Navigating Depression in the

Metabolic Syndrome Patient

JACQUELINE CALDERONE M.D.ASSOCIATE DIRECTOR OF PRIMARY CARE TELEPSYCHIATRY HELEN & ARTHUR E. JOHNSON DEPRESSION CENTER

TEAM PSYCHIATRIST, DENVER NUGGETS

ASSISTANT PROFESSOR, DEPARTMENT OF FAMILY MEDICINE & DEPARTMENT OF PSYCHIATRY UNIVERSITY OF COLORADO SCHOOL OF MEDICINE

CHAIR, EARLY CAREER PSYCHIATRISTS, AMERICAN PSYCHIATRIC ASSOCIATION ASSEMBLY EXECUTIVE COMMITTEE

Disclosures

u NONE.

I receive all my income from the University of Colorado SOM.

Learning Objectives:

u Identifying Depressionu How to Start the Conversationu Considering Differential & Comorbiditiesu Patient Engagement & Educationu Initiating Managementu Consider a Team Approach: Innovative

Consults & Referrals

Mrs. Feeling Blue presents to your office today….u What are the signs, symptoms and risk factors that alert you that

she is struggling with a depressive disorder/illness?

u Why is it important to treat?

u Do you feel adequately comfortable talking about depression so that you can help her open up and get treatment?

u Does part of you want to focus on the “real” medical problems or concerned that you do not have time to talk about depression?

u What treatments will you recommend? Can you provide full medication consent?

My hope is that you will have more confidence, comfort, and competence to recognize & discuss depressive symptoms and know how to think about diagnosis, initiate management, or consider novel referral services.

The goal is to build on your current skill set and not to make you mental health experts in 35 minutes.

Our Shared Patients

Tran et al. 2018https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002513

Prevalence of Chronic Disease in America

Shared Pathwaysin Metabolic Syndrome & Mental Illness

Multiple Complex Mechanisms

u Depression has been positively associated with central obesity, chronic inflammation, and insulin resistance, which are underlying etiological mechanisms for MetS.

u Depression has known neuroendocrine effects (e.g., dysregulation of the hypothalamic-pituitary-adrenocortical axis and sympathetic nervous system activation), which could influence MetS risk by affecting abdominal fat accumulation, glucose metabolism, and blood pressure regulation.

u Third, depressed individuals tend to have poor diet and sleep disturbance and engage in less physical activity, and these behaviors are known risk factors for the development of MetS.

u Fourth, conventional medication treatment for depression may exert direct effects on various components of MetSand partially explain the observed association.

Depression Overview

• The lifetime prevalence of MDD is 20.6%• The 12-month prevalence of MDD is 10.4%• Most common psychiatric disorder in

primary care• Under-recognized: 30-70% percent missed• Inadequately “treated”: Less than 50%

receive adequate treatment

Common

• Without adequate treatment often becomes chronic and recurrent

• Results in 2-3 fold increase in medical utilization

• *Increased morbidity and mortality• Leading cause of disability worldwide

(World Health Organization 2016)

Significant1. Vigo D, Thornicroft G, Atun R. Estimating the true global burden of mental illness. Lancet Psychiatry 2016;3:171-8. 2. Whiteford HA, Degenhardt L, Rehm J, Baxter AJ, Ferrari AJ, Erskine HE, et al. Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. Lancet 2013;382:1575-86. 3. Cunningham PJ. Beyond Parity: Primary Care Physicians’ Perspectives On Access To Mental Health Care: More PCPs have trouble obtaining mental health services for their patients than have problems getting other specialty services. Health Affairs 2009;28:w490-501. 4. Rowan K, McAlpine DD, Blewett LA. Access And Cost Barriers To Mental Health Care, By Insurance Status, 1999-2010. Health Affairs 2013;32:1723-30. 5. Walker ER, Cummings JR, Hockenberry JM, et al. Insurance Status, Use of Mental Health Services, and Unmet Need for Mental Health Care in the United States. PsychiatrServ 2015;66:578-84.6.Hasin DS, Sarvet AL, Meyers JL, et al. Epidemiology of adult DSM-5 major depressive disorder and its specifiers in the United States [published online February 14, 2018]. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2017.4602

Almost 60% of People with Any Mental illnessDo Not Receive Any Mental Health Services

Why is Mental Health Untreated in Our Country?

