© bhm healthcare solutions 2014 understanding the mind/body connection and the treatment of...

© BHM Healthcare Solutions 2014

Understanding the Mind/Body Connection and the Treatment of Depression

Presented by Mark Rosenberg, MD, Ph.D.

CEO, BHM Healthcare Solutions


Learning Objectives

To gain a General Understanding of Major Depressive Disorder (MDD)

To Understand the Economic Burden of MDD from multiple perspectives

To Provide a Comprehensive Review of Diagnosis Strategies Based on the Diagnostic and Statistical Manual of Mental Disorders

To Discuss and Understand Traditional Pharmacologic Treatment, and Gain an Appreciation of Treatment from the Mind-Body Perspective

To Discuss Initial Treatment of MDD and Treatment after Therapeutic Failure as Recommended by the APA Guidelines

To Identify Follow-up Tools and Communication Strategies to Improve Management of MDD


Presentation OverviewDisease Overview

Costs of MDD

Diagnosis Strategies for MDD

Pharmacologic Treatment and Gaining a Mind-Body Perspective

Improving the Outcome


DISEASE OVERVIEW


Prevalence of the MDD

• In any given year 14.8 million American adults, or 6.7% of the US population, suffer from major depressive disorders

• Depression is the leading cause of disability in the US

• By 2020 it is projected that depression will be the leading cause of disability worldwide

• Average age of onset = 32

http://www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america/index.shtml#Intro


Prevalence of MDD

http://www.cdc.gov/features/dsdepression/


Prevalence of MDD

• High rate of occurrence – 17% lifetime prevalence, this prevalence corresponds to a national population projection of 32.69 to 35.1 million US adults with lifetime MDD and 13.1 to 14.2 million US adults with a 12 month prevalence of MDD

• Episodes of long duration- 33% of patients have episodes > 2 years’ duration

• >50% rate of recurrence within 2-3 years of recovery (8 weeks of minimal depressive symptoms)

• Morbidity comparable to angina and advanced coronary artery disease

• High mortality (15%) from suicide in depressed patients hospitalized once for depression

Keller MB. J. Clin Psychiatry. 1999; 50(suppl 17):41-45Kessler RC, et al. Arch Gen Psychiatry. 1994:51:9-19Laveril PW, et al. Int J Meth Psychiatry Res. 1994;4:211-229Meuller 11, et al. Amer J Psychiatry. 1999;156:1000-1006Wells KB, et al. JAMA. 1989;262:914-919

Aben L, et al. Stroke. 2002;33:2391-2395Barefoot JC, et al. Circulation. 1996;93:1976-1996.Aben L, et al. J Neurol Neurosurg Psychiatry. 2003; 74:581-585Keller MB, et al. Arch Gen Psychiatry. 1992;49:809-816

© BHM Healthcare Solutions 2014© BHM Healthcare Solutions 2014

BH/PC: The Treatment Gap

• Surveys show that 40% of patients with major depression do not want, or perceive the need, for treatment.

• Only 20%-30% of patients with mental health disorders report them to a primary care physician.

• 33% of patients presenting in the ER with acute chest pain are suffering from either panic disorder or depression.

• 80% of patients with depression initially present with physical symptoms such as fatigue or chronic aches.


Major Depression Disorder (MDD): Urgency to Treat

• MDD has become a major public health concern and is responsible for significant social impairment, including deterioration of family and interpersonal relationships, lost work productivity, and general suffering

• MDD is the most common psychiatric disorder in the United States

• Few patients receive adequate treatment• Depression is frequently associated with, and may negatively

impact other medical disorders• Inadequately treated depression may have progressive course

and may be associated with functional and structural changes in the brain

Murray CJ, et al. Science. 1996;274:740-743Greenberg PE, et al. J Clin Psychiatry 2003;64:1465-1475Kessler RC, et al. JAMA. 2003;289:3095-3105Everson SA, et al. Arch Intern Med. 1998;158:1138


