University of Pittsburgh

Management of Depression in Primary Care

Ellen M Whyte, MDMedical Director, Psychiatric Services

UPMC Benedum Geriatric CenterMedical Director

Integrated Behavioral Health – Primary Care

DISCLOSURES

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Grant Support in last 12 months:Geriatric Workforce Enhancement Program (HRSA) U1Q HP028736 (PI: Schulz)

Off-label use of medication will be discussed.

LEARNING OBJECTIVES

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Improve patient outcomes by identifying patients with major depression who require early psychiatric consultation.

Improve patient outcomes by utilizing measurement based, stepped care medication management in the treatment of major depression.

Improve skill in choosing and instituting pharmacotherapy for major depression.

PCP AS BEHAVIORAL HEALTH PROVIDERS

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Most behavioral health care in the US is delivered by the primary care provider.

Ø National Comorbidity Survey (2001-2003), patients reported that they received BH treatment through 40% PCP^ (PCP only >> PCP + another BH provider)26% Psychiatrist 21% non-physician Behavioral Health provider9% Human Services Only3% Complementary/Alternative Medicine

Wang et al 2006

^ Patients followed by PCP: typically older, female, lower SES, rural

MAJOR DEPRESSIVE EPISODE

Must endorseSadness/depressed mood and/or Loss of pleasure/anhedonia

For at least 5 total symptoms

At least 2 weeks duration, more days than not

Causes distress or functional impairment

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• Impaired sleep

• Impaired appetite

• Low energy

• Restlessness or looking ‘slowed down’

• Poor concentration

• Feelings of worthlessness or guilt

• Thoughts of death or suicidal thoughts

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BENEFITS OF TREATMENT

Ø Improved quality of lifeØ Reduced risk Ø Mitigated disabilityØ Improved medical outcomesØ Decreased health care utilization

MAJOR DEPRESSIVE EPISODE

Cardinal Episode in…

Major Depressive Disorder

Persistent Depressive Disorder (Dysthymia + Double Depression)

Bipolar Disorder – Type I and Type 2

Schizoaffective Disorder

Commonly Co-Morbid with…

Personality Disorders

Schizophrenia and Other Psychotic Disorders

Substance Abuse

Dementia (Neurocognitive Disorders)

TBI, CVA, Parkinson’s Dz, other neurological disorders

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MAJOR DEPRESSIVE EPISODECardinal Episode in…

**Major Depressive DisorderMajor Depressive Disorder with elevated suicide riskPersistent Depressive Disorder (Dysthymia + Double Depression)Bipolar Disorder – Type I and Type 2Schizoaffective Disorder

Commonly Co-Morbid with…Personality DisordersSchizophrenia and Other Psychotic DisordersSubstance Abuse**Dementia (Neurocognitive Disorders)**TBI, CVA, Parkinson’s Dz, other neurological disorders

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Maximizing Acute Treatment Outcomes for Depression

Management in Primary Care

IMPACTPROSPECT

-------STAR*D

Texas Medication Algorithm Project

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PHASES OF DEPRESSION TREATMENT

Kupfer DJ. J Clin Psychiatry 1991.

Maximizing Acute Treatment Outcomes for Depression

Management in Primary Care

Measurement Based Care

Stepped Care

Collaborative Care11

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PHQ-9

**

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Total Score Depressive Severity

1-4 Minimal Depression

5-9 Mild Depression

10-14 Moderate Depression

15-19 Moderately Severe Depression

20-27 Severe Depression

PHQ-9

PHQ-9 scores > 10 have a sensitivity of 88% and a specificity of 88% for Major Depressive Episode.

MEASUREMENT BASED CARE

Use PHQ-9 to serially monitor response to treatment.

PHQ-9 scores (as well as patient’s impression) determine next step of treatment.

--------Reflected in MIPS 371 “Depression Utilization of the PHQ-9 Tool” (q 4 months while treating depression)

Flowsheet available in EPIC “PHQ-9 [1357]”

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STEPPED CARE Medication Management is time focused and algorithm driven and leverages measurement based care.

-- initiate treatment with simple medications (e.g., SSRI), but other choices may be reasonable.

