Transcript Managing Mood Disorders In Primary Care

“I HAVE THIS PATIENT…….”
Managing Mood Disorders in
Primary Care
Amy Heneghan, M.D.
Pediatrics
Palo Alto Medical
Foundation
Manpreet Singh, M.D. , M.S.
Child & Adolescent Psychiatry
Lucille Packard Children’s
Hospital
Educational Objectives
• Inspire you to embrace the role of primary care in screening and
managing mood disorders
– How to identify mood disorders in primary care
– What constitutes management of mood disorders in primary care
– When to refer to and collaborate with mental health colleagues
• Increase your knowledge about treatment of mood disorders
– Pharmacologic
– Behavioral
• Convince you to design your own practice to provide team based
collaborative care
– What are the principles of collaborative care
Mental Health Screening & Depression Management:
Integral to Pediatric Primary Care
Why:
• Mental health issues are common in children and teens and can
portend complex medical and mental disorders in adulthood
Why primary care:
• Primary care is usually the first and often the only contact that
patients have with health care professionals.
• Primary care interventions can be sufficient, without need for
referral to mental health specialists.
Who says so:
Epidemiology of Childhood
Depression
• ≈5% of children and adolescents in general
population suffer from depression at any given
time (2% children, 4-8% adolescents)
• Male:Female ratio 1:1 during childhood, 1:2 in
adolescents
• 1.7% of children suffer from dysthymia (1.6-8%
in adolescents)
• Depressive disorders are appearing at a
younger age of onset
CASE OF MY PATIENT (M.P.)
• 11 year old male presents for his annual check up
– Doing well in school
– Getting along at home with parents and siblings
– Likes video games
– Physical exam normal
KEEP UP THE GOOD WORK! SEE YOU NEXT YEAR!
CASE OF MY PATIENT (M.P.)
• M.P back for his annual 12 year check up
– Doing well in school
– Fighting more with parents and siblings
– Wants to play video games all the time
– Physical exam normal; in early puberty
COUNSELED ABOUT VIDEO GAMES, PEER
RELATIONSHIPS, FAMILY RELATIONSHIPS, PUBERTY
SCREEN FOR MOOD?
Readily Accessible Screening Tools
General HEADDSS
Depression:
PHQ 9
PHQ 2  9
PHQ 9 for Teens
9 questions about depression & its severity
2 question screen, then 9 if screen is positive
PHQ 9 + 2 ?’s about suicidality
Depression, ADD, Anxiety, Conduct
Pediatric Symptom Checklist For Youth and Parent
37 questions about mood, behavior, attention issues
2 questions about suicidal thoughts, plans
Drugs and Alcohol:
CRAFFT
3 initial questions, then 6 more
PHQ 9 Modified for Teens
Depression Severity
Rating
<5
None
5–9
10 – 14
Mild
Moderate
15 – 19 Mod. Severe
20 +
Severe
Impact on Function
Not difficult
Somewhat Difficult
Very difficult
Extremely Difficult
CASE OF MY PATIENT (M.P.)
– PHQ 9 for teens
• Scored 6:
– felt irritable, low energy, and like he was letting his family
down. No functional impairment
Depressed? Manic? Anxious?
Major Depressive Disorder Diagnosis
DSM IV
> 5 of 9 sx (must include mood issue) + impaired function
• Mood: irritable or depressed plus
•
•
•
•
•
•
•
•
Sleep: increased or insomnia
Interest: markedly decreased in activities
Guilt: feeling worthless, inappropriate guilt
Energy: fatigue or loss of energy
Concentration: hard to think/concentrate
Appetite: significant wt loss / gain (~ 5% change)
Psychomotor activity: physically slowed or agitated
Suicide: thoughts, attempts, death thoughts
Grading Depression Severity
Based on Sx and Function (DSM IV)
Mild: 5-6 sx of mild severity (including mood) +
function mildly impaired or normal but w/ substantial and
unusual effort
Moderate in between mild and severe
Severe: most sx present and severe +
Function is disabled, clearly observable
Or
Psychotic features are present
Screen for Other Mood symptoms and
Comorbidities
• Physical illness: targeted review of systems, labs
• Substance / alcohol use, 20 – 30%
– usually follows depression onset by ~ 5 years
• Other mood and psychiatric disorders:
– Dysthymia, Bipolar Disorder, Anxiety, ADD, PDD, ODD or
Conduct Disorders, Psychotic disorders (hallucinations,
paranoia)
• Abuse: physical / emotional / sexual
How mania present in kids
Warning Signs
Risk-taking behaviors with false beliefs of achievement
Getting only a few hours of sleep but not feeling sleepy during
the day
(Children need 8-10 hours of sleep; Adolescents 10-12 hours)
Sneaking out of the house, running away, sexual activity, using
drugs
“I hear voices telling me to hurt myself”
“Energizer bunny”
“My brain is going 100 miles/hour”; Jumping from topic to topic
Grades getting worse from incomplete or unattempted school
work
Visits to the principal’s office for behavior problems.
