1 / 64

A Practical Review of Depression for the Primary Care Provider

A Practical Review of Depression for the Primary Care Provider. Jennifer Salisbury, D.O., M.P.S. Harvard Medical School South Shore Psychiatry Residency Training Program 2012 UNECOM Alumni Reunion & Fall CME Weekend. Disclosures. None. Learning Objectives.

monte
Download Presentation

A Practical Review of Depression for the Primary Care Provider

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. A Practical Review of Depression for the Primary Care Provider Jennifer Salisbury, D.O., M.P.S. Harvard Medical School South Shore Psychiatry Residency Training Program 2012 UNECOM AlumniReunion & Fall CME Weekend

  2. Disclosures • None

  3. Learning Objectives • Understand differences among various treatments for depression and when to use these treatments. • Understand safety assessment in the primary care setting. • Understand the assessment and treatment of common comorbidities of depression in the primary care setting. • Understand when the use of antipsychotic medication is indicated. • Understand when patients should be referred to a psychiatrist. • Understand the potential benefits of OMT for patients with depression and anxiety disorders.

  4. Outline • Depression • Statistics • Case • Assessment • Unipolar versus bipolar depression • Treatment • Comorbid Conditions • Alcohol dependence • PTSD • Monitoring for antipsychotic medications • OMT for psychiatric disorders • References “You’ll have to excuse George- he suffers from perfectly normal child disorder.” www.toonpool.com www.cartoonstock.com www.glasbergen.com

  5. Depression- Statistics • Affects ~121 million people worldwide. • Responsible for 850,000 deaths per year via suicide • Prevalence is 10-15% • One of the leading causes of disability worldwide. • Expensive • >$79 Billion annual loss to business (loss of productivity and absenteeism) • 1 of 5 most common conditions in primary care • Nearly 10% of all primary care office visits are depression related www.cdc.gov

  6. Depression- Statistics • Patients with co-morbid chronic illness and depression have: • More symptoms • Worse function • Impaired self care and adherence • Higher costs • Treatment of depression is especially important in patients with: • Arthritis • Diabetes mellitus type II • Cardiovascular disease • Cerebrovascular disease • A large barrier to care for mental illness in primary care = STIGMA www.cdc.gov www.whyhope.com www.seagullfountain.com

  7. Depression- Statistics • Primary care-based programs for depression have been shown to improve: • Quality of care • Satisfaction with care • Health outcomes • Functioning • Economic productivity www.utopianist.com Jorge, RE et al. Mortality and Poststroke Depression: A Placebo-Controlled Trial of Antidepressants Am J Psychiatry 2003;160:1823-1829. Culpepper L et al. Treating Depression and Anxiety in Primary Care. 2008. Prim Care Companion J Clin Psychiatry; 10(2): 145-152.

  8. Depression- Case • ID : Mr. A is a 46-year-old married, Caucasian male who works as the manager of a grocery store chain. • CC: “Doc- You gotta help me. My back is killing me.” • PMHx • Obesity • Hypertension • Diabetes mellitus type II • HPI • 4-5 months of fatigue and chronic, occasionally debilitating back pain treated with OTC analgesics. • Denies trauma or injury. • Feels “frazzled” because “work is kind of crazy right now.” • He appears to be in a relatively pleasant mood. • The remainder of the history is unremarkable. • PE • No spinal tenderness and neurological exam is normal. • Osteopathic examination is unremarkable. www.dfox-inkfeathers.blogspot.com

  9. Depression- Patient Presentation Other 69% presented ONLY with physical symptoms N= 1146 patients with depression Simon GE et al. An International Study of the Relation between Somatic Symptoms and Depression. 1999. N Eng J Med; 341:1329-1335

  10. Depression- Diagnosis is often missed when presenting with somatic complaints 100 80 60 40 20 0 N=685 77% % of Physician Recognition and Diagnosis of MDD/Anxiety Disorder 22% Psychosocial Complaints Somatic Complaints Type of Clinical Presentation Kirmayer LJ, et al. Somatization and the recognition of depression and anxiety in primary care. 1993. Am J Psychiatry; 150(5):734-741.

  11. MDD- DSM-IVTR Criteria

  12. Depression- Assessment • Administered Assessment Tools • Beck Depression Inventory http://www.fehb.org/CSE/CCSEConference2012/BeckDepressionInventory.pdf • PHQ-9 http://www.integration.samhsa.gov/images/res/PHQ%20-%20Questions.pdf • Interview

  13. Depression- Assessment • Assess mood • SIGECAPS • Sleep/Sex • Interest • Guilt • Energy • Concentration • Appetite • Psychomotor agitation/retardation • Suicide • Briefly assess for bipolar- very important!!

