Transcript spotlight on mental health

SPOTLIGHT ON MENTAL HEALTH
Yelizaveta Sher, M.D.
Department of Psychosomatic
Medicine
Meg Dvorak, LCSW
Adult CF Social Worker
TIDES: The International Depression
Epidemiological Study
• 154 cystic fibrosis centers in 9 countries (Europe & US)
• 6,088 patients w/ CF (12 yo & up), and 4,102 caregivers
of children w/ CF, birth-18 yo
• ↑depression in 10% of adolescents, 19% of adults,
37% of mothers and 31% of fathers.
• ↑ anxiety in 22% of adolescents, 32% of adults, 48% of
mothers and 36% of fathers.
• Elevations 2–3 times ↑ those of community samples.
Quittner AL, Goldbeck L, Abbott J, et al. Thorax 2014
Cystic Fibrosis & Mental Health
• Study comparing
• Psychological distress
adolescents with CF &
in CF is associated with:
• ↓pulmonary function
• ↑ hospitalizations
• ↑ healthcare costs
• ↓ health-related
quality of life
Quittner AL, Goldbeck L, Abbott J, et al. Thorax 2014
depression vs no dep:
• Those who were depressed
were 3X more likely to be
hospitalized for a
pulmonary exacerbation,
and incurred ↑healthcare
costs over 2 years
CFF and ECFS International Committee on
Mental Health in CF (ICMH) Guidelines
• Prevention:
– Ongoing education & preventative, supportive
interventions
– Behavioral approaches be used to reduce the risk of
distress
• Screening
– Annual screening for adolescents and adults with CF (ages
12–adulthood) with PHQ-9 and GAD-7
– Annual screening of caregivers of children and adolescents
– Screening of children (<12) if one caregiver is depressed or
there is concern
Quittner A et al, Thorax 2015
CFF and ECFS International Committee on
Mental Health in CF (ICMH) Guidelines
• Clinical Assessment/Intervention:
– Clinically evaluate elevated scores and refer to
PCP/MH as needed
– Use flexible, stepped care model of clinical
intervention
– Based on severity and availability, use evidencebased psychological interventions and/or
pharmacotherapy
Quittner A et al, Thorax 2015
MDD
Dysthymia
SubstanceInduced
Mood
Disorder
Adjustment
Disorder w/
Depressed Mood
Depression
Demoralization
Depression
2/2 Medical
Illness
Bipolar
Disorder,
Depressed
Normal
Reaction to
Stress
5 + symptoms x 2 weeks:
MDD
Dysthymia
• depressed mood
Adjustment
disorder w/
depressed mood
• ↓ interest/pleasure
• Changes in appetite
and/or sleep
Substance-
Induced changes
• psychomotor
• lowMood
energy
Depression
Disorder or guilt
• worthlessness
Bipolar
Disorder,
Depressed
• ↓concentration
• thoughts of death,
suicidal ideations,
attempt
Demoralization
Depression
2/2 Medical
Illness
Normal
Reaction to
Stress
MDD
Dysthymia
SubstanceInduced
Mood
Disorder
Adjustment
Disorder w/
Depressed Mood
Depression
Bipolar
 Symptoms within 3
monthsDisorder,
of the stressor
onset
Depressed
 Marked distress in
excess of expected and
significant impairment
in functioning
Demoralization
Depression
2/2 Medical
Illness
Normal
 Sxs do
not persist 6
months
after stressor
Reaction
to
termination
Stress
MDD
Dysthymia
Depressed Mood
SubstanceInduced
Mood
Disorder
Demoralization
Adjustment
Disorder w/
Depression
Bipolar
Disorder,
Depressed
• Episodes of mania or hypomania in addition to
Normal
depressed episodes
•
Depression
Reaction
to
Depression
may
be
characterized
by
hypersomnia,
2/2 Medical
Stress
hyperphagia, mood reactivity
Illness
• Very different treatment from unipolar depression
GAD
Adjustment do
w/ anxious mood
PTSD
Panic
Disorder
Anxiety
Phobias
OCD
American Psychiatric Association, 2013, DSM 5
Medical
Conditions:
Hypoxia
Metabolic
Infection
Tumor
Medications:
Steroids
Albuterol
Thyroid meds
Stimulants
Theophylline
GAD
Adjustment do
w/ anxious mood
PTSD
Excessive anxiety and
worry x 6 months
about few things
Associated with 3+:
Restlessness
Panic
Easily fatigued
Disorder
Diff concentrating
Irritability
Muscle tension
Sleep disturbance
Impairment
Phobias
Not due to effects of
substance or illness
Anxiety
OCD
American Psychiatric Association, 2013, DSM 5
Medical
Conditions:
Hypoxia
Metabolic
Infection
Tumor
Medications:
Steroids
Albuterol
Thyroid meds
Stimulants
Theophylline
 Presence of
obsessions,
compulsions or both
GAD
Adjustment do
w/ anxious mood
 Obsessions –
recurrent
thoughts, urges,
images
PTSD
 Compulsions –
repetitive
behaviors in
response to
Panic to
obsession
decrease
Disorder
anxiety
Anxiety
 Time-consuming or
cause sign distress
(1+ hr/day)
Phobias
 Not due to effects of
substance or medical
illness
OCD
American Psychiatric Association, 2013, DSM 5
Medical
Conditions:
Hypoxia
Metabolic
Infection
Tumor
Medications:
Steroids
Albuterol
Thyroid meds
Stimulants
Theophylline
 Recurrent unexpected panic attacks AND
 Attack(s) followed by 1 month of 1+ of following:
GAD
Persistent concern about having additional attacks
 Worry about the implications of the attack
 Significant change in behavior related to the attacks

