Primary Care Providers Should Screen For Depression: US Task Force

USPSThis week the U.S. Preventive Services Task Force posted a draft recommendation statement and draft evidence review on screening for depression in adults. Both are available for review and public comment from July 28 through August 24, 2015. In this proposal, the Task Force broadens its 2009 recommendation that adults should be screened in doctors’ offices if staff-assisted depression care is available.

The USPSTF recommends screening in all adults regardless of risk factors. There are a number of factors that are associated with an increased risk of depression. “Among general adult populations, prevalence rates vary by sex, age, race/ethnicity, education, marital status, geographic location, and employment. Women, young and middle-aged adults, and nonwhite individuals have higher rates of depression than their counterparts, as do persons who are undereducated, previously married, and unemployed. Other groups at increased risk of developing depression include persons with chronic illnesses (e.g., cancer or cardiovascular disease), other mental health disorders (including substance misuse), and a family history of psychiatric disorders.”

Risk factors for depression during pregnancy and postpartum should be reviewed and include “prenatal depression, poor self-esteem, childcare stress, prenatal anxiety, life stress, decreased social support, single/unpartnered relationship status, history of depression, difficult infant temperament, maternity “blues,” lower socioeconomic status, and unintended pregnancy.” Older adults also can present a number of risk factors for depression including “disability and poor health status related to medical illness–complicated grief, chronic sleep disturbance, loneliness, and a personal history of depression. However, the presence or absence of risk factors alone cannot distinguish patients with depression from patients without depression.”

The Task Force recommend measurement-based screening tools such as
the “Patient Health Questionnaire (PHQ), Hospital Anxiety and Depression Scales in adults, the Geriatric Depression Scale in older adults, and the Edinburgh Postnatal Depression Scale (EPDS) in postpartum and pregnant women. “All positive screening tests should trigger additional assessment that considers severity of depression and comorbid psychological problems (e.g., anxiety, panic attacks, or substance abuse), alternate diagnoses, and medical conditions.”

Treatments for depression include antidepressant medications, psychotherapy or both, according to the recommendation.

Source:
U.S. Preventive Services Task Force on Depression in Adults in Primary Care

Posted in Antidepressant medication, Depression, Diagnosis, Measurement-based care, Post-partum, Screening in Primary Care, Women | Comments Off

National Academy of Medicine Establishes Standards for Psychosocial Treatments

A new reppsychosocialreptort by the National Academy of Medicine, titled, “Psychosocial Interventions for Mental and Substance Use Disorders: A Framework for Establishing Evidence-Based Standards” highlights the need to strengthen evidence on the effectiveness of psychosocial interventions, and to develop guidelines and quality measures for implementing these interventions in professional practice.

Two important pieces of legislation aim to improve the delivery of and access to treatments for mental health and substance use disorders, the Mental Health Parity and Addiction Act, and the Affordable Care Act (ACA). These two important pieces of legislation set the stage for establishing standards for psychosocial treatment.

Approximately 20% of the U.S. population, are affected by mental health and substance use disorders and frequently occur together. The comorbidity of these disorders with physical disorders is also common. Psychosocial interventions for mental and substance use disorders include psychotherapies, community-based treatments, vocational rehabilitation, peer support services, and integrated care interventions. The treatment modalities include: individual, group and virtual settings, and may be administered as stand-alone treatments or combined with other interventions such as medications.

NAM-framework The NAM report proposes an iterative process that engages consumers at every step. The framework highlights the need to: (1) support research to strengthen the evidence base on the efficacy and effectiveness of psychosocial interventions; (2) identify the key elements that lead to improved health outcomes; (3) conduct systematic reviews to inform clinical guidelines that incorporate these key elements; (4) develop quality measures of the structures, process, and outcomes of interventions; and (5) establish methods for successfully implementing, sustaining, and improving psychosocial interventions in regular practice

Source:  Institute of Medicine

Posted in Addiction, Diagnosis, Guideline, Health Industry, Measurement-based care, Mental health, Substance abuse | Tagged | Comments Off

Atypical Antipsychotic Shows Promise for New MDD Subtype

New to the diagnosis of major depressive disorder as of DSM-5 is the specifier “with mixed features.” According to DSM-5, “specifiers provide an opportunity to define a more homogeneous subgrouping of individuals with the disorder who share certain features (e.g., major depressive disorder, with mixed features) and to convey information that is relevant to the management of the individual’s disorder.”

