Paul Block, PhD Director, Psychological Centers Paul.Block@PsychologicalCenters

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Managing Depression Effectively:Managing Depression Effectively:What we think we know may not be What we think we know may not be

truetrueThe many ways care can be organized, can be inadequate, and many The many ways care can be organized, can be inadequate, and many things we know about depression and its treatment that may not be things we know about depression and its treatment that may not be

truetrue

Paul Block, PhDPaul Block, PhDDirector, Psychological CentersDirector, Psychological [email protected]

mailto:[email protected]

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Software ScreenSoftware Screen

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Paul Block, PhDPaul Block, PhDDirector, Psychological CentersDirector, Psychological Centers

[email protected]

Today’s Speaker



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Why Why depression?depression?

Depression is associated with more severe (and costly) Depression is associated with more severe (and costly) medical problems, less effective medical treatment, medical problems, less effective medical treatment, higher health care costshigher health care costs

Disability (#2 impact on DALYs*)Disability (#2 impact on DALYs*) Treating depression in patients with Treating depression in patients with

historically high medical expenditures historically high medical expenditures reduced medical cost from $13.28 to $6.75 reduced medical cost from $13.28 to $6.75 per dayper day

Depression impedes long-term Depression impedes long-term rehabilitation and recovery, and increases rehabilitation and recovery, and increases length of hospital stay and re-length of hospital stay and re-hospitalization by as much as a factor of hospitalization by as much as a factor of threethree* Disability-adjusted life years* Disability-adjusted life years

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Why depression?Why depression?Association of depression/anxietyAssociation of depression/anxietywith the top chronic diseaseswith the top chronic diseases(diabetes, heart disease, cancer, etc.)(diabetes, heart disease, cancer, etc.)

Disease-related biological causes of depressive Disease-related biological causes of depressive symptoms, esp. CNS and endocrine disorderssymptoms, esp. CNS and endocrine disorders

Behavioral causes of depressive symptoms, Behavioral causes of depressive symptoms, inc. adjusting to illness, limits of rewarding inc. adjusting to illness, limits of rewarding activities, interference with rolesactivities, interference with roles

Diagnostic difficultyDiagnostic difficulty Overlapping symptoms lead to over-diagnosisOverlapping symptoms lead to over-diagnosis Under-diagnosis is far more commonUnder-diagnosis is far more common

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Why depression?Why depression?Results of comorbid depression:Results of comorbid depression:

Reduced quality of lifeReduced quality of life 2x restriction of activities and lost work 2x restriction of activities and lost work

daysdays 50-100% higher health care spending50-100% higher health care spending Increased morbidity (worse medical Increased morbidity (worse medical

outcomes)outcomes) Increased mortalityIncreased mortality

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Costs of mental illnessCosts of mental illnessWork performance is affected by:Work performance is affected by:

decreased productivity (“presenteeism”)decreased productivity (“presenteeism”) increased absenteeismincreased absenteeism increased industrial accidentsincreased industrial accidents higher rates of termination and turnoverhigher rates of termination and turnover increased rates of disability and worker increased rates of disability and worker

compensation claimscompensation claims

$$

$

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Costs of mental illnessCosts of mental illness15% of total corporate profits15% of total corporate profits nationally nationally($671 billion per year) are lost to behavioral problems ($671 billion per year) are lost to behavioral problems

based on American Psychological Association reports of costs to employers due to depression, anxiety disorders, substance based on American Psychological Association reports of costs to employers due to depression, anxiety disorders, substance abuse, and stress, compared to President’s annual report of total U.S. economic activityabuse, and stress, compared to President’s annual report of total U.S. economic activity

$

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Costs of mental Costs of mental illnessillnessSocial effects of mental illness or Social effects of mental illness or substance abuse includesubstance abuse include

increased likelihood of relying on increased likelihood of relying on welfarewelfare

increased criminal activityincreased criminal activity increased violenceincreased violence homelessnesshomelessness family disruption andfamily disruption and

breakupbreakup

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Ways to organize care in Ways to organize care in medical settingsmedical settings

Models of management of depression in primary Models of management of depression in primary care, where most depression is found and care, where most depression is found and treated: treated: (with descriptions of each)(with descriptions of each)

Referral to specialty careReferral to specialty care Case/care managementCase/care management Primary Care Behavioral HealthPrimary Care Behavioral Health Co-locationCo-location IntegrationIntegration

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Ways for care to be Ways for care to be inadequateinadequate

