From Depression to Wellness in MDD - Primary Care...
Transcript of From Depression to Wellness in MDD - Primary Care...
From Depression to Wellness in MDD
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From Depression to Wellness in MDD
Paul P. Doghramji, MD, FAAFP
Family Practice Physician
Collegeville Family Practice & Pottstown Medical Specialists, Inc.
Medical Director of Health Services, Ursinus College – Collegeville, PA
Attending Family Practice Physician, Pottstown Memorial Medical Center – Pottstown, PA
Learning Objectives
▪ Improve diagnosis of MDD
▪ Implement patient centered treatment approaches to
promote physical, emotional and cognitive wellness
▪ Change practice systems to improve diagnosis,
achieve remission, and return patients to complete
wellness
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UNDER-treatment is common
▪ 6.7% of patients meet criteria for 12-month diagnosis of MDD
▪ 74% recognize need for treatment
▪ Of the 77% who receive treatment,
▪ 46% receive minimally adequate treatment
▪ RESULT − only 1 in 4 patients meeting criteria for diagnosis of MDD
receive adequate treatment
Thornicroft G et al. Br J Psych 2016. bjp.bp.116.188078.
Treatment Goals in Depression
1. Full remission
▪ 2-month period devoid of signs and symptoms*
▪ Lowers risk of relapse
2. Maintain recovery
3. Return to wellness
*APA 2013; DSM 5th Edition
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Early Individualized TreatmentReview of 30 studies
▪ Increases likelihood of full
symptomatic and functional
recovery
▪ Allows early decisions that
optimize treatment rapidly
Habert et al. Prim Care Companion CNS Disord. 2016:18(5):10.4088/PCC.15m01926.
Meet Amanda
Annual visit
▪ 45 yo married female
▪ Hasn’t felt herself for >2 months
▪ Low energy
▪ Reduced appetite
▪ No interest in sex
▪ Husband feels she is withdrawn
▪ Insomnia - uses diphenhydramine
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Practical Treatment of MDD
▪ Assess
▪ Evaluate patient safety - suicidal
▪ Address functional impairments and QOL
▪ Provide education
▪ Coordinate care
▪ Monitor status
▪ Enhance treatment adherence
APA: Practice guideline for Treatment of patients with MDD, 3rd edition 2010.
Detect and Diagnose
Have system in place to
determine if patient is
depressed
1. Screening
questionnaires
(PHQ-2 and PHQ-9)
2. DSM-5 Criteria
Maurer DM. 2012 Am Fam Phy 85(2):139-144.
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For ≥ 2 weeks:
5 or more symptoms →
▪ ≥ 1 symptom =
depressed mood or loss
of interest/pleasure
▪ Symptoms = change
from previous functioning
1. Depressed mood (subjective or observed); in children and adolescents,
mood can be irritable
2. Loss of interest or pleasure
3. Change in weight or appetite
4. Insomnia or hypersomnia
5. Psychomotor retardation or agitation (observed)
6. Loss of energy or fatigue
7. Feelings of worthlessness or guilt
8. Impaired concentration or indecisiveness
9. Thoughts of death or suicidal ideation or attempt
American Psychiatric Association; 2013 Diagnostic and statistical manual of mental disorders.5 th ed. Arlington.
DSM-5 Criteria for MDD
Several days
More than half of 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
3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3
4. Feeling tired or having little energy 0 1 2 3
5. Poor appetite or overeating 0 1 2 3
6. Feeling bad about yourself—or that you are a failure and that you have let yourself or your family down
0 1 2 3
7. Trouble concentrating on things, such as reading the newspaper or watching televisions
0 1 2 3
8. Moving or speaking so slowly that other people could have noticed. Or the opposite—being so fidgety or restless that you have been moving around a lot more than usual
0 1 2 3
9. Thoughts that you would be better off dead, or of hurting yourself in some way
0 1 2 3
Add columns:
Total: 0
10. If you checked off any problems, how difficult has it been for you to do your work, take care of things at home, or get along with other people?