A study presented at the American Society of Clinical Psychopharmacology (ASCP) 2015 Annual Meeting, demonstrated that patients with MDD presenting with mixed (subthreshold hypomanic) features showed significantly greater improvement when treated with lurasidone vs placebo, as evidenced by scores on the Montgomery-Åsberg Depression Rating Scale (MADRS) and the Clinical Global Impression–Severity (CGI-S) scale. This is the first randomized placebo-controlled, prospective study to evaluate this group of patients (n=109) who present with subthreshold manic or hypomanic features or irritability during a depressive episode and do not meet the criteria for bipolar disorder. It is estimated that 20% to 40% of patients with MDD may have mixed features.

The 6-week study presented by Trisha Suppes, MD, PhD, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, excluded any patients with a history of manic episodes or any mixed manic episodes. Treatment with lurasidone was demonstrated with significantly greater improvement compared with placebo from week 2 through 6 on both the depression and severity scales.

Sources:
Medscape Medical News
DSM-5

Posted in Antipsychotic medication, Depression, Diagnosis, DSM-5, mixed features, Treatment | Comments Off

Long-Acting Injectable Antipsychotic To Prevent Relapse in First Episode Schizophrenia

JAMAResearch published in JAMA Psychiatry demonstrated that long-acting, injectable, second-generation antipsychotic medication has tremendous potential to bring clinical stability to persons with first-episode schizophrenia. According to the authors, “long-acting medications are rarely used following a first episode of schizophrenia.”

Patients with recent onset of schizophrenia (n=86) were randomized to receive long-acting injectable risperidone or oral risperidone. Half of each group was also randomized to receive cognitive remediation to improve cognitive functioning or healthy-behaviors training to improve lifestyle habits and well-being.  The study showed that there was a significant and dramatic difference in 12-month relapse rates between the groups, favoring LAI risperidone. “The psychotic exacerbation and/or relapse rate was 5% in the LAI risperidone group vs 33% in the oral risperidone group ― a relative risk reduction of 84.7%. Treatment with LAI risperidone also provided better control of hallucinations and delusions.”
Obviously, adherence to medication was better with the LAI groug; it was also associated with prevention of exacerbation and/or relapse and control of breakthrough psychotic symptoms. What was interesting to note was that the LAI antipsychotic medication was readily accepted by schizophrenia patients soon after the onset of the disorder. The authors concluded that “the use of long-acting injectable risperidone after a first episode of schizophrenia has notable advantages for clinical outcomes. The key clinical advantages are apparently owing to the more consistent administration of the long-acting injectable. Such formulations should be offered earlier in the course of illness.”

Source:

JAMA Psychiatry. Published online June 24, 2015.

 

Posted in Antipsychotic medication, Early intervention, Mental health, Schizophrenia | Comments Off

Institute of Medicine Report on Cognitive Aging

JAMAThe Institute of Medicine has recently released a report entitled Cognitive Aging: Progress in Understanding and Opportunities for Action. This special report addresses “the emerging concept of cognitive aging, the importance of this issue for the nation’s public health, and actions the nation needs to take to better understand and maintain the cognitive health of older adults.” The report emphasizes that “cognitive aging is not a disease or a quantifiable level of dysfunction. It is distinct from Alzheimer disease and other neurocognitive and psychiatric disorders that affect older adults’ cognitive health, so it is best measured and studied longitudinally among adults who are free of these disorders.”

The IOM report highlights that the “health care systems and health care professionals will play a key role in educating patients and their families about cognitive aging and in implementing interventions to ensure optimal cognitive health across the life cycle. The committee noted the importance of programs to avoid delirium associated with medications or hospitalizations. Educating the patient and family members should include these clear messages: the brain ages, just like other parts of the body; cognitive aging is not a disease; cognitive aging is different for every individual (there is wide variability across persons of similar age); some cognitive functions improve with age and neurons are not dying as in Alzheimer disease (hence, realistic hope is inherent in cognitive aging); and patients can take certain steps to help protect their cognitive health.

According to the IOM report, cognitive aging is not a disease, but it is a major public health issue. Despite the public health importance of cognitive aging, there is limited research available on this process. “Patients are already concerned. The time has come for physicians, other health care professionals, and researchers to enter the conversation with them.”

Source: JAMA June 2, 2015, Vol 313, No. 21

IOM Report

 

Posted in Cognition, Cognitive Stimulation, Dementia, Early intervention, Education, Geriatrics, Research, Wellness | Comments Off

Delays In Diagnosis and Treatment of Patients with Bipolar Disorder

PLOS-1According to a study in PLOS One journal, there is often a substantial delay before diagnosis and treatment initiation of patients with bipolar disorder. Researchers sought to investigate factors associated with the delay before diagnosis of bipolar disorder and the onset of treatment in secondary mental healthcare.

Medical records of 1364 adults diagnosed with bipolar disorder between 2007 and 2012 were reviewed. Results showed that some individuals experience a significant delay in diagnosis and treatment of bipolar disorder after beginning care in a mental health treatment facility. This was particularly true for those who have prior diagnoses of alcohol and substance misuse disorders. The median diagnostic delay was 62 days and median treatment delay was 31 days.

Authors state that “these findings highlight a need for further study on strategies to better identify underlying symptoms and offer appropriate treatment sooner in order to facilitate improved clinical outcomes, such as developing specialist early intervention services to identify and treat people with bipolar disorder.”

Study

Delays before Diagnosis and Initiation of Treatment in Patients Presenting to Mental Health Services with Bipolar Disorder. PLOS One. May 2015.

Posted in Bipolar Disorder, Delayed diagnosis, Diagnosis | Comments Off

Imparied Sleep and Pain Sensitivity

painA recent study in PAIN, the official publication of the International Association for the Study of Pain has demonstrated that in people who suffer from both insomnia and chronic pain there is a strong negative effect on pain tolerance and that these individuals may benefit from treatments targeting both conditions.

The study included more than 10,400 adults from a large, ongoing Norwegian health study. Self-reported sleep measures provided information on, sleep duration, sleep onset latency, and sleep efficiency, as well as frequency and severity of insomnia. The main outcome measure was pain sensitivity tests, including assessment of cold-pressor pain tolerance. The researchers found that all sleep parameters, except sleep duration, were significantly associated with reduced pain tolerance. The study also looked at other factors potentially affecting sleep impairment and pain perception, including chronic (persistent or recurring) pain and psychological distress (such as depression and anxiety).

Pain sensitivity increased with both the frequency and severity of insomnia. For example, compared with individuals who reported no insomnia, rates of reduced pain tolerance were 52 percent higher for subjects reporting insomnia more than once weekly versus 24 percent for those with insomnia once monthly. Pain sensitivity was also linked to sleep latency, although not to total sleep time. The relationships were unchanged after adjustment for age and sex. The effect was smaller, but still significant, after further adjustment for psychological distress.

Sleep and Pain Sensitivity in Adults

Posted in Chronic Pain, Pain, Sleep | Comments Off

April Is Alcohol Awareness Month

The National Institute on Alcohol Abuse and Alcoholism (NIAAA) and The National Council on Alcoholism and Drug Dependence (NCADD) recognize April as alcohol awareness month. This is a time to learn about alcohol and the health and social problems caused by drinking too much. Both organizations encourage the public to dedicate this month to understanding how excessive drinking can affect health and to evaluating their own drinking habits.

With this year’s NCADD theme, “For the Health of It: Early Education on Alcoholism and Addiction,” the month of April 2015 will be filled with local, state, and national events aimed at educating people about the treatment and prevention of alcoholism, particularly among our youth, and the benefits of providing early education to give kids a better understanding of the impact that alcohol can have on their lives.