MDD: Progression to Disorder and Recovery

1

Nonadherence,4

Treatment Phases

up to 50% up to 70%

Acute Continuation/MaintenanceRemission Delay Time to

Major Depressive EpisodeTreatment Goals

> 12 wks10-12 wksTime

Response

Remission Recovery

Seve

rity

Safety & Tolerability

Effic

acy

Symptoms

Euthymia

Syndrome

Progression

to Disorder1. Kupfer DJ. J Clin Psychiatry.1991;52(5 suppl):28-34.2. APA. Am J Psychiatry.2000;157(4 suppl):1-45.3. Lin EH, et al. Med Care.1995;33(1):67-74.4. Simon GE, et al. Gen Hosp Psychiatry. 1993;1:399 -408.

5. AHCPR Depression Guideline Panel. 1993.6. VHA/DoD Major Depressive Disorder Working Group. 2000 (ModuleA).1-35.

Kupfer DJ. J Clin Psychiatry. 1991;52(suppl):28-34APA. Am J Psychiatry. 2000;157(4 suppl):1-45Lin EH, et al. Med Care. 1995;33(1):67-74Simon GE, et al. Gen Hosp Psyciatry. 1993;15:399-408

AHCPR Depression Guideline Panel 1993.VHA/DoD Major Depressive Disorder Working Group 2000 (Module A). 1-35


Progression of Depression: Adverse Effects of each Successive Episode


There are at Least Two Sides to the Neurotransmitter Story

Sex

Appetite

Aggression

Concentration

Interest

Motivation

Depressed Mood

Anxiety

Irritability

Thought process

References:

1. Adapted from: Stahl SM. In: Essential Psychopharmacology: Neuroscientific Basis and Practical Applications: 2nd ed. Cambridge University Press 2000.

2. Blier P, et al. J Psychiatry Neurosci. 2001;26(1):37-43.

3. Doraiswamy PM. J Clin Psychiatry. 2001;62(suppl 12):30-35.

4. Verma S, et al. Int Rev Psychiatry. 2000;12:103-114.

Norepinephrine (NE)

Both serotonin and norepinephrine mediate a broad spectrum of depressive symptoms

Serotonin (5-HT)

Vague Aches and pain

Functional domains of Serotonin and Norepinephrine1-4


The Neurotransmitter Pathway story

Adapted from References:

1. Stahl SM. J. Clin Psych. 2002;63:203-220.

2. Verma S, et al. Int Rev Psychiatry. 2000;12:103-114.

3. Blier P, et al. J Psychiatry Neurosci. 2001;26(1):37-43.

• Dysregulation of Serotonin (5HT) and Norepinephrine (NE) in the brain are strongly associated with depression

• Dysregulation of 5HT and NE in the spinal cord may explain an increased pain perception among depressed patients1-3

• Imbalances of 5HT and NE may explain the presence of both emotional and physical symptoms of depression.

Descending Pathway

Ascending Pathway

AscendingPathway

DescendingPathway


THE COSTS OF MAJOR DEPRESSIVE DISORDER


MDD is Disabling and an Economic Burden

Rank 1990 2020 (est.)

1. Lower respiratory infections

Ischemic heart disease

2. Peri-natal conditions

Major Depressive Disorder

3. HIV/Aids Road Traffic Accidents

4. Major Depressive Disorder

Cerebro-vascular disease

5. Diarrheal diseases

Chronic obstructive pulmonary disease Total Costs of $83.1

Billion (2000)

31%

7%

62%

The High Cost of MDD

Direct MedicalSuicide RelatedWorkplace

Murray CJ, et al. Science. 1996;274:740-743Greenberg PE, et al. J Clin Psychiatry. 2003;64:1465-1475

Disability Rank


Workplace Burden: Impact of Depression on Absenteeism

http://www.gallup.com/poll/163619/depression-costs-workplaces-billion-absenteeism.aspx