GeneralGeneralPrimary Care Behavioral HealthPrimary Care Behavioral Health

missed referralsmissed referrals Screening, but self-report?Screening, but self-report?

missed diagnosesmissed diagnoses (e.g., 20% MDE (e.g., 20% MDE €€ BPD) BPD)

which services are typically accessedwhich services are typically accessed (meds, not therapy)(meds, not therapy)

incomplete careincomplete care

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MedicationMedicationMedication management:Medication management:

Wrong patientWrong patient Wrong problemWrong problem Wrong medicineWrong medicine Too littleToo little Too shortToo short Not enough Not enough

follow upfollow up Not combined with other interventionsNot combined with other interventions

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Behavioral healthBehavioral healthPrimary Care Behavioral Health andPrimary Care Behavioral Health andpatient preference (vs. providers’ skill)patient preference (vs. providers’ skill)

Do patients prefer if health behavior Do patients prefer if health behavior focus is built in to all care as opposed to focus is built in to all care as opposed to identified as an individual need (stigma)?identified as an individual need (stigma)?

Do patients seen by a behavioral Do patients seen by a behavioral clinician to work on health behavior clinician to work on health behavior prefer to see the same clinician for prefer to see the same clinician for mental health treatment?mental health treatment?

(“hub and spoke” model)(“hub and spoke” model)

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Ways for care to be Ways for care to be inadequateinadequateIdentificationIdentification

Importance of screening vs.Importance of screening vs.referral onlyreferral only TypicalTypical: PHQ2, maybe PHQ9, BAI3, rarely complete : PHQ2, maybe PHQ9, BAI3, rarely complete

screening or screening of all patientsscreening or screening of all patients Is full behavioral/mhsa screening impractical?Is full behavioral/mhsa screening impractical? PC development of 1 page screenerPC development of 1 page screener

How to manage identified concernsHow to manage identified concerns (PCP time)(PCP time) Truly accessible resourcesTruly accessible resources

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TargetsTargets

Focus on depression onlyFocus on depression only Anxiety disorders more common than Anxiety disorders more common than

depressiondepression Substance abuse (SBIRT)Substance abuse (SBIRT) Health behaviorsHealth behaviors Estimate that 50% of deaths are preventable, Estimate that 50% of deaths are preventable,

related to health behaviorrelated to health behavior Obesity responsible for 10% ofObesity responsible for 10% of

health costs, increasing to 20%health costs, increasing to 20% SmokingSmoking

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PopulationPopulationSpecific details of safety net populations and Specific details of safety net populations and providers, inc. access to adequate care:providers, inc. access to adequate care:

Low income populations and Low income populations and people from ethnic minority people from ethnic minority groups that are over-represented groups that are over-represented in Medicaid have: in Medicaid have: significantly higher behavioral significantly higher behavioral

health needs health needs more often ineffectively-addressed more often ineffectively-addressed dramatically increased healthcare dramatically increased healthcare

costscosts ““Good” news: until 2014, only Good” news: until 2014, only

population fairly sure to be coveredpopulation fairly sure to be covered

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Specific details of safety net populations and Specific details of safety net populations and providers, inc. access to adequate care:providers, inc. access to adequate care:

Increasing use of behavioral health services by Increasing use of behavioral health services by Medicaid patients alone dramatically reduced Medicaid patients alone dramatically reduced costs in the population-based "Hawaii Project" costs in the population-based "Hawaii Project" including including

38% lower costs for patients without chronic illnesses38% lower costs for patients without chronic illnesses 18% for patients with chronic illnesses18% for patients with chronic illnesses 15% for substance abusers15% for substance abusers among high users of medical services, significant total among high users of medical services, significant total

cost reductions through use of even brief psychological cost reductions through use of even brief psychological interventionsinterventions

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Things we know about Things we know about depressiondepression

(that aren’t necessarily true)(that aren’t necessarily true)Role of medicationRole of medication

Combined treatment isCombined treatment isbetterbetter (maybe for teens)(maybe for teens)

Severe depression respondsSevere depression respondsbetter to medications thanbetter to medications thanto therapyto therapy

It’s better not to use medsIt’s better not to use meds Patient preference is primary Patient preference is primary

(vs. professional recommendations)(vs. professional recommendations)

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Newer medications are better Newer medications are better than older medicationsthan older medications

Antidepressants may cause mild and often Antidepressants may cause mild and often temporary side effects in some people, but temporary side effects in some people, but they are usually not long–term. they are usually not long–term.

