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Clarifying Diagnosis and Monitoring Recovery: Self Report Mental Health Scales can Help!

Dr. Margie Oakander

Sunridge Primary Mental Health

Clinical Associate Professor

University of Calgary

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Disclosure: Dr. Margie Oakander

Advisory Board or Committee: Astra Zeneca, Biovail, GlaxoSmith Kline, Janssen, Lilly, Lundbeck, Otsuka, Pfizer, Valeant, Wyeth

Honouraria or other fees: Astra Zeneca, Biovail, Bristol Myers Squibb, Janssen, Lundbeck, Lilly, Otsuka, Pfizer, Shire, Wyeth, Valeant

Research: GlaxoSmithKline, Lilly, Lundbeck, Pfizer, Wyeth

CME Development: Canadian Psychiatric Association

University of Calgary

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70-year-old male

35-year-old female

Let’s Start with the many faces of major depression

+ Depressed mood+ Hypersomnia+ Increased appetite / weight+ Psychomotor retardation+ Difficulty making decisions + Suicidal ideation

- Marked loss of interest / pleasure- Insomnia- Decreased appetite / weight- Psychomotor agitation- Impaired concentration - Inappropriate guilt

DSM-IV criteria

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DSM 5 Major Depressive Disorder

●Depressed mood

●Loss of interest or pleasure

●Significant changes in weight and/or appetite

●Insomnia or hypersomnia

●Psychomotor agitation or retardation

●Fatigue or loss of energy

●Feelings of worthlessness or excessive/inappropriate guilt

●Diminished ability to think or concentrate, or indecisiveness

●Recurring thoughts of death or suicide, including plans and attempts

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th edition 2013.

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DSM 5 Criteria: SIGGE-CAPS Mnemonic

S—Suicidal preoccupation

I—Interest/pleasure ()G—Gain/lose weight

G—Guilty feelings

E—Energy ()

C—Concentration

A—Affect ( mood)

P—Psychomotor retardation

S—Sleep disturbance

DSM-5 major depressive disorder: 5 of 9 symptoms x 2 weeks

Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. 2013.

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Most frequent conditions leading to short-term and long-term disability in Canada

Other

Genitourinary / urogenital

Respiratory

Gastrointestinal

Maternity

Cardiovascular

Cancer

Accident

Musculoskeletal / back

Mental / behavioural health

0 10 20 30 40 50 60 70 80 90

8

3

4

9

16

24

28

37

76

83

8

1

1

1

0

29

63

13

76

85

Long-term disabilityShort-term disability

Respondents, %

n=87

Note: Respondents were asked to select the top three conditions.

The Conference Board of Canada. 2013.

Most frequent conditions leading to short-term and long-term disability in Canada according to employers

Lopez et al. Lancet 2006;26:1747-57.

2.5

2.8

2.8

3.5

3.6

3.6

5.0

5.6

6.0

8.3Ischemic heart disease

Cerebrovascular disease

Unipolar depressive disorders

Alzheimer's & other dementias

Respiratory cancers

Adult-onset hearing loss

COPD

Diabetes mellitus

Alcohol use disorders

Osteoarthritis

% of total DALYs lost

Top 10 Conditions in High-Income Countries

Global Burden of Disease Study

COPD: chronic obstructive pulmonary disease; DALY: disability-adjusted life-year

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Mental illness carries a huge burden to society

● Is more than 1.5 times that of ALL cancers● Is more than 7 times that of ALL infectious diseases● Contributed to loss of 600,000 health-adjusted life years (HALYs)● Included the top 5 conditions with

highest impact on life and health:– Depression– Bipolar disorder– Alcohol use disorders– Social phobia– Schizophrenia

The burden of mental illness and addictions in Ontario:

Health-adjusted life years (HALYs): A combination of years lived with less than full function and years lost to early death.Ratnasingham S, et al. Institute for Clinical Evaluative Science, 2012.

Considerations for Measurement-based Care (MBC)

How many people would consider… Treating diabetes without measuring and following a

patient’s HbA1c?

Prescribing an antihypertensive and not measuring a patient’s BP?

Measurement-based care (MBC) provides specific and objective information on which to base clinical decisions and should therefore

enhance quality of care and treatment outcomes.

Rush J. et al., Psychiatric Times. Vol. 26 No. 9 , 2009

Why don’t clinicians use scales to measure outcome when treating depressed patients?

How often do you use a rating scale to monitor the course of treatment for depression?

Why not? Please indicate all that apply.

Zimmerman & McGlinchey, J Clin Psychiatry 2006.