Answer:u Shortage of Mental Health Providers

u Access

u Cost & Fragmented Reimbursement Structures

u Stigma Pervades

u The Culture of Medical Systems and Training

Diagnosis Can Be Difficult

Only Through Clinical Examination

u Astute evaluationu Constellation of signs and symptomsu Impact on functioning and/or high distressu Enduring for Specified Period of Time

u *Highly Heterogeneousu Many comorbidities

MDD Diagnosing

Stahl SM . Stahl’s Essentia l Psychopharm acology. 4th ed. 2013

At least 5 Symptoms should be present for a period of 2+ weeks and represent a change from previous functioning

Feeling Depressed or Lost Enjoyment are Required

Causes of Depressive Disorders

Complex interactions of biologic, psychologic, social & wellnessfactorsHighly Heterogeneous Illness

u BiologicGenetics: Family History, Propensity, Epigenetics, female 2xMedications: IFN, beta-blockers, steroids, αmethyldopa, L-dopa, OCPs, opiates Diseases: HIV, Lyme, Hypothyroidism, Porphyria, Uremia, Cushings Dz, Liver disease, Huntington’s, MS, Lupus, L-MCA stroke, hyperparathyroidism, cancer…Substances: ETOH, cocaine/amphetamine withdrawalExposures: Lead Toxicity

Complex interactions of biologic, psychologic, social & wellness factorsHighly Heterogeneous Illness

u Psychologic

History of abuse/trauma (ACE score)Early parent lossBullyingTrust, Safety, SecurityEsteemAttachment, Relatedness, Intimacy

Causes of Depressive Disorders

Complex interactions of biologic, psychologic, social & wellnessfactorsHighly Heterogeneous Illness

u Social / SDOHPoor Social SupportEconomic hardshipFood InsecurityHousing InsecurityAcute Stress or Life Change-Job loss- in men-Relationship loss- in women Care taking responsibilities

Marital status: Unmarried men and married women

Causes of Depressive Disorders

Causes of Depressive Disorders

Complex interactions of biologic, psychologic, social & wellness factors

Highly Heterogeneous Illness

u WellnessSleep

Nutrition

Exercise

Sunlight Exposure

Stress Management

Relationships

Step 1: Identify Depression

COMMON PRESENTATIONS:

u Multiple persistent physical symptoms with no clear causeu Low energy, fatigue, sleep problems

u Persistent sadness or depressed mood, anxietyu Loss of interest or pleasure in activities that are normally

pleasurable

Patient Case:

Charles is a 58-year-old married man seen by his primary physician for scheduled care of diabetes. Diagnosed 4 years ago with type 2 diabetes, he is mildly obese (5 feet, 11 inches, 218 lb, body mass index 30.4 kg/m2) and hypertensive (blood pressure 165/92 mmHg), but otherwise has no evidence of coronary heart disease or other complications of diabetes. He uses insulin and has insufficient control of hyperglycemia (recent hemoglobin A1c [A1C] concentrations range from 10 to 11.5%). He does not perform blood glucose testing.

u Six months ago, the patient started having difficulty falling and staying asleep. As a result, he felt tired and fatigued most of the time.

u When he presented to your office, he had gained 12lbs in 3 months.

u When asked, he adamantly denied depression or feeling sad.

u Now what?

Patient Case:

Option 1:

You have 20 minutes.

Evaluate the insomnia and treat with sleep hygiene and Trazodone 25-50mg PO QHS PRN.Optimize plan for diabetes management.

Identify your concern for exacerbation and have a close follow-up in 1 week,

Note to self: Have PHQ-9 administered at the start of next visit (or in between visits) and discuss.

These are symptomsConsider Differential

Option 2:You have 20 minutes. You decide to evaluate further potential depression.

