul.Block@PsychologicalCenters.com

4. Why depression? Depression is associated with more severe (and costly) medical problems, less effective medical treatment, higher health care costs • Disability (#2 impact on DALYs*) • Treating depression in patients with historically high medical expenditures reduced medical cost from $13.28 to $6.75 per day • Depression impedes long-term rehabilitation and recovery, and increases length of hospital stay and re-hospitalization by as much as a factor of three * Disability-adjusted life years

5. Why depression? Association of depression/anxiety with the top chronic diseases (diabetes, heart disease, cancer, etc.) • Disease-related biological causes of depressive symptoms, esp. CNS and endocrine disorders • Behavioral causes of depressive symptoms, inc. adjusting to illness, limits of rewarding activities, interference with roles Diagnostic difficulty • Overlapping symptoms lead to over-diagnosis • Under-diagnosis is far more common

6. Why depression? Results of comorbid depression: • Reduced quality of life • 2x restriction of activities and lost work days • 50-100% higher health care spending • Increased morbidity (worse medical outcomes) • Increased mortality

7. Costs of mental illness $ Work performance is affected by: • decreased productivity (“presenteeism”) • increased absenteeism • increased industrial accidents • higher rates of termination and turnover • increased rates of disability and worker compensation claims $ $

8. Costs of mental illness 15% of total corporate profits nationally ($671 billion per year) are lost to behavioral problems • based on American Psychological Association reports of costs to employers due to depression, anxiety disorders, substance abuse, and stress, compared to President’s annual report of total U.S. economic activity $

9. Costs of mental illness Social effects of mental illness or substance abuse include • increased likelihood of relying on welfare • increased criminal activity • increased violence • homelessness • family disruption and breakup

10. Ways to organize care in medical settings Models of management of depression in primary care, where most depression is found and treated: (with descriptions of each) • Referral to specialty care • Case/care management • Primary Care Behavioral Health • Co-location • Integration

11. Ways for care to be inadequateGeneral Primary Care Behavioral Health • missed referrals • Screening, but self-report? • missed diagnoses • (e.g., 20% MDE € BPD) • which services are typically accessed • (meds, not therapy) • incomplete care

12. Ways for care to be inadequateMedication Medication management: • Wrong patient • Wrong problem • Wrong medicine • Too little • Too short • Not enough follow up • Not combined with other interventions

13. Ways for care to be inadequateBehavioral health Primary Care Behavioral Health and patient preference (vs. providers’ skill) • Do patients prefer if health behavior focus is built in to all care as opposed to identified as an individual need (stigma)? • Do patients seen by a behavioral clinician to work on health behavior prefer to see the same clinician for mental health treatment? • (“hub and spoke” model)

14. Ways for care to be inadequateIdentification Importance of screening vs. referral only • Typical: PHQ2, maybe PHQ9, BAI3, rarely complete screening or screening of all patients • Is full behavioral/mhsa screening impractical? • PC development of 1 page screener • How to manage identified concerns • (PCP time) • Truly accessible resources

15. Ways for care to be inadequateTargets Focus on depression only • Anxiety disorders more common than depression • Substance abuse (SBIRT) • Health behaviors • Estimate that 50% of deaths are preventable, related to health behavior • Obesity responsible for 10% of health costs, increasing to 20% • Smoking

16. Ways for care to be inadequatePopulation Specific details of safety net populations and providers, inc. access to adequate care: • Low income populations and people from ethnic minority groups that are over-represented in Medicaid have: • significantly higher behavioral health needs • more often ineffectively-addressed • dramatically increased healthcare costs • “Good” news: until 2014, only population fairly sure to be covered

17. Ways for care to be inadequate Specific details of safety net populations and providers, inc. access to adequate care: • Increasing use of behavioral health services by Medicaid patients alone dramatically reduced costs in the population-based "Hawaii Project" including • 38% lower costs for patients without chronic illnesses • 18% for patients with chronic illnesses • 15% for substance abusers • among high users of medical services, significant total cost reductions through use of even brief psychological interventions

18. Things we know about depression(that aren’t necessarily true)Role of medication • Combined treatment is better (maybe for teens) • Severe depression responds better to medications than to therapy • It’s better not to use meds • Patient preference is primary (vs. professional recommendations)

19. Newer medications are better than older medications • Antidepressants may cause mild and often temporary side effects in some people, but they are usually not long–term. • Newer antidepressants have fewer side effects. • For all classes of antidepressants, patients must take regular doses for at least three to four weeks before they are likely to experience a full therapeutic effect.

