primary care management of depression · primary care management of depression molina behavioral...
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Primary Care Management of DepressionJohn Briles, MD, Medical Director
October 11, 2017
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Primary Care Management of Depression
• Molina Healthcare of Michigan uses aHEDIS measure for AntidepressantMedication Management (AMM) tomeasure how well treating providers(PCPs) appropriately diagnose, treat,follow-up with major depression
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Primary Care Management of Depression
Tools and resources available:
• The Michigan Quality ImprovementConsortium Guideline for Primary CareDiagnosis and Management of Adults withDepression
http://mqic.org/guidelines.htm
• Molina Behavioral Health Toolkit for PrimaryCare Providers
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Primary Care Management of Depression
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Primary Care Management of Depression
• When to refer:– When additional counseling is desired
– Primary physician is not comfortable managing patient’s depression
– Diagnostic uncertainty
– Complex symptoms or social situation
– Response to medication at therapeutic dose is not optimal
– Considering prescribing multiple agents
– More extensive interventions are warranted
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Primary Care Management of Depression
• How to refer:
– Call Molina Healthcare of MichiganMember Services: 888 898-7969
For a referral to a behavioral health specialist - psychiatrist,therapist, community mental health, etc. For referral to a Molina Behavioral Health Case Manager or
Community Connector
*As of October 1, the 20 visit limit for Medicaid recipientshas been lifted!
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Primary Care Management of Depression
• Molina Behavioral Health Toolkit for Primary CareProviders (available on molinahealthcare.com)
– Includes assessment and diagnosis of common conditions(depression, alcohol and other drug use, ADHD)
– HEDIS Tips (including Antidepressant MedicationManagement)
– Risk Adjustment
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Primary Care Management of Depression
Molina Behavioral Health Toolkit for Primary Care Providers (availableon molinahealthcare.com)
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Primary Care Management of Depression
Molina Behavioral Health Toolkit for Primary Care Providers (availableon molinahealthcare.com)
![Page 10: Primary Care Management of Depression · Primary Care Management of Depression Molina Behavioral Health Toolkit for Primary Care Providers (available on molinahealthcare.com) •](https://reader035.vdocuments.mx/reader035/viewer/2022063013/5fcc66904661fd7b877e3ef4/html5/thumbnails/10.jpg)
Primary Care Management of Depression
Molina Behavioral Health Toolkit for Primary Care Providers (availableon molinahealthcare.com)
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Psychopharmacology For Behavioral HealthUtilization Management
Medical Conditions that may cause or mimic depression
• Hypothyroidism/other endocrine disorders• Stroke• Heart Disease• Kidney Disease• Diabetes• Anemia• Arthritis• HIV/AIDS• Lupus/other auto-immune diseases• Dementia• CNS Tumors• Multiple Sclerosis• Sleep disorders
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Psychopharmacology For Behavioral HealthUtilization Management
Medications with Severe or Very Common Psychiatric SideEffects, Including Depression
• Antibiotics- confusion, euphoria, depression, psychosis
• Beta-Blockers (Propranolol, Atenolol, Metoprolol)- depression
• Calcium Channel Blockers (Norvasc, Cardizem)- depression
• Steroids- depression, manic, mixed symptoms,paranoia/hallucinations, aggression
• Interferon (for Hepatitis C)- depression
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Primary Care Management of Depression
Molina Behavioral Health Toolkit for Primary Care Providers (availableon molinahealthcare.com)
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Primary Care Management of Depression
Molina Behavioral Health Toolkit for Primary Care Providers (availableon molinahealthcare.com)
• Antidepressant Medication Management (HEDIS tip) Best Practices:
– When starting an antidepressant medication, educate patients that it usually takes 1-6weeks to start feeling better. Sleep and appetite often improve first – mood, energy andthinking may take longer
– Inform patients that once they begin to feel better it’s important to stay on medicationfor at least another 6 months
– Develop plan in event of a crisis or thoughts of self-harm
– Regularly monitor to assess response to treatment as well as side effects and safety
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Primary Care Management of Depression
Molina Behavioral Health Toolkit for Primary Care Providers (availableon molinahealthcare.com)
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Primary Care Management of Depression
Antidepressants
• SSRIs (Prozac, Zoloft, Paxil, Celexa, Lexapro, Luvox)- general sideeffects- headache, akathisia/anxiety/increased energy, sexualdysfunction, increased risk of bleeding, generally mild weight gain,suicidal thoughts (black box warning, controversial).Discontinuation syndrome (nausea, headache, dizziness, chills, etc),especially Paxil; less so with Prozac.
• SNRIs (Effexor, Cymbalta, Pristiq)- similar side effects to SSRIs,perhaps slightly less severe. Also discontinuation syndrome,especially Effexor. May elevate blood pressure, should be carefullymonitored. Cymbalta also indicated for fibromyalgia/chronic pain.
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Primary Care Management of Depression
Antidepressants
• Wellbutrin (NDRI) – also for smoking cessation. Increased risk forseizures. No sexual dysfunction or weight gain.
• Remeron- Sedation, weight gain, dry mouth. Little or no sexualdysfunction.
• Trazodone- sleep-inducing effects (often the reason used inhospitals). Rare but dramatic side effect = priapism (sustained > 4hour erection).
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Primary Care Management of Depression
Older Antidepressants
• Tricyclics (TCAs- Elavil, Anafranil, Tofranil, Pamelor)- dry mouth,urinary retention, drowsiness, akathisia/anxiety/increased energy,sexual dysfunction, discontinuation syndrome, cardiacarrhythmias and more danger in overdose (main reasons lessused).
• MAOIs (monoamine oxidase inhibitors- Nardil, Parnate)- veryeffective in treating atypical depression (increased appetite,increased sleep). Less used due to potentially lethal dietary (foodscontaining tyramine –aged cheese, wine- may cause hypertensivecrisis) and drug interactions. Discontinuation syndrome. Serotoninsyndrome, especially if taking another serotonergic agent.
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Primary Care Management of Depression
Thank you!
• Questions???