"DEPRESSION"
DEPRESSION
IN
CHRONIC ILLNESS
Adapted from
The MacArthur Foundation
Depression Education Program
and
Cole, Raju, Barrett, Gerrity, Dietrich
General Hospital Psychiatry, 2000

OUTLINE
 The problem
 Types of depression
 Assessment, tools, algorithms
 Practice design
 Self-management support
 Decision support

DEPRESSION IS COMMON
 20-40% of patients with diabetes
    or cardiac disease have major
   depression
Depressed patients visit primary
    care physicians 3 times more
    often than patients not depressed

DEPRESSION IS SIGNIFICANT
Increased morbidity and mortality in medical conditions
Increased utilization
Increased costs
Leading cause of disability worldwide

DEPRESSION IN DIABETES
Ý non-adherence
Ý GHb
Ý retinopathy;Ý neuropathy;
   Ý nephropathy
Ý macrovascular complications
    (CAD, etc)
        Groot et al Psychosom Med 2001
       Van Tilburg et al Psychosom Med 2001

 DEPRESSION
IN CARDIAC DISEASE
Ý risk of hypertension; Ý CVA; Ý CAD
Ý risk of death after MI (independent of other risks)
Mechanisms
Ý HPA activation
Ý sympatho-medullary activity
Ý platelet aggregation; Ý coagulation; ßfibrinolysis;
ß heart rate variability
      Musselman et al Archives Gen Psych 1998
      van Kanel et al Psychosom Med 2001

 DEPRESSION
and ASTHMA IN CHILDREN
 Depression is common (30%) and…
Predicts poor school performance
Predicts medication nonadherence
Associated with poor asthma outcome/death
Afflicts 50% of mothers of asthmatic children
depression in mothers associated with 40% Ý in ER visits of children
Genetic and biologic mechanisms
Linkage of depression and asthma; atopy
Common dysregulation of cholinergic system

UNDER-RECOGNITION/
UNDERTREATMENT
 30%-70% of depression is
    missed
 50% of patients stop medication
    within first 3 months

TYPES OF DEPRESSION
 Major depression
 Chronic depression
    (dysthymia)
 Minor depression
 adjustment disorder
 depressive disorder nos


MAJOR DEPRESSION
Four Hallmarks:
 Depressed mood
 Anhedonia
 Physical symptoms
 Psychological symptoms

DEPRESSED MOOD
Hallmark 1
 Neither necessary, nor
    sufficient
 Can be misleading
 Beware of asking the question, “Are you depressed?”

ANHEDONIA
 Hallmark 2
 Loss of interest or pleasure
 May be most important and
    useful hallmark
 Ask, “What do you enjoy
    doing?”

PHYSICAL SYMPTOMS
 Hallmark 3
 Sleep disturbance
 Appetite or weight change
 Low energy or fatigue
 Psychomotor changes

PSYCHOLOGICAL SYMPTOMS Hallmark 4
 Low self-esteem or guilt
 Poor concentration
 Suicidal ideation or persistent
    thoughts of death

DSM-IV CRITERIA FOR MAJOR DEPRESSION
 Depressed mood or anhedonia
 A total of 5 out of 9 symptoms
 Symptoms that persist most of
    the day, nearly every day, for 2
    weeks

CHRONIC DEPRESSION (DYSTHYMIA)
 Characterized by 2 years of
    depressed mood, occurring
    more days than not
 Persists with at least 2 other
    symptoms of depression
 Increases risk of major
    depressive episodes

MINOR DEPRESSION
 Adjustment disorder
 Depressive disorder nos
 Significant disability

Slide 18

ASSESSMENT
Patient Health Questionnaire (PHQ)
Treatment guidelines
Barriers
Diversity and depression
Communication strategies

Patient Health Questionnaire: (PHQ)
9-item, self-administered questionnaire
Closely follows the DSM-IV criteria
Validated for diagnostic assessment
Validated for follow up of outcomes