MDD and Healthcare Costs

• Depression is one of the top ten conditions driving medical costs, ranking 7th in a national survey of employers• The greatest cause of productivity loss among workers

• Depression is an important factor in morbidity and mortality of co-existing diseases

• The presence of type 2 diabetes nearly doubles an individual’s risk of depression and an estimated 28.5% of diabetic patients meet criteria for clinical depression

• Back/neck and other chronic pain also have a

significant depression/SA component

Jaeckels, Nancy “Improving the Value of Health Care Through a Successful Collaborative Care Model.” Ppnt. 2nd Annual Lifespan Psychiatry Quality Conference. 22 Oct. 2010


Impact on Healthcare Costs

• High costs of unmet Behavioral Health needs and other unsuccessful chronic disease management due to the BH needs

• High costs of fragmented and uncoordinated care from PC to BH and inpatient settings• BH disorders account for half as many disability days as “all” physical conditions• Annual medical expenses--chronic medical & behavioral health conditions

combined cost 46% more than those with only a chronic medical condition• Top five conditions driving overall health cost (work related productivity + medical +

pharmacy cost)• Depression • Obesity• Arthritis • Back/Neck Pain• Anxiety



Annual Cost – those without MH condition

Annual Cost – those with MH condition

Heart Condition $4,697 $6,919

High Blood Pressure $3,481 $5,492

Asthma $2,908 $4,028

Diabetes $4,172 $5,559

Impact on Healthcare Cost Cont.

• Healthcare use/costs twice as high in diabetes and heart disease patients with depression

• Untreated mental disorders in chronic illness is projected to cost commercial and Medicare purchasers between $130 and $350 billion annually

• Approximately 217 million days of work are lost annually to related mental illness and substance use disorders (costing employers $17 billion/year



DIAGNOSIS STRATEGIES FOR MAJOR DEPRESSIVE

DISORDER


DSM-5 Depression Disorders

http://www.adaa.org/understanding-anxiety/DSM-5-changes

Disruptive Mood Dysregulation Disorder

Major Depressive Disorder, Single and Recurrent Episodes

Persistent Depressive Disorder (Dysthymia)

Premenstrual Dysphoric Disorder

Substance/Medication-Induced Depressive Disorder

Depressive Disorder Due to Another Medical Condition

Other Specified Depressive Disorder


Comparison of DSM-IV to DSM-5 for Depressive Disorders

• DSM-5 contains new depressive disorders:

http://pro.psychcentral.com/dsm-5-changes-depression-depressive-disorders/004259.html

Disruptive Mood

Dysregulation Disorder

Premenstrual Dysphoric Disorder


What’s new in DSM-5?

Major Depressive

Disorder

Bereavement Exclusion

Specifiers for Depressive Disorders



• Major Depressive Disorder – No changes to the core criteria or symptoms for major depression, nor the prerequisite 2 week time period needed before it can be diagnosed. The coexistence within a major depressive episode of at least three manic symptoms is now acknowledged by the specifier “with mixed features”.




• Bereavement Exclusion – removed in DSM-5:• To change the misperception that bereavement is temporary,

generally only lasting about 2 months. In actuality, bereavement can last up to 2 years.

• Bereavement is recognized as having a causal effect on major depressive episode(s) in vulnerable individual, which may begin to surface soon after the loss. When major depressive disorder occurs in the context of bereavement, an additional layer of risk may be added for suffering, feelings of worthlessness, suicidal ideation, poorer somatic health, worse interpersonal and work functioning, and an increased risk for persistent complex bereavement disorder.




• Bereavement Exclusion cont. • Bereavement-related major depression is most likely to occur in

individuals with past personal and family histories of major depressive episodes. It is genetically influenced and is associated with similar personality characteristics, patterns of comorbidity, and risks of chronicity and/or recurrence as non–bereavement-related major depressive episodes.