NIAAA website

NCADD website

Posted in Addiction, Alcohol | Comments Off

Less Than Half Of Alzheimer’s Patients/Caregivers Told Diagnosis

AlzThe Alzheimer’s Association’s 2015 Alzheimer’s Disease Facts and Figures report found that only 45 percent of people with Alzheimer’s disease or their caregivers say they were told the diagnosis by their doctor. In contrast, more than 90 percent of people with the four most common cancers (breast, colorectal, lung and prostate cancer) say they were told the diagnosis.

One of the reasons most commonly cited by health care providers for not disclosing an Alzheimer’s diagnosis is fear of causing the patient emotional distress. However, according to the new report, “studies that have explored this issue have found that few patients become depressed or have other long-term emotional problems because of the [Alzheimer’s] diagnosis.” The benefits of promptly and clearly explaining a diagnosis of Alzheimer’s have been established in several studies. Benefits include better access to quality medical care and support services, and the opportunity for people with Alzheimer’s to participate in decisions about their care, including providing informed consent for current and future treatment plans. Knowing the diagnosis early enables the person with Alzheimer’s to get the maximum benefit from available treatments, and may also increase chances of participating in clinical drug trials that help advance research.

Source:
Alzheimer’s Disease Facts and Figures Report 2015

Posted in Alzheimer's Disease, Dementia | Comments Off

Antidepressants Can Improve Cardiovascular Outcomes

ACCA study being presented at the American College of Cardiology meeting this coming weekend reports that patients with moderate to severe depression who took antidepressants alone had a lower risk of death, coronary artery disease and stroke than patients with moderate to severe depression who did not take antidepressant or statin medications. Moderately to severely depressed patients taking only antidepressants also seemed to do better than those taking statins alone or a combination of statins and antidepressants.

Researchers in Salt Lake City analyzed the health records and death rates, coronary artery disease and stroke of more than 26,000 patients treated in the statewide network over a three-year period. Patients completed a nine-question depression screening questionnaire to determine their level of depressive symptoms. Based on the questionnaires, researchers identified 5,311 patients as having moderate to severe depression and 21,517 patients as having no to mild depression.

Depression is a known risk factor for cardiovascular disease. This is the first study to assess the relative effects of the simultaneous use of antidepressants and cholesterol-lowering drugs among patients with varying levels of depressive symptoms.
Patients with moderate to severe depression who were taking antidepressants alone had a 53 percent lower risk of dying, developing coronary artery disease or having a stroke during the three-year follow-up period as compared to patients with moderate to severe depression who were not taking antidepressants or statins. Moderately to severely depressed patients taking antidepressants alone appeared to also fare better than those taking statins alone or a combination of statins and antidepressants, although these relationships were not directly analyzed.  According to the lead researcher, Heidi May, PhD., MSPH, “We thought we’d see an additive effect—that taking both medications would lower the risk more than either drug alone—but we found that in the more depressed people, the antidepressant really was what made the biggest difference. Antidepressants were not associated with a reduced cardiovascular risk in people with little or no depression, but in moderately to severely depressed people, antidepressants were shown to significantly improve cardiovascular outcomes.”

Findings from another study scheduled for presentation at ACC also add to the evidence that depression may influence cardiovascular outcomes, prompting authors to call on cardiologists to pay closer attention to depression when managing patients with heart disease.

Source: American College of Cardiology News Release

Studies presented

“The Association of Antidepressant and Statin Use to Future Death and Incident Cardiovascular Disease Varies by Depression Severity,” will be presented on March 15 at 9:30 a.m. PT/12:30 p.m. ET/4:30 p.m. UTC at the American College of Cardiology’s 64th Scientific Session in San Diego.
“Depression and Outcome of Patients with Acute Coronary Syndrome: A 3 Year Follow-up Study,” will be presented on March 14 at 9:30 a.m. PT/12:30 p.m. ET/4:30 p.m. UTC.

Posted in Cardiovascular, Depression | Comments Off