  14. Depression- Assessment Briefly assess for bipolar disorder. www.nursingmnemonics.blogspot.com

  15. Depression- Assessment • Briefly assess for bipolar • “Have you ever been the opposite of depressed- not just happy, but feeling euphoric or on top of the world, or extremely irritable for days at a time?” • “During this time did you not need much sleep?” • “Did people say you talked faster than usual or were your thoughts racing?” • “Did you do things you wouldn’t normally do or have a higher sex drive than you usually do?” (Uncharacteristic Behavior- Gambling, prostitution, maxing out credit cards, driving very fast, etc.) www.scienceblogs.com

  16. Depression- Safety • Primary care physicians assess for suicide in patients with depression in only about 1/3 of visits. • 50% of persons who commit suicide had sought professional help in prior month • Assess suicide risk • Ask: “This past week, have you had any thoughts that life is not worth living or that you’d be better off dead?” • Ideation, intent, plan, availability, lethality Feldman et al. Do Patient Requests for Antidepressants Enhance or Hinder Physicians' Evaluation of Depression?: A Randomized Controlled Trial. 2006. Medical Care; 44(12):1107-1113.

  17. Depression- Safety • Refer for inpatient psychiatric admission if the patient… • is suicidal • is homicidal • is unable to care for themselves • Psychosis • Severe mood dysregulation • Cognitive impairment • will require complicated medication adjustments • For example- severe depression requiring titration of a MAOI Feldman et al. Do Patient Requests for Antidepressants Enhance or Hinder Physicians' Evaluation of Depression?: A Randomized Controlled Trial. 2006. Medical Care; 44(12):1107-1113.

  18. Depression- Assessment • EKG • Labs • CBC • B12 • Folate • TSH • Pregnancy test

  19. Depression- Case • Further interview: • Feeling down x 4 months • Increased sleep • Poor concentration • 15 lb weight gain • Isolating and no longer going fishing or golfing • PE • No spinal tenderness and neurological exam is normal. • Osteopathic examination is unremarkable. • Labs • Within normal limits www.dfox-inkfeathers.blogspot.com

  20. Depression- Treatment Uncomplicated Depression? Depression with Psychotic Features N Start SSRI with an Antipsychotic. Choose based on S/E profile. Continue medication for at least 9 months. Consider maintenance treatment. Remission? Y N Refer to psychiatrist Modified from: Stein. Algorithms for Primary Care: An Evidence-Based Approach to the pharmacotherapy of Depression and Anxiety Disorders. Primary Psychiatry. 2004;11(6):55-78 Trivedi M. et al. Texas Implementation of Medication Algorithms Guidelines for Treating Major Depressive Disorder TIMA PHYSICIAN PROCEDURAL MANUAL . 2000.

  21. Depression- Treatment Assess and Address Co-Morbidities: Anxiety, Insomnia, PTSD, substance abuse Uncomplicated Depression? N Start with SSRI, bupropion, SNRI, or mirtazapine. Choose based on S/E profile and comorbid conditions. Initiate psychotherapy (if available) Modified from: Stein. Algorithms for Primary Care: An Evidence-Based Approach to the pharmacotherapy of Depression and Anxiety Disorders. Primary Psychiatry. 2004;11(6):55-78 Trivedi M. et al. Texas Implementation of Medication Algorithms Guidelines for Treating Major Depressive Disorder TIMA PHYSICIAN PROCEDURAL MANUAL . 2000.

  22. Depression- Treatment Start with SSRI, bupropion, SNRI, or mirtazapine. Choose based on S/E profile and comorbid conditions. Initiate psychotherapy (if available) Modified from: Stein. Algorithms for Primary Care: An Evidence-Based Approach to the pharmacotherapy of Depression and Anxiety Disorders. Primary Psychiatry. 2004;11(6):55-78 Trivedi M. et al. Texas Implementation of Medication Algorithms Guidelines for Treating Major Depressive Disorder TIMA PHYSICIAN PROCEDURAL MANUAL . 2000.

