Clarifying Diagnosis and Monitoring Recovery: Self Report Mental Health Scales can Help! Dr. Margie Oakander Sunridge Primary Mental Health Clinical Associate Professor University of Calgary 1 Disclosure: Dr. Margie Oakander Advisory Board or Committee: Astra Zeneca, Biovail, GlaxoSmith Kline, Janssen, Lilly, Lundbeck, Otsuka, Pfizer, Valeant, Wyeth Honouraria or other fees: Astra Zeneca, Biovail, Bristol Myers Squibb, Janssen, Lundbeck, Lilly, Otsuka, Pfizer, Shire, Wyeth, Valeant Research: GlaxoSmithKline, Lilly, Lundbeck, Pfizer, Wyeth CME Development: Canadian Psychiatric Association University of Calgary 2 Let’s Start with the many faces of major depression DSM-IV criteria 35-year-old female 70-year-old male + Depressed mood + Hypersomnia + Increased appetite / weight + Psychomotor retardation + Difficulty making decisions + Suicidal ideation - Marked loss of interest / pleasure - Insomnia - Decreased appetite / weight - Psychomotor agitation - Impaired concentration - Inappropriate guilt 3 DSM 5 Major Depressive Disorder ●Depressed mood ●Loss of interest or pleasure ●Significant changes in weight and/or appetite ●Insomnia or hypersomnia ●Psychomotor agitation or retardation ●Fatigue or loss of energy ●Feelings of worthlessness or excessive/inappropriate guilt ●Diminished ability to think or concentrate, or indecisiveness ●Recurring thoughts of death or suicide, including plans and attempts American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th edition 2013. 4 DSM 5 Criteria: SIGGE-CAPS Mnemonic S—Suicidal preoccupation I—Interest/pleasure () G—Gain/lose weight G—Guilty feelings E—Energy () C—Concentration A—Affect ( mood) P—Psychomotor retardation S—Sleep disturbance DSM-5 major depressive disorder: 5 of 9 symptoms x 2 weeks Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. 2013. 5 Most frequent conditions leading to short-term and long-term disability in Canada Most frequent conditions leading to short-term and long-term disability in Canada according to employers 85 83 Mental / behavioural health 76 76 Musculoskeletal / back 13 Accident 37 63 Cancer 28 29 Cardiovascular 24 Long-term disability 0 Maternity Short-term disability 16 1 Gastrointestinal 9 n=87 1 Respiratory 4 1 Genitourinary / urogenital 3 8 8 Other 0 20 40 60 Respondents, % Note: Respondents were asked to select the top three conditions. The Conference Board of Canada. 2013. 6 80 100 Global Burden of Disease Study Top 10 Conditions in High-Income Countries Ischemic heart disease 8.3 Cerebrovascular disease Unipolar depressive disorders 6.0 5.6 Alzheimer's & other dementias 5.0 Respiratory cancers 3.6 Adult-onset hearing loss 3.6 COPD 3.5 Diabetes mellitus 2.8 Alcohol use disorders 2.8 Osteoarthritis COPD: chronic obstructive pulmonary disease; DALY: disability-adjusted life-year % of total DALYs lost 2.5 Lopez et al. Lancet 2006;26:1747-57. Mental illness carries a huge burden to society The burden of mental illness and addictions in Ontario: ● Is more than 1.5 times that of ALL cancers ● Is more than 7 times that of ALL infectious diseases ● Contributed to loss of 600,000 health-adjusted life years (HALYs) ● Included the top 5 conditions with highest impact on life and health: – – – – – Depression Bipolar disorder Alcohol use disorders Social phobia Schizophrenia Health-adjusted life years (HALYs): A combination of years lived with less than full function and years lost to early death. Ratnasingham S, et al. Institute for Clinical Evaluative Science, 2012. 8 Considerations for Measurement-based Care (MBC) How many people would consider… Treating diabetes without measuring and following a patient’s HbA1c? Prescribing an antihypertensive and not measuring a patient’s BP? Measurement-based care (MBC) provides specific and objective information on which to base clinical decisions and should therefore enhance quality of care and treatment outcomes. Rush J. et al., Psychiatric Times. Vol. 26 No. 9 , 2009 Why don’t clinicians use scales to measure outcome when treating depressed patients? How often do you use a rating scale to monitor the course of treatment for depression? Why not? Please indicate all that apply. Percent Survey of 314 psychiatrists attending a CME conference in 2006 and 2007. Reason (N=248) % Do not believe it would be clinically helpful. 28 Do not know what scale to use. 21 Takes too much time. 34 Too disruptive to practice. 