20. Medication details The most popular types of antidepressant medications are selective serotonin reuptake inhibitors (SSRIs) SSRIs include • fluoxetine (Prozac), • paroxetine (Paxil) • citalopram (Celexa), • sertraline (Zoloft) • escitalopram (Lexapro- ? esp. effective in agitated or bipolar depression) • fluvoxamine (Luvox) Common side effects: • Headache–usually temporary and will subside. • Nausea–temporary and usually short–lived. • Insomnia and nervousness (often subside over time or if dose is reduced). • Agitation (feeling jittery or restless). • Sexual problems–men and women, including reduced sex drive, erectile dysfunction, delayed ejaculation, or inability to have an orgasm.

21. Medication details Serotonin and norepinephrine reuptake inhibitors (SNRIs) include • venlafaxine (Effexor) • duloxetine (Cymbalta) • desvenlafaxine (Pristiq) • Common side effects similar to SSRIs • In high doses, sweating and dizziness Norepinephrine and dopamine reuptake inhibitor • Bupropion (Wellbutrin) • No sexual side effects (at high doses can increase seizure risk)

22. Medication details Older classes of antidepressants, such as tricyclics and monoamine oxidase inhibitors (MAOIs) • MAOIs • Food and medicinal restrictions (tyramine, found in many cheeses, wines and pickles, and some medications including decongestants) • Tricyclic antidepressants (e.g., Amitriptyline, Doxepin, Imipramine, Desipramine, Nortriptyline)significant side effects include: • Dry mouth • Constipation • Bladder problems– emptying the bladder may be difficult, and urine stream may not be as strong as usual • Sexual problems–side effects are similar to those from SSRIs. • Blurred vision. • Drowsiness during the day. • Low blood pressure (especially on standing quickly)

23. Medication details Augmentation strategies FDA Warning on Antidepressants • 4% of adolescents and young adults taking antidepressants thought about or attempted suicide (no suicides occurred), compared to 2% of those receiving placebos. • Prompted the 2005 FDA "black box" warning label, extended in 2007 to include young adults up through age 24 • Emphasizes that patients of all ages taking antidepressants should be closely monitored, especially during initial weeks of treatment. • Benefits of antidepressant medications outweigh their risks to children and adolescents with major depression and anxiety disorders (even in terms of suicide risk).

24. Things we know about depression (that aren’t necessarily true)Psychotherapy Cognitive Behavioral Therapy (CBT) and Interpersonal Therapy (IPT) are the best behavioral treatments • Is CBT > IPT? • BT, BMT, SCT, MT, ACT, others (even psychodynamic treatments) • Main issue to consider may be relapse, more than recovery Gerald Klerman and Myrna Weissman

25. Things we know about depression(that aren’t necessarily true)Modifying the team Case management is optimal (e.g., Diamond, IMPACT, PRISM-E) • but vs. alternatives, inc. on-site integration? • Acceptance of referrals (43%, 49-52% with case management, 71-80% on-site)

26. Things we know about depression(that aren’t necessarily true)Relapse • Depression is a relapsing disorder (14.3% who receive EBT given the very loose definition, even lower % who receive relapse prevention) • EBT requires 14 sessions, not 1-3, 6, 8, or 12 • Formulation • Treatment to full remission to reduce risk of relapse

27. Things we know about depression(that aren’t necessarily true)Comorbidity Comorbidity predicts lower recovery • Substance abuse • Trauma • Personality disorder • Undiagnosed comorbidity & misdiagnosis Combined treatments

28. Things we know about depression(that aren’t necessarily true)Role of primary care Primary care manages most depressions • 50% are identified • 30% of those identified receive guideline-based care • 90%+ receive meds only • Specialty care is much better • % receiving EBT

29. Things we know about depression(that aren’t necessarily true)PCP expertise PCPs can’t manage medications • MCPAP • CHC experiences • Therapist diagnosis and consultation

30. What would adequate care look like? • Individualized • Whole-person • Integrated • Actually provided • Flexible • “Complete” • Relapse Prevention

31. Recommendations • Screening • Evaluation • Collaboration • Design of treatment • Management of care • LPHC: full integration Ψ LPHC

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33. Questions / Discussion ?