Handling depression/anxiety in None primary care settings How well - PDF document

10/11/19 Disclosures Handling depression/anxiety in • None primary care settings – How well is PHQ9 used? Tools for providers Tammy Duong, MD Clinical Assistant Professor UCSF Department of Psychiatry Asian Health Symposium, October 11 th , 2019 1 2 Objectives Mental health worldwide Following this talks, participants will be able to: • Worldwide, anxiety disorders are the most prevalent • Discuss barriers to mental health access for Asian mental health disorders Americans • Select appropriate depression screening tools for • Depressive disorders are the second most prevalent primary care settings group of mental disorders • Recognizes benefits and drawbacks of using depression screening tools • By 2020, major depression will be the most disabling disease behind cardiovascular disease 3 4 1

10/11/19 Primary care Asian Americans • Prevalence major depressive disorder (MDD) in • 2010: 18.2 million Asian Americans in the US primary care settings: 5-13% population • Primary care providers deliver majority of treatment • 2050: estimated 40.6 million, 9.2% total population for MDD – 1/3 – ½ adult patients • 2 nd highest risk of suicide risk in females 18-24 = – 2/3 geriatric patients Asian American women • Majority patients go undiagnosed • Incidence suicide among Asian Americans grew – Training, time constraints, non-specific somatic 100% between 2000-2009 complaints 5 6 Barriers to access Barriers to access • Lack appropriate mental health providers • Augsberger (2015): 701 Asian American female participants • Turning to religious leaders, family, peers for help – Chinese > Korean > Vietnamese > mixed • Public stigma – Factors influencing under utilization of mental health • Language barriers (English vs non-English) services • Generational • Family, community stigma – 1 st , 2 nd generation vs 3 rd generation – Dismissive, saving face – Asian American college students highest rate stigma • Culturally appropriate treatments • Self-help books, hotlines – Dual culture providers 7 8 2

10/11/19 Screening for depression Ideal screening tool • US Preventative Task Force (JAMA 2016) : • Valid – Recommends screening depression in the general adult • Reliable population • Brief • Only ~half (48.6%) of adults are assessed for • Easy to administer depression within primary care • Low cost/free – Often not screened unless symptom complaint • Effective clinical outcomes • Asian Americans less likely to be screened (OR 0.35, 95% CI 0.19 – 0.67) compared to Hispanic or African American populations • No single screening tool recommended over another • Selection based on setting, population 9 10 Center for Epidemiologic Study Depression Screening tools for depression Scale (CES-D) • Beck Depression Inventory (BDI) • 20-item questionnaire • Zung Self-Assessment Depression Scale (ZSDS) • Most commonly used in studies with Asian Americans (versus clinic populations?) • General Health Questionnaire (GHQ) • Accounts for somatic symptoms more commonly • Patient Health Questionnaire 9 (PHQ-9) found in Asian American patients • Patient Health Questionnaire 2 (PHQ-2) – Changes in appetite, headache, stomach aches, insomnia, • Center for Epidemiologic Study Depression Scale fatigue (CES-D) • Can also be used in adolescents • Geriatric Depression Scale (GDS) 11 12 3

10/11/19 Geriatric Depression Scale (GDS) • 15-item and 30-item versions • 15-item GDS sensitivity (82-100%) (72-87%) • Recommended for easy yes/no format 13 14 Geriatric Depression Scale (GDS) PHQ-2 • 2-item questions asks about depressed mood and anhedonia • May be administered verbally, takes < 2 minutes to administer • Validated, may be as effective as more extensive instruments • Can be used as a first step screener 15 16 4

10/11/19 PHQ-9 PHQ-9 • Cut-off score varies between countries, settings (primary care, community care, non-primary care) • Sometimes considered the “gold standard” for depression screening • Cut-off score >10, less sensitive but more specific (74%, 86%) 17 18 PHQ-9: will it work for Asian populations? Disclosures • Reliability and validity confirmed in Asian populations – Korean, including geriatric – Chinese, including adolescents – Thai – Indian adolescents – English speaking Singaporean residents • Available in Mandarin, Hindi, Punjabi, Gujarti, Japanese, Korean, Thai 19 20 5

10/11/19 Screening tool drawbacks Summary • Not diagnostic! • Depression is a major cause of morbidity worldwide • Higher scores do not necessarily correlate with • Asian American populations are less likely to be severity screened than other populations • Short item questionnaires (2-3 items) have high false • Ideal screening tools should be cost-effective, easy positive rates to administer, accurate • Varying degrees of sensitivity, specificities among • Variety of screening tools available; no evidence that screening tools one is more effective than others • Varying cut-off values • Screening should be followed with interview and appropriate treatment, follow up • Confounding co-morbid disease • Must have adequate treatment and follow-up 21 22 References References • Augsberger A, Yeung A, Dougher M, Hahm HC. Factors influencing the underutilization of mental • Siu AL, and the US Preventive Services Task Force (USPSTF). Screening for Depression in health services among Asian American women with a history of depression and suicide. BMC Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2016;315(4):380– Health Services Research . 2015;15:542. 387. doi:10.1001/jama.2015.18392 • Coleman KJ et al. Predicting Suicide Attempts for Racial and Ethnic Groups of Patients During • Tsai FJ, Huang YS, Liu HC, Huang KY, Huang YH, Liu SI. Patient Health Questionnaire for Routine Clinical Care. Suicide and Life-Threatening Behavior . 2019;49(3):724-734. Doi: School-Based Depression Screening Among Chinese Adolescents. Pediatrics . 2014;133(2):e402- 10.1111/sltb.12454 e409. doi: 10.1542/peds.2013-0204 • Kato E, Borsky AE, Zuvekas SH, Soni A, Ngo-Metzger Q. Missed Opportunities for Depression • Wang W, et al. Reliability and validity of the Chinese version of the Patient Health Questionnaire Screening and Treatment in the United States. J Am Board Fam Med . 2018;31:389-397. doi: (PHQ-9) in the general population. General Hospital Psychiatry. 2014;36:539-544 10.3122/jabfm.2018.03.170406 • Kim HJ, Park E, Storr CL, Tran K, Juon HS. Depression among Asian-American Adults in the Community: Systematic Review and Meta-Analysis. PLoS One . 2015;10(6): e0127760. doi:10.1371/journal.pone.0127760 • Lakkis NA, Mahmassani DM. Screening instruments for depression in primary care: a concise review for clinicians. Postgraduate Medicine . 2015:127(1):99-106. Doi: 0.1080/00325481.2015.992721 • Lotrakul M, Sumrithe S, Saipanish. Reliability and validity of the Thai version of the PHQ-9. BMC Psychiatry . 2008;8(46). doi:10.1186/1471-244X-8-46 • Na PJ, Kim KB, Lee-Tauler SY, Han HR, Kim MT, Lee HB. Predictors of suicidal ideation in Korean American older adults: analysis of the Memory and Aging Study of Koreans (MASK). Int J Geriatr Psychiatry . 2017;32:1272-1279. doi: 10.1002/gps.4608 • 23 24 6