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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.

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A Practical Review of Depression for the Primary Care Provider

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  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.

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