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
PHQ-2
Patient Health QuestionnairePHQ-2 or PHQ-9
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Interpreting PHQ-9
PHQ-9 Score
DSM-IV-TR Criterion
Symptoms Depression Severity Proposed Treatment Action
1-4 Few None None
5-9 5 Mild depressive symptoms Watchful waiting, repeat PHQ-9 at follow-up
10-14 5-6 Mild Major DepressionTreatment plan, considering counseling,
follow-up and/or pharmacotherapy
15-19 6-7 Moderately Major DepressionImmediate initiation of pharmacotherapy
and/or psychotherapy
20-27 7 Sever Major Depression
Immediate initiation of pharmacotherapy
and, if severe impairment or poor response
to therapy, expedited referral to a mental
health specialist for psychotherapy and/or
collaborative management
Back to Amanda
▪ PHQ-9 Score = 11
▪ DSM-5 Criteria = 5
▪ Rule out
▪ Bipolar disorder
▪ Medication induced
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Meds That May Cause Depressive Symptoms
Neurologic Oncologic Cardiovascular
Barbiturates Vincristine β-Blockers (controversial)
Anticonvulsants Vinblastine Clonidine
Levodopa Pemetrexed Methyldopa
Amantadine L-Asparaginase Reserpine
Flunarizine Paclitaxel Hydralazine
Docetaxel Amiodarone
Interleukin-2 Digoxin
Corticosteroids
Tyrosine kinase inhibitors
Anti-infective agents Other agents Substances
Efavirenz Isotretinoin Marijuana
Zidovudine GnRH agonists Alcohol
Interferon-α Clomiphene Others
MefloquineOral and depot contraceptives
(controversial)
Amphotericin B
Celano CM, et al. Dialogues Clin Neurosci. 2011;13:109-125.
Path to ‘WELLNESS’
Jain S. Mental Wellness Matters: Applying Wellness Interventions Even in the Busiest Clinical Practice; US Psych Mental Health Congress.
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Assessing Patient Wellness
Where is your patient and where do they want to be?
▪ Physical
▪ Emotional
▪ Social
▪ Cognitive
Tools for Achieving Wellness
▪ Nutrition
▪ Sleep
▪ Exercise
▪ Social connectedness
▪ Mindfulness
▪ Cognitive functioning
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Wellness Interventions Improve Outcomes
Intervention
▪ Exercise: walk >5 days/week
▪ Sleep hygiene
▪ Nutrition: log meals, snacks,
alcohol
▪ Mindfulness meditation daily
▪ Social connectedness practice
Results
▪ PHQ-9 improved: 8.9 to 5
▪ Anxiety-GAD improved: 7.9 to 4.3
▪ WHO-5 Wellness: 10.7 to 15.4
▪ Other improvements
▪ Social connectedness
▪ Emotional eating
▪ Mindful awareness
▪ Sleep quality
Wellness through Physical Activity
Moderate exercise and physical activity reduces
depressive symptoms
▪ Walking, dancing, swimming, gardening, etc.
▪ 150-300 minutes/week
▪ 10-60 minute intervals - need not be done in one setting
▪ Monitor
Catalan-Matamoros D et al. Exercise Improves Depressive Symptoms in Older Adults. 2016 Psych Res 244:202-9.
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Wellness through Healthy Diet
Healthy diet promotes overall health
Appropriate calorie level
▪ 1600-2400 calories/day for women
▪ 2000-3000 calories/day for men
Healthy eating pattern on most days
▪ Dash diet
▪ Mediterranean diet
http://health.gov/dietaryguidelines/2015/guidelines/
Wellness through Sleep Hygiene
7-9 hours of sleep reduces depression
and disease risk
▪ Avoid caffeine and rich foods near bedtime
▪ Alcohol in moderation
▪ Establish a bedtime routine
▪ Create a pleasant sleep environment of 60-67 degrees
sleepfoundation.org/sleep-topics/sleep-hygiene
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Wellness through Mindfulness
Mindfulness: Fully present and aware of where
we are and what we are doing - not over reacting
to what is going on around us
▪ Practice daily
▪ Set aside a time and space to relax and focus
▪ Be physically attentive to the present moment
▪ Dispel judgmental thoughts
▪ Return to the present as it is
https://www.psychologytoday.com/blog/the-courage-be-present/201001/how-practice-mindfulness-meditation
Wellness through Social Connectedness
How a person interacts with community,
friends, and family.
▪ Micro socialization
▪ Daily, small opportunities to say hello, smile
▪ Micro socialization add up to feel better
▪ Macro socialization
▪ Getting together with close friends and family members to have fun, and have deep,
meaningful conversations
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Cognitive Behavioral Therapy (CBT)is Effective
Negative, dysfunctional thinking affects mood, sense of self,
behavior, and physical state.
CBT based on 2 tasks:
1. Cognitive restructuring to change
thinking patterns
2. Behavioral activation - learning to
engage in enjoyable activities and
develop problem-solving skills
Twomey C, O’Reilly G, Byrne M. 2014 Fam Prac 32(1):3-15.