Newer antidepressants have fewer side Newer antidepressants have fewer side effects.effects.

For all classes of antidepressants, patients For all classes of antidepressants, patients must take regular doses for at least three to must take regular doses for at least three to four weeks before they are likely to four weeks before they are likely to experience a full therapeutic effect. experience a full therapeutic effect.

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Medication detailsMedication detailsThe most popular types of antidepressant medications are selective The most popular types of antidepressant medications are selective serotonin reuptake inhibitors (SSRIs)serotonin reuptake inhibitors (SSRIs)

SSRIs includeSSRIs include fluoxetine (Prozac),fluoxetine (Prozac),paroxetine (Paxil)paroxetine (Paxil)citalopram (Celexa), citalopram (Celexa), sertraline (Zoloft)sertraline (Zoloft)escitalopram (Lexapro-escitalopram (Lexapro-

? esp. effective in agitated or bipolar depression) ? esp. effective in agitated or bipolar depression) fluvoxamine (Luvox)fluvoxamine (Luvox)

Common side effectsCommon side effects::Headache–usually temporary and will subside. Headache–usually temporary and will subside. Nausea–temporary and usually short–lived. Nausea–temporary and usually short–lived. Insomnia and nervousness (often subside over time or if dose is Insomnia and nervousness (often subside over time or if dose is reduced). reduced). Agitation (feeling jittery or restless). Agitation (feeling jittery or restless). Sexual problems–men and women, including reduced sex drive, erectile Sexual problems–men and women, including reduced sex drive, erectile dysfunction, delayed ejaculation, or inability to have an orgasm.dysfunction, delayed ejaculation, or inability to have an orgasm.

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Medication detailsMedication detailsSerotonin and norepinephrine reuptake Serotonin and norepinephrine reuptake inhibitors (SNRIs) include inhibitors (SNRIs) include venlafaxine (Effexor) venlafaxine (Effexor) duloxetine (Cymbalta)duloxetine (Cymbalta)desvenlafaxine (Pristiq)desvenlafaxine (Pristiq)

Common side effects similar to SSRIsCommon side effects similar to SSRIs In high doses, sweating and dizzinessIn high doses, sweating and dizziness

Norepinephrine and dopamine reuptake Norepinephrine and dopamine reuptake inhibitorinhibitorBupropion (Wellbutrin)Bupropion (Wellbutrin)No sexual side effects (at high doses can No sexual side effects (at high doses can increase seizure risk)increase seizure risk)

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Medication detailsMedication detailsOlder classes of antidepressants, such as tricyclics and Older classes of antidepressants, such as tricyclics and monoamine oxidase inhibitors (MAOIs) monoamine oxidase inhibitors (MAOIs) MAOIsMAOIs

Food and medicinal restrictions (tyramine, found in many Food and medicinal restrictions (tyramine, found in many cheeses, wines and pickles, and some medications including cheeses, wines and pickles, and some medications including decongestants)decongestants)

Tricyclic antidepressants (e.g., Amitriptyline, Doxepin, Tricyclic antidepressants (e.g., Amitriptyline, Doxepin, Imipramine, Desipramine, Nortriptyline)Imipramine, Desipramine, Nortriptyline) significant side effects significant side effects include:include:

Dry mouthDry mouth ConstipationConstipation Bladder problems– emptying the bladder may be difficult, and Bladder problems– emptying the bladder may be difficult, and

urine stream may not be as strong as usualurine stream may not be as strong as usual Sexual problems–side effects are similar to those from SSRIs. Sexual problems–side effects are similar to those from SSRIs. Blurred vision. Blurred vision. Drowsiness during the day.Drowsiness during the day. Low blood pressure (especially on standing quickly)Low blood pressure (especially on standing quickly)

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Medication detailsMedication detailsAugmentation strategiesAugmentation strategies

FDA Warning on AntidepressantsFDA Warning on Antidepressants 4% of adolescents and young adults taking antidepressants thought 4% of adolescents and young adults taking antidepressants thought

about or attempted suicide (no suicides occurred), compared to 2% about or attempted suicide (no suicides occurred), compared to 2% of those receiving placebos.of those receiving placebos.

