Managing Mood Disorders in Primary Care

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Managing Mood Disorders in Primary Care
I HAVE THIS PATIENT.

• Manpreet Singh, M.D. , M.S.
• Child Adolescent Psychiatry
• Lucille Packard Childrens Hospital

Amy Heneghan, M.D. Pediatrics Palo Alto Medical
Foundation
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Educational Objectives

• Inspire you to embrace the role of primary care
  in screening and managing mood disorders
• How to identify mood disorders in primary care
• What constitutes management of mood disorders in
  primary care
• When to refer to and collaborate with mental
  health colleagues
• Increase your knowledge about treatment of mood
  disorders
• Pharmacologic
• Behavioral
• Convince you to design your own practice to
  provide team based collaborative care
• What are the principles of collaborative care

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Mental Health Screening Depression Management
Integral to Pediatric Primary Care

• Why
• Mental health issues are common in children and
  teens and can portend complex medical and mental
  disorders in adulthood
• Why primary care
• Primary care is usually the first and often the
  only contact that patients have with health care
  professionals.
• Primary care interventions can be sufficient,
  without need for referral to mental health
  specialists.
• Who says so

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Epidemiology of Childhood Depression

• 5 of children and adolescents in general
  population suffer from depression at any given
  time (2 children, 4-8 adolescents)
• MaleFemale ratio 11 during childhood, 12 in
  adolescents
• 1.7 of children suffer from dysthymia (1.6-8 in
  adolescents)
• Depressive disorders are appearing at a younger
  age of onset

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CASE OF MY PATIENT (M.P.)

• 11 year old male presents for his annual check up
• Doing well in school
• Getting along at home with parents and siblings
• Likes video games
• Physical exam normal
• KEEP UP THE GOOD WORK! SEE YOU NEXT YEAR!

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CASE OF MY PATIENT (M.P.)

• M.P back for his annual 12 year check up
• Doing well in school
• Fighting more with parents and siblings
• Wants to play video games all the time
• Physical exam normal in early puberty
• COUNSELED ABOUT VIDEO GAMES, PEER RELATIONSHIPS,
  FAMILY RELATIONSHIPS, PUBERTY
• SCREEN FOR MOOD?

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Readily Accessible Screening Tools

• General HEADDSS
• Depression
• PHQ 9 9 questions about depression its
  severity
• PHQ 2 ? 9 2 question screen, then 9 if screen
  is positive
• PHQ 9 for Teens PHQ 9 2 ?s about
  suicidality
• Depression, ADD, Anxiety, Conduct
• Pediatric Symptom Checklist For Youth and Parent
• 37 questions about mood, behavior, attention
  issues
• 2 questions about suicidal thoughts, plans
• Drugs and Alcohol
• CRAFFT 3 initial questions, then 6 more

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PHQ 9 Modified for Teens
Depression Severity Rating lt 5 None 5
9 Mild 10 14 Moderate 15 19 Mod.
Severe 20 Severe Impact on
Function Not difficult Somewhat Difficult Very
difficult Extremely Difficult
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CASE OF MY PATIENT (M.P.)

• PHQ 9 for teens
• Scored 6
• felt irritable, low energy, and like he was
  letting his family down. No functional impairment
• Depressed? Manic? Anxious?

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Major Depressive Disorder Diagnosis DSM IV gt 5
of 9 sx (must include mood issue) impaired
function

• Mood irritable or depressed plus
• Sleep increased or insomnia
• Interest markedly decreased in activities
• Guilt feeling worthless, inappropriate guilt
• Energy fatigue or loss of energy
• Concentration hard to think/concentrate
• Appetite significant wt loss / gain ( 5
  change)
• Psychomotor activity physically slowed or
  agitated
• Suicide thoughts, attempts, death thoughts

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Grading Depression Severity Based on Sx and
Function (DSM IV)

• Mild 5-6 sx of mild severity (including mood)
• function mildly impaired or normal but w/
  substantial and unusual effort
• Moderate in between mild and severe
• Severe most sx present and severe
• Function is disabled, clearly observable
• Or
• Psychotic features are present