• The depressive symptoms associated with bereavement-related depression respond to the same psychosocial and medication treatments as non–bereavement-related depression. In the criteria for major depressive disorder, a detailed footnote has replaced the more simplistic DSM-IV exclusion to aid clinicians in making the critical distinction be-tween the symptoms characteristic of bereavement and those of a major depressive episode.




• Specifiers for Depressive Disorders – a new specifier was added to indicate the presence of mixed symptoms across both bipolar and depressive disorders, allowing the possibility of manic features in individuals with a diagnosis of bipolar depression.



DSM-5 Characteristics of MDD

• 5+ of following symptoms present during the same 2-week period and represent change from previous functioning. At least 1 of the symptoms is either (1) depressed mood or (2) loss of interest in pleasure.

http://csmh.umaryland.edu/Conferences/ship/SHIPArchives/1.DSM5.%20SHIP%20CarltonMunson.pdf

Depressed mood most of the day, nearly everyday, as he indicated by subjective report or observation made by others (Note: In children and adolescents can be irritable mood).

Markedly diminished interest or pleasure in all or almost all, activities most of the day, nearly every day.

Significant weight loss when not dieting or weight gain (note: In children,… failure expected weight gain)

Insomnia or hypersomnia nearly every day.


DSM-5 Characteristics of MDD cont.

http://csmh.umaryland.edu/Conferences/ship/SHIPArchives/1.DSM5.%20SHIP%20CarltonMunson.pdf

Psychomotor agitation or retardation nearly every day.

Fatigue or loss of energy nearly every day.

Feelings of worthlessness or excessive or inappropriate guilt.

Diminished ability to think or concentrate, or indecisiveness, nearly every day.

Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.


DSM-5 Diagnostic Criteria for MDD

• According to the DSM-5 Criteria, a person who suffers from MDD must either have a depressed mood or a loss of interest or pleasure in daily activities consistently for at least two week period and represent change from previous functioning


Reference:1. Simon GE, et al. N Engl J Med. 1999;341(18):1329-1335.

Depression The Physical Presentation

In primary care, physical symptoms are often the chief complaint in depressed patients

N = 1146 Primary care patients with major depression

In a New England Journal of Medicine study, 69% of diagnosed depressed patients reported unexplained physical symptoms as their chief compliant1


Depression Screening Tools

Tool Cost ReferenceHamilton Depression Rating Scale Free http://img.medscape.com/pi/emed/ckb/psychiatry/79926-1889862-1859039-212

4408.pdf

Beck Depression Inventory Cost http://psychcorp.pearsonassessments.com/HAIWEB/Cultures/en-us/Productdetail.htm?Pid=015-8018-370&Mode=summary

Patient Health Questionnaire (PHQ-9) Free http://img.medscape.com/pi/emed/ckb/psychiatry/79926-1889862-1859039-2128912.pdf

Major Depression Inventory Free http://img.medscape.com/pi/emed/ckb/psychiatry/79926-1889862-1859039-2129923.pdf

Center for Epidemiologic Studies Depression Scale

Free http://img.medscape.com/pi/emed/ckb/psychiatry/285911-1335297-1859039-1859099.pdf

Zung Self-Rated Depression Scale Free http://img.medscape.com/pi/emed/ckb/psychiatry/79926-1889862-1859039-2129979.pdf

Geriatric Depression Scale Free http://img.medscape.com/pi/emed/ckb/psychiatry/285911-1335297-1859039-1859094.pdf

Cornell Scale for Depression in Dementia

Free http://www.scalesandmeasures.net/files/files/The%20Cornell%20Scale%20for%20Depression%20in%20Dementia.pdf

http://emedicine.medscape.com/article/1859039-overview#showall

http://img.medscape.com/pi/emed/ckb/psychiatry/79926-1889862-1859039-2124408.pdf


http://psychcorp.pearsonassessments.com/HAIWEB/Cultures/en-us/Productdetail.htm?Pid=015-8018-370&Mode=summary

http://psychcorp.pearsonassessments.com/HAIWEB/Cultures/en-us/Productdetail.htm?Pid=015-8018-370&Mode=summary











http://www.scalesandmeasures.net/files/files/The%20Cornell%20Scale%20for%20Depression%20in%20Dementia.pdf

http://www.scalesandmeasures.net/files/files/The%20Cornell%20Scale%20for%20Depression%20in%20Dementia.pdf