  23. Which Anti-depressant Should I Use? • SSRI • All have sexual side effects • Citalopram (Celexa) • Doses limited to 40mg (20mg in Elderly) due to QTc prolongation. • Avoid for patients with co-morbid OCD • Paroxetine (Paxil) • Sedating, weight gain, helpful for combat-related PTSD. • Short half-life  discontinuation syndrome • Sertraline (Zoloft) • Sedation? • Approved for PTSD (most evidence for childhood trauma) • Fluoxetine (Prozac) • Long half-life • SNRI • Venlafaxine (Effexor) • Activating. • Monitor blood pressure. • Short half-life  discontinuation syndrome. • XR formulation- fewer side effects. • Duloxetine (Cymbalta) • FDA approved for chronic pain • Generally not sedating www.cartoonstock.com

  24. Which Anti-depressant Should I Use? • Other • Bupropion (Wellbutrin) • No sexual side effects. Activating  can cause insomnia. • Mirtazapine (Remeron) • No sexual side effects. Very helpful for sleep. Increased appetite. Weight gain can be significant. • TCAs(amitriptyline, etc.) • Sedating, Weight gain. • Many side effects and drug interactions. • MAOIs • Best managed by psychiatrist. Please do NOT use antipsychotics as monotherapy for non-psychotic depression

  25. Depression- Treatment Start with SSRI, bupropion, SNRI, or mirtazapine. Choose based on S/E profile. Initiate psychotherapy (if available) Tolerable Side Effects? Change Treatment N Y Optimize dose of medication. Follow up every 1-2 weeks Continue medication for at least 9 months. Consider maintenance treatment. Remission? Y N Refer to psychiatrist Augment Treatment Change Treatment Refer to psychiatrist N Remission? Y Modified from: Stein. Algorithms for Primary Care: An Evidence-Based Approach to the pharmacotherapy of Depression and Anxiety Disorders. Primary Psychiatry. 2004;11(6):55-78 Trivedi M. et al. Texas Implementation of Medication Algorithms Guidelines for Treating Major Depressive Disorder TIMA PHYSICIAN PROCEDURAL MANUAL . 2000. Continue medication for at least 9 months. Consider maintenance treatment.

  26. Augmentation • Lithium • Antipsychotics • Other www.cartoonbank.com

  27. Augmentation • Lithium • Monitor blood levels and thyroid and renal function • Watch for weight gain, hair loss • Antipsychotic medication (Atypicals recommended over typicals) • Monitor as indicated in chart • Olanzapine (Zyprexa), Risperidone (Risperdal), Quetiapine (Seroquel) • Significant weight gain • Sedation • Potential elevated prolactin (can lead to galactorrhea) • Aripiprazole (Abilify) • Can cause akathisia, sometimes severe • Ziprasidone (Geodon) • Less weight gain • Requires BID dosing. • Must take with at least 500 cal of food for proper absorption

  28. Augmentation- Other Options • Buspirone • Second Antidepressant (different class) • Add bupropion (Wellbutrin) to SSRI or SNRI • Try “California Rocket Fuel” • Venlafaxine (Effexor) and Mirtazapine (Remeron) www.48hourslogo.com

  29. Augmentation- Other Options • L-Methyl Folate (Deplin) • Not the same as folic acid • Crosses BBB • MTHFR polymorphism • Up to 70% of people • Decreased ability to generate neurotransmitters • Deplin bypasses folic acid metabolism www.deplin.com

  30. Augmentation- Other Options • Add Psychotherapy if not already in place • Group • Supportive • Cognitive Behavioral Therapy • Acceptance and Commitment Therapy • Interpersonal Psychotherapy • Cognitive Processing Therapy (if co-morbid PTSD) • Dialectical Behavioral Therapy (if co-morbid Borderline Personality Disorder) http://lh3.ggpht.com/ www.mikeink.com

  31. Back to the Depression Case • ID : Mr. A is a 46-year-old married, Caucasian male who works as the manager of a grocery store chain. • PMHx • Obesity • Hypertension • Diabetes mellitus type II • CC: “Doc- You gotta help me. My back is killing me.” • Further Assessment: • Currently denies any symptoms of mania/hypomania • BUT: • He was hypomanic 3 years ago before he moved to Maine. www.dfox-inkfeathers.blogspot.com

  32. Bipolar Disorder AVOID Antidepressants Treatment of Choice = Mood Stabilizers Some are better for depression, others better for mania Consider referral to Psychiatry Lewis FT, et al. Bipolar Depression in Primary Care: A Hidden Threat. 2004. JAOA: 104: 59-514.