Talking too much, being loud, hard to interrupt or understand
Initial Management of M.P.
• Form an alliance w/ the teen and affirm hope
• Educate, counsel pt and family about depression,
management options, limits of confidentiality
• Establish a safety plan: restrict access to lethal means,
engage 3rd party to monitor for deterioration/risk,
develop emergency communication plan to use if
needed
• Develop a specific tx plan and goals regarding function in
home, school and peer relationships
Initial Management of M.P. (cont.)
• Share resources for support: phone #s, websites,
handouts
• Refer pt and family to mental health providers
• Arrange follow up visit within one week
• Have family sign release of information form to allow
communication w/ school staff, outside providers.
• Obtain information from and communicate w/ school
staff, health care providers. Keep them informed about
your tx plans and concerns.
AAP http://www.aap.org/stress/teen1-a.cfm
Book: Ginsburg K, Building
Resilience in Children and Teens: Giving Your Child Roots and Wings
Initial Treatment of
Mild, Uncomplicated Depression
• Active support through PCP
• See pt weekly or biweekly x 6 – 8 wks:
– Non directive support (support is equally
effective as formal psychotherapy for mild
depression)
– Monitor depressive symptoms and function
(school, home, peer)
• If sx persist > 6 – 8 wks, offer psychotherapy and
/ or antidepressants
• Refer patient and family to mental health care
providers when appropriate
Psychological and Social Treatments
• Stress management & regular sleep
• Lifestyle: Exercise, weight control, avoid caffeine and alcohol
• Resources and Support: AACAP, APA
–
–
–
–
Youth Bipolar Foundation of Northern Calif (YBFNC)ybfnc.cfsites.org
Child & Adolescent Bipolar Foundation (CABF) www.bpkids.org
Depression & Bipolar Support Alliance (DBSA) www.dbsalliance.org
American Foundation for Suicide Prevention (AFSP) www.afsp.org
• School Intervention
• Psychotherapy
– Multifamily Psychoeducational Group therapy
– Family Focused Therapy
• Mood charting www.manicdepressive.org
• Complementary and alternative medicine: Mental Health
Naturally, by Kathi Kemper
Promoting Resiliency through Active Support
Teen’s definition: Resilience means “bouncing back from
problems and stuff with more power and more smarts."
Nurturing resiliency:
• Demonstrate to pt that s/he has strengths (name them,
show pt how s/he is using them, suggest how pt can use
them in the future)
• Be patient, keep communicating these to pt over serial
visits
Adapted from Nan Henderson, The Resiliency Training Program
CASE OF MY PATIENT (M.P.)
• Spoke to mother at 2 weeks, M.P better
• 8 weeks later, mother calls:
– Does not want to wake up in the morning for school
– Note from teacher about missed assignment
– Outbursts of anger at home and at soccer
– Some nights does not sleep at all
• PHQ 9 modified score 15 (moderate-severe)
– very difficult to function
– Not suicidal
DEPRESSED? MANIC? ANXIOUS?
REFERRAL?
Medication and Talk Therapy: Sequential
or in Combination?
TADS (Treatment for Adolescents with Depression Study): 439 teens 13 - 17 y/o with
moderate to severe depression
1. Cognitive Beh Tx (CBT) + Fluoxetine
2. CBT alone
3. Fluoxetine alone
–
–
–
–
Higher first response rate CBT+ Fluoxetine combined - Improved @ 12 wks:
71% Combo (v. 61% SSRI v. 44% Talk; @ 36 wks: similar outcomes for all
groups
Remission: faster for combo tx: by 36 wks: 55% for fluoxetine, 60% combo,
64% CBT
Anti depressants can take 1 – 3 months to work
Once stable continue med for 6 - 9 mo
Treatment for Adolescents w/ Depression Study, Am J Psychiatry. 2009 ;166(10): 1141-1149.
https://trialweb.dcri.duke.edu/tads/manuals.html
Talk Therapy: What Works?
