Depression: The Hidden Co-Morbidity

1. Depression: The Hidden Co-Morbidity Neil Korsen, MD, MS MaineHealth January 18, 2007

2. Overview • Depression and chronic medical illnesses • Chronic medical illness and serious persistent mental illness (SPMI) • Using the PHQ-9 for screening and management of depression

3. Pop Quiz – Question #1 • Which is true? • Depression increases risk for diabetes. • Diabetes increases risk for depression. • Both are true. • Neither is true.

4. Pop Quiz – Question #2 • What is the most common cause of death in people with SPMI? • Heart Disease • Suicide • Accidents • Cancer

5. Pop Quiz – Question #3 • The PHQ-9 is useful for: • Screening for depression • Assessing response to treatment • Measuring outcomes • All of the above

6. Depression and Chronic Medical Illness • The rate of depression in the general population is 5-10% per year. • The rate of depression in people with chronic medical illness is higher: • CV Disease 20-30% • Diabetes 20-30% • Stroke 30% or higher

7. Depression Increases the Risk of Diabetes • 13-year prospective community-based follow-up study: Depressed subjects 2.2 times as likely to develop diabetes • 8-year Japanese workplace follow-up study: Depressed men 2.3 times as likely to develop diabetes Eaton WW. Diabetes Care. 1996; 10:1097-1102. Kawakami N, et al. Diabetes Care. 1999; 7:1071-1076

8. Impact of Depression on Diabetes Outcome • Increased functional impairment • Decreased glycemic control • Increased vascular complications Williams et al. Ann Int Med. 2004;140:1015-1024

9. Depression is a risk factor for stroke and coronary artery disease • Likelihood of developing myocardial infarction 4X • Likelihood of stroke 2.6 X general population • Increased Platelet Activation, reversed by SSRI’s • Independent of age, gender, lifestyle Larson et al, Stroke. 2001;32:1979; Yamanaka et al, Biomed Pharmacother. 2005 Oct; 59 Suppl 1:S31;Marzari et al, J Gerontol A Biol Sci Med Sci. 2005;60(1):85-92

10. Impact of Depression on Outcome of Cardiovascular Disease Frasure-Smith, et al., Circulation; 1995:999; Lesperance, et al. J. Am Coll Cardiol. 1998; Freedland. Psychosom Med.. 1998

11. Impact of Depression on Stroke Outcome • Decreased benefit from rehab • Increased inpatient and outpatient utilization • Increased mortality Ghose et al. Med Care. 2005 Dec;43(12):1259-64

12. What Do We Know About the Health Status of Persons with Serious Mental Illness?

13. Deaths from Heart Disease by age group.DMH Enrollees with SMI compared to Massachusetts 1998-2000 2.2RR 1.5RR 4.9RR 3.5 RR

14. Mortality from Pneumonia/InfluenzaMass DMH clients, ages 25-64 5.0 RR 4.0 RR 3.0 RR

15. Ohio SMI Mortality Study Leading Causes of Death

16. Using the PHQ-9 • Screening • Diagnosis • Response to treatment • Outcomes

18. Screening – Who and How US Preventive Services Task Force, 2003 statement supporting screening for depression: (We) recommend screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow-up. www.ahrq.gov

19. Screening for Depression: Who do you screen? • All adults at least every 5 years (as part of a health maintenance visit?) • High risk groups every year • History of depression • Family history of depression or bipolar • Chronic illnesses such as diabetes, heart disease, pain problems • High utilization of services • People with complaints that suggest depression such as insomnia or fatigue

20. Screening for Depression: The first two questions of the PHQ-9 have been validated as a sensitive way to screen for depression • 96% of people with depression will say yes to one of those two questions • Answer of ‘2’ or ‘3’ on either of those questions is a positive screen • Administer the full PHQ-9 to those who screen positive

21. Guideline for Using the PHQ-9 for Initial Management

22. What is Watchful Waiting? • It is estimated that a third of people with mild symptoms will recover without treatment. • Watchful waiting means you are seeing the patient about once a month and monitoring their PHQ-9 score, but not starting active treatment. • Self-care activities such as exercise or relaxation are usually a component of watchful waiting. • If the patient’s symptoms have not resolved after 2-3 months, active treatment ought to be considered.

23. Interpreting Follow Up Scores

24. How often should the PHQ be done? • Once a month until the patient reaches remission (score 0-4) or for the first 6 months of treatment • Every 3 months after that while the patient is on active treatment • Once a year for people with a history of depression who are no longer on active treatment

25. Treatment Goals • BEST • Remission = Score of 0-4 • Good • Score between 5-9 • Score drop by more than 50% of baseline

26. Things to Consider in Initiating Use of the PHQ-9 in your daily work • How will you identify those patients who should fill out a PHQ? • Who will give the patient the PHQ? • Who will score the PHQ? • Who will enter the results into the registry? When will that be done?

27. Useful Websites • MaineHealth • www.mainehealth.org • MacArthur Foundation Initiative on Depression and Primary Care • http://www.depression-primarycare.org/ • Robert Wood Johnson Foundation Depression in Primary Care program • http://www.wpic.pitt.edu/dppc/