Depression Initiative

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Depression Initiative

• Jorge R. Petit, MD
• Associate Commissioner of Program Services
• Division of Mental Hygiene
• New York City Department of Health and Mental
  Hygiene

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Outline

• General Mental Health Findings NCS
• Depression Overview
• Depression in Primary Care
• DSM IV Criteria
• Depression Screening Standardization and use of
  PHQ9
• Depression Management Patient Education,
  Treatment, Ongoing Monitoring, and Self
  Management
• DOHMH Depression in Primary Care Initiative

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Take Care New York (TCNY)

• A health policy that prioritizes actions to help
  individuals, health care providers and New York
  City as a whole to improve health
• Sets an agenda for 10 key areas for intervention
• Addresses preventable causes of illness/death
• Focuses on undeserved communities with
  disproportionately high disease burden to reduce
  health disparities

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10 Steps to a Healthier New York

• 1. Have a regular doctor or other health care
  provider
• 2. Be Tobacco-Free
• 3. Keep your Heart Healthy
• 4. Know your HIV Status
• 5. Get Help for Depression
• 6. Live Free of Dependence on Alcohol and Drugs
• 7. Get Checked for Cancer
• 8. Get the Immunizations You Need
• 9. Make Your Home Safe and Healthy
• 10. Have a Healthy Baby

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General Findings
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National Comorbidity Survey - Replication (NCS-R)

• ½ of Americans will suffer from a
  mental/substance abuse disorder in their lifetime
• ¾ of those affected are ill by age 24
• 60 of those diagnosed (12 month prevalence) had
  serious (22) or moderate (37) illness
• 60 of those with a disorder received no
  treatment in past 12 months

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National Comorbidity Survey - Replication
(NCS-R)

• Of those who received care, only 33 met criteria
  for minimally adequate care
• Very substantial lags exist between illness onset
  and diagnosis and treatment
• Delays and inadequate treatment far more common
  in poor, poorly educated and people of color

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Institute of Medicine

• Mental or substance-use problems and
• illnesses are the leading cause of
• combined disability and death of women
• and the second highest of men.
• Improving the Quality of Health Care for Mental
  and
• Substance-Use Conditions November 2005

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Depression - Overview
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Prevalence

• In any given year, about 21 million American
  adults suffer a major depressive episode
• Lifetime Prevalence for a Major Depressive
  Disorder
• 10-25 of women
• 5-12 of men
• Major Depression affects 10 13 of medical
  outpatients

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Depression in NYC (NYHANES)

• 8 of all adult New Yorkers have a diagnosis of
  Major Depression.
• Of those diagnosed with Major Depression
• 9.1 are female and 5.5 are male
• 9.4 Black, 7.9 White, and 7.3 Hispanic
• Only 37 of New Yorkers report receiving mental
  health treatment. Of the NYers in treatment only
  a quarter of African Americans and Hispanics (26
  and 27 respectively) compared with nearly half
  (49) of Whites.

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Burden of Depression

• Untreated depression causes distress, disability,
  and, most tragically suicide.
• Of those with MDD, close to 50 report feelings
  of wanting to die, 33 consider suicide and 8.8
  report a suicide attempt.

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Burden of Depression

• Patients who are depressed are more likely to
  engage in behaviors that contribute to poor
  health, such as smoking, limited or no exercise,
  poor eating habits and are likely to have greater
  difficulty managing their co-morbid conditions.
• US workers with depression cost employers an
  estimated 44 billion per year.

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Depression and Chronic Disease

• Depressive disorders were associated with
  increased prevalence of chronic diseases (e.g.
  asthma, diabetes)
• Depressive disorders tend to precipitate chronic
  disease
• Chronic disease exacerbates symptoms of
  depression
• Seven out of 10 office visits to a primary care
  doctor concern chronic diseases.

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Depression Medical Comorbidities
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Implications of Comorbid Depression

• Patients with chronic medical conditions and
  concomitant major depression have poorer
  outcomes
• Increased somatic symptoms, eg, multiple pain
  complaints
• Excess functional disability
• Increased morbidity/mortality
• Increased healthcare utilization and costs
• Poor self-care
• Decreased adherence to treatment regimens
• Higher drug interaction potential due to
  polypharmacy

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Depression in Primary Care

• Depression is more commonly seen in primary care
  than any other condition except hypertension.
• 6-9 of patients in a primary care practice have
  a treatable depressive disorder.
• PCPs fail to diagnose depression in up to 50 of
  their depressed patientsthis oftentimes
  translates into more time spent on history taking
  and physical examination as well as more
  diagnostic procedures ordered, especially in
  light of vague presenting somatic complaints.

