integration models into primary health care: the example of late-life depression
DESCRIPTION
Integration Models into Primary Health Care: the Example of Late-life Depression. Benoit H. Mulsant, MD, MS, FRCPC Professor and Vice-Chair Department of Psychiatry University of Toronto Physician in Chief Centre for Addiction and Mental Health. L earning Objectives. - PowerPoint PPT PresentationTRANSCRIPT
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Benoit H. Mulsant, MD, MS, FRCPCProfessor and Vice-ChairDepartment of Psychiatry
University of TorontoPhysician in Chief
Centre for Addiction and Mental Health
Integration Models into Primary Health Care:
the Example of Late-life Depression
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At the conclusion of this session, the participants should be able to:
1. Assess the evidence supporting the efficacy of antidepressant medications in the treatment of late-life depression.
2. Assess the risks of antidepressant medications used in the treatment of late-life depression.
3. Maximize the effectiveness of pharmacotherapy when treating a patient with late-life depression in the primary care sector.
Learning Objectives
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Treating Late-Life DepressionFighting therapeutic nihilism
One of the few medical conditions in which treatment can make a rapid and dramatic difference in an elderly patient’s level of function
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Pinquart, Duberstein, & Lyness
Treatments for later-life depressive conditions: a meta-analytic comparison of pharmacotherapy and psychotherapy
Am J Psych, 163(9):1493-501, 2006
Meta-analysis of 62 placebo-controlled studies (N = 3,921)
Favorable outcomes: Drugs: 66% vs. Placebo: 31%
“Available treatments for depression work,
with effect sizes that are moderate to large…”
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Outcome of Usual Care for Depressed PatientsTreated by Well-Trained Psychiatrists
Meyers et al (2002) Archives Gen Psych
• Six psychiatric clinics in Westchester County (USA)
• 165 patients with major depression
• 65% received an antidepressant• 45% received an adequate dose for 4+ weeks
(academic vs. non-academic sites: 53% vs. 36%, p =0.04)
• Remission rate after 3 months: 30%
• Adequate treatment: 3 fold higher likelihood of remission (OR = 3.2; p = 0.04)
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Treating Late-Life Depression Closing the Efficacy-Effectiveness Gap
1. Systematic vs. personalized approach
2. Selecting a class and a specific agent
3. Optimal dose
4. Optimal trial duration
5. Management of treatment resistance
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1. Argument for a systematic approach (“algorithm”, “clinical pathways”, “stepped care”) vs. an individualized approach (“usual care”)
2. Defining one’s algorithm for late-life depression:
• What is your first-line intervention?• Your second-line intervention?• Your third-line intervention?• How long should each step lasts?• When do you switch? When do you augment?
Outline
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A Tale of Two Approaches
Systematic Approach• Based on best evidence or
guidelines• Clinical experience based
on large number of patients• Keeping the course: the
clinician is protected against personal biases, pressures form the patient or family
• Focus is on the patient
Usual Care• Based on fad “du jour”• Little cumulative experience
due to small numbers of patients receiving many different medications
• Ill-advised or ill-timed changes in treatment
• Focus is on the treatment (making decisions is exhausting)
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Two Examples of Randomized Comparisons for Stepped-Care for Late-Life Depression:
1. IMPACT (Unutzer et al, JAMA, 2002)
2. PROSPECT (Bruce et al, JAMA, 2004)
Systematic Approach (algorithm, stepped care) vs. Individualized Approach (usual care)
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PROSPECT: A Case Study
DEPRESSIONDEPRESSIONSPECIALISTSPECIALIST
Physician Education
Patient & FamilyPsycho-Education
&
Identification of Diagnosis
TREATMENT TREATMENT ALGORITHMALGORITHM
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PROSPECT: Treatment Algorithm
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Main Features of Treatment Algorithm
• Based on evidence and practice guideline
• Modified for the primary care office
• Use of psychopharmacological and psychosocial interventions
• Psychiatric consultation is offered in complex cases
• Covers acute and continuation/maintenance treatment
• Covers a wide range of syndromes ranging from mild to severe depression
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PROSPECT Algorithm (1)
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PROSPECT Algorithm (2)
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PROSPECT: Results
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PROSPECT: Cumulative Probability of Remission
All comparisons: p < 0.001 Alexopoulos et al (2005) Am J Psych
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PROSPECT: Probability of Being Treated
All comparisons: p < 0.001 Alexopoulos et al (2009) Am J Psych
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Psychoeducation is Essential for Successful Antidepressant Treatment
• Address the patient’s personal illness model
• It takes 2-6 weeks to show beneficial effects
• Side effects occur right away
• Patients must be encouraged and supported to be take dose regularly as prescribed
• Reassure that side effects usually wear off
• Need for continuation and maintenance treatment
Mulsant et al (2003) CNS Spectrum; 8: 27-34
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Response Rates in 13 Studies of Treatment-Resistant Late-Life Depression
Cooper et al (2011) Am J Psych; 168: 681-688
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1. Argument for a systematic approach (“algorithm”, “clinical pathways”, “stepped care”) vs. an individualized approach (“usual care”)
2. Defining one’s algorithm for late-life depression:
• What is your first-line intervention?• Your second-line intervention?• Your third-line intervention?• How long should each step lasts?• When do you switch? When do you augment?