CBT: Who is likely to benefit?
Patient’s take active role in learning/monitoring negative thoughts for 14-16 weeks
▪ Motivated
▪ Sees self as able to control events that happen
▪ Capacity for introspection
Online sessions validated as successful:
▪ www.learntolive.com
▪ www.moodgym.anu.edu.au/welcome
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Wellness Recommendation for Amanda
▪ Medication?
▪ CBT?
▪ Wellness modifications?
▪ Follow up
Meet Sam
▪ 36 year old Male
▪ Return visit: 12 weeks since Dx
▪ Treated with SSRI
▪ Feels better
▪ Annoyed by problems with concentration,
especially with work projects that require
immediate attention and problem-solving
▪ Feels others think he is ‘not pulling his weight’
▪ Relationship with his wife has improved,
but sexual performance is still ‘off’ for Sam
▪ Repeated PHQ-9 score is 10
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Selecting an Anti-DepressantFactors to Consider
Patient Factors
▪ Clinical features and dimensions
▪ Comorbid conditions
▪ Response and side effects during
previous use of antidepressants
▪ Patient Preference
Medication Factors
▪ Efficacy - generally comparable
▪ Comparative tolerability (AEs)
▪ Interactions with other meds
▪ Simplicity of use
▪ Cost and availability
Kennedy SH, et al. Can J Psych 2016:61(9):540-560.
Patient Treatment Preference Predicts Treatment Outcome
45.5
7.7
27.6
39.3
22.2
50.0
28.0
17.6
45.5
39.8 39.1
52.2
0
20
40
60
Medication Psychotherapy Combination None
Perc
ent
Rem
issi
on
Preferred Treatment
Medication Psychotherapy Combination
Kocsis JH et al. J Clin Psychiatry. 2009;70(3):354-361.
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Pharmacotherapy in MDD
▪ Choose an initial medication and starting dose
▪ If side effects occur
▪ Lower dose
▪ Change to a different med
▪ Evaluate response allowing sufficient duration
▪ Titrate dose up
▪ Combine medications
Evolution of Depression Meds
Symptom Reduction
Response
Remission
Improved Function
Functional Remission
Improved QOL
Cognitive Remission
McIntyre RS J Clin Psychiatry. 2013;74:14-18.
>1990
2000
2010
2014
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Pharmacologic Classes for DepressionClass Examples Side Effects
SSRI
fluoxetine (1987), sertraline (1991),
paroxetine (1992), fluvoxamine (1994),
citalopram (1998), escitalopram (2002)
GI, activation, insomnia, sexual dysfunction, migraines, falls, weight gain,
potential for serotonin syndrome discontinuation syndrome
SNRI
venlafaxine (1993), desvenlafaxine
(2008), duloxetine (2004),
levomilnacipran (2013)
GI, activation, sexual dysfunction, increased pulse rate, dry mouth, excessive
sweating, increased blood pressure, potential for serotonin syndrome,
discontinuation symptoms
TCA
amitriptyline (1961), nortriptyline
(1964), imipramine (1959),
desipramine (2014), doxepin (2010)
Cardiovascular effects, arrhythmias, orthostatic hypotension, dry mouth, sexual
dysfunction, tachycardia, impaired vision, memory and concentration
impairments, sedation, weight gain, myoclonus
MAOI
phenelzine (1961), tranylcypromine
(1960), isocarboxazid (1999),
selegiline (2006)
Hypertensive crisis, potential for serotonin syndrome, orthostatic hypotension,
weight gain, sexual dysfunction, headaches, insomnia
Others
bupropion (1985), nefazodone (1996),
trazodone (1981), mirtazapine (1996),
agomelatine
Nausea, headaches, dizziness, insomnia, somnolence, tremors, seizures, dry
mouth sedation, weight gain
Multimodal
AntidepressantsVilazodone (2011), vortioxetine (2013) Nausea, diarrhea
APA: Practice guideline for the treatment of patients with major depressive disorder. 2010.;Taylor et al. Maudaley Prescribing Guidelines, 10th ed. 2009.
Institute for Clinical Systems Improvement; Depression in Primary Care 2016. 1-57.Frampton, JE. Vortioxetine; A Review in Cognitive Dysfunction in Depression 2016 Drugs 76:1675-1682.
EMA Summary of Product Characteristics for Valdoxan (agomelatine) 2009.PI Forest Labs. Vilazodone hydorchloride 2012. Updated 2014.