-- titrate to maximum tolerated doses of antidepressants quickly.

-- patient status assessed at weeks 2,4,6,9,& 12-- decision regarding continuation vs. change in

medication regime every ∼ 6-8 weeks.

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STEPPED CAREGeneral Rule:

After 6-8 weeks at a therapeutic dose of an antidepressant, assess response and adjust treatment plan....

After an additional 6-8 weeks, assess response and adjust treatment plan...

Repeat until patient is ‘symptom free’ and enters Continuation Phase of Treatment.

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STEPPED CAREGeneral Rule: After 6-8 weeks at a therapeutic dose of an antidepressant….

IMPLICATION: Titrate to maximum tolerated (therapeutic) antidepressant dose quickly.

Sertraline start at 12.5-25mg/d (↑to 50mg over 1-3 weeks)

Duloxetine start 30mg/d x 7 days, then↑ 60mg/d[or start 20mg/d x 7 d then ↑ 40mg (renal)]

Mirtazapine start at 15mg/hs x 1-2 weeks, then↑30mg/hs

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STEPPED CARE

General Rule: After 6-8 weeks…assess response and adjust treatment plan.

IMPLICATION: Response based on

Ø Change in PHQ-9 scores

Ø Patient’s subjective report

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STEPPED CAREFull Response = PHQ-9 demonstrates nearly 100% resolution or symptoms and patient reports ‘back to normal’.

RECOMMENDATIONS:

Ø Pt exits ACUTE treatment

Ø Pt enters CONTINUATION treatment

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STEPPED CARENon-Response = PHQ-9 ↓ by < 30% and/or patient is reporting little to no change

RECOMMENDATIONS:

Ø Switch antidepressants

Examples: SSRI à SSRI (Limit to 2 SSRI trials)

SSRI à SNRISSRI or SNRI à Mirtazapine (Remeron)SSRI or SNRI à Bupropion (Wellbutrin)

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STEPPED CARE

Partial Response = PHQ-9 ↓ by > 30% and/or patient

is reporting improvement

RECOMMENDATIONS:

Ø Watchful waiting for patients reporting near complete

resolution of symptoms.

Ø Dose increase (if possible) to maximum dose

(e.g., sertraline 50mg à 200mg/d; mirtazapine 30mg à 45mg)

Ø Augmentation with a 2nd medication with different

mechanism of action

Examples: SSRI/SNRI + bupropion

SSRI/SNRI + mirtazapine

SSRI/SNRI + atypical antipsychotic

SSRI/SNRI + lithium

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Discuss psychotherapy as treatment option

MOA = mechanism of action

PROSPECT Algorithm

STEPPED CARE:

General Rule:

After 6-8 weeks at a therapeutic (max) dose of an antidepressant, assess response and adjust treatment plan....

Repeat until patient is ‘symptom free’ and enters Continuation Phase of Treatment…

or refer to psychiatry after failure of 2 – 4 treatment trials.

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ACUTE TREATMENT- BASELINEPatient with elevated PHQ-9 score (including mood/anhedonia)

Assess suicide risk àthoughts that life is not worth livingdesire for death (e.g., “wish I would not wake up”)*suicidal ideation^suicide plan (including giving away possessions, etc)^suicide intent

reasons for living (protective factors)*risk factors (e.g., substance abuse, interpersonal loss)history of suicide attempt

^requires emergency assessment; *consider emergency assessment

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ACUTE TREATMENT- BASELINEClarify diagnosis

Screen for maniaScreen for substance abuseScreen for psychosis (“what has been worrying you recently”)

Review prior depression tx and family hx of txà informs medication choices

Assess for medical contributions to depressionThyroid function Sleep apnea HypercalcemiaVit B12/ Vit D Pancreatic CA

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SCREEN FOR HISTORY OF MANIAAll antidepressants can trigger a mania in patients with bipolar disorder who are not on a mood stabilizer.

Patients tend not to remember their manias as ‘problematic’ especially early in the disease.