Prompted the 2005 FDA "black box" warning label, extended in Prompted the 2005 FDA "black box" warning label, extended in 2007 to include young adults up through age 242007 to include young adults up through age 24

Emphasizes that patients of all Emphasizes that patients of all ages ages taking antidepressants should be taking antidepressants should be closely closely monitored, especially during initial monitored, especially during initial

weeks weeks of treatment.of treatment. Benefits of antidepressant Benefits of antidepressant

medications medications outweigh their risks to children and outweigh their risks to children and adolescents with major depression adolescents with major depression

and and anxiety disorders (even in terms of anxiety disorders (even in terms of suicide suicide risk).risk).

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Things we know about Things we know about depression depression

(that aren’t necessarily true)(that aren’t necessarily true)PsychotherapyPsychotherapy

Cognitive Behavioral Therapy (CBT) Cognitive Behavioral Therapy (CBT) and Interpersonal Therapy (IPT) are and Interpersonal Therapy (IPT) are the best behavioral treatmentsthe best behavioral treatments

Is CBT > IPT?Is CBT > IPT? BT, BMT, SCT, MT, ACT, others BT, BMT, SCT, MT, ACT, others

(even psychodynamic treatments)(even psychodynamic treatments) Main issue to consider may beMain issue to consider may be

relapse, more than recoveryrelapse, more than recovery

Gerald Klerman and Myrna Weissman

http://www.beckinstitute.org/default.asp?SessionID=%7BD311D1D1-CED3-4F2E-96C4-FD62E2F24930%7D

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(that aren’t necessarily true)(that aren’t necessarily true)Modifying the teamModifying the team

Case management is optimalCase management is optimal(e.g., Diamond, IMPACT, PRISM-E) (e.g., Diamond, IMPACT, PRISM-E)

but vs. alternatives, inc. on-site but vs. alternatives, inc. on-site integration?integration?

Acceptance of referrals (43%, 49-52% with Acceptance of referrals (43%, 49-52% with case management, 71-80% on-site)case management, 71-80% on-site)

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(that aren’t necessarily true)(that aren’t necessarily true)RelapseRelapse

Depression is a relapsing disorderDepression is a relapsing disorder(14.3% who receive EBT given the very loose (14.3% who receive EBT given the very loose definition, even lower % who receive relapse definition, even lower % who receive relapse prevention)prevention)

EBT requires 14 sessions, not 1-3, 6, EBT requires 14 sessions, not 1-3, 6, 88, or 12, or 12 FormulationFormulation Treatment to full remission to reduceTreatment to full remission to reduce

risk of relapserisk of relapse

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(that aren’t necessarily true)(that aren’t necessarily true)ComorbidityComorbidity

Comorbidity predicts lower recoveryComorbidity predicts lower recovery Substance abuseSubstance abuse TraumaTrauma Personality disorderPersonality disorder Undiagnosed comorbidity &Undiagnosed comorbidity &

misdiagnosismisdiagnosisCombined treatmentsCombined treatments

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(that aren’t necessarily true)(that aren’t necessarily true)Role of primary careRole of primary care

Primary care manages most depressionsPrimary care manages most depressions 50% are identified50% are identified 30% of those identified receive30% of those identified receive

guideline-based careguideline-based care 90%+ receive meds90%+ receive meds

onlyonly Specialty care isSpecialty care is

much bettermuch better % receiving EBT% receiving EBT

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(that aren’t necessarily true)(that aren’t necessarily true)PCP expertisePCP expertise

PCPs can’t manage medicationsPCPs can’t manage medications MCPAPMCPAP CHC experiencesCHC experiences Therapist diagnosisTherapist diagnosis

and consultationand consultation

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What would adequate care look What would adequate care look like?like?

IndividualizedIndividualized Whole-personWhole-person IntegratedIntegrated Actually providedActually provided FlexibleFlexible ““Complete”Complete” Relapse PreventionRelapse Prevention

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ScreeningScreening EvaluationEvaluation CollaborationCollaboration Design of treatmentDesign of treatment Management of careManagement of care LPHC: full integrationLPHC: full integration Ψ

RecommendationsRecommendations

LPHC

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Wang, Phillip S., Patricia Berglund, and Ronald C. Kessler. (2000). Prevalence and Conformance with Evidence-Based Recommendations. Wang, Phillip S., Patricia Berglund, and Ronald C. Kessler. (2000). Prevalence and Conformance with Evidence-Based Recommendations. Journal of General Internal Medicine, Journal of General Internal Medicine, 1515, 284-292., 284-292.

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Paul Block, PhD Director, Psychological Centers Paul.Block@PsychologicalCenters