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Screen for Other Mood symptoms and Comorbidities

• Physical illness targeted review of systems,
  labs
• Substance / alcohol use, 20 30
• usually follows depression onset by 5 years
• Other mood and psychiatric disorders
• Dysthymia, Bipolar Disorder, Anxiety, ADD, PDD,
  ODD or Conduct Disorders, Psychotic disorders
  (hallucinations, paranoia)
• Abuse physical / emotional / sexual

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How mania present in kids
Warning Signs
Risk-taking behaviors with false beliefs of achievement
Getting only a few hours of sleep but not feeling sleepy during the day (Children need 8-10 hours of sleep Adolescents 10-12 hours)
Sneaking out of the house, running away, sexual activity, using drugs
I hear voices telling me to hurt myself
Energizer bunny
My brain is going 100 miles/hour Jumping from topic to topic
Grades getting worse from incomplete or unattempted school work Visits to the principals office for behavior problems.
Talking too much, being loud, hard to interrupt or understand
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Initial Management of M.P.

• Form an alliance w/ the teen and affirm hope
• Educate, counsel pt and family about depression,
  management options, limits of confidentiality
• Establish a safety plan restrict access to
  lethal means, engage 3rd party to monitor for
  deterioration/risk, develop emergency
  communication plan to use if needed
• Develop a specific tx plan and goals regarding
  function in home, school and peer relationships

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Initial Management of M.P. (cont.)

• Share resources for support phone s, websites,
  handouts
• Refer pt and family to mental health providers
• Arrange follow up visit within one week
• Have family sign release of information form to
  allow communication w/ school staff, outside
  providers.
• Obtain information from and communicate w/ school
  staff, health care providers. Keep them informed
  about your tx plans and concerns.

AAP http//www.aap.org/stress/teen1-a.cfm Bo
ok Ginsburg K, Building Resilience in Children
and Teens Giving Your Child Roots and Wings
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Initial Treatment of Mild, Uncomplicated
Depression

• Active support through PCP
• See pt weekly or biweekly x 6 8 wks
• Non directive support (support is equally
  effective as formal psychotherapy for mild
  depression)
• Monitor depressive symptoms and function
  (school, home, peer)
• If sx persist gt 6 8 wks, offer psychotherapy
  and / or antidepressants
• Refer patient and family to mental health care
  providers when appropriate

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Psychological and Social Treatments

• Stress management regular sleep
• Lifestyle Exercise, weight control, avoid
  caffeine and alcohol
• Resources and Support AACAP, APA
• Youth Bipolar Foundation of Northern Calif
  (YBFNC)ybfnc.cfsites.org
• Child Adolescent Bipolar Foundation (CABF)
  www.bpkids.org
• Depression Bipolar Support Alliance (DBSA)
  www.dbsalliance.org
• American Foundation for Suicide Prevention (AFSP)
  www.afsp.org
• School Intervention
• Psychotherapy
• Multifamily Psychoeducational Group therapy
• Family Focused Therapy
• Mood charting www.manicdepressive.org
• Complementary and alternative medicine Mental
  Health Naturally, by Kathi Kemper

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Promoting Resiliency through Active Support

• Teens definition Resilience means bouncing
  back from problems and stuff with more power and
  more smarts."
• Nurturing resiliency
• Demonstrate to pt that s/he has strengths (name
  them, show pt how s/he is using them, suggest how
  pt can use them in the future)
• Be patient, keep communicating these to pt over
  serial visits
• Adapted from Nan Henderson, The Resiliency
  Training Program

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CASE OF MY PATIENT (M.P.)

• Spoke to mother at 2 weeks, M.P better
• 8 weeks later, mother calls
• Does not want to wake up in the morning for
  school
• Note from teacher about missed assignment
• Outbursts of anger at home and at soccer
• Some nights does not sleep at all
• PHQ 9 modified score 15 (moderate-severe)
• very difficult to function
• Not suicidal
• DEPRESSED? MANIC? ANXIOUS?
• REFERRAL?

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Medication and Talk Therapy Sequential or in
Combination?