Survey of 314 psychiatrists attending a CME conference in 2006 and 2007.

Reason (N=248) %

Do not believe it would be clinically helpful. 28

Do not know what scale to use. 21

Takes too much time. 34

Too disruptive to practice. 19

Wasn’t trained to use them. 34

Percent

Rosenbluth M et al., The Canadian Journal of Diagnosis, June 2011

Does Measurement-based Care Help Guide Treatment?Canadian Practice Reflective Audit Results

* Physicians may have changed more than one part of a patient’s treatment regimen, therefore, percentages do not equal 100%.

Change Med-ication

Increase dose of current

medication

Add-on therapy

No change0%

20%

40%

60%

80%

100%

20%30%

22%33%

25%38%

23% 23%

Primary CareSpecialist

% o

f Pat

ient

s67% of Primary Care and 77% of psychiatrists made changes to treatment regimens

A Quick Look at the Scales

PHQ-15

GAD-7 PHQ-9

A Quick Look at the ScalesWhat makes a scale useful to clinicans and patients?

• Validated• Sensitive to change• Brief enough to allow routine administration• Preferably patient rated• Easy to administer and require minimal training

PHQ -9 (for Major Depressive Disorder) GAD-7 (for Generalized Anxiety) Sheehan Disability Scale (For Functionality) PHQ-15 (for Physical Symptoms) BC-CCI (for Cognitive Complaints)

When Time Is Limited…The 30 second PHQ-2 depression screen:

Kroenke et al. Med Care 2003;41:1284-94

Cut-off score of 3

• Sensitivity = 83%, specificity = 92% for MDD

Over the past 2 weeks, how often have you been bothered by any of the following items?

Not at All

Several Days

More Than Half the Days

Nearly Every Day

1. Little interest or pleasure in doing things 0 1 2 3

2. Feeling down, depressed or hopeless 0 1 2 3

Practical Screening Tool

Patient Health Questionnaire- PHQ 9• Self-rated scale is the “HbA1c”

of depression.• Designed specifically for

primary care.• Highly sensitive and specific

for the diagnosis of depression.

• Useful in monitoring treatment response

TOTAL SCORE DEPRESSION SEVERITY

1-4 Minimal Depression

5-9 Mild Depression

10-14 Moderate Depression

15-19 Moderately-severe Depression

20-27 Severe MDD

PHQ-9 is adapted from PRIME MD TODAY, developed by Drs Robert L. Spitzer, Kurt Kroenke, and Janet B.W. Williams. Copyright ©1999 Pfizer Inc

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Treatment options based on the PHQ9 score

Score Severity Proposed Treatment Plan 0 – 4 None-minimal None 5 – 9 Mild Watchful waiting; repeat at follow-up 10 – 14 Moderate Consider psychotherapy and/or pharmacotherapy

15 – 19 Moderately Severe Consider pharmacotherapy and/or psychotherapy 20 – 27 Severe Initiate pharmacotherapy and, if severe

impairment, or actively suicidal considerconsultation +/- admission to psychiatry

GAD: DSM-IV Diagnostic criteria

Excessive anxiety and worry (apprehensive expectation) occurring more days than not for at least 6 months, about a number of events or activities (such as work, school performance)

The individual finds it difficult to control the worry.

Screening Questions for GAD

Are you by nature a worrier?

Do you worry more than other people?

What do you worry about?

Does the worry interfere with your life?

 

 

GAD-7 For Scoring Symptom Severity In GAD

Spitzer RL. Arch Intern Med 2006;166:1092-1097.

following problem?

Feeling nervous, anxious, on edge

Generalized Anxiety Disorder - GAD-7

Spitzer RL. Arch Intern Med 2006;166:1092-1097.

TOTAL SCORE Provisional Diagnosis

0-4 Minimal anxiety

5-9 Mild anxiety

10-14 Moderate anxiety

15-21 Severe anxiety

• Self rated• Specific for GAD but

useful to detect an anxiety disorder in depression

• Can be used to monitor treatment progress

*GAD-2 is the first 2 questions of the GAD-7

 

 

Substance/Medication-Induced Anxiety Disorder

• Examples of Substances that can cause anxiety:• Alcohol• Caffeine• Cannabis• Phencyclidine• Other Hallucinogens• Inhalant• Opioid• Sedative, hypnotic or anxiolytic• Amphetamine• Cocaine

How Patients with Depression & Anxiety Initially Present to Primary Care Physicians

Most people with psychological problems go to their family doctor with a physical complaint rather than recognizing that they have a form of mental distress.