Adjustment do
w/ anxious mood
 +/- Agoraphobia
PTSD
 Impairment
 Not due to effects of substance or illness
Panic
Disorder
Anxiety
Phobias
OCD
American Psychiatric Association, 2013, DSM 5
Medical
Conditions:
Hypoxia
Metabolic
Infection
Tumor
Medications:
Steroids
Albuterol
Thyroid meds
Stimulants
Theophylline
American Psychiatric Association, 2013, DSM 5
GAD
Adjustment do
w/ anxious mood
PTSD
 A. Exposure to actual/threatened
death, serious injury or sexual
Panic
violence
Anxiety
 B.Disorder
Intrusion Sxs




Intrusive thoughts
Nightmares
Flashbacks
Psychological and/or physiologic
distress with reminders
Phobias
 C. Avoidance of stimuli and numbing
 D. Negative alterations in mood and
cognitions
 E. Changes in arousal and reactivity
 F. Lasts for > 1 month
OCD
Medical
Conditions:
Hypoxia
Metabolic
Infection
Tumor
Medications:
Steroids
Albuterol
Thyroid meds
Stimulants
Theophylline
Treatment
• Diet
• Exercise
• Physical health
• Support
• Psychotherapy
• Medications
Treatment: Psychotherapy
• Psychodynamic Therapy
– Understanding of how one’s past shapes today
• Motivational Interviewing
– Patient-focused; eliciting talk of change from the patient
• Cognitive Behavioral Therapy
– relationship between thoughts, emotions, and behaviors
• Interpersonal Therapy
– social support; changes in role functioning ; resolution of grief
• Existential Psychotherapy
– Meaning of life; dealing with death and grief
• Mindfulness
– Staying in the moment; focus on now
• Supportive Psychotherapy
– Active listening; problem solving
Pharmacotherapy
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MAOIs
TCAs
SSRIs
SNRIs
Atypicals: mirtazapine, buproprion, vilazodone
Augmentors: lithium, thyroid, aripiprazole
Percent of Patients 18 Years and Older with Depression,2005-2014
Percent of Patients 18 Years and Older with Depression in 2014 ,by Center
Adult Mental Health Coordinator
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3 year grant through CFF
Faculty psychiatrist embedded in CF clinic
Expertise in CF, lung txp, psychosomatic medicine
Work closely with LCSW to improve screening
process
Bridging the Mental Health Gap
Access to MH services now
Improvements with MHC
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• Services embedded in CF clinic
• Evidenced based interventions in
your clinic appointment *
• Access to medications
• Increased focus on MH
• Improved data tracking for
research and QI
• Psychiatrist with CF expertise
MH screening, referral
MH system broken
Medi-Cal, GHPP
Private insurance
Patients
– Depression as barrier
– CF as barrier
• Providers
– Expensive
– Don’t take insurance