• TADS (Treatment for Adolescents with Depression
  Study) 439 teens 13 - 17 y/o with moderate to
  severe depression
• Cognitive Beh Tx (CBT) Fluoxetine
• CBT alone
• Fluoxetine alone
• Higher first response rate CBT Fluoxetine
  combined - Improved _at_ 12 wks 71 Combo (v. 61
  SSRI v. 44 Talk _at_ 36 wks similar outcomes for
  all groups
• Remission faster for combo tx by 36 wks 55
  for fluoxetine, 60 combo, 64 CBT
• Anti depressants can take 1 3 months to work
• Once stable continue med for 6 - 9 mo
• Treatment for Adolescents w/ Depression Study,
  Am J Psychiatry. 2009 166(10) 1141-1149.
• https//trialweb.dcri.duke.edu/tads/manuals.html

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Talk Therapy What Works?

• Cognitive Behavioral Therapy (CBT) is effective
  and less costly than other talk tx, eg
  Interpersonal Therapy
• CBT Principles thoughts cause feelings
  behaviors, not external things (people,
  situations, events).
• Focus Change the way you think and react in
  order to feel act better even if externalities
  dont change.
• Approaches attend to thoughts and behaviors,
  practice to change them
• (in contrast to Interpersonal Therapy, which
  focuses primarily on improving relationships)
• Recommended by WHO
• Adopted by National Health Service, UK

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Other Treatments to Initiate for Moderate
Depression without complicating features

• Consider starting antidepressant after discussion
  w/ psychiatrist and recommend psychotherapy
• Or
• Refer to Psychiatrist
• If teen / family decline psychotherapy or
  psychiatrist
• Active support through PCP
• See pt weekly or every other week x 6 8 wks
• Non directive support
• Monitor depressive sx and function (school, home,
  peer)

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When to Refer to Psychiatrist

• Anyone who wants such a referral
• Moderate Depression w/ Complicating Factors (eg
  substance abuse, ADHD, other psych illnesses)
• Severe Depression
• Suicidal patient

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If Improved after 6 8 wks

• Next 6 months Continue meds after sx resolution
  track adherence and side effects
• After full remission monitor monthly for 6
  months
• Up to 24 months regular follow up in primary care

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If not fully improved after 6 8 wks

• If Partially Improved
• If no med, consider adding
• If on med, consider increase dose
• If no psychotherapy, start
• Consult with or refer to psychiatrist
• Review safety plan
• Provide further education

• If Not Improved
• Reassess dx and if confirmed,
• Do all actions noted on left

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Before Starting Antidepressant Medication in Teens

• Establish safety plan
• Establish schedule for close follow up and
  communication
• Review short longer term side effects of meds
  and warning signs requiring immediate attention
  (including mania, suicidal ideation)

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SSRI Antidepressant Prescription for Teens by PCPs

• Who says so? AAP, AACAP, PC-Glad - II
• Why?
• Many teens and / or parents are reluctant to
  seek help from mental health providers.
• Widespread problems with limited or delayed
  access to psychiatrists for teens
• Which pts? uncomplicated mild depression that
  persists
• moderate depression
• How? Guidelines are clear about how to start
  meds, follow pts and when to seek specialty
  referral

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Medication for Teen Depression SSRIsDoses,
Efficacy and FDA Approval
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Medication for Teen Depression SSRI Side
Effects
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Required Followup Schedule for Teens on SSRIs for
depression

• First f/u should be a face to face meeting w/ MD
  1 wk after starting medication
• If pt is doing well, follow up schedule
• For 1st month Every week w/ MD or therapist
• During 2nd month Every other week
• After second month Monthly thereafter
• If dose is changed, see pt in 2 wks
• See pt sooner for any concerns

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CASE OF MY PATIENT (M.P.)

• Started on Prozac 10mg daily
• Seen biweekly not improved and dose increased
  to 20mg daily
• Symptoms improved markedly by week 12
• Next 6 months Continue meds track adherence and
  side effects
• After full remission monitor monthly for 6-12
  months

• Started on Prozac 10mg daily
• Seen biweekly, not improved and dose
  increased to 20mg daily
• Returns with complaints of
• agitation/irritability
• abdominal pain
• weight gain
• suicidal thoughts

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Assessing Suicide Risk
Ask about both ideation and attempts

• Have you wished you were dead or you could go
  to sleep
• not wake up?
• 2. Have you actually had any thoughts of killing
  yourself?