Cognitive Behavioral Therapy (CBT) is effective and less costly than other talk tx,
eg Interpersonal Therapy
CBT Principles: thoughts cause feelings & behaviors, not external things (people,
situations, events).
Focus: Change the way you think and react in order to feel & act better even if
externalities don’t change.
Approaches: attend to thoughts and behaviors, practice to change them
(in contrast to Interpersonal Therapy, which focuses primarily on improving
relationships)
Recommended by WHO
Adopted by National Health Service, UK
Other Treatments to Initiate for
Moderate Depression without complicating features
Consider starting antidepressant after discussion w/
psychiatrist and recommend psychotherapy
Or
Refer to Psychiatrist
If teen / family decline psychotherapy or psychiatrist:
• Active support through PCP
• See pt weekly or every other week x 6 – 8 wks:
– Non directive support
– Monitor depressive sx and function (school, home,
peer)
When to Refer to Psychiatrist
Anyone who wants such a referral
Moderate Depression w/ Complicating Factors
(eg substance abuse, ADHD, other psych
illnesses)
Severe Depression
Suicidal patient
If Improved after 6 – 8 wks
• Next 6 months: Continue meds after sx resolution;
track adherence and side effects
• After full remission: monitor monthly for 6 months
• Up to 24 months: regular follow up in primary care
If not fully improved after 6 – 8 wks
If Partially Improved
If Not Improved
• If no med, consider adding
• Reassess dx and if
confirmed,
• If on med, consider increase dose
• If no psychotherapy, start
• Consult with or refer to
psychiatrist
• Review safety plan
• Provide further education
Do all actions
noted on left
Before Starting Antidepressant Medication
in Teens
• Establish safety plan
• Establish schedule for close follow up and
communication
• Review short & longer term side effects of
meds and warning signs requiring immediate
attention (including mania, suicidal ideation)
SSRI Antidepressant Prescription for Teens by PCPs
Who says so? AAP, AACAP, PC-Glad - II
Why?
Many teens and / or parents are reluctant to seek help from
mental health providers.
Widespread problems with limited or delayed access to
psychiatrists for teens
Which pts?
* uncomplicated mild depression that persists
* moderate depression
How? Guidelines are clear about how to start meds, follow pts and
when to seek specialty referral
Medication for Teen Depression: SSRIs
Doses, Efficacy and FDA Approval
Medication
Fluoxetine
Trade
Name
Prozac
Escitalopram Lexapro
Citalopram
Celexa
Sertraline
Zoloft
Initial Dose
10 mg
QD/QOD
5 mg QD/QOD
10 mg
QD/QOD
25 mg
QD/QOD
RCT shows
efficacy /
Incremental Maximum
FDA
dose
Daily
Approved for
changes
Dose
Teen
Depression
10 – 20 mg
60 mg
Yes / Yes
5 mg
20 mg
Yes / Yes
10 mg
60 mg
Yes / No
12.5 – 25 mg
200 mg
Yes / No
Fluoxetine is the only SSRI approved for use in pre teens. Doses listed here for
teens and are not necessarily applicable for pre teens.
Medication for Teen Depression:
SSRI Side Effects
Side Effects of SSRIs, 5 HT Selective:
May attenuate over several weeks. In general, any SSRI may cause:
nausea, anxiety, agitation, anorexia, tremor, somnolence, sweating,
dry mouth, headache, dizziness, diarrhea, constipation, sexual
dysfunction
Medication
Trade
Anticholinergic Sedating
Comments
(generic)
Name
Side Effects
Effect
+, esp nausea,
FDA
sexual
Fluoxetine
Prozac
+
approved,
dysfunction,
stimulating
anorexia
Escitalopram Lexapro
+
+
FDA approved
Citalopram
Celexa
+
+
Generic avail.
0, esp diarrhea &
FDA
Sertraline
Zoloft
+
male sexual
Approved for
dysfunction
Teen OCD
Required Followup Schedule for Teens on
SSRIs for depression
First f/u should be a face to face meeting w/ MD 1 wk
after starting medication
If pt is doing well, follow up schedule:
• For 1st month: Every week w/ MD or therapist
• During 2nd month: Every other week
• After second month: Monthly thereafter
If dose is changed, see pt in 2 wks
See pt sooner for any concerns
CASE OF MY PATIENT (M.P.)