  33. Bipolar Depression- Treatment • Mood Stabilizers • Lithium • Baseline weight, EKG, CBC, electrolytes, renal function, thyroid function, pregnancy test • Need to monitor blood levels and above tests • Dosing • Aim for blood levels 0.6-0.8 mEq/L • Generally start at 300mg BID • Check level at 1 week and adjust • Most patients are on a total of 900-1200mg daily in divided doses • Risk for decompensation if lithium is abruptly discontinued www.thoughtbroadcast.com

  34. Bipolar Depression- Treatment • Mood Stabilizers • Lamotrigine • Effective only for depression, not hypomania/mania • No impact on weight, cognition, or sexual functioning • No serum monitoring required • Risk for Steven Johnson’s Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) - <0.5% in most studies • Less risk if slowly titrated • Dosing • Start with low doses and slowly increase over weeks • 12.5mg daily x 1 week, then • 25mg daily x 2 weeks, then • Increase by 25-50mg per week to effective dose • Usually need 100-200mg per day for adequate treatment • STOP if patient develops ANY rash • Need double the dose if patient is also taking carbamazepine • Need half the dose if patient is also taking valproic acid • Lithium and lamotrigine work well together www.thoughtbroadcast.com

  35. Bipolar Depression- Treatment • Antipsychotics • Quetiapine (Seroquel) • FDA approved but NOT a first line treatment due to side effects • Lurasidone (Latuda) • Looks promising! www.thoughtbroadcast.com

  36. Why is my patient’s depression not improving? Reassess for comorbidities

  37. Assess and Address Co-Morbidities • Insomnia • Unipolar Depression • Choose antidepressant with sedating properties • Add trazodone • Bipolar Depression • Be careful with trazodone- can be destabilizing • Lorazepam- helpful for mixed states • Avoid long-term use of sedative-hypnotics such as zolpidem (Ambien) • Lose effectiveness • Addiction potential • Sleep behaviors (sleep-eating, etc.)

  38. Assess and Address Co-Morbidities • Anxiety • Unipolar depression • Most antidepressants will improve anxiety • May want to avoid bupropion (Wellbutrin) • Buspirone (Buspar) • If no addiction history • Short-term use of low-dose long-acting benzodiazepine • Clonazepam can worsen depression in some patients • PLEASE do NOT use alprazolam (Xanax)! • Bipolar Depression • Avoid antidepressants • Buspirone • Short-term use of benzodiazepines

  39. Assess and Address Co-Morbidities • Obsessive-Compulsive Disorder • Unipolar depression • High doses needed • Avoid citalopram- QTc issues • Bipolar depression • Avoid SSRIs • Refer for cognitive behavioral therapy • Consider referral to psychiatry • Substance Abuse • Post-Traumatic Stress Disorder

  40. Alcohol Dependence- Case • ID : Mr. B is a 55 year-old divorced Caucasian male. • CC: “My daughter told me you might be able to help me.” • PMHx • Hypertension • GERD • Alcohol Dependence x 10 years. • HPI • History of four admissions for detoxification from alcohol. • Recently fired from his job due to absenteeism. • Discharged from detox last week. • Maintained sobriety for the past week by Attending Alcoholics Anonymous. • Having significant cravings for alcohol. • Wants your help to avoid relapse. • PE • Unremarkable • Labs • Mildly elevated LFTs www. thejrexperiment.com

  41. Outpatient Substance Abuse Treatment • Refer for detoxification if needed • Encourage participation in group therapy, Alcoholics Anonymous, Narcotics Anonymous • Medication (can combine with SSRIs, etc.) • Naltrexone (Depade, ReVia, Vivitrol) • Acamprosate (Campral) • Topiramate (Topamax) • Disulfiram (Antabuse)

  42. Outpatient Substance Abuse Treatment • Naltrexone • Dose- 50mg daily • In studies, subjects taking naltrexone: • Drink less. • Longer sobriety. • Had more time between relapses. • Had increased resistance to cravings. • Contraindicated in patients with hepatitis C infection • Monitor LFTs • Need to be opioid-free for 2 weeks prior to treatment • Available in long-acting IM form Anton RF, et al. Naltrexone and Cognitive Behavior Therapy for the Treatment of Outpatient Alcoholics: Results of a Placebo-Controlled Trial. 2003. Focus 1 (2).