PHQ-9

• PHQ-9 is the nine item depression scale of the Patient Health Questionnaire

• Powerful tool for assisting primary care physicians diagnose depression and select and monitor treatment


PHARMACOLOGIC TREATMENT, AND GAINING A

MIND-BODY PERSPECTIVE


Per

cen

t R

em

issi

on

45.5

27.6

39.3

22.2

50.0

28.0

17.6

45.539.8 39.1

52.2

7.7

0

20

60

40

Medication Psychotherapy Combination

Medication(n=33)

Psychotherapy(n=53)

Combination(n=255)

None(n=88)

Preferred Treatment

In 429 patients with MDD who participated in a large multisite study ofnefazodone vs Cognitive Behavioral Analysis System of Psychotherapy

vs a combination of both modalities, patient preference strongly predicted outcomes over 12 weeks of treatment. Patients did better when they were randomly assigned to the treatment they would have preferred if given a choice.

Kocsis JH et al. J Clin Psychiatry. 2009;70(3):354-361.

Patient Treatment Preference Predicts Outcome


Depression: Current treatment outcomes

• In any given year, between 13.1 million and 14.2 million U.S. citizens will experience an episode of major depressive disorder (MDD).

• Although approximately half of these people seek help for this condition, only 20 percent—10 percent of the total population with MDD—receive adequate treatment.

• Even then, only 30 percent of those who receive adequate treatment reach the treatment goal of remission.

• The remaining 70 percent will either have a response without remission (about 20 percent) or not respond at all (50 percent).

http://www.guideline.gov/expert/expert-commentary.aspx?id=36835


Treatment Options

Pharmacologic Options• Serotonin Selective Reuptake

Inhibitors (SSRIS)

• Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)

• Tricyclic Antidepressants

• Monoamine Oxidase Inhibitors

• Adjunct Therapies▫ Atypical Antipsychotics▫ Mood Stabilizers▫ Anxiolytics

Psychotherapy• Cognitive Behavioral

Therapy

• Interpersonal Therapy

• Problem-Solving Therapy

• Supportive Therapy

• Group Therapy


SalivaryCortisol(µg/dL) Beforethe4weekprogram Afterthe4weekprogram t P

Forestgroup 0.113(0.053) 0.082(0.044) 2.97 0.008

Hospitalgroup 0.125(0.052) 0.132(0.057) -1.62 0.121

Controls 0.137(0.100) 0.148(0.106) -1.31 0.206

Montgom

ery-Asberg

Rating Scale

Score

Mean (SD), paired t-test

Kim W et al. Psychiatry Investig. 2009;6(4):245-254.

30

25

15

10

5

0Week 1 Week 2 Week 3 Week 4

25.3725.24

23.7

25.0524.3822.31

24.53

22.48

16.87

11.83

23.33

20.32

***

* P<0.007;**P<0.048.

ControlsHospital

Forest

MDD Remission Rates:CBT in Forest = 61%

CBT in Hospital = 21%

Controls = 5%

Beauty in Nature and the Impact on Depression


Cardiovascular Fitness and Depression Correlation

Low

Mod

erat

eHigh

0

4

8

12

16

Men

Linear trend P<0.0001

Cardiorespiratory Fitness Level

Cu

mu

lati

ve I

nci

den

ce R

ate,

%

Low

Mod

erat

eHigh

0

4

8

12

16

Women

Linear Trend P<0.001

Cardiorespiratory Fitness Level

Cu

mu

lati

ve I

nci

den

ce R

ate,

%

Objectively assessed cardiorespiratory fitness independently predicted development of clinical depression over a 12-year follow-up period in 11,258 men and 3,085 women Sui X et al. J Psychiatr Res. 2009;43(5):546-552