If patient presents with somatic symptoms instead of psychological symptoms thediagnosing of depression or anxiety is much less

Pre

sen

tatio

n

Phy

sici

an D

iagn

osis

of

Dep

ress

ion

or A

nxi

ety

Dis

ord

er

83%

22%

77%

17%

Kirmayer LJ, et al. Somatization and the recognition of depression and anxiety in primary care. Am J Psychiatry 1993;150:734-41.

Somatic Symptoms Somatic SymptomsPsychological SymptomsPsychological Symptoms

0-1 2-3 4-5 6-8 ≥9

Strong Correlation Between Number of Physical Symptoms and Prevalence of Psychiatric Disorders

The more physical complaints there are, the more likely there is a psychiatric problem.

Kroenke K, et al. Arch Fam Med 1994;3:774-9.

0

20

40

60

80

100

Number of Physical Complaints

Pa

tie

nts

wit

h

P

sy

ch

iatr

ic D

iso

rde

rs (

%)

Anxiety Disorder Mood Disorder Any Psychiatric Disorder

TOTAL SCORE

SEVERITY OF SOMATIC SYMPTOMS

5-9 Low

10-14 Moderate

15-20 HIgh

• Brief, self-rated somatic symptom scale

• Useful for screening somatization as well as monitoring somatic symptom severity.

• Strong correlation between PHQ15 and functional status, disability days and symptom related difficulty.

Kroenke K et al. The PHQ 15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med. 2002 Mar-Apr, 64(2):258-66

The Somatic Symptom Scale – PHQ-15

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Patient language to describe cognitive symptoms

ATTENTION MEMORY

PSYCHOMOTOR SPEED EXECUTIVE FUNCTION

CONFUSEDINADEQUATE

OVERWHELMED

Tired / lethargic

Slow motion

Forgetful

Loss of short-term memory

Concentration

Lack of focus

Indecisive

Procrastinate

Not listeningAttention

Lacking confidence

Lose train of thought

Brain is cloudy

Patients use a diverse range of

language to describe their

cognitive symptoms

Some terms are specific to an

individual domain,

whereas others encompass

multiple domains of cognitive

dysfunction

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Qualitative market research with patients (July 2011)on patients in Canada and Europe, conducted by H. Lundbeck A/S

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Mini-Mental State Exam (MMSE) and the Montreal Cognitive Assessment (MoCA)

● Common bedside tests to assess cognitive impairment● Not very sensitive for milder degrees of cognitive impairment

seen in depression

British Columbia Cognitive Complaints Inventory (BC-CCI)

• 6 item scale that measures perceived cognitive problems.

• Brief, self-rated, easy to incorporate clinically, ensures standardized cognitive assessment

• Sensitive to cognitive complaints in patients with depression

• Can be used to monitor change over time • Should be used in conjunction with a

depression rating scale eg PHQ-9

TOTAL SCORE

SEVERITY OF PERCEIVED COGNITIVE SYMPTOMS

0-4 Broadly normal

5-8 “mild” cognitive complaints

9-14 “moderate” cognitive complaints

15-18 “severe” cognitive complaints

Iverson GL, Lam RW, Rapid screening for perceived cognitive impairment in major depressive disorder, Ann Clin Psychiatry, 2013 May; 25(2) 135-40

The Sheehan Disability Scale- SDS

Sheehan DV. The Anxiety Disease. New York. Charles Scribner and Sons, 1983.

• 10-point self-rated scale• Assists clinician to monitor

function in 3 domains - work, social and family functioning

• Uses visuospatial, numeric and verbal descriptive anchors

• Reflects change over time with effective treatment

SCORING

No recommended cut-off score; change-over-time useful in monitoring response

Clinicians should pay attention to patients with scores over 5 in any domain

30Prepared in response to an unsolicited request – Not for further distribution

Arizona Sexual Experience Scale (ASEX)

The Arizona Sexual Experience Scale (ASEX) is designed to assess five major global aspects of sexual dysfunction: • Drive• Arousal• Penile erection/vaginal lubrication• Ability to reach orgasm• Satisfaction from orgasm

All of these are domains most commonly impaired by psychotropic dugs Items are rated 1-6; higher scores = greater dysfunction Sexual dysfunction is defined as:

• ASEX total score 19 or 1 item 5 or 3 items 4

ASEX, Arizona Sexual Experience Scale McGahuey CA et al. J Sex Marital Ther. 2000;26(1):25-40.

31Prepared in response to an unsolicited request – Not for further distribution

Arizona Sexual Experiences Scale (ASEX)

How strong is your sex drive?