Reflect & Summarize:You are having some difficulty with your diabetes management. Your having some difficulty with sleep. I hear you are not feeling depressed or sad.

Clarifying Questions?Tell me what have you enjoyed the last 2 weeks?

What do you usually enjoy? Have you noticed that lately it is more difficult to engage in the things you used to enjoy?

If patient reports decreased pleasure/interest/motivation, utilize PHQ-9 or another tool to further evaluate symptoms of Major Depressive Disorder.

Consider if Charles has at least 4 of the following additional symptoms for at least 2 weeks to meet the criteria for MDD??

– Disturbed sleep or sleeping too much– Significant change in appetite or weight (decrease or increase)– Beliefs of worthlessness or excessive guilt– Fatigue or loss of energy– Reduced concentration– Indecisiveness– Observable agitation or physical restlessness– Talking or moving more slowly than usual– Hopelessness– Suicidal thoughts or acts

Charles shares the following:

Due to fatigue, he stopped exercising and then felt bad about the 12 lb weight gain. For the last 6 weeks, he gradually stopped socializing and eventually lost interest in most things, including sexual activity. He continued to work but has trouble concentrating, frequently forgets things, and feels impatient, irritable, and frustrated. For the past month, the constellation of symptoms has been persistent and interfering. No SI or psychosis.

Reflect and Summarize:

I hear your sleep is disturbed, you are fatigued, you don’t enjoy the things you used to, you are struggling with concentration at work, you don’t feel good about the weight gain, and your relationships have been strained. And this has been going on for several weeks. Did I hear that right?

R/O: anemia, hypothyroidism, substance abuse and medication side-effects

Step 2 is Psychoeducation: Educate & Engage the Patient

Because of all these symptoms, I am concerned that you have a depressive disorder. It is very common. Up to 1 in 4 patients with diabetes can have depression.

You don’t always have to feel sad or depressed especially for men.

Depression is an illness that affects the brain and there are many treatment options.

It is imperative that we treat so it does not become chronic and because your diabetes will likely exacerbate if we do not.

Provide a handout on symptoms of Major Depressive Disorder and see if he agrees that he meets many of these criteria.

Ask if he has questions or concerns?Anderson, R. J., Freedland, K. E., Clouse, R. E., & Lustman, P. J. (2001). The prevalence of comorbiddepression in adults with diabetes: A meta-analysis. Diabetes Care, 24, 1069 –1078.

2018 American Association of Diabetes Educators.

Pending Time:

Query past depressive episodes, family history, past safety concerns, past manic episode?

Step 3 Brief Determination of Severity

This patient is not severe or an emergency.

He is not suicidal or psychotic. He has no past suicide attempts.He does not have substance disorder.He is married and still working. You have a good rapport with him. You trust he will come in for follow-up.

Step 4: Initial Management for MDD

1.Provide psychoeducation to the person and their primary supports.

2. Reduce stress and strengthen social supports.

3. Promote functioning in daily activities and community life.

4. A course of psychotherapy is just as effective as medication treatment in mild/moderate depression. Consider interpersonal therapy (IPT), cognitive behavioral therapy (CBT), and behavioral activation.

5.*Consider antidepressants.

mhGAP Intervention Guide WHO 2016

Promoting Mental Health Treatment in Non-Specialized Health Settings*Key Tips from WHO

Psychosocial Interventions are Part of Every Depression Management Plan

Assess for and try to reduce acute stressors. (acute loss of finances, relationship, health, housing, food, trauma)

Reactivate the person’s previous social support.

*Promote daily functioning:Even if it is difficult, encourage the person to try to do as many of the following as possible:– Try to start an activity that was previously pleasurable.– Try to maintain regular sleeping and waking times.– Try to be as physically active as possible.– Try to eat regularly despite changes in appetite.– Try to spend time with trusted friends and family.– Try to participate in community and other social activitiesas much as possible.

*These are all part of behavioral activation to promote mood

mhGAP Intervention Guide WHO 2016

-Solicit patients understanding of their own depression-Validate the difficulty & Importance of Treatment

-Educate about depression-Discuss treatment options

u Therapy, Wellness, Behavioral Activation, Medication

-Solicit preferences about treatment-Discuss and set self-management goals

-Support empowerment-Interrupt catastrophizing and distorted thinking

American Psychiatric Association (APA) Practice Guidelines:Importance of Patient Engagement

American Psychiatric Association. The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults [Internet]. Third Edition. American Psychiatric Association, 2015.

Initial Management for Charles’ Depression

-Evaluate and treat known comorbiditiesFor CD, evaluate and treat for insomnia

-CBT for Insomnia, Sleep Hygiene, Trazodone 25-50mg PO QHS PRN

-Engage his wife, obtain ROI

-Assess for and try to reduce acute stressors

-Have him Commit to improving one aspect of daily functioning -Behavioral Activation, exercise if he is willing

-Offer referral to CBT or IPT - Psychology Today is an effective tool

-*Consider Medication

-Close Follow-Up (1 week, RN call in between visits)

RECOMMENDATIONS ON FREQUENCY OF CONTACT

» Schedule the second appointment within 1 week.

» Initially maintain regular contact via telephone, home visits, letters, or contact cards more frequently,e.g. monthly, for the first 3 months.

mhGAP Intervention Guide WHO 2016

Step 5: Patient Alignment with Medication Treatment

u Combination Psychotherapy and Medications most efficacious for all MDD

u Strongly Recommend Medication in severe or recurrent MDD

Little evidence to support one medication vs. another in the population

Comparative Efficacy and Acceptability of 12 New-generation Antidepressants (LANCET’s meta-analysis)*

Most ToleratedEscitalopram, Sertraline

Most EfficaciousMirtazapine, Escitalopram, Venlafaxine,

Sertraline

Cipriani et al. LANCET 2009:373;746-58.

*small differences*concomitant illnesses may not have been accounted for, not “real world”

u Largest prospective clinical trial of treatment of major depressive disorder

u NIH Fundedu 2,876 “real-world” patients with treatment-

resistant depressionu Fewer exclusion criteriau Followed a 4 step algorithm for treatment

Sequenced Treatment Alternatives to Relieve Depression (STAR*D)

Rush AJ, Trivedi MH, Wisniewski SR, Nierenberg AA, Stewart JW, Warden D, et al. Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR* D report. Am J Psychiatry. 2006;163(11):1905–17.

STAR*D 4-step Algorithm 40

Rush et al. Am J Psych. 2006;163(11):1905-17.

STAR*D Study Results

• No specific medication had better results than another

• Time to achieve remission ~ 7 weeks• Max effectiveness up to 12-14 weeks

u Step 1: 33% achieved Remission

u Step 2: 20% (cumulative remission 53%)u Step 3: 6-7% (cumulative remission 60%)

u Step 4: 6-7% (cumulative remission 67%)

Rush et al. Am J Psych. 2006;163(11):1905-17.

American Psychiatric Association (APA)Practice Guidelines:Patient Centered Medication Choices Nature of prior response to medications Indications

s Co-occurring psychiatric or general medical conditions

s Safety

s Tolerability and anticipated side effectss Potential drug interactions

s Half-life

s Cost

s Patient Preference Supports Placebo and AdherenceAmerican Psychiatric Association. The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults [Internet].Third Edition. American Psychiatric Association, 2015.

Treating Comorbidities: FDA Indications for Antidepressants

u Unipolar depressionu Panic disorderu Generalized anxiety

disorderu Obsessive-compulsive

disorderu Bulimia nervosa

u Premenstrual Dysphoric Disorder (PMDD)

u Seasonal affective disorder (SAD)

u Smoking Cessationu Post Traumatic Stress

Disorder (PTSD)u Diabetic neuropathy

STAR-D, the largest NIH study on Major Depressive Disorder (MDD) Treatment, along with American Psychiatric Association Practice Guidelines teach us to choose an initial medication for a patient with MDD based on the following: (Choose all that are correct.)

