Transcript: Managing Depression In The Primary Care Setting

Liz Rohr:
Well, hey there. It's Liz Rohr from Real World NP and you are watching the Real World NP YouTube channel. We make weekly episodes to help save you time, frustration, and help you take the best care of your patients. Well, hey there. In this episode, we're going to be talking about depression, the approach to assessment, as well as management principles. So when it comes to depression, I first want to talk about two things. One is about red flags and two is about resources and then we'll get into the assessment and the management pieces. So the first thing is we always want to assess for red flags of harm, whether self-harm or harm to others for that patient. I'm choosing my words wisely because I don't want this episode to get blocked off of the internet. So I don't actually know, but it's the same thing. SI, HI, harm to themselves, harm to other people.

Liz Rohr:
So we want to be assessing for that. There are a couple of different ways we can assess. Number one, we can just ask. We can just practice getting better at asking. I know it can be an uncomfortable question to ask, but it is the most important thing we can ask somebody who comes in with a complaint of depression. Another thing that we can do that can be helpful for asking... Well, before I get into that, we want to ask if they have any thoughts of that, if they've had any of those thoughts before, if they've had any attempts before or hospitalizations before, and we also want to ask if the answer is, yes, we want to ask a couple more probing questions. Like, do they have a plan? Do they have a timeline? Things like that. There's a more structured approach. I can link to that down below, but we want to ask for more context around it.

Liz Rohr:
And there is a fear sometimes that people have where if they ask those questions it's going to prompt somebody to have those feelings or thoughts or desires and that's just not the case. Our job is to assess for safety and we have to do that. So the other piece of that though is what are the resources you have? And this is something to think about preemptively before you're faced with this clinical situation, if you haven't yet been already. So I practice in the state of Massachusetts and we have a couple of supportive structures where I practice. One of them is there is actually a law that says if somebody is deemed to be, like assessed and deemed to be a harm to themselves or others they can be involuntarily hospitalized, like taken via ambulance to the hospital and it's called Section 12.

Liz Rohr:
And it's a longer name than that, but that's like the anecdotal name for it that we use in this area and so it would be worth, it is worth looking into to see if that is a thing in your state. And I did a little quick Googling before I made this episode and it was a little confusing. So I would ask the people who we work with what the deal is, if they've ever encountered that. So that's one thing. Another thing, which again is not necessarily, it's not a punitive thing for patients. It's a support structure to make sure we keep patients safe. The other thing to think about is what are the resources you have in your area that are supportive to patients who have thoughts of self-harm or harm to others. And so in my state there are a couple of different resources.

Liz Rohr:
There's a hotline for emergency services where they will come to the clinic when you call them as a clinician, or I believe patients can also call them at their home and get support services if they need them, if they need to be quote unquote, sectioned is the verbiage that we use in Massachusetts at least, is do they, are they at risk for harm to themselves? Do they need to be hospitalized? Another thing is that there are psychiatry resources where you can call a number and then it's almost like an e-consult where you can call a psychiatrist about whether it's a pediatric patient or an adult patient, and they can give you some guidance about what's going on with a patient. I would also, I would highly recommend, especially if you're newer in practice or if you haven't started yet, or if you're on the job search for sure, asking about what the resources are for the patients in your clinic.

Liz Rohr:
Do they have behavioral health therapists? Do you have an on call behavioral health provider? Do they have a psychiatrist, physician, NP, PA, et cetera. That's really, really helpful to know, just to set yourself up for success before you need it because if you wait till you need it then it can be very uncomfortable. So those are the first disclaimer pieces about depression. Assessing for red flags of self-harm or harm to others and then the other thing is about what your resources are. So let's get into the assessment piece though and the management. So when it comes to assessment, I'm a family nurse practitioner. I do not have a psych mental health degree although working in primary care has me wanting that. It would've been really nice to do a dual degree because of the limited resources, unfortunately that we have, at least in the clinics that I've practiced.

Liz Rohr:
But all of this stuff is just from the approach of a primary care provider, family nurse practitioner and just doing our due diligence and of safety and triage, and then calling in support when we need to. The reason I say that is that there can be some contention in the medical culture of what should we treat for psych mental illness in primary care versus what should be treated by a specialist and the sad reality is that we don't have as many resources or access to resources as we need so we just have to do our best to take care of our patients safely within our scope of practice. So when it comes to assessment of depression, couple of supportive structures that can help us. One is assessment tools. So I am not, again, I'm not a psych mental health provider.

Liz Rohr:
I wish I was. Their histories are way more in depth than mine are, but I do my best. So starting with screeners can be a really helpful tool. So PHQ-9 is the screener tool of choice that I love and it comes in multiple languages and it asks a variety of questions, all of... It helps with the diagnostic criteria of depression, including asking about thoughts of self-harm or harm to others and you get a score. So the scoring, the treatment goals according to the psychiatrist that I used to work with, although there may be a guideline for this, PHQ-9 treatment goal is to be a four or less on average and screening tools are not necessarily diagnostic tools, but just they help us gather information. And then from there there's mild, moderate and severe. So we want to kind of look and see, and I can link to that tool down below.