• Started on Prozac 10mg daily
• Seen biweekly; not improved
and dose increased to 20mg
daily
• Symptoms improved markedly
by week 12
• Started on Prozac 10mg daily
• Seen biweekly, not improved
and dose increased to 20mg daily
•
Returns with complaints of
agitation/irritability
abdominal pain
• Next 6 months: Continue meds;
track adherence and side effects
• After full remission: monitor
monthly for 6-12 months
weight gain
suicidal thoughts
Standard of Care
Assessing Suicide Risk
Ask about both ideation and attempts
Ideation*
1. Have you wished you were dead or you could go to sleep
& not wake up?
2. Have you actually had any thoughts of killing
yourself?
1. Have you made a suicide attempt? Tried to kill yourself?
Attempts*
2. Done anything to harm yourself?
3. Anything dangerous where you could have died?
*Adapted from the Columbia Suicide Severity Rating Scale, Posner et al 2009
“Black Box” Warning about Antidepressant
use in Children and Teens
In 2004, FDA reviewed 23 clinical trials (~ 4,400 children &
adolescents) rx’ed any of nine antidepressants for MDD, anxiety,
or OCD
Outcomes:
• No completed suicides
• Pts rx’ed anti depressants reported more suicidality (thoughts
& attempts) vs. pts on placebo (4 vs. 2 out of 100).
• Suicidality was not induced in pts without suicidality, not
increased in pts who already had suicidality
All studies showed reduced suicidality over tx course
More SSRI rx’s associated w/ lower suicide rates
Collaborative Care: By Many Other Names….
Chronic Care Model
Pt Centered Medical Home
Pt centered, comprehensive, coordinate, superb access, and systems
approach to quality and safety
Who says? > 30 RCTs confirm this, eg IMPACT model*
Who is using it: Mayo Clinic, Intermountain Health, Minnesota, U Washington,
many public health clinics
*Gilbody S et al. Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes. Arch Intern Med. 2006;166(21):2314-2321
Collaborative Care for Depression is Best:
It Takes a Team
PCPs and mental health providers working together:
Co location in same clinic
Consults by phone, e - consults
Sharing notes efficiently thru EHR or fax/mail
Maximize EHR tools:
track visits, PHQ scores, reminders, communicate w/ pts and team
Observation for medication complication or side effects:
weight gain, thyroid dysfunction, kidney and liver dysfunction
Care Managers: MA, RN, or therapist
educate, support pt self management
recommend stepped care, adjusted for severity and response to tx
arrange follow up at regular intervals
coordinate w/ PCP and mental health providers
Train staff for this work: on line (free!) or in person
http://impact-uw.org/training/web.html
Resources
AAP: Addressing Mental Health Issues in Primary Care: A Clinician’s Toolkit
http://www.aap.org/commpeds/dochs/mentalhealth/KeyResources.html
Guidelines for Adolescent Depression in 10 Care: Glad - PC http://www.glad-pc.org/
TeenScreen: National Center for Mental Health Checkups
http://www.teenscreen.org/programs/primary-care
IMPACT: Evidence based depression care: http://impact-uw.org/
NAMI: resources for pts, families, providers http://www.nami.org/
Heard Alliance: Collaborative of primary and mental health
providers in SF Bay Area Peninsula www.HeardAlliance.org/
AACAP and APA: Resource Center and Parents Medication Guide www.aacap.org/;
www.psych.org/
Youth Bipolar Foundation of Northern Calif (YBFNC) ybfnc.cfsites.org
Child & Adolescent Bipolar Foundation (CABF) www.bpkids.org
Depression & Bipolar Support Alliance (DBSA) www.dbsalliance.org
American Foundation for Suicide Prevention (AFSP) www.afsp.org
Current Research Studies at Stanford’s
Pediatric Mood Disorders Program
• Offspring of Parents with Bipolar and Major Depressive
Disorders (Mechanisms of Risk and Resilience)
– Studying offspring both with and without mood
problems
– Brain imaging (fMRI, MRS, DTI)
– Genetics
• Clinical trials of safety and benefit of medications to treat
symptoms of mood and attention in children
• Studies of effects of mania & depression on developing
adolescent brain
• Psychotherapies and cognitive training for youth and
families affected by depressive and bipolar disorders
Research referrals:
Call Us: (650) 725-6760
Email Us: [email protected]
Our website: PediatricBipolar.Stanford.Edu