  43. Outpatient Substance Abuse Treatment • Acamprosate (Campral) • Metabolized by kidneys. • Useful for patients with liver disease. • Typical dose 666 mg PO TID. • Topiramate • Off-label. • Reduces cravings and drinking frequency and increases abstinence. • Usual dose- 200-300 mg/day in divided doses. • Disulfiram (Antabuse) • Not recommended for routine use in primary care. Paparrigopoulos T, et al. Treatment of alcohol dependence with low-dose topiramate: an open-label controlled study. 2011. BMC Psychiatry: 11 (41).

  44. PTSD- Case • ID : Mr. C is a 24 year-old married Caucasian male college student. • PMHx • Status post right medial meniscus repair. • CC: “I feel fine- I just need a refill.” • HPI • New to the area and to your practice. • Presented to the ER last week due to insomnia. • Prescribed quetiapine 100mg qHS. • No other complaints • PE: Unremarkable www.npr.org www.drozfan.com

  45. PTSD- Case • Further History • Returned from serving in Afghanistan in 2010. • Exposed to firefights & IED blasts. • Best friend died in front of him. • Frequent intrusive thoughts and nightmares • Spends much of the night “checking the perimeter” • Avoids crowds, watching war movies www.npr.org

  46. PTSD- Statistics • Lifetime Prevalence • Up to 8% in the general population • Up to 10% in women • 30% of veterans • 45% of battered women • 50% of sexually abused children • 35% of adult rape victims A victim of childhood sexual abuse, Stan DeFalco dedicated his life to the creation of pedophile lures that dispensed bubonic super-AIDS. The resulting epidemic decimated half the world’s population--- but still Stan felt nothing. Nothing at all. www.ptsd.va.gov www.namrata05.blogspot.com Elklit A & Christiansen DM. Predictive Factors for Somatization in a Trauma Sample. 2009. Clinical Practice and Epidemiology in Mental Health; 5 (1).

  47. PTSD- Statistics • PTSD affects health. • Increased somatic symptoms in patients with PTSD • Childhood abuse and neglect are related to increased diagnoses of: • Cancer • Ischemic heart disease • Chronic lung disease. • Cost • Overall Increased utilization of health care services • PTSD is under-recognized by practitioners. www.ptsd.va.gov www.namrata05.blogspot.com Elklit A & Christiansen DM. Predictive Factors for Somatization in a Trauma Sample. 2009. Clinical Practice and Epidemiology in Mental Health; 5 (1).

  48. PTSD- Assessment • What can health care providers do? • Screen for PTSD • Provide a referral • Provide educational materials • Follow up with the patient • Medications • Screen for PTSD • PTSD Check List (PCL-C or PCL-M)- Score >45 = PTSD • Primary Care PTSD Screen (PC-PTSD) • In your life, have you ever had any experience that was frightening or life-threatening? • Over the past month have you had nightmares about it or thought about it when you did not want to? • Over the past month have you tried hard not to think about it or went out of your way to avoid situations that reminded you of it? • Over the past month have you feeling constantly on guard, watchful, or easily startled? • Over the past month have you felt numb or detached from others, activities, or your surroundings?

  49. PTSD- Treatment Algorithm Sleep Disturbed? Y N Nightmares/ Hyperarousal: Prazosin Sleep initiation: Trazodone Both: Prazosin then Trazodone Continued PTSD Symptoms? Y N SSRI Continue Treatment Continued PTSD Symptoms? N Y Refer to Psychiatry Without psychosis: Try 2nd SSRI, SNRI, or mirtazapine With psychosis: Add antipsychotic (risperidone best) Scheurer D. et al. Restrained Use of Antipsychotic Medications: Rational Management of Irrationality. 2012. Independent Drug Information Service.

  50. PTSD- Treatment • Medication • Sleep • Prazosin (Minipres) • Selective alpha1-adrenergic blocking agent that crosses BBB • Slow titration to avoid hypotension • Men • Start at 1 mg at bedtime x 3 days • Increase as follows, as tolerated: • 2mg for 4 nights • 4mg for 7 nights • 6mg for 7 nights • Day 21: 10 mg dose at bedtime • Day 28: 15 mg given at bedtime • Women • 1mg at bedtime x 1 week • Increase by 1mg as tolerated • Daytime Dosing • Found to be helpful for hypervigilence • Current DOD study: 5mg in AM and 15mg qHS. • Taylor FB et al. Daytime prazosin reduces psychological d • stress to trauma specific cues in civilian trauma posttraumatic • stress disorder. Biol Psychiatry 2006: 59:577-581.

More Related