USE OF THE PHQ
Assess high-risk, ‘red flag’ patients
Chronic illness
Unexplained physical complaints
Patients who appear sad or stressed
Patients who have lost interest or pleasure in their lives

SCORING THE PHQ: SEVERITY
Count numerical values of symptoms
0-4    not clinically depressed
5-9    mild depression
10-14   moderate depression
>14    severe depression

PHQ-9 Compared to Clinician Assessment of MDD

BARRIERS TO RECOGNITION
 Culture and stigma
 Somatization
 Comorbidity
 Fallacy of ‘good reasons’
 ‘Pandora’s box’
 Discomfort with emotional issues

DIVERSITY AND DEPRESSION
Surgeon General’s Report on Minorities
Higher rates of depression
Less adequate treatment
Cultural barriers
Different paradigm
Stigma

THE SPIRIT CATCHES YOU
AND YOU FALL DOWN
Anne Fadiman
Anthropological medical account of intractable infant epilepsy in Lia Lee, a 3 month old Hmong child in California who died at age 4
“This fine book recounts a poignant tragedy…It has no heroes or villains, but it has an abundance of innocent suffering.”
Melvin Konner, The NY Times Book Review

WHAT CAUSED THE ILLNESS?
“Of 40 or so doctors, nurses, and agency employees…Jeanie Hilt was the only one who actually asked the Lees what they thought was the cause of their daughter’s illness.” (p. 22)
“…the chart grew longer and longer, until it contained more than 400,00 words reflecting intelligence, training, and good intentions, but not one dealt with the Lees’ perception of their daughter’s illness.”  (p. 259)

 WHAT CAUSED THE ILLNESS?
“When Lia was about three months old, her older sister slammed the front door of the Lees’ apartment. A few moments later, Lia’s eyes rolled up, her arms jerked over her head, and she fainted. The Lees had little doubt what had happened. The noise of the door had been so profoundly frightening that her soul had fled her body and become lost. They recognized the resulting symptoms as quag dab peg, which means “the spirit catches you and you fall down.” (p. 20)

HOW WAS IT TREATED?
US doctors prescribed
14 different medications with 23 changes (p. 46)
Hmong
“a little medicine and a little neeb”
   (p. 265)
US doctors “had no idea what the Lees were doing to heal Lia because they never thought to ask”  (p.112)

“JUST ASK…”
“I’ve made a million errors. When I came here everyone said you can’t touch people on the head, you can’t talk to a man, you can’t do this, you can’t do that, and I finally said, this is crazy! I can’t be restricted like that! I just threw it all out. Now I have only one rule. Before I do anything I ask, Is it okay?”
Jeanie Hilt, p. 95

STRATEGIES FOR DIVERSITY
Appreciate limitations of biomedical model
Elicit explanatory models
Ask what the patient/family wants
Compromise/negotiate
“Ask not what disease the person has, but what person has the disease”…
                                                 Sir William Osler

‘TACCT’

Tailored Approach for
Caring and Counseling Transculturally

T.A.C.C.T.
 conceptual and pragmatic framework
 provider communication skills
 for use with culturally diverse patients
 to promote self-management support

BEFORE TACCT…
ELICIT EXPLANATORY MODEL
 Ask patient and family
“What do you think is causing the patient’s problems?”
Use open-ended questions
Use facilitation
Use open-to-closed cone
Use checking and summarization

T.A.C. C. T.
 T ell – about illness
 A sk – about information provided/reactions
 C are – respond to emotions
 C ounsel – provide information responding to
       concerns and explanatory model (education)
 T ailor plan to patient’s concerns and
       priorities

Slide 36

INTEGRATION OF DEPRESSION:
PRACTICE DESIGN
 Identify “red-flag” patients
 Administer PHQ (once/year) for all
    chronic illness patients
 Identify/develop mechanism for
    specialist support
 Integrate care manager or care
     management function for patient
     self-management support

SELF-MANAGEMENT SUPPORT: SIX FUNCTIONS
Develop and maintain rapport
Educate patient
Monitor progress using serial PHQs
Encourage adherence
Resolve treatment-emergent problems
Encourage exercise, pleasant activities