Screening for Mania: • Mood Disorder Questionnaire (MDQ)

• Bipolar Type I (mania) >> Bipolar Type II (hypomania)• In primary care, sensitivity 0.58 & specificity 0.93

• Ask about a unique period (lasting 4+ days) of • Increased energy• Increased activity +/- decreased sleep• Increased self – confidence (can lead to ‘reckless behavior’)

• Abnormal elevated/irritable mood (not ‘normal self’)27

ACUTE TREATMENT

Pharmacotherapy + Adjunct Meds

Psycho-Education

Support/Encouragement

Psychotherapy

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PHARMACOTHERAPY-GENERAL PRINCIPLES

All antidepressants are equally effectiveCannot predict which medication will work for a particular patient

Ø Genetic testing can predict side effect burden.

Side effects appear early & are usually transient

Choose medication based on tolerability, utility of a side effect, or history of response (patient or family)Avoid abrupt discontinuation of antidepressants

Ø Especially venlafaxine, paroxetine

Age alone does not dictate medication dosing

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ANTIDEPRESSANTS

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SSRI*Prozac (fluoxetine)Luvox (fluvoxetine)Paxil (paroxetine)*Zoloft (sertraline)Celexa (citalopram) Lexapro (escitalpram)Viibryd+ (vilazodone)Brintellix++ (vortioxetine)

SNRIEffexor (venlafaxine)Pristiq (desvenlafaxine)*Cymbalta (duloxetine)Fetzima (levomilnacipran)

ATYPICAL*Remeron (mirtazapine)Wellbutrin (buprorion)

+ 5HT1A partial agonist; ++5HT3antagonist & 5HT1A agonist

ANTIDEPRESSANTS

Common to All: Risk of Hypomania/Mania

SSRI: nausea, diarrhea, ↑ bleeding, hyponatremia (SIADH), serotonin syndrome (rare), sexual SE

SNRI: same as SSRIs plus orthostatic hypotension, hypertension, exacerbate closed angle glaucoma

Bupropion: activation/anxiety, insomnia, tremor, seizure^ (1/1000)

[low incidence weight gain and sexual SE]

Mirtazapine: sedation (at lower doses), weight gain, ↑ triglycerides, [low incidence hyponatremia and sexual SE]

^SR/XL versions better tolerated, lower sz incidence

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ANTIDEPRESSANTS

SSRI: Fluoxetine, paroxetine, fluvoxamine-avoid in elderly d/t CYP inhibitionCitalopram - monitor QTc above 20mg/dSertraline - competes with warfarin - protein binding

SNRI: Duloxetine - renal dosing; pain benefit Venlafaxine – likely pain benefit; + orthostatic BP, HTN risk,

significant withdraw syndrome

Bupropion: weight neutral; tremor, sz risk, anxiety

Mirtazapine: helps with sleep; + weight gain

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Psycho-EducationKey points• People can and do get better: Treatment works!• Medication compliance is important; slow onset of benefit• Side effects occur early & are usually transient; can be

managed• Three stages of treatment (Acute + Continuation +/- Maintenance)

• Role of psychotherapy• Importance of behavioral activation (little steps)• Importance of good sleep hygiene

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PSYCHOTHERAPY

Appropriate as treatment, without medications, for mild depression and as an adjunct to medication in moderate to severe cases.

Structured, brief psychotherapies are preferred and more likely to be reimbursed by insurance companies.

Likely needs to be de-mystified for patients. Safe place to tell your storySafe place to consider your optionsLearn skills to manage depression/anxiety

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BRIEF STRUCTURED PSYCHOTHERAPIES

Cognitive Therapy (CBT): Identify and correct core beliefs

that lead to and/or reinforce depression; alter behaviors that

lead to and/or reinforce depression.

Problem Solving Therapy (PST): Reduce learned

helplessness by teaching an explicit process of solving

problems. Includes 6 problem solving steps plus behavioral

activation.

Interpersonal Therapy (IPT): Focus on 1 of 4 areas

associated with depression -- grief, role transitions, role

disputes, interpersonal deficits that lead to isolation.

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DEPRESSION MANAGEMENT

Recommendations are for contact at a minimum at2, 4, 6, 9, 12 weeks during acute treatment.

• monitor side effects• monitor/encourage compliance• monitor response• re-assess suicide risk

Goal is complete resolution of symptoms à residual symptoms predict recurrence of depressive

episode36

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PHASES OF TREATMENT

Kupfer DJ. J Clin Psychiatry 1991.

PHASES OF DEPRESSION TREATMENT

Acute Phase: From onset of treatment to resolution of ALL symptoms. [If medically ill, resolution of depressed mood, anhedonia, low self esteem, passive death wish/suicidal thoughts.]

Continuation Phase: patients advised to remain on medications for 6-9 months AFTER resolution of ALL symptoms; followed by slow taper and discontinuation.

Maintenance Phase: Prevention of recurrence after 6-9+ months symptom free.

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PROGNOSISMajor depression is a recurrent illness but full inter-episode remission is the norm.

~ 60% of patients who have one episode of majordepression will have a 2nd episode.

~ 90% of patients who have 3 episodes of majordepression will have a 4th episode.

~ 2/3 of patients have full recovery between episodes.

~ 1/3 of patients have partial recovery between episodes and are at high risk for recurrence.

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If first lifetime episode, uncomplicated… Ø taper & discontinue antidepressant after completion

of continuation phase (at least 6 months of ‘wellness’).

If 3rd or more lifetime episode [or at least one episode with significant suicidality and/or functional impairment]…

Ø indefinite continuation of ‘full dose’ antidepressant regime.

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MAINTENANCE TREATMENT - ADULTS

APA Practice Guidelines for Depression2000

Maximizing Outcomes in Depression ACUTE TREATMENT

Measurement Based Care

Stepped (time sensitive) Care

Collaborative Care

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Collaborative Care Model

Collaborative Care Management of Late-Life Depression in Primary Care Setting

Patients: N = 1,801; 60 + years oldInclusion Criteria:

MDE (17%), Dysthymia (30%) or both

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IMPACT STUDY

Unutzer et al 2002

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IMPACT Results

Unutzer et al 2002

IMPACTN=906

Usual CareN=895

Any Antidepressant Use 73% 57.2%

Any Psychotherapy or specialty BH visit

42.7%1 15.6%

Any Antidepressant or Psychotherapy

82.3% 61%

Response 44.7% 19.2%

Remission 25% 8.3%All differences statistically significant1 30% received PST-PC; 11% met with study psychiatrist

Prevention of Suicide in Primary Care Elderly: Collaborative Trial

Patients: N = 578; 60 + years oldInclusion Criteria:

CES-D > 20CES-D < 20 (5% random sample)CES-D < 20 + prior hx of depression

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PROSPECT STUDY

Bruce et al 2004

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PROSPECT ResultsProspect

N=320Usual Care

N=278

Any Antidepressant Use 66.3%^ 44.2%Psychotherapy Only 15%^ 1.3%Any Antidepressant and Psychotherapy 6.8% 13.6%

Response @ 4-8-12 mo 43%^-46%^-52% 29%-36%-42%

Remission @ 4-8-12 mo 48%^-50%-55% 34%-44%-53%

Bruce et al 2004

^differences statistically significant

UPMC Behavioral Health Care

UPMC Western Psychiatric Hospital

Supports for Primary Care Providers

q INTEGRATED BEHAVIORAL HEALTH SERVICE

q OPTIMUM STUDY

q TELEPHONIC PSYCHIATRIC CONSULTATION

q GREAT-MH EVALUATION-REFERRAL PROGRAM

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Collaborative Care-lite Model, started March 2015

Goal: Improve Behavioral Health access for patients w/o current BH providers by partnering with PCPs

Short –Term Model of Care: 6-10 months

Ages 18+

All diagnoses are eligible, including depression, anxiety, stress-management, etc.

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INTEGRATED BEHAVIORAL HEALTH SERVICE

INTEGRATED BEHAVIORAL HEALTH SERVICE

Phone/email if unsure evaluation is indicated

Enter EPIC Order

Evaluation with Behavioral Health Specialist (LCSW)

Brief therapy with Behavioral Health Specialist

Short-term treatment completed

Back to PCP

PCP identifies need

Psychiatric Input§ Phone§ In person

Refer to specialty or community

services

Integrated Providers INTEGRATED BEHAVIORAL HEALTH SERVICE

Location Therapists Psychiatrist

CMI Hampton L. Bonavita & A. ZajacsUmang Shah, MD

(Em Ketterer MD for RFP patients)

CMI Absolute Justin Miller

CMI Steel City Sarah Johnson

RFP Aspinwall -----

Emily Ketterer, MD

RFP Millvale Rebecca Weiss

RFP Penn Hills Kirsten Yaggi

CMI VFM Natrona Ben Fisher

Partners-in-Health Rachel Porterfield

CMI White Oak Ingrid Edwards

Ellen Whyte, MD

CMI Bethel Park Kathleen Dzura

Solano Ayesha Crawford

Health Center Assoc (Oakland) Ben Fisher

CMI Monroeville x Danielle Thorpe

CMI Squirrel Hill x Connie Crain

BH Specialist Experience (Jan-June 2019)q4,516 patient visits

q30% visits were for new patients

q48% of new patients do not return:v Referral for specialized treatmentv Conflict with work hours/transportationv Patient choicev Only wanted medication recommendations

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INTEGRATED BEHAVIORAL HEALTH SERVICE

When older patients don’t respond to two antidepressant trials, what should be the next step in treatment?Collaborative care approach:üPatients stay with their primary care provider.üResearch assessors measure outcomes and reports to PCPs.üGeriatric psychiatrists provide recommendations to the PCP based on a

standard algorithm (bupropion, venlafaxine, aripiprazole, lithium, nortriptyline)üPatients can do the entire study by phone.

OPTIMUM StudyOptimizing Depression Tx in Older Adults

Collaborative Care Model

OPTIMUM StudyOptimizing Depression Tx in Older Adults

• Principle Investigator Jordan Karp MD• Inclusion

– Age > 60– Major Depression– Failed > 2 trials of antidepressant meds

• Exclusion– Dementia– Parkinson’s Disease

If patient is interested in hearing more about the study, email study group through EPIC In Basket at P_TRD.

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Geriatric Psychiatric Evaluation & Referral Program

Pilot Project, funded through University of Pittsburgh Department of Psychiatry

Eligible Patients Aged 60+Any Mental Health or Cognitive ConcernConsult letter to PCPReferral to research studies or clinical services

Marie Anne Gebara MD, lead

Locations: UPMC Primary Care – White Oak & Hampton

Scheduling: 412 523-3261

SELECTED REFERENCESPHQ-9Kroenke K, Spitzer RL, Williams JB: The PHQ-9 Validity of a Brief Depression Severity Measure. J Gen Intern Med. 2001 Sep; 16(9): 606–613.

MDQHirschfield RMA, et al: Development and validation of a screening instrument for bipolar spectrum disorder: The Mood Disorder Questionnaire. American Journal of Psychiatry, 2000, 157: 1873-1875

Hirschfield RMA. The Mood Disorder Questionnaire: A simple, paitent-rated screening instrument for Bipolar Disorder. Journal of Clinical Psychiatry Primary Care Companion 2002, 4:9-11

Hirschfield RMA, et al: Screening for Bipolar Disorder in patients treatment for depression in a family medicine clinic. JABFP 2005, 18:233-239

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SELECTED REFERENCES

COLLABORATIVE, MEASUREMENT BASED, STEPPED CAREBruce et al. Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: a randomized controlled trial. JAMA.2004 Mar 3;291(9):1081-91 [PROSPECT]

Unutzer et al. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA.2002;288(22):2836-45. [IMPACT]

Trivedi MH, Rush AJ, Crismon ML, et al. Clinical results for patients with major depressive disorder in the Texas Medication Algorithm Project. Arch Gen Psychiatry. 2004;61:669-680. [TEXAS]

Trivedi MH, Rush AJ, Wisniewski SR, et al. Evaluation of outcomes with citalopram for depression using measurement-based care in STAR*D: implications for clinical practice. Am J Psychiatry. 2006;163:28-40. [STAR*D]

American Psychiatric Association Practice Guideline for the Treatment of Patients With Major Depressive Disorder, Third Edition, originally published in October 2010.

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THANK YOU!

Questions?

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