Ideation

1. Have you made a suicide attempt? Tried to kill
   yourself?
2. Done anything to harm yourself?
3. Anything dangerous where you could have died?

Attempts
Adapted from the Columbia Suicide Severity
Rating Scale, Posner et al 2009
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Black Box Warning about Antidepressant use in
Children and Teens

• In 2004, FDA reviewed 23 clinical trials (
  4,400 children adolescents) rxed any of nine
  antidepressants for MDD, anxiety, or OCD
• Outcomes
• No completed suicides
• Pts rxed anti depressants reported more
  suicidality (thoughts attempts) vs. pts on
  placebo (4 vs. 2 out of 100).
• Suicidality was not induced in pts without
  suicidality, not increased in pts who already had
  suicidality
• All studies showed reduced suicidality over tx
  course
• More SSRI rxs associated w/ lower suicide rates
  

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Collaborative Care By Many Other Names.

• Chronic Care Model
• Pt Centered Medical Home
• Pt centered, comprehensive, coordinate, superb
  access, and systems approach to quality and
  safety
• Who says? gt 30 RCTs confirm this, eg IMPACT
  model
• Who is using it Mayo Clinic,
  Intermountain Health, Minnesota, U Washington,
  many public health clinics
• Gilbody S et al. Collaborative care for
  depression a cumulative meta-analysis and
  review of longer-term outcomes. Arch Intern Med.
  2006166(21)2314-2321

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Collaborative Care for Depression is Best It
Takes a Team

• PCPs and mental health providers working
  together
• Co location in same clinic
• Consults by phone, e - consults
• Sharing notes efficiently thru EHR or fax/mail
• Maximize EHR tools
• track visits, PHQ scores, reminders, communicate
  w/ pts and team
• Observation for medication complication or side
  effects
• weight gain, thyroid dysfunction, kidney and
  liver dysfunction
• Care Managers MA, RN, or therapist
• educate, support pt self management
• recommend stepped care, adjusted for severity
  and response to tx
• arrange follow up at regular intervals
• coordinate w/ PCP and mental health providers
• Train staff for this work on line (free!) or in
  person http//impact-uw.org/training/web.html

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Resources
AAP Addressing Mental Health Issues in Primary
Care A Clinicians Toolkit
http//www.aap.org/commpeds/dochs/mentalhealth/Ke
yResources.html Guidelines for Adolescent
Depression in 10 Care Glad - PC
http//www.glad-pc.org/ TeenScreen National
Center for Mental Health Checkups
http//www.teenscreen.org/programs/primary-care
IMPACT Evidence based depression care
http//impact-uw.org/ NAMI resources for pts,
families, providers http//www.nami.org/ Heard
Alliance Collaborative of primary and mental
health providers in SF Bay Area Peninsula
www.HeardAlliance.org/ AACAP and APA Resource
Center and Parents Medication Guide
www.aacap.org/ www.psych.org/ Youth Bipolar
Foundation of Northern Calif (YBFNC)
ybfnc.cfsites.org Child Adolescent Bipolar
Foundation (CABF) www.bpkids.org Depression
Bipolar Support Alliance (DBSA)
www.dbsalliance.org American Foundation for
Suicide Prevention (AFSP) www.afsp.org

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Current Research Studies at Stanfords Pediatric
Mood Disorders Program

• Offspring of Parents with Bipolar and Major
  Depressive Disorders (Mechanisms of Risk and
  Resilience) Studying offspring both with and
  without mood problems Brain imaging (fMRI, MRS,
  DTI) Genetics
• Clinical trials of safety and benefit of
  medications to treat symptoms of mood and
  attention in children
• Studies of effects of mania depression on
  developing adolescent brain
• Psychotherapies and cognitive training for youth
  and families affected by depressive and bipolar
  disorders

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