A: The antidepressant that is proven to be most effective and efficacious

B: Side Effect Profile

C: Comorbidities

D: CostE: Patient Preference

B, C, D, & E are all correct

Rush et al. Am J Psych. 2006;163(11):1905-17 American Psychiatric Association. The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults [Internet]. Third Edition. American Psychiatric Association, 2015.

Medication Consent:Discuss with the person and decide together whether to prescribe antidepressants. Explain that:

- Antidepressants are not addictive.- It is very important to take the medication every day asprescribed.- Some side effects may be experienced within the first fewdays but they usually resolve.- It usually takes several weeks before improvements inmood, interest or energy is noticed.-Antidepressant medications usually need to be continued for at least 9-12 months after the resolution of symptoms.-Medications should never be stopped just because the personexperiences some improvement.

mhGAP Intervention Guide WHO 2016

SSRI Side Effects

AcuteuDrowsiness 17%u Insomnia 11%uDizziness 11%uHeadache 10 %uDry Mouth 7%uGI Distress/Nausea 6%uActivation/Anxiety

11% go slowOften Transient

Delayed OnsetuSexual

dysfunction17% -30%

uWeight gain 12%uCognitive or

Affective blunting

uSIADH (rare)

Acute Side Effects Decrease Over Time

Zajecks et al. J Clin Psychiatry, 1999.

% of Patients

Weeks

Fava et al. Ann Clin Psychiatry, 1998

SSRIʼs Effects on Weight

Perc

ent w

ith >

7% W

eigh

t Gai

n

APA: Items to Monitor Throughout Treatmentu Symptomatic Statusu Functional Statusu Risk/Safety Assessmentsu Signs of switch to maniau Side effectsu When patient is taking medicineu Adherenceu Patient acceptabilityu Other mental disorders, including

alcohol and drug disorders, anxietyAmerican Psychiatric Association. The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults [Internet]. Third Edition. American Psychiatric Association, 2015.

Refine and Understand Your Goals of Treatment and Follow-Up

Three Phases of Treatment

Sym

ptom

Sev

erity

Acute Phase 3 months Continuation 4-9 months Maintenance years

*Response

Remission

Relapse Recurrence

Relapse

> 50% STOP

Rx

65 to 70% STOP Rx

Recovery

Rush A, Trivedi M. Treating Depression to Remission. Psychiatr Ann. 1995; 25: 704-709. doi: 10.3928/0048-5713-19951201-03 ]Oxman, 2001

TX

• Almost 30 Million people receive a prescription for an antidepressant in a given year

• 20-30% drop out of treatment too early

• 25-50% stay on ineffective treatments for too long

Goals of Therapyu Complete remission (100% reduction of symptoms)u Maintaining level of improvement (no relapse or

recurrence)

Stahl SM. Stahl’s Essential Psychopharmacology. 4th ed. 2013.

53

u Maintain all individuals on Medication 6-9 months after initial response

u Maintenance Dose should be at full Doseu Make a Relapse Prevention Plan before

slowly discontinuingu Treat those at high risk for recurrence for 2

years or longer

Recommending Maintenance Therapy

Based on Risk of Recurrence

Judd LL et al., American Journal of Psychiatry 2000Mueller TI et al., American Journal of Psychiatry 1999

Non-adherence of antidepressant medications has been documented as high as 60% to 70% in some studies and contributes to the pervasive undertreatment of mental Major Depressive Disorder (MDD). Adherence to medications in supported by the following steps: (Choose all that are correct.)

A: Choosing the most effective medication on the market

B: Doctor-Patient Alignment

C: Managing Stigma

D: Educating patients that antidepressants are not addictive & reviewing common side effects

E: Setting expectation on treatment course including dose, adequate trial, and maintenance treatment with goal of remission