19 Wasn’t trained to use them. 34 Zimmerman & McGlinchey, J Clin Psychiatry 2006. Does Measurement-based Care Help Guide Treatment? Canadian Practice Reflective Audit Results 67% of Primary Care and 77% of psychiatrists made changes to treatment regimens 100% Primary Care Specialist % of Patients 80% 60% 40% 20% 20% 25% 38% 30% 22% 23% 33% 23% 0% Change Increase dose Medication of current medication Add-on therapy No change * Physicians may have changed more than one part of a patient’s treatment regimen, therefore, percentages do not equal 100%. Rosenbluth M et al., The Canadian Journal of Diagnosis, June 2011 A Quick Look at the Scales A Quick Look at the Scales What makes a scale useful to clinicans and patients? • Validated • Sensitive to change • Brief enough to allow routine administration • Preferably patient rated • Easy to administer and require minimal training PHQ -9 (for Major Depressive Disorder) GAD-7 (for Generalized Anxiety) Sheehan Disability Scale (For Functionality) PHQ-15 (for Physical Symptoms) BC-CCI (for Cognitive Complaints) Practical Screening Tool When Time Is Limited… The 30 second PHQ-2 depression screen: Over the past 2 weeks, how often have you been bothered by any of the following items? Not at All Several Days More Than Half the Days Nearly Every Day 1. Little interest or pleasure in doing things 0 1 2 3 2. Feeling down, depressed or hopeless 0 1 2 3 Cut-off score of 3 • Sensitivity = 83%, specificity = 92% for MDD Kroenke et al. Med Care 2003;41:1284-94 Patient Health Questionnaire- PHQ 9 • Self-rated scale is the “HbA1c” of depression. • Designed specifically for primary care. • Highly sensitive and specific for the diagnosis of depression. • Useful in monitoring treatment response TOTAL SCORE DEPRESSION SEVERITY 1-4 Minimal Depression 5-9 Mild Depression 10-14 Moderate Depression 15-19 Moderately-severe Depression 20-27 Severe MDD PHQ-9 is adapted from PRIME MD TODAY, developed by Drs Robert L. Spitzer, Kurt Kroenke, and Janet B.W. Williams. Copyright ©1999 Pfizer Inc Treatment options based on the PHQ9 score Score Severity Proposed Treatment Plan 0–4 None-minimal None 5–9 Mild Watchful waiting; repeat at follow-up 10 – 14 Moderate Consider psychotherapy and/or pharmacotherapy 15 – 19 Moderately Severe Consider pharmacotherapy and/or psychotherapy 20 – 27 Severe Initiate pharmacotherapy and, if severe impairment, or actively suicidal consider consultation +/- admission to psychiatry 16 GAD: DSM-IV Diagnostic criteria Excessive anxiety and worry (apprehensive expectation) occurring more days than not for at least 6 months, about a number of events or activities (such as work, school performance) The individual finds it difficult to control the worry. Screening Questions for GAD Are you by nature a worrier? Do you worry more than other people? What do you worry about? Does the worry interfere with your life? GAD-7 For Scoring Symptom Severity In GAD following problem? Feeling nervous, anxious, on edge Spitzer RL. Arch Intern Med 2006;166:1092-1097. Generalized Anxiety Disorder - GAD-7 • Self rated • Specific for GAD but useful to detect an anxiety disorder in depression • Can be used to monitor treatment progress Spitzer RL. Arch Intern Med 2006;166:1092-1097. TOTAL SCORE Provisional Diagnosis 0-4 Minimal anxiety 5-9 Mild anxiety 10-14 Moderate anxiety 15-21 Severe anxiety *GAD-2 is the first 2 questions of the GAD-7 Substance/Medication-Induced Anxiety Disorder • • • • • • • • • • • Examples of Substances that can cause anxiety: Alcohol Caffeine Cannabis Phencyclidine Other Hallucinogens Inhalant Opioid Sedative, hypnotic or anxiolytic Amphetamine Cocaine 100 83% Presentation 80 60 40 17% 20 Physician Diagnosis of Depression or Anxiety Disorder How Patients with Depression & Anxiety Initially Present to Primary Care Physicians 100 80 77% 60 40 22% 20 0 0 Somatic Symptoms Psychological Symptoms Most people with psychological problems go to their family doctor with a physical complaint rather than recognizing that they have a form of mental distress. Psychological Symptoms Somatic Symptoms If patient presents with somatic symptoms instead of psychological symptoms the diagnosing of depression or anxiety is much less Kirmayer LJ, et al. Somatization and the recognition of depression and anxiety in primary care. Am J Psychiatry 1993;150:734-41. Strong Correlation Between Number of Physical Symptoms and Prevalence of Psychiatric Disorders Anxiety Disorder Mood Disorder Any Psychiatric Disorder Patients with Psychiatric Disorders (%) 100 80 60 40 20 0 0-1 2-3 4-5 6-8 ≥9 Number of Physical Complaints The more physical complaints there are, the more likely there is a psychiatric problem. Kroenke K, et al. Arch Fam Med 1994;3:774-9. The Somatic Symptom Scale – PHQ-15 • Brief, self-rated somatic symptom scale • Useful for screening somatization as well as monitoring somatic symptom severity. • Strong correlation between PHQ15 and functional status, disability days and symptom related difficulty. TOTAL SCORE SEVERITY OF SOMATIC SYMPTOMS 5-9 Low 10-14 Moderate 15-20 HIgh Kroenke K et al. The PHQ 15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med. 2002 Mar-Apr, 64(2):258-66 Patient language to describe cognitive symptoms ATTENTION MEMORY Lose train of thought Not listening Loss of short-term memory Attention Forgetful Concentration Lack of focus Brain is cloudy CONFUSED INADEQUATE OVERWHELMED Indecisive Slow motion Procrastinate Lacking confidence Tired / lethargic PSYCHOMOTOR SPEED Patients use a diverse range of language to describe their cognitive symptoms Some terms are specific to an individual domain, whereas others encompass multiple domains of cognitive dysfunction EXECUTIVE FUNCTION Qