Transcript Surprises about effective management of depression: How

Managing Depression Effectively:
What we think we know may not be true
The 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
[email protected]
1
Software Screen
2
Today’s Speaker
Paul Block, PhD
Director, Psychological Centers
[email protected]
3
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
4
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
5
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
6
$ 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
$
$
7
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
8
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
9
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
10
Ways for care to be inadequate
General
Primary Care Behavioral Health

missed referrals


missed diagnoses


(e.g., 20% MDE € BPD)
which services are typically accessed


Screening, but self-report?
(meds, not therapy)
incomplete care
11
Ways for care to be inadequate
Medication
Medication management:







Wrong patient
Wrong problem
Wrong medicine
Too little
Too short
Not enough
follow up
Not combined with other interventions
12
Ways for care to be inadequate
Behavioral 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)
13
Ways for care to be inadequate
Identification
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
14
Ways for care to be inadequate
Targets
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
15
Ways for care to be inadequate
Population
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
16
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
17
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)
18
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.
19
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.
20
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)
21
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)
22
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).
23
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
24
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)
25
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
26
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
27
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
28
Things we know about depression
(that aren’t necessarily true)
PCP expertise
PCPs can’t manage medications



MCPAP
CHC experiences
Therapist diagnosis
and consultation
29
What would adequate care look like?







Individualized
Whole-person
Integrated
Actually provided
Flexible
“Complete”
Relapse Prevention
30
Recommendations






Screening
Evaluation
Collaboration
Design of treatment
Management of care
LPHC: full integration
Ψ
LPHC
31
References


























American Psychological Association, 2000d
Cummings, N.A., Dorken, H., Pallak, M.S., & Henke, C. (1990). The impact of psychological intervention on healthcare utilization and costs. San Francisco: Biodyne Institute.
Fischer, PJ, & Breakey, WR. (1991). The epidemiology of alcohol, drug, and mental disorders among homeless persons. American Psychologist, 46, 1115-1128.
Eronen, M.; Angermeyer, M. C.; Schulze, B. (1998) Social Psychiatry and Psychiatric Epidemiology, Vol 33(Suppl 1), S13-S23.
Jansen, MA. (1986). Mental health policy: Observations from Europe. American Psychologist, 41, 1273-1278
Kartha A, Anthony D, Manasseh CS, et al. (2007). Depression is a risk factor for rehospitalization in medical inpatients. Primary Care Companion. Journal of Clinical Psychiatry,
9,:256–262.
Katzelnick, D. J., Kobak, K.A., Greist, J.A., Jefferson, J.W., Henk, H.J. (1997). Effect of Primary Care Treatment of Depression on Service Use by Patients With High Medical
Expenditures. Psychiatric Services, 48, 59-64
Kimerling, R., Ouimette, P.C., Cronkite, R.C., & Moos, R.H. (1999). Veterans Affairs Palo Alto Health Care System and Stanford University School of Medicine. Annals of
Behavioral Medicine, 21, 317-21.
Kronson, M. E. (1991). Substance abuse coverage provided by employer medical plans. Monthly Labor Review, 114(4), 3-10.
Lynch, F.L., Dickerson, J.F., Clarke, G., Vitiello, B., Porta, G., Wagner, K.D., Emslie, G., Rosenbaum Asarnow, R., Keller, M.B., Birmaher, B., Ryanj, N.D., Kennard, B. Mayes,
T., DeBar, L., McCracken, J.T., Strober, M., Suddath, R.L., Spirito, A., Onorato, M., Zelazny, J., Iyengar, S., Brent, D. (2011). Incremental Cost-effectiveness of Combined
Therapy vs Medication Only for Youth With Selective Serotonin Reuptake Inhibitor–Resistant Depression: Treatment of SSRI-Resistant Depression in Adolescents Trial Findings.
Archives of General Psychiatry, 68, 253-262.
McDonnell-Douglas Corporation. (1989). Employee Assistance Program Financial Offset Study: 1985–1988. Long Beach, CA: McDonnell-Douglas Corporation.
Mecca, AM. (1997). Blending policy and research: The California outcomes study. Journal of Psychoactive Drugs, 29, 161-163.
Mental Health Policy Resource Center. (1990). Health status and the use of outpatient mental health services. Washington, D.C.
Pallak, M. S., Cummings, N. A., Dorken, H., & Henke, C. J. (1995). Effect of mental health treatment on medical costs. Mind/Body Medicine, 1, 7-12.
Primeau, F. (1988). Post-stroke depression: A critical review of the literature. Canadian Journal of Psychiatry, 33, 757-765.
Regier, DA, Boyd, JH, Burke, JD, Rae DS, Myers JK, Kramer M, Robins LN, George LK, Karno M, Locke BZ (1988). One month prevalence of mental disorders in the United
States. Archives of General Psychiatry, 45, 977-986
Rice, ME, Quinsey, VL, & Houghton, R. (1990). Predicting treatment outcome and recidivism among patients in a maximum security token economy. Behavioral Sciences & the
Law, 8, 313-326.
Schoenbaum, M., Miranda, J., Sherbourne, C., Duan, N., & Wells, K. (2004). Cost-effectiveness of interventions for depressed Latinos. Journal of Mental Health Policy and
Economics 7, 69–76.
Simon, G. E. (2011.) Treating depression in patients with chronic disease. [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071593/]
Sisley, A, Jacobs, LM, Poole, G, Campbell, S, & Esposito, T. (1999). Violence in America: A Public Health Crisis-Domestic Violence. Journal of Trauma-Injury Infection &
Critical Care, 46, 1105-1112.
Smith, E. M., North, C. S., & Spitznagel, E. L. (1992). A systematic study of mental illness, substance abuse, and treatment in 600 homeless men. Annals of Clinical Psychiatry,
4, 111-120.
Strosahl, K. (1998, August). A model for integrating behavioral health and primary care medicine. Paper presented at the annual conference of the American Psychological
Association, San Francisco.
Thomas, M. R., Waxmonsky, J. A., McGinnis, G. F., & Barry, C. L. (2006). Realigning clinical and economic incentives to support depression management within a Medicaid
population: The Colorado Access experience. Administration and Policy in Mental Health and Mental Health Services Research, 33, 26-33.
Torer N, Nursal TZ, Caliskan K, Ezer A, Colakoglu T, Moray G, Haberal M. (2010). The effect of the psychological status of breast cancer patients on the short term clinical
outcome after mastectomy. Acta Chirigica Belgique, 110, 467-70.
U.S. Department of Health and Human Services. 2001. Report of a Surgeon General’s Working Meeting on the Integration of Mental Health Services and Primary Health Care:
2000 November 30–December 1. Atlanta, Georgia. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General.
Available at http://www.surgeongeneral.gov/library/mentalhealthservices/mentalhealthservices.html.
Wang, Phillip S., Patricia Berglund, and Ronald C. Kessler. (2000). Prevalence and Conformance with Evidence-Based Recommendations. Journal of General Internal Medicine,
32
15, 284-292.
Questions / Discussion
?
33