DECISION SUPPORT:
ACUTE DEPRESSION
 Phases of depression
 Criteria for consultation,
    collaboration or referral
 Support/office counseling
 Treatment selection

Three Phases of Treatment

SPECIALIST
DECISION SUPPORT
 Consider three types of decision support
Consultation
One-time specialist evaluation
Collaboration (co-management)
Specialist provides decision support on regular or intermittent ongoing basis
Referral
Care provided by specialist

Consultation,
Collaboration, or Referral
Suicidality
Psychosis
Bipolarity
Chemical dependency
Personality disorder

OFFICE COUNSELING:
NON-SPECIFIC SUPPORT
Reflective listening
If I understand you correctly, you…
Empathic communication
I can see you feel very sad…(reflection)
I can understand…(legitimation)
Specific offer of support
I am here to help you…
Partnership
Let’s you and I together…
Respect
I am very impressed by…

"S schedule regular activities"
S schedule regular activities
P plan pleasant events
E exercise
A assertiveness
K kind thoughts about self

TREATMENT SELECTION:
FOUR OPTIONS
Watchful waiting
Psychotherapy
Pharmacotherapy
Combination therapies

WATCHFUL WAITING (WW)
 Many depressions remit spontaneously
 WW is an acceptable “treatment plan”
 Initial treatment of choice for minor
     depression
 Intensity of WW
Low:  repeat PHQ only (mild depression)
Moderate:  w/active SMS  (mod. depression)

PSYCHOTHERAPY
 Effective
Mild to moderate major depression
Adjunct to antidepressants
Chronic depression
 Possibly effective
Minor depression
For patients in life transitions or with personal conflicts

PHARMACOTHERAPY
 Effective
Major depression
Chronic depression (dysthymia)
 Untested
Minor depression

ANTIDEPRESSANTS
 TRICYCLICS
  SSRIs
  citalopram (Celexa)
  escitalopram (Lexapro)
  fluoxetine (Prozac)
  paroxetine CR (Paxil)
  sertraline (Zoloft)
OTHER NEW AGENTS
  bupropion SR (Wellbutrin)  - DA/NE
  mirtazapine (Remeron)        -  NE/5HT
  nefazodone (Serzone)            -  SRI/5HT
  venlafaxine XR (Effexor)     -  SRI/NRI

"TREATMENT GUIDELINES:"
TREATMENT GUIDELINES: ACUTE DEPRESSION
 Start with SSRI or new agent
 Increase every 2-4 weeks
 Treat to remission (PHQ<5)
 If no response, switch class
 If partial response at maximum
    dose, consider augmentation or
    consultation

PARTIAL OR NO RESPONSE
 Check for adherence
 Re-evaluate diagnosis
assess for co-morbidities
 Adjust dosage
 Change antidepressant/augment
 Add psychotherapy
 Consider specialty consultation,
     collaboration, or referral

TREATMENT GUIDELINES:
CONTINUTATION TREATMENT
 Continue for at least 4-9 months
     after full remission (PHQ<5)
 Longer continuation decreases risk
    of relapse

TREATMENT GUIDELINES:
TO MAINTAIN OR NOT TO MAINTAIN?
If no previous episode of major depression
50% chance of recurrence if stop medication
If one previous episode of major depression
75% chance of recurrence
If two previous episodes of major depression
90% chance of recurrence
Maintenance decision made in partnership with patient based on above information, patient preferences and severity of depressive episode(s)
Maintenance dose Is FULL treatment dose

PHQ-9 Initial Rx. Guidelines
1-4: Not depressed — no further action
5-9: Mild  — probable minor depression
Watchful waiting (WW)  treatment of choice
Self-management support (SMS)
Schedule reassessment
10-14: Moderate — clinically significant depression Medication and/or psychotherapy; SMS
> 15: Severe depression
Medication primary; SMS; consider psychotherapy