Recommendations Based on Primary Symptoms
Symptoms Recommendation Comments
AnxietyAll the anti-depressants are generally
equally effective
Research suggests no significant differences between SSRIs,
SNRIs, or bupropion
Sadness, gloomyAll the anti-depressants are generally
equally effective
Research suggests no significant differences between SSRIs,
SNRIs, or bupropion
Cognitive dysfunction
Vortioxetine
Bupropion
Duloxetine
SSRIs
Early research suggests some newer meds may have effects on
improved cognition (such as attention, concentration, memory,
organizing, etc.)
Insomnia
Melatonin
Mirtazapine
Trazodone
Beneficial effects on helping sleep need to balance daytime
sleepiness
Physical symptoms, pain,
fatigue
SNRIs
Bupropion
Certain anti-depressants may be better than others in
addressing pain
Kennedy SH, et al. CANMET Guidelines 2016; Qaseem A et al. ACP Clinical Guidelines 2008.
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Does Sam have Cognitive Impairment?
▪ 36 year old Male
▪ Return visit: 12 weeks since Dx
▪ Treated with SSRI
▪ Feels better
▪ Annoyed by problems with concentration,
especially with work projects that require
immediate attention and problem-solving
▪ Feels that others think he is ‘not pulling
his weight’
▪ Relationship with his wife has improved, but
sexual performance is still ‘off’ for Sam
▪ Repeat PHQ-9 score = 10
Cognitive Impairment in MDD
▪ Prevalence in adults with MDD:
▪ Among all: 30% - 40%1
▪ Among >65 years old: 50% - 70%1
▪ Impact QOL and functional outcomes
▪ Cognitive symptoms can remain after
remission2
▪ 1 in 3 patients responding to therapy
report residual cognitive symptoms3
1. Gualtieri CT, Morgan DW J Clin Psych 2008;69:1122-1130. 2. Conradi JH, et al Psychol Med 2001;41:1165-1174. 3. Fava et al, J Clin Psychiatry 2006;67:1754.
4. McIntyre RS et al. Depress Anxiety 2013;30:515-527.
Impaired cognition is strongly associated
with high rate of relapse and
recurrence4!!
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Key Domains of Cognitive Function in MDD
Attention Domain Ability to focus on several objects/trains of thought
Real-life-manifestation Difficulty with concentrating, focus, attention
Memory Domain Visual and verbal memory, time/places, meaning of things
Real-life-manifestation Forgetfulness, word-finding difficulty
Executive Function DomainInhibition, working memory, verbal fluency, planning,
problem solving
Real-life-manifestation Indecisive in prioritizing, multitasking, decisions, planning
Psychomotor Domain Time to perform motor actions from mental activity
Real-life-manifestation Slow processing and responding
Screening for Cognitive Function
▪ Ask patient questions from
4 Domains
▪ Use tools like Perceived Deficit
Questionnaire PDQ-5
▪ Measures self-reported
cognitive impairment
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“Traditional” Antidepressant Studies: Effects on Cognition
▪ Improvements in cognition secondary to improvements in
mood symptoms
▪ Conventional antidepressants have not shown significant
improvements in cognitive symptoms
▪ Some antidepressants worsen cognitive deficits
McIntyre RS, et al. Depress Anxiety. 2013;30:515-527; Fava M, et al. J Clin Psychiatry. 2006;67:1754-1759; Greer TL, et al. CNS Drugs. 2010;24:267-284; Herrera-Guzman I. J Affect Disord. 2010;123:341-350; McClintock SM, et al. J Clin Psychopharmacol. 2011;31:180-186; Trivedi MH, Daly EJ. Dialogues Clin Neurosci. 2008;10:377-384; Millan MJ, et al. Nat Rev Drug Discov. 2012;11:141-168.
New Multimodels -Responsible for Diverse Effects?
▪ Vortioxetine
▪ Combined effects on 5-HT
receptors and serotonin
transporter
▪ Acts as serotonin reuptake
inhibitor
▪ 5-HT1A agonist
▪ 5HT3
▪ 5HT7 antagonist
▪ 5-HT1B receptor partial agonism
▪ Serotonin transporter inhibition
▪ Full mechanism remains unclear
▪ Vilazodone
▪ Combines inhibition of serotonin
reuptake and partial agonism of
5-HT1A
▪ Full mechanism remains unclear
Lam RW, Kennedy SH, McIntyre RS, Khullar A. Cognitive Dysfunction in Major Depressive Dsorder: Effects on Psychosocial Functioning and Implications for
Treatment. 2014 Psychiatry 59(12):649-654. Katona CL, Katona CP. New generation multi-model antidepressants: focus on vortioxetine for MDD. 2014
Neuropsych Dis Treat 10:349-354. Richelson E. Multi-modality: a new approach for the treatment of MDD 2013 Int J Neuropsychopharmacol 16(6): 1433-1442.
