Medical Management of Depression

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Medical Management of Depression

• Public Health Detailers Training
• NYC Department of Health and Mental Hygiene
• Jorge R. Petit, MD
• Associate Commissioner, Bureau of Program Services

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Overview

• Depression management
• Types of antidepressants
• Choosing an antidepressant
• PCP concerns suicide risk, misdiagnosis of
  bipolar
• PHQ9 as a monitoring tool
• Treatment algorithm

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Overview

• Acute, Maintenance, Continuation Phases
• Ongoing monitoring
• Referral to Psychiatry
• Involvement of non-physician staff

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Depression Management

• Once a diagnosis has been made, effective
  management in primary care includes
• Medication management (Pharmacotherapy)
• Patient education
• Self management support
• Ongoing monitoring, including monitoring of
  concurrent psychotherapy

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Pharmacotherapy Types of Meds

• Selective serotonin uptake inhibitors (SSRIs)
• Other newer antidepressants (norepinephrine plays
  a key role)
• Tricyclic antidepressants (not considered a
  first-line antidepressant)
• MAO Inhibitors (rarely used by primary care
  physicians)

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SSRIs

• Citalopram (Celexa)
• Escitalopram (Lexapro)
• Fluoxetine (Prozac)
• Paroxetine (Paxil, Paxil CR)
• Setraline (Zoloft)
• Duloxetine (Cymbalta)

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SSRIs

• Potential side effects
• GI (N/V, diarrhea)
• Activation/insomnia
• Sexual Dysfunction
• Neurological (headaches, etc)
• Weight changes
• Serotonin syndrome
• Drug Interactions (MAOIs)

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Dopamine-norepinephrine reuptake inhibitor

• Buproprion (Wellbutrin SR, Wellbutrin XL)
• Potential side effects
• Neurological/seizures
• Insomnia
• GI upset
• Psychotic symptoms

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Norepinephrine serotonin neurotransmission
enhancer

• Mirtazapine (Remeron)
• Potential side effects
• Sedation
• Dry mouth
• Weight gain
• Increase serum cholesterol

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Serotonin-norepinephrine reuptake inhibitor

• Venlafaxine (Effexor XR)
• Potential side effects
• Similar side effect profile to SSRIs, including
  N/V, sexual dysfunction, and activation
• Possible dose-related increase in BP

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Tricyclics

• As effective as newer agents
• Side effects potentially more dangerous
• dry mouth, constipation, bladder problems, sexual
  dysfunction, blurred vision, dizziness,
  drowsiness and increased heart rate.
• Cheaper-especially generic forms
• May be good for selected patients

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Choosing an antidepressant

• In general, no particular antidepressant is more
  effective than another
• Choice should be based on
• Family history of response
• Safety and side effect profiles
• Ease of use
• Consider symptom profile/presence of
  comorbidities, ie. anxious, obsessive compulsive
• cost

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1st line antidepressants

• All categories mentioned with the exception of
  trycyclics, MAOs
• 1st line antidepressants have these factors in
  common
• Once a day dosing (ease of use aids compliance)
• Favorable side-effect profile (also aids
  compliance)
• Safety in overdose
• Broad efficacy for mood disorders

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1st line antidepressants

• Using these better tolerated, newer meds can
• prevent the need for complicated
  titration-allowing for a quicker response
• improve compliance
• Lead to fewer office visits
• Result in less overall cost

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Suicide Risk

• FDA Public Health Advisory March, 2004 possible
  risk of worsening depression and suicidality in
  patients taking antidepressants
• Done in reaction to reports of suicidal ideation
  and attempts in treatment of major depression in
  pediatric patients.
• Black box warning for children / adolescents
  September, 2004

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FDA Public Health Advisory

• Points out the need to closely monitor patients
  receiving antidepressants for worsening and
  suicidality especially at beginning of treatment
  and with changes in dosage
• Also need to instruct patients and families to be
  alert for worsening or suicidal thoughts and to
  immediately report such symptoms

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Misdiagnosis of Bipolar Patients