PHQ-9: Monthly Follow-Up Guide
for Clinically Significant Depression

TRICYCLIC ANTIDEPRESSANTS
Side Effects:
 anticholinergic
 antihistaminergic
 antiadrenergic
 quinidine-like effects
* nortriptyline and desipramine
    least toxic

ADVANTAGES OF SSRIs AND OTHER NEW AGENTS
 Fewer side effects
 Safety profile
 Increased patient satisfaction
 Improved adherence to therapy
 Cost savings

CHOOSING AMONG SSRIs AND OTHER NEW AGENTS
Evaluate:
 half-life
 drug interactions
 side effects
 mode of action

HALF-LIFE
 Long (longer than 1 day)
 fluoxetine (Prozac)
 Short
 other SSRIs (once a day)
 Effexor XR (once a day)
 Wellbutrin SR (1-2x/day)
 other new agents (2x/day)

DRUG INTERACTIONS
 Obtain medication history
 Be aware that all drugs can
    affect the action and serum
    levels of other drugs
 Monitor the clinical effects and
    serum levels of all medications
 Use electronic data base

"DRUG INTERACTIONS
(ANTIDEPRESSANT INHIBITION"
DRUG INTERACTIONS
(ANTIDEPRESSANT INHIBITION   OF CYTOCHROME P450)
 IID6
Moderate inhibition (fluoxetine, paroxetine)
Low inhibition (escitalopram, sertraline)
Low inhibtion (other new agents)

CHOOSING SSRIs
Generic SSRI saves $
     (fluoxetine – now available; others soon)
With respect to fluoxetine (Prozac) consider…
medication history
half-life, drug interactions (P450 inhibition)
modify use if significant sleep disorder/anxiety
Paroxetine (Paxil) – sedating/anxiety indications/weight gain/P450 inhibition/withdrawal reactions
Less problematic drug interactions
Sertraline (Zoloft) – anxiety indications/post MI data
Escitalopram (Lexapro) - little or no titration

POTENTIAL ROLE OF  DUAL AGENTS 
(venlafaxine, tricyclics, others)
 all antidepressants may not be equally
     effective
 dual agents (NE, 5 HT) may be more effective
 if more patients reach remission with dual
     agents, there may be pharmacoeconomic
     advantage for dual agents

VENLAFAXINE VS. SSRIs

ANTIDEPRESSANTS IN
DIABETES
Diabetes
Tricyclics
 useful for diabetic neuropathy
 may cause hypotension and   gastroparesis
 may impair glycemic control
SSRIs shown to improve depression/GHb

ANTIDEPRESSANTS IN
CARDIAC DISEASE
 Cardiac disease
Tricyclics:
prolong conduction
postural hypotension risk
Venlafaxine - monitor BP (3% Ý BP)
Monitor:
Digitalis, INR, BP

Slide 67

Slide 68

SIDE EFFECTS
(SSRIs)
 Agitation/insomnia
 GI distress
 Sexual dysfunction

SIDE EFFECTS
(other new agents)
 bupropion - activation/agitation
 nefazodone - sedation
 mirtazapine – sedation; weight gain
 venlafaxine - like SSRI’s; Ý BP (3 %)

MANAGING SIDE EFFECTS
 Insomnia/agitation
Use adjunctive sedating agent
Switch to mirtazapine, nefazodone
 Sexual dysfunction
Switch to bupropion,  mirtazapine, nefazodone
Add bupropion, sildenafil,  yohimbine

MANAGING SIDE EFFECTS
 Sedation
Give medication HS
 GI distress
Give medication after meals
 Anticholinergic effects
Bulk in diet, lemon drops
 Postural hypotension
Hydration, change position slowly, support hose

COMORBID ANXIETY/PANIC
Educate – SSRIs may Ý anxiety at first
SSRI’s have anxiety indications
    (paroxetine+++, sertraline+++)
 start with low dose SSRI
 titrate slowly
 may need adjunctive short-term
    sedative-hypnotic or benzodiazepine
Consider venlafaxine, nefazodone, or mirtazepine monotherapy

Slide 74

"The"
The
End