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Pharmacologic Effects on Cognitive Function in Young Adults with MDD
Learning &
Memory
Attention/
Concentration
Executive
Function
Processing
Speed
Vortioxetine 1 1 1 1
Duloxetine 1
Lisdexamfetamine 2
Other(SSRIs,
SNRIs, buproprion)
3 3 3 3
Modafinil 3 3 3 3
Erythropoietin 2 2 2 2
Level 1: Replicated placebo-controlled trial evidence with demonstration of independent effect
Level 2: Single placebo-controlled trial evidence with demonstration of independent effect
Level 3: Uncontrolled evidence with lack of demonstration of independent effect
McIntyre RS et al. CNS Drugs 2015:29:577-589.
Cognitive Effects of Antidepressants in MDD
McIntyre RS et al. Effects of Vortioxetine on Cognitive Function in Patient with MDD:
A Meta-Analysis of Three Randomized Controlled Trials. 2016 Intl Journ of Neuropsychopharmaco 19(1):1-9.
Meta-Analysis
▪ 3 Randomized, DB, PC
8 week trials of vortioxetine
▪ 2 duloxetine-referenced
trials
▪ Vortioxetine consistently
improved cognition function
independent of depressive
symptoms
Change in DSST from baseline to 8 weeks after adjustment in change in MADRS total score.
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Switch or Add Medication?
Consider ‘switching’
▪ It is the first antidepressant trial
▪ Poorly tolerated side effects
▪ Lack of response (<25%
improvement)
▪ More time to wait for patient
response - less severe, less
functional impairment
▪ Patient prefers to switch
Consider combining med
▪ 2 or more antidepressant trials
▪ Initial antidepressant well
tolerated
▪ Partial response to (>25%
improvement) initial antidep.
▪ Specific residual symptoms and
SEs can be targeted
▪ Less time to wait for response
▪ Patient prefers adding medication
Kennedy SH, et al. Can J Psychiatry. 2016;61(9):540-560.
Adherence in MDD: <40% Patients adhere to initial therapy1
▪ Educate
▪ Length of therapy
▪ Alternative medication options
▪ Side effect monitoring/management
▪ Consequences of unsuccessful
treatment
▪ Follow up q 2 weeks
▪ Communicate frequently
▪ Apps and reminders to engage patients
▪ Encourage wellness activities
1. Offson M. et al. Am J Psych 2006;163:101-108.
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Patient Satisfaction Key to Psychiatry Adherence
2017 Meta analysis
▪ 20%-75% of patients receiving psychosocial
mental health services “drop out”
▪ 60% on anti-depressants are not taking by
6 months
The Patient-Provider Relationship
was key:
Patients want..
1. Quality information
2. Sharing in decision-making
3. Continuity of care
Patient Satisfaction Key to Psychiatry Adherence ‘Crisis’.
Medscape Apr 05,2017 Abstract at EPA 2017 Congress
Shared Decision Making in MDD Improves patient participation, adherence, and clinical outcomes
▪ Uses educational aids
▪ Incorporates patient values,
priorities, concerns, goals
▪ Reviews risk and benefits of
treatment options (O’Connor, 2007)
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Wellness Recommendation for Sam
▪ Medication(s)?
▪ CBT?
▪ Wellness?
▪ Follow up?
▪ Continuity of care?
Follow-up and Monitoring to Achieve Outcomes
Can we measure WELLNESS?
Tools:
▪ PHQ-9
▪ PDQ-5
▪ HERO
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HERO: Measure Wellness
▪ During last 7 days
▪ How Happy?
▪ How Enthusiastic?
▪ How Resilient?
▪ How Optimistic?
▪ Rate mental wellness
▪ Not at all good to
Extremely good
Copyright 2017, Dr. Saundra Jain and Dr. Rakesh Jain.
Summary
▪ MDD can present in many subtle ways, and screening for it is imperative in symptoms suggestive of MDD
▪ Use PHQ-9 to screen for MDD, and assess severity, as well as follow progress
▪ Make full remission, then wellness your goal in treating MDD patients with appropriate treatment and continued lifestyle modification
▪ Address all 3 domains of depression, including mood, energy, and cognitive function