• Potential risks from antidepressants
• May induce mania or hypomania
• Can cause rapid cycling
• Requires mood stabilizer (e.g. lithium or
  valproic acid) before brief use of antidepressant
• Generally need psychiatry consultation or referral

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PHQ-9 as a monitoring tool

• Quantifies the severity of depression (gives a
  number)
• Provides measurement over the time which aids in
  assessing effectiveness of chosen treatment
  course
• Follow-up PHQ9s should be conducted every month
  in person or over the phone

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Remission

• Goal of treatment full remission (absence of
  symptoms)
• Monitoring with the PHQ9 can assist in the
  process of achieving full remission
• A score of 5 or less on the PHQ9 full remission
• Once remission is achieved, patient should remain
  on the current dose of medication for 6-9 months
  to prevent relapse

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Treatment Algorithm

• Decision support tool PCPs can use to manage
  depression
• Assists with monitoring of medication and
  psychotherapy over all phases of treatment
• Provides timeframes for effective monitoring
• Pocket size version available

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Phases of Treatment

• Acute
• Continuation
• Maintenance

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Acute Phase

• Usually 6-12 weeks
• Effective treatment response is usually obtained
  in this phase--initial remission

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Continuation Phase

• Usually 6-9 months
• Residual symptoms can continue to impair patients
  and complicate co-morbid medical illness
• Patients are prone to relapse during this phase
• Important to continue full therapeutic dose
  during this phase

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Maintenance Phase

• 9 months
• If 1st episode, meds should be tapered and
  discontinued
• If recurrent episode, long term maintenance
  should be considered, generally at the
  therapeutic dose established in acute phase

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Maintenance Phase

• Other factors that would extend a course of
  antidepressant treatment include
• patient preference
• illness severity and related disability when
  affected

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Ongoing Monitoring

• Important for practices to have some sort of
  system in place for monitoring
• Close follow up by telephone and or visits until
  stable
• Severity tool (PHQ-9) to assess progress
• Titrate dose for total remission

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Ongoing Monitoring

• Maintain effective dose for 4 to 9 months
  (continuation phase)
• Monitor for early signs of recurrence
• Consider maintenance therapy

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Consider referral to psychiatrist if

• PHQ9 20
• Fails 1-2 medication trials
• Is Suicidal
• Exhibits psychotic or bipolar depression
• Comorbid substance, physical, or sexual abuse
• Severe psychosocial problems

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Consider referral to psychiatrist if

• Requires specialized treatment (MAO inhibitors,
  ECT)
• Deteriorates quickly
• Has unclear diagnosis

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To Locate a Psychiatrist

• American Psychiatric Association Answer Center
• apa_at_psych.org or (888) 35-PSYCH
• LIFENET (accessible 24/7)
• 1-800-LIFENET (800-543-3638) or call 311 and ask
  for LIFENET

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Patient Education

• Key to promoting compliance with the treatment
  plan, patient becomes partner in care
• Dispels negative perceptions/addresses stigma
  that may contribute to non-adherence
• If patients know what to expect will be less
  likely to discontinue meds prematurely

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Patient Education

• Compare depression to other treatable medical
  illnesses to help patients feel less stigmatized
• Inform patients that antidepressant medication
  helps correct imbalances in brain chemicals
• Educate about medication options
• Effectiveness, onset of action, potential adverse
  side effects
• All patients should be cautioned not to expect
  immediate symptom relief
• may need to take antidepressants for as long as 6
  weeks before they experience benefits

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Key Educational Messages

• For patients starting antidepressant meds
• Antidepressants only work if taken every day
• Antidepressants are not addictive
• Benefits from meds appear slowly
• Continue meds even after you feel better

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Key Educational Messages

• For patients starting antidepressant meds, cont
• Mild side effects are common and usually improve
  with time
• Some medications must be stopped gradually.
  Always consult a doctor before changing,
  reducing, or stopping a drug regimen.
• The goal of treatment is complete remission
  sometimes it takes a few tries.

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Use of Non-physician and 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

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Use of Non-physician and Support Staff

• Scheduling follow-up visits
• Assisting with referral process
• Care management
• active patient follow-up through regularly
  scheduled phone contacts or visits