1Extremely Strong

2Very Strong

3Somewhat Strong

4 Somewhat Weak

5Very Weak

6No Sex Drive

How easily are you sexually aroused?

1Extremely Easily

2Very Easily

3Somewhat Easily

4 Somewhat Difficult

5Very Difficult

6Never Aroused

Male: Can you easily get and keep an erection? / Female: How easily does your vagina become moist?

1Extremely Easily

2Very Easily

3Somewhat Easily

4 Somewhat Difficult

5Very Difficult

6Never

How easily can you reach an orgasm?

1Extremely Easily

2Very Easily

3Somewhat Easily

4 Somewhat Difficult

5Very Difficult

6Never Reach Orgasm

Are your orgasms satisfying?

1Extremely Satisfying

2Very Satisfying

3Somewhat Satisfying

4 Somewhat

Unsatisfying

5Very

Unsatisfying

6Can’t Reach Orgasm

For each item, please indicate your OVERALL level during the PAST WEEK, including TODAY.

ASEX, Arizona Sexual Experience Scale McGahuey et al. J Sex Marital Ther. 2000;26(1):25-40.

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Evaluating Comorbidity

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• Beck Depression Inventory• HAMD-7• PHQ-9MDD• MDQBipolar Disorder

• Fear Questionnaire• GAD-7• Hamilton Anxiety Scale GAD• Substance Abuse and Dependence Scale

Substance Use Disorder

• Adult ADHD Self-Report Scale (ASRS)ADHD

Hirschfeld RM, et al. Am J Psychiatry. 2000;157(11);1873-75.

Patient self-assessment screening tool for a broad diagnosis of the bipolar spectrum according to DSM-IV criteria

13 questions covering hypo/mania symptoms, clustering of symptoms, and impaired functioning

Criteria for a diagnosis within the bipolar spectrum: 7 positive questions + clustering of symptoms + moderate-to-severe impairment

9 out of 10 correctly identified (specificity)7 out of 10 ruled out (sensitivity)

Mood Disorder Questionnaire“… useful screening instrument”

Lifecycle of ADHD

Hyperactive as child

Drop out of school

Job performance Parent

RelationshipIssues

Alcohol/Substance Abuse

Accidents

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When to Screen?

Patients presenting with:

Major Mood and Anxiety D/O (including poor response to treatment)

Drug abuse or drug dependence

Family history or children with ADHD

Poor school performance as a child (not reaching potential)

Frequent job changes or moving often

Frequent driving infractions

Higher number of accidents than average population

Forgetfulness (missed appointments, trouble with adherence to medications)

History of maternal smoking during pregnancy

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Questions for Suspected ADHD

McIntosh D, Kutcher S, Binder C, et al. Neuropsychiatr Dis Treat. 2009.

Anything positive – move to Step 2

Anything positive – move to Step 3

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Do you currently have substantial difficulties with forgetfulness, attention, impulsivity or restlessness that are interfering with your relationships or your success at work?

Have you ever been diagnosed with ADHD? Do you have a family history of ADHD (siblings, children, parents or extended family)? Did you have any difficulty in school?

Did you daydream or have difficulty paying attention? Did you get your homework done on time? Were you disruptive?

Complete ASRS & Complete Diagnostic Interview

The Adult ADHD Self-Report Scale (ASRS-V1.1)1 Symptom Checklist• A checklist of 18

questions about symptoms that are based on the diagnostic criteria for ADHD from the DSM-IV

• Developed in conjunction with the World Health Organization and the Workgroup on Adult ADHD.

1. ASRS-v1.1 Screener COPYRIGHT ©2003 World Health Organization (WHO). Reprinted with permission of WHO. All rights reserved.37

RemissionNot officially

defined; varies between studies

(e.g., HAM-D <7-10)

Functional Recovery

Outcomes were here

Outcomes are now here

Ideal outcome should be here

Defining Treatment Goals

Adapted from: Nierenberg & DeCecco. J Clin Psychiatry 2001;62 (Suppl 16):5-9.

Response

50% improvement in a validated depression

rating scale from baseline (e.g., HAM-D)

Defining “remission” from a patient’s perspective

Factors identified as very important, in rank order:

1. Presence of positive mental health (e.g. optimism, vigour, self-confidence)

2. Feeling like your usual, normal self

3. Return to usual level of functioning at work, home or school

4. Feeling in emotional control

5. Participating in, and enjoying, relationships with family and friends

6. Absence of symptoms of depression

Zimmerman et al. Am J Psychiatry 2006; 163:148-150

Thanks! Q&A Time!