Shared Decision Making Tool for Antidepressant Choices

mayologoThe choice of antidepressant in primary care can directly affect outcomes and quality of care for patients with depression. Faculty at the Mayo Clinic developed the Depression Medication Choice (DMC) encounter decision aid, designed to help patients and clinicians consider the available antidepressants and the extent to which they improved depression and other issues important to patients.

A tool to help patients with depression make informed decisions about appropriate antidepressants improves the antidepressant decision-making process without extending the length of primary care visits, according to a report in JAMA Internal Medicine. The tool, developed by researchers at the Mayo Clinic in Rochester, Minn., is called Depression Medication Choice (DMC). DMC consists of a series of cards that present general information about antidepressant efficacy and highlight various features of antidepressants—for instance, effects on sleep, sexual issues, and weight gain. The cards are used by the patient with the clinician during the primary care visit.

Mayo researchers conducted a cluster randomized trial of adults with moderate to severe depression considering treatment with an antidepressant. Primary care practices in 10 rural, suburban, and urban primary care practices across Minnesota and Wisconsin were randomly allocated to treatment of depression with or without use of the DMC decision aid. Compared with usual care, use of DMC significantly improved patients’ decisional comfort, knowledge, satisfaction, and involvement. It also improved clinicians’ decisional comfort. There were no differences in encounter duration, medication adherence, or improvement of depression control between study arms.

Source: JAMA Internal Medicine

Posted in Adherence, Depression, Screening in Primary Care, Shared decision making | Leave a comment

Americans Say They View Mental and Physical Health As Equally Important

A recent Harris Poll survey about attitudes toward mental health was conducted on behalf of the Anxiety and Depression Associations of America, American Foundation for Suicide Prevention and the National Alliance for Suicide Prevention. Over 2,000 US adults over 18 responded. Results revealed that “ majority (65%) of U.S. adults has seen a primary care physician within the past 12 months, yet only 12% have seen a mental health counselor or therapist. Despite this, about 9 in 10 adults (89%) feel that mental health and physical health are equally important for their own overall health. However, more than half (56%) say that, in our current healthcare system, physical health is treated as more important than mental health, and less than one-third (28%) feel that mental and physical health are treated equally. It is not surprising then that the overwhelming majority (92%) of adults feel that health services that address mental health, such as treatment for depression and suicide prevention, are fundamental to overall health and should be part of any basic health care plan.”

While nearly two in five adults (38%) believe that seeing a mental health professional is a sign of strength, more than four in ten (43%) believe it is something that most people can’t afford. Similarly, three in ten feel it is not accessible for most people (31%) or something people do not know where to find (30%). The most common diagnoses were depression (21%) and anxiety/panic disorder (20%). While only a third of adults have ever been diagnosed, nearly half (47%) admit that they have thought they may have had a mental health condition at some point. Nearly a third (31%) presumed they had anxiety/panic disorder (31%), while more than a quarter (28%) considered that they may have depression.

  • Among adults who have been employed in the past 12 months, more than 1 in 10 have missed work days because they were too anxious (14%) or too depressed (16%) to go to work.
  • Nearly two in five (38%) adults have ever received treatment for a mental health condition. Talk therapy (29%) is the most commonly used treatment resource, followed by prescription medication (25%).

Source: American Foundation for Suicide Prevention Website

Posted in Anxiety Disorders, Depression, Diagnosis, Health Industry, Mental health, Wellness | Comments Off

Revised Practice Guidelines for the Psychiatric Evaluation of Adults

The AmePractGuiderican Psychiatric Association has released the third edition of the Practice Guidelines for the Psychiatric Evaluation of Adults. These guidelines are different from previous versions in that they represent the first APA guidance developed using a new process that addresses standards set forth in a 2011 Institute of Medicine (IOM) report titled “Clinical Practice Guidelines We can Trust.”

In line with the IOM recommendations, this new edition of the practice guidelines was developed following an extensive review of the literature as well as input from around 800 experts in the field. The most noticeable change in the third edition of the Practice Guidelines for the Psychiatric Evaluation of Adults is the way it is organized. Rather than resembling a manual, these new guidelines are divided into nine separate guideline “modules” that are connected by the overarching theme of psychiatric evaluation. These are the nine guidelines:

Review of Psychiatric Symptoms, Trauma History, and Psychiatric Treatment History
Substance Use Assessment
Suicide Risk Assessment
Assessment of Risk for Aggressive Behaviors
Assessment of Cultural Factors
Assessment of Medical Health
Quantitative Assessment
Involvement of the Patient in Treatment Decisions
Documentation of the Psychiatric Evaluation

In situations where there may be less expert consensus, the guidelines offered “suggestions” instead of recommendations. When writing out the recommendations, care was taken to avoid unclear words like “consider” which can be hard to implement and may vary in interpretation. There is a section in each of the modules on implementation that discusses barriers to carrying out the recommendations and adjustments for patient preferences. As new science informs the evaluation process, the iterative design of the practice guidelines will allow them to be reviewed and updated as needed.

Source: Psych News

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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.

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

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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.

Medscape Medical News

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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.”


JAMA Psychiatry. Published online June 24, 2015.


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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.”


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

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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

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