Depression in primary care

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Myron on Jun 15, 2009 Says :

Very helpful, particularly stats.

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Slide 1 :

Screening for Depression in Primary Care Kathryn M. Magruder, M.P.H., Ph.D. Derik E. Yeager, M.B.S. VA Medical Center Medical University of South Carolina Charleston SC

Slide 2 :

Overview Epidemiology of depression in primary care Which screening tool should be used? Implementing depression screening in primary care What developments are on the horizon? Conclusions

Slide 3 :

Epidemiology: 1. Population Prevalence NCS-R: DSM-IV dx (12 month prevalence) 9.5% any mood disorder 6.7% MDD 19.5% mild 50.1% moderate 30.4% serious 1.5% dysthymia European 6-country study (12 month prevalence) MDD 3.9% European meta-analysis (27 studies) (12 month prevalence) MDD 3.1-10.1%

Slide 4 :

Epidemiology: 2. Primary Care Prevalence Pre-DSM-III-R PC MDD prevalence: 4.8-8.6% WHO PPGHC (15 cities/14 countries) MDD (ICD10): 10.4% (2.6-29.5%) Backenstrass et al. (2006) 4.6% MDD 6.2% minor depression 9.1% nonspecific depression sx

Slide 5 :

Primary Care: The de facto MH System ECA MDD (12 months prior) 45% any health service 27.8% specialty mental health care 25.3% general medical sector NCS-R MDD (12 months prior) 51.6% any health service 27.2% general medical sector 12.8% classified as mild 50-80% of all depression management in PC

Slide 6 :

Recognition of Depression: The Primary Care Irony General medical settings: primary venue for treating depression (and other mental disorders) <50% with MDD are diagnosed in PC Magruder et al. VA sample of 819: 52% correct dx of depression (MDD, NOS, dysthymia) WHO PPGHS: 54.2% (range 19.3%-74.0%) with depression correctly recognized as having psychological illness

Slide 7 :

Which Screening Tool? 1. Standard Screeners

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Which Screening Tool? 2. Short Screeners

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Which Screening Tool? 3. Ultra-Short/Ultra-Brief Screeners

Slide 10 :

Two-stage Approaches Combine screening and diagnosis Quick screen (“stem” questions) Dx modules for screen+ patients SDDS-PC PRIME-MD

Slide 11 :

Screening for General Emotional Distress

Slide 12 :

Screening for Multiple Disorders General screener – 1-2 items/disorder Anxiety & Depression Detector (ADD) (Means-Christensen et al., 2006): 5 questions Panic d/o PTSD Social phobia GAD MDD

Slide 13 :

Severity Ratings Beyond case-finding Evaluate treatment response/effectiveness Helps with “watchful waiting” for at risk patients with subthreshold or minor depression Administer screeners repeatedly Sx changes Examples Zung SDS PHQ-9

Slide 14 :

Implementing Screening in Primary Care Consider: Screening instrument performance characteristics Clinical context Underlying non-psychiatric case-mix Overall staffing patterns Underling prevalence of depression With above parameters, can estimate resource use for various implementation strategies

Slide 15 :

1-Stage Screening Approach 5% Prevalence 80% Sensitivity, 80% Specificity

Slide 16 :

1-Stage Screening Approach 10% Prevalence 80% Sensitivity, 80% Specificity

Slide 17 :

1-Stage Screening Approach 20% Prevalence 80% Sensitivity, 80% Specificity

Slide 18 :

Performance of a One-Stage Screening Approach Sample size: 1000 Sensitivity: 80% Specificity: 80%

Slide 19 :

2-Stage Screening Approach 5% Prevalence

Slide 20 :

2-Stage Screening Approach 10% Prevalence

Slide 21 :

2-Stage Screening Approach 20% Prevalence

Slide 22 :

Performance of a Two-Stage Screening Approach Sample size: 1000 Sensitivity: 95% (Stage I); 80% (Stage II) Specificity: 60% (Stage I); 80% (Stage II)

Slide 23 :

Screening Burden by Task

Slide 24 :

Single Stage Screening Approach (Sensitivity: 80%, Specificity 80%)

Slide 25 :

Two Stage Screening Approach: Stage I (Sensitivity: 95%, Specificity 60%) Stage II (Sensitivity: 80%, Specificity 80%) Stage I Stage II

Slide 26 :

Comparison of Patient, Staff, and Provider Time (min) for One and Two Stage Screeners

Slide 27 :

What Developments Are on the Horizon? Increasing acceptance of screening (USPSTF) Reduce stigma Improve screening benefit/cost ratio Improve tx outcomes Reduce screening time Reduce clinician and staff time by modifying screening modality Patient self-administered computerized screens Automated EMR screening reminders 2-stage screening process Dedicated nurses for screening & dx (also case-management) Screening for multiple psychiatric disorders Screening less often (e.g., 2-5 years instead of every year)

Slide 28 :

Conclusions Improvements in depression screening have paralleled improvements in depression treatment and reduced stigma PCPs have embraced responsibility for screening, recognizing, and treating depression For additional efficiencies, we will need Advances in technology (e.g., computerized screening and scoring) Improved tx outcomes

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