Liz Rohr:
What are those things, where to look for, and that can help with diagnosis, but then also can help us assess how things are improving if their symptoms are deemed to be depression in fact. Two other screening tools I want to suggest or recommend. I've also made an episode about managing anxiety where I believe I mentioned the screening tool but GAD-7, the GAD-7 helps us to assess for anxiety. Is there comorbid anxiety going on or is it in fact truly anxiety, excuse me, in fact truly anxiety versus straight up depression. Last tool that I want to recommend is something called the Mood Disorder Questionnaire, the MDQ. So again, a screening tool is not a diagnostic process necessarily and the histories that I see from the psych providers are way more in depth than mine, but it's a good, it's a helpful place to start to assess for mood disorders because if you have an inclination that somebody has a mood disorder, we want to potentially veer away from things like SSRIs for management. So, I'm not going to say that full acronym, you know what SSRIs are.

Liz Rohr:
So those are the places to start is the screening tools. The next piece is you want to assess, is there any underlying comorbidity that could be contributing to their symptoms. Do they have straight up depression? Do they have any psych comorbidities, depression, I'm sorry, anxiety, mood disorders, schizoaffective disorder, PTSD, et cetera. Right. And I'm hoping to get a psychiatrist on the channel that can help us assessing for those things a little bit better than I currently do, but are we assessing for those psych comorbidities as well as medical comorbidities? There's a whole long laundry list of things that can be associated with depressive symptoms, not just diagnoses, but also medications. Globally speaking we're talking about things that, I kind of break it into body systems. So neurologically, we have to do a lot of neurologic assessment. Do they have any traumatic brain injury?

Liz Rohr:
Did they have a stroke? Do they have Parkinson's? Do they have seizure disorder? Things like that. So kind of like neurologically speaking, do they have any neurologic comorbidities? And again, another hack is if you just have somebody in front of you and you're like, I don't remember that laundry list. Just start, just take a look at what else they have going on, what other symptoms they have going on and then we can kind of assess. Other things are like endocrine disorders, various cardiology disorders. There's a whole bunch of them. Diabetes, things like that. So definitely consult your resources to look at that. I can link to some stuff down below, but we want to just think about what are the medical comorbidities as well as the psychiatric comorbidities that could be going on. There's a very high level approach to how to assess for depression, red flags.

Liz Rohr:
What are the support systems that you have? How do you assess for them? What are the screening tools? And then what are the potential comorbidities. If you walk away with nothing else from this episode, number one is what are your resources? Are you assessing for harm? And what are the underlying comorbidities that this could be so you don't miss anything that way and consulting those resources because again, it's like a huge laundry list of potential comorbidities as well as potential medications. I don't think it's really supportive for me to list them off in this episode because that's probably going to be in one ear or the other or maybe that's just me. I prefer to reference things at the time. But the main thing with primary care is what I try to do with management is I try to assess is somebody this is straight up garden variety depression?

Liz Rohr:
Are there other comorbidities that would not be safe for me to treat? Am I not sure if this is schizoaffective disorder? Am I not sure if there's a mood disorder here and then I'm going to see what are the resources I have for an e-consult or a quick consult curbside, whether in-house or a service that your clinic subscribes to, to get some support on that. But if you're pretty certain or if you are certain that it's first line depression there's a couple of management principles I want to talk about. Whenever I talk about management in these episodes, whether the podcast or the YouTube channel, I really want to focus on broad approaches because so much of the details change and these stay on for a while and I don't want to be advising outdated practices. So I'm going to talk about high level approach.

Liz Rohr:
So first step, if you're feeling confident this is a garden variety, plain major depressive disorder, we've assessed using the PHQ-9, you can kind of see is it, based on the results of the scoring you can see if it's mild, moderate or severe with a treatment goal of around four. You can use it for initial assessment as well as their follow up assessments to see how they're doing. We can start with SSRIs. There's a whole bunch of options when it comes to SSRIs and you may find that you have preferences for one over the other. Typically, when it comes to choosing an SSRI I'm looking at what is it most studied for? Is it more studied for anxiety? Is it more studied for depression? Is it more helpful with sleep? Is it a long half life?

Liz Rohr:
Is it a short half life? Things like that. So I tend to avoid the shorter half life medications because if they don't take it at the exact same time every day they're going to have withdrawal symptoms and that's unpleasant. So I tend to go with the longer half life options. Citalopram and escitalopram, those are more apt for anxiety. You can use them for depression as well, but if you're going to have mixed comorbid anxiety and depression you may decide to choose escitalopram or citalopram. Things to remember about citalopram is that it has that QTC prolongation potentially so something to keep in mind in terms of a initial screen and follow up and then look thinking about their comorbidities. Sertraline is a great middle of the road option for both depression and anxiety. I've anecdotally seen in practice that patients may feel a little bit sleepy with one, with that one more than the others.

Liz Rohr:
They might have more GI symptoms initially and then there's a whole bunch of other options. Those are the main ones that I tend to see in primary care though. Sertraline, citalopram, escitalopram and then some of the other SSRI options. Fluoxetine is the other one that I tend to see a little bit more of. Anyway, I'm trying not to use brand names, but there's two F ones and one of them has a short half-life and one that has a longer half-life and I think fluvoxamine does. Don't quote me on that. I don't want to say the brand name. I know the brand name. I don't want to say it. So thinking about all of the profiles of them and what's going on with your patient, which one would be the most supportive. A really important thing to talk about with patients when you're prescribing SSRIs is you want to talk about side effects.

Liz Rohr:
I always counsel them that you know what this can cause some side effects. Here they are. They can start mildly, more severe. We'll just see, they tend to be like, you have them a little bit at first and then they tend to go away. Some people have a more significant reaction, a more marked reaction when they first start. Just let me know how you're doing. The other thing I let them know though is whenever we choose a medication for depression is that we start at the lowest dose and we work our way up and it takes about four to six weeks to see a full effect. When they start off knowing that this might not be the right choice for them, we are going to start the lowest dose, you might not see results right away. We might have to change because of side effects.

Liz Rohr:
When they know that going in, it's potentially less discouraging for them later on, versus if you didn't counsel them in the first place, they're like what is going on here? This is just not working for me. I'm not going to try medications and then they leave and then they don't get support. So I try to really be mindful about that counseling initially for them so that they can feel empowered and have more success potentially with it. Couple caveats about that. Not everybody responds to the SSRI that you've chosen initially. So if they're not responding, especially as you go up on the dose every four, I give it at least like four-ish weeks to start, depending on how severe their symptoms are. If it's two to four weeks, if it's yeah, I tend to do, it takes about four to six weeks to take a full effect.

Liz Rohr:
They may start seeing things at two weeks. So I might do two weeks, dose increase at four weeks if I know they're going to need to go up on the dose because the depression is really severe, but I tend to follow that approach with them. If they're not responding, especially as the dose is going up or they're having side effects, you may need to change to a different SSRI. Not everybody responds to the one that you've chosen. Another option after you've switched SSRIs, you could change to a different option category, second line option. You could either do a combined therapy. You could switch to a different category of medication or you can do combined therapy where you can consider adding one that will augment the effects or change altogether.

Liz Rohr:
And this is getting a little bit nuanced for a shorter episode of the podcast and YouTube channel so I'll kind of keep it high level, but generally second line after SSRIs are things like SNRIs. So non SSRI antidepressants like bupropion, and then sometimes there's also, some of those can be combined with SSRIs. Not all of them. I'm not going to get into specifics, just keeping it high level here. And then you may also see, especially if they get transferred to a high level of care, if they're not responding to an initial medication, dose increase, switch to a different medication, switch classes altogether, they may need to have something augmented. Whether you can do that in primary care or you can do that with a specialist that's really kind of up to your personal practice preference, your scope, the culture of your clinic so I'm not going to get into super those specifics because again, safety first. I always think about safety first, especially when I make these episodes as well.

Liz Rohr:
I don't want to be giving guidance about a patient and what doses to choose and want medications to choose out of context. So basically the general principles when it comes to SSRIs are you choose when to start based on their symptom profile as well as the profile of the medications as you become more familiar with them. We start a low dose, increase that dose, see how they respond, see how if they have any side effects. The next one is you can switch to a different SSRI if they're not responding and, or you can switch to another category altogether that's not an SSRI. So the second line options are things like SNRIs, duloxetine, venlafaxine, non SSRI antidepressants like bupropion. There is another option though of combination of variety of different types of medications to augment if you're having a partial response with some other agents. It's getting a little sophisticated for this episode because I don't want to give advice about specific patients without the context of the full picture.

Liz Rohr:
But general management principles are things like augmented options that typically you'll see the psychiatric providers do. I feel comfortable adding some of them on, but again, I'm not going to get into details here, but things like buspirone, aripiprazole, those kind of atypical antipsychotics. Olanzapine, things like that. You may see those as augmenters to help SSRIs that are partially responding work, but I really want to keep it to the basics here of this episode because if you're getting into that place, especially as a newer grad, I really recommend number one, utilizing your resources, collaborating with your supervising provider, collaborating with psychiatric providers and just always doing safety first.

Liz Rohr:
We really, it's not just about knowing what medications you can add. You have to understand the medications, the side effects, the effectiveness, how to dose them, how to titrate them, how to come off of them. There's a lot to know so I just don't want to try to cram all of that into one little episode, but just hopefully that'll be a helpful primer for you of where do I go from here with each of those. So if you have not grabbed the ultimate resource guide for the new NP, head over to realworldnp.com/guide. You'll get these episodes sent through to inbox every week with notes from me, patients stories and bonuses I really just don't share anywhere else. Thank you so much for tuning in, hang in there and I'll see you soon.