Outline
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Efficacy
Tolerability
Safety
Cost
Possible Criteria for Choosing an Antidepressants for an Older Adult
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Response Rates (%) in Eight Published Randomized Placebo-Controlled Trials
0%
10%
20%
30%
40%
50%
60%
70%
80%
1: Fluoxetine 2: Sertraline 3: ParoxetineIR Paroxetine
CR
4: Citalopram 5: FluoxetineEscitalopram
6: FluoxetineVenlafaxine
IR
7:Escitalopram
8: Duloxetine
Placebo
1. Tollefson et al (1995) Int Psychogeriatrics; 7:89–104 – 2. Schneider et al (2003) Am J Psych; 160:1277-85 – 3. Rapaport et al (2003) J Clin Psych; 64:1065–74 – 4. Roose et al (2004) Am J Psych; 161:2050-9 – 5. Kasper et al (2005) Am J Geri Psych; 13:884-91 – 6. Schatzberg & Roose (2006) Am J Geri Psych; 14:361-70 – 7. Bose et al. (2008) Am J Geri Psych; 16:14-20 – 8. Raskin et al (2007) Am J Psychiatry; 164:900-9
* *
*
*
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Fluoxetine in the treatment of late-life depression Marked site variability in remission rates
Small et al (1996) Int J Geri Psych; 11:1089-95
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Citalopram in the treatment of depression in the very old Marked site variability in response and remission rates
Roose et al (2004) Am J Psych; 161:2050-9
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Efficacy
Tolerability
Safety
Cost
Possible Criteria for Choosing an Antidepressants for an Older Adult
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Discontinuation Rates (%) Attributed to Adverse Effects in Eight RpCTs
0%
5%
10%
15%
20%
25%
30%
1: Fluo. 2: Sertraline 3:Paroxetine
IRParoxetine
CR
4: Cit. 5: Fluo.Escit.
6: Fluo.Venlafaxine
IR
7: Escit. 8:Duloxetine
Placebo
3-DColumn5
1. Tollefson et al (1995) Int Psychogeriatr; 7:89–104 – 2. Schneider et al (2003) Am J Psych; 160:1277-85 – 3. Rapaport et al (2003) J Clin Psych; 64:1065–74 – 4. Roose et al (2004) Am J Psych; 161:2050-9 – 5. Kasper et al (2005) Am J Geri Psych;13:884-91 – 6. Schatzberg & Roose (2006). Am J Geriatr Psychiatry; 14:361370 - 7. Bose et al. (2008) Am J Geriatr Psychiatry; 16:14-20 –8. Raskin et al (2007) Am J Psychiatry; 164:900-9
** *
*
*
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Overall Discontinuation Rates (%) in Eight RpCTs
0%
5%
10%
15%
20%
25%
30%
35%
40%
1: Fluo. 2: Sertraline 3:Paroxetine
IRParoxetine
CR
4: Cit. 5: Fluo.Escit.
6: Fluo.Venlafaxine
IR
7. Escit. 8.Duloxetine
Placebo
1. Tollefson et al (1995) Int Psychogeriatr; 7:89–104 – 2. Schneider et al (2003) Am J Psych; 160:1277-85 – 3. Rapaport et al (2003) J Clin Psych; 64:1065–74 – 4. Roose et al (2004) Am J Psych; 161:2050-9 – 5. Kasper et al (2005) Am J Geri Psych;13:884-91 – 6. Schatzberg & Roose (2006). Am J Geri Psych; 14:361-70 -- 7. Bose et al. (2008) Am J Geri Psych; 16:14-20 – 8. Raskin et al (2007) Am J Psychiatry; 164:900-9
*
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Role of newer antidepressants?• Escitalopram • Desvenlafaxine • Duloxetine
Role of atypical antipsychotics?• Quetiapine XR •Aripiprazole
New Safety Concerns• Venlafaxine • Citalopram & Escitalopram• Atypical antipsychotics
What is new since 2001?
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Response Rates (%): Older vs. Newer Medications
0%
10%
20%
30%
40%
50%
60%
70%
80%
1: Fluoxetine 2: Sertraline 3: Paroxetine IRParoxetine CR
5: FluoxetineEscitalopram
7: Escitalopram 8: Duloxetine 9: QuetiapineXR
Placebo
* *
*
*
*
1. Tollefson et al (1995) Int Psychogeriatrics; 7:89–104 – 2. Schneider et al (2003) Am J Psych; 160:1277-85 – 3. Rapaport et al (2003) J Clin Psych; 64:1065–74 – 5. Kasper et al (2005) Am J Geri Psych;13:884-91 – 7. Bose et al. (2008) Am J Geri Psych; 16:14-20 – 8. Raskin et al (2007) Am J Psych; 164:900-9 – 9. Katila et al (2012) Am J Geri Psych
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Discontinuation Rates Attributed to Adverse Effects: Older vs. Newer Medications
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
1: Fluoxetine 2: Sertraline 3: ParoxetineIR Paroxetine
CR
5: Fluo. Escit. 7:Escitalopram
8: Duloxetine 9: QuetiapineXR
Placebo
1. Tollefson et al (1995) Int Psychogeriatrics; 7:89–104 – 2. Schneider et al (2003) Am J Psych; 160:1277-85 – 3. Rapaport et al (2003) J Clin Psych; 64:1065–74 – 5. Kasper et al (2005) Am J Geri Psych;13:884-91 – 7. Bose et al. (2008) Am J Geri Psych; 16:14-20 – 8. Raskin et al (2007) Am J Psych; 164:900-9 – 9. Katila et al (2012) Am J Geri Psych
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Role of newer antidepressants?• Escitalopram • Desvenlafaxine • Duloxetine
Role of atypical antipsychotics?• Quetiapine •Aripiprazole
New Safety Concerns• Venlafaxine • Citalopram & Escitalopram• Atypical antipsychotics
What is new since 2001?
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Ray WA et al (2009) New England Journal of Medicine; 360:225-35
Atypical Antipsychotics and Risk of Sudden Cardiac Death Among Patients of All Age
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Role of newer antidepressants?• Escitalopram • Desvenlafaxine • Duloxetine
Role of atypical antipsychotics?• Quetiapine •Aripiprazole
New Safety Concerns• Venlafaxine • Citalopram & Escitalopram• Atypical antipsychotics
What is new since 2001?
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Antidepressants for the Older AdultPotential Safety Concerns
• Drug-drug interactions1
• Hyponatremia2
• Falls3,4
• Hip fractures5,6
• GI bleeds7
• Cardiovascular effects,8,9 • Cognitive impairment10,11,12
• Suicide13
• Bone metabolism14, 15
1. Mulsant & Pollock, BG (2004). American Psychiatric Publishing Textbook of Geriatric Psychiatry, 3rd Edition – 2. Fabian et al (2004) Arch Int Med; 164:327-32 – 3. Joo et al (2002) J Clin Psych; 63:936-41 – 4. Thapa et al (1998) NEJM; 339:875-82 – 5. Liu et al (1998) Lancet;351:1303-7 – 6. Richards et al (2007) Arch Int Med; 167:188-95 – 7. Yuan et al (2006) Am J Med; 119:719-27 – 8. Johnson et al (2006) Am J Geri Psych; 14:796-802 – 9. Oslin et al (2003) J Clin Psych; 64:875–882 – 10. Furlan et al (2001) Am J Geri Psych; 9:429-38 – 11. Ridout et al (2003) Hum Psychopharm; 18:261 – 12. Wingen et al (2005) J Clin Psych; 66:436-43 – 13. Jurlink et al (2006) Am J Psych;163:813-21 – 14. Diem et al (2007) Arch Intern Med; 167:1240-5 – 15: Richards et al (2007) Arch Intern Med 167:188–94
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Discontinuation due to Adverse Events:
51% augmentation v. 8% switching
Falls:
42% augmentation v. 24% switching
Whyte et al (2004) J. Clin Psych; 65: 1634-1641
Augmentation v. SwitchingTolerability and Safety
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Conclusions: Late-Life Depression
• Can be effectively treated
• Success requires a systematic approach
• Success requires persistence
• DO NOT GIVE UP!
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Questions and Discussion