LowestTertile IntermediateTertile HighestTertile

OR OR(95%CI) a

POR(95%CI) a

P

Wholefooddietarypattern

b

Model11 0.63(0.46-0.87) 0.005 0.66(0.47-0.92) 0.01

c

Model21 0.70(0.50-0.96) 0.03 0.74(0.52-1.04) 0.08

d

Model31 0.68(0.50-0.94) 0.02 0.73(0.51-1.02) 0.07

Processedfooddietarypattern

Model1 1 1.44(1.02-2.02) 0.04 1.83(1.20-2.79) 0.004

Model2 1 1.41(1.00-2.00) 0.05 1.76(1.14-2.70) 0.01

Model3 1 1.38(0.98-1.95) 0.06 1.69(1.10-2.60) 0.02

While the presence of depressive symptoms did not predict subsequent dietary patterns, consumption ofa diet rich in processed foods independently increased the risk of developing depressive symptomsover the ensuing 5 years, whereas a diet rich in whole foods was found to protect against thedevelopment of depression.

Akbaraly TN et al. Br J Psychiatry. 2009;195(5):408-413.

Associations between dietary pattern scores at phase 5 and CES-D depression at phase 7 after excludingparticipants identified as having depression at phase 5 (total n=3059)a

Processed Food and Depression Correlation


IMPROVING THE OUTCOME: FOLLOW-UP TOOLS AND

COMMUNICATION STRATEGIES


Depression Chronic Care Model


Common Issues Regarding Antidepressant Therapy

• Non-compliance is an important reason for suboptimal treatment outcomes.

• Patients frequently report the following:• Read up on it on the internet and didn’t like side

effects.• Took it for a week then stopped.• Only take it when I feel bad.• Once I felt better I stopped the medication.

• 75 % of antidepressants are discontinued by month 4


Interventions to Reduce Non-Compliance

Educate patients

regarding the disease and

treatment options.

Discuss common side effects of the

antidepressant medication openly with

patients.

Reassure patients that

other medication

options will be explored in case of side

effects.


Interventions to Reduce Non-Compliance

Emphasis that these

medications need to be taken on a daily basis to be effective.

Reassure patients that

Antidepressant medications are not addictive.

Explain to patients that

continued treatment with antidepressant

medication has a neuro protective

effect.


Behavioral Modifications

• Understanding the Mind-Body Connection in Depression can inform a variety of treatment methods to provide optimal patient care. For Instance:• Encourage physical activity which increases Brain

Drive Neurotropic Factor• Encourage a healthy diet and limitation of

processed foods• Let the patient preference inform treatment• Engage patients in support groups, and if possible

conduct support groups outdoors or in aesthetically pleasing environments


Behavioral Modifications cont.

• Let the patient’s preference inform treatment• Engage patient in support groups, and if possible

conduct support groups outdoors or in aesthetically pleasing environments

• Educate patient on importance of structure in daily life, need to continue with ADLs and avoid spending increase time in bed.


Behavioral Modifications cont.

• Patient needs to adhere to regular sleep and wake times.

• Involve family members early in treatment. Educate them regarding the disease process. They can provide extra support and help implement recommendations, monitor medication compliance, and provide better feedback on patient’s functioning.


Management of Patients who are not Responding to Treatment

• Identify mind body treatment approaches

• Reconsider diagnosis• Refer to Psychiatrist• Implement case

management • Monitor med

compliance through the pharmacy services

• Consider more aggressive Pharmacotherapy


Question and Answer Session

Website: www.bhmpc.comEmail: [email protected]

Phone Number: 1-888-831-1171Fax Number: 1-888-818-2425

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