B, C, D & E are all correctOxman, 2001

References: Importance & Management of Antidepressant Medication Adherence

u Floor Holvast, Richard C Oude Voshaar, Hans Wouters, Karin Hek, Francois Schellevis, Huibert Burger, Peter F M Verhaak, Non-adherence to antidepressants among older patients with depression: a longitudinal cohort study in primary care, Family Practice, Volume 36, Issue 1, February 2019, Pages 12–20, https://doi.org/10.1093/fampra/cmy106

u Sirey JA, Banerjee S, Marino P, et al. Adherence to Depression Treatment in Primary Care: A Randomized Clinical Trial. JAMA Psychiatry. 2017;74(11):1129–1135. doi:10.1001/jamapsychiatry.2017.3047

u Ho SC, Jacob SA, Tangiisuran B (2017) Barriers and facilitators of adherence to antidepressants among outpatients with major depressive disorder: A qualitative study. PLOS ONE 12(6): e0179290. https://doi.org/10.1371/journal.pone.0179290

u Tamburrino MB, Nagel RW, Chahal MK, Lynch DJ. Antidepressant medication adherence: a study of primary care patients. Prim Care Companion J Clin Psychiatry. 2009;11(5):205–211. doi:10.4088/PCC.08m00694

u Hunot VM, Horne R, Leese MN, Churchill RC. A cohort study of adherence to antidepressants in primary care: the influence of antidepressant concerns and treatment preferences. Prim Care Companion J Clin Psychiatry. 2007;9(2):91–99. doi:10.4088/pcc.v09n0202

Optionswhenpatientsfailtorespondtoaninitialantidepressanttrial

• ReconsiderDiagnosis&Comorbidities(Trauma,Anxiety,Substanceabuse)

• OptimizeCurrentMedication:Pushdose• Augmentantidepressant• Switchtoadifferentantidepressant• Combine2ormoreantidepressants• ConsultorRefer

OptimizingAntidepressantDosage-IfToleratingPushing up specific antidepressants:Fluoxetine: 60-80 mg/dParoxetine: 60-80 mg/dEscitalopram: 30-40 mg/dSertraline: 250 mg/dVenlafaxine: 300 mg-450 mg/dDuloxetine: 120 mg/dMirtazapine: 60 mg/d

Don’t push:Tricyclics: risk of toxicity, cardiac arrhythmiasCitalopram: 40 mg/d. The FDA has issued a warning to not exceed 40 mg/din adults < 60, and not to exceed 20 mg/d in adults > 60, due to risk of QT prolongationBupropion: increased risk of seizures at doses > 450 mg of IR and XL or 400 mg SR

Partial Response (Optimize/Augment)

Vs.

No Response (Switch)

MoreEvidence

LessEvidence

Lithium (levels ~ 0.8 mEq/L)

Thyroid (triidothyronine 25-50 µg/d)

Buspirone (30-60 mg/d)

Atypical Antipsychotics• Aripiprazole • Meta-analysis: 47% (drug) vs 22% (pcb)

Lamotrigine (50-200 mg/d)

Hormones (Estrogen, Testosterone)

Folate/Deplin (500 µg/d)

Thase ME et al. CNS Spectrum 12:12 (supple 22), 2007

*L-Methylfolate (15 mg)SAMe (400-1600 mg/d)

*Exercise

Augmentation Strategies

Exercise for MDD

u Inflammatory cytokines are elevated in depressed patientsué Interleukin-6 (IL-6)ué tumor necrosis factor α (TNF-α)

u ATD-Treatment (SSRIs) decreases some inflammatory cytokinesuê IL-1β, IL-6, TNF-α

u Elevated baseline TNF-α and IL-6 correlated with treatment failure with SSRIs

Rethorse CD et a l. M olecular Psych (2013) 18, 1119-1124

Rationale/Mechanism of Action

u 4 potential mechanismsu é B-endorphins linked to neurogenesis, and é

during exerciseu Vascular endothelial growth factor (VEGF)

increases during exercise & linked to hippocampal neurogenesis in rats.

u BDNF é during exerciseu Exercise é’s tryptophan hydroxylase, needed

for 5HT synthesisu Level I, Grade A evidence, large effect size (0.8)

Rethorst et al. Sports Med 2009

Recommendations for Prescription of Exercise for MDD

Exercise Recommendation

Modality Aerobic > resistance training

Session frequency 3-5 exercise sessions/week

Session duration 45-60 minutes

Exercise intensity 50-85% max HR (aerobic) or80% 1-RM (resistance)

Intervention duration At least 10 weeks

Rethorse CD & Trivedi M H. J Psych Practice, vol. 19, No. 3

Consider a Team Approach: Innovative Psychiatric Consults & Referrals

Currently in Family Medicine, Internal Medicine, OB-GYN, Neurology

Unützer J, Park M. Strategies to improve the management of depression in primary care. Prim Care. 2012;39(2):415–431. doi:10.1016/j.pop.2012.03.010

“2/3 of primary care providers report they are unable to get their mental health patients into outpatient mental health services”

Peter Cunningham (2009)

If they are not coming to us,tele-psychiatry helps us come to them.

Cunningham PJ. Beyond Parity: Primary Care Physicians’ Perspectives On Access To Mental Health Care: More PCPs have trouble obtaining mental health services for their patients than have problems getting other specialty services. Health Affairs 2009;28:w490-501.

How do we virtually embed

psychiatric providers into a primary care clinic ?

u

University of Colorado School of Medicine

AF WilliamsLarge Family Medicine Clinic

NCQA PCMH

Residency Training (18)

Behavioral Health &

IH Team Primary Care

Physicians (40 PT)

19,000 patients 30,000+ visits per year

University of Colorado School of Medicine

Depression CenterLarge Mental Health Outpatient Clinic

NNDC

6 Part Time Psychiatrists2 Psychiatric NP

4 PhD Psychologists2 LCSW

Depression Center AF Williams

BH Team

2 Psychiatrists 0.35 cFTE

PCPs

ResidentsTele-Medicine Platform

Psychiatry Residents 19, 000 patients

Program Design: Stepped Model of Available Services

Technology: Cloud-based virtual telemedicine platform, real-time, video-based (Vidyo/Zoom platforms)

1) E-consults: Staff message through EPIC EMR for brief questions/chart review2) Provider-to-Provider Consultations: Scheduled or brief curbsides with PCP

and/or BHP 3) Co-Consultations: Provide Consultations with PCP, Patient, and sometimes

BHP to develop a plan together 4) Psychiatric Evaluation: Initiate plan, document recommendations for

continued management5) Interdisciplinary Team Meetings: Discuss patients with high medical

complexity6) Didactic Education

Waugh M, Calderone J, Brown Levey S, et al. Using Telepsychiatry to Enrich Existing Integrated Primary Care. Telemed J E Health 2019;25:762-8.

Take Away Pointsu Shared Patients: Bidirectional Relationship Between Depression & Metabolic Syndrome

u Common, Leading Cause of Disability

u Correlated with High Medical Complexity, Comorbidity, and Mortality

u Correlated with Excess Costs and ED Utilization

u Potential to become Chronic illness

u Asking patients about depression is the first step toward treatment and it takes all health professionals to meet this challenge.

u Physicians who ask about depression help reduce stigma and encourage treatment (not just PHQ)

u Many Medication Options, SSRI is First Line, No one medication has proven superior effectiveness

u Keep Patient Centered, Encourage Adherence to Adequate Medication Trial, Remission is Goal

u Psychotherapy with Medications Improves Outcomes

u Wellness & Exercise

u Consider Novel Team Aproaches

Thank You for Your Time

QUESTIONS?

Patient Case 2 – if helpful

u Case: We received a consult concerning a 59- yo male with a previous history of major depressive disorder (MDD) who achieved remission on Venlafaxine 225 mg PO QAM many years ago but who recently re-presented with return of “depression”. Because he had been tried on several antidepressants in the past with either significant adverse effects or lack of efficacy, we were asked for additional medication options.

u Evaluation: Upon further questioning during our telepsychpatient evaluation, we learned that the patient’s father had passed away a few months ago, the patient was feeling resentment and guilt due to their fractured relationship, and that he recently increased his alcohol use to 3–4 drinks every day to manage these difficult feelings. While this patient has clear risk for a recurrent MDD episode, and it is obviously important to consider medications, the ultimate focus of his treatment was on grief counseling, psychotherapy, and cessation of alcohol use.

u