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Depression in Primary Care

• The diagnosis and treatment of depression by PCPs
  often do not follow current guidelines.
• Even when depression is recognized, the dosage
  and duration of antidepressant therapy may be
  inadequate.
• 50 of treated patients stop medication within
  first 3 months
• Medication often not used at dosage sufficient to
  achieve full remission

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Depression in Primary Care
In primary care, physical symptoms are often the
chief complaint in depressed patients.
In a New England Journal of Medicine study, 69
of diagnosed depressed patients reported
unexplained physical symptoms as their chief
compliant
N 1146 Primary care patients with major
depression
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DSM-IV Criteria for Major Depressive Episode

• Five (or more) of the following symptoms have
  been present during the same
• 2-week period, nearly very day, and represent a
  change from previous
• functioning at least 1 of the symptoms is either
  (1) depressed mood or (2)
• loss of interest or pleasure
• Depressed mood most of the day
• Markedly diminished interest or pleasure in all,
  or almost all, activities most of the day
• Significant weight loss when not dieting, or
  weight gain, or decrease or increase in appetite
• Insomnia or hypersomnia

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DSM-IV Criteria for Major Depressive Episode

• Psychomotor agitation or retardation
• Fatigue or loss of energy
• Feelings of worthlessness or excessive or
  inappropriate guilt
• Diminished ability to think or concentrate, or
  indecisiveness
• Recurrent thoughts of death, recurrent suicidal
  ideation without a specific plan, or a suicide
  attempt or specific plan for committing suicide

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Detection of Depression Why Screen and Manage in
primary care?

• Primary care is the 1st line of defense To
  find people who may be depressed or at risk for
  depression who dont know it
• Screening for depression in the primary care
  setting improves detection rates
• US Preventative Service Task Force (USPSTF)
  recommends screening adults for depression in
  clinical practices that have systems in place for
  accurate diagnosis, effective treatment, and
  follow-up.
• Only 50 of those referred to specialty mental
  health practitioners complete more than one visit

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Depression Screening PHQ2

• A physician can simply and quickly screen for
  depression by asking 2 questions (PHQ2)
• During the past month, have you been bothered by
• 1. little interest or pleasure in doing things?
• 2. feeling down, depressed, or hopeless?
• If the patient responds yes to either question,
  follow up with the PHQ9.

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The Patient Health Questionnaire (PHQ-9)

• A 9-item, self-administered questionnaire
• Can be completed by the patient before, during,
  or after the office visit
• Corresponds with the 9 signs and symptoms of the
  DSM-IV
• A screening tool not a diagnostic tool

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The Patient Health Questionnaire (PHQ-9)

• Quantifies the severity of depression (gives a
  number)
• Provides measurement over time
• Available in multiple languages (Spanish,
  Chinese, Russian, Creole, Bengali, Korean)
• Strong evidence of reliability and validity
• Sensitivity 88 for Major Depression
• Specificity 88 for Major Depression

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Scoring the PHQ-9
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Consider referral to mental health specialist
if

• PHQ 9 20
• Fails 1-2 medication trials
• Suicidal
• Psychotic or bipolar depression
• Comorbid substance, physical, or sexual abuse
• Severe psychosocial problems

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Consider referral to mental health specialist if

• Requires specialized treatment (MAO inhibitors,
  ECT)
• Deteriorates quickly
• Unclear diagnosis
• For referral resources Call 1-800 LIFENET/ (800)
  543-3638 or 311

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Depression Management

• Patient Education
• Treatment
• Ongoing Monitoring
• Self Management

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Patient Education

• Explain causes, mechanisms, and impact of illness
• Compare depression to other treatable medical
  illnesses to help patients feel less stigmatized
• Inform patients that antidepressant medication
  helps
• correct imbalances in brain chemicals
• Provide information about available medications,
  including effectiveness, onset of action, and
  potential adverse side effects
• All patients should be cautioned not to expect
  immediate relief

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Treatment

• Treatment is effective
• Treatment includes medication, psychotherapy or
  both
• Type of treatment recommended depends on the type
  of symptoms, the severity of symptoms and the
  patients personal preferences
• Combined treatment with antidepressants and
  psychotherapy is recommended as first line
  treatment for patients with severe major
  depressive disorder

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Ongoing Monitoring

• Close follow up by telephone and or visits until
  stable
• Severity tool (PHQ-9) to assess progress
• Titrate dose for total remission
• Maintain effective dose for 4 to 9 months
  (continuation phase)
• Monitor for early signs of recurrence
• Consider maintenance therapy

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Use of Support Staff

• Many of the monitoring and education functions
  important in the care of depressed patients can
  be handled by support staff, including
• Administration/scoring of PHQ to monitor symptoms
• Providing educational materials
• Explaining care plan, what to expect, side
  effects
• Scheduling follow-up visits

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Self Management

• The individuals ability to manage the symptoms,
  treatment, physical and social consequences, and
  lifestyle changes inherent in living with a
  chronic condition.
• Self management support (SMS)
• emphasize the patients central role in managing
  their illness
• use of effective SMS strategies, ie. assessment,
  goal setting, action planning, problem-solving,
  and follow-up
• organize internal and community resources to
  provide ongoing self management support to
  patients

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Self Management
Tools available from MacArthur Depression
Initiative website www.depression-primarycare.or
g Sample Action Plan
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Self Management
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DOHMH Depression in Primary Care Initiative

• Assist PCPs with implementing depression
  screening and management in primary care
• Training and technical assistance
• Target voluntary hospitals, FQHCs, university
  student health centers
• Work with HHC Chronic Disease Collaborative
  faculty
• Initiative Goal Increase by 10 the number of
  people treated for depression by 2008
• Baseline 37 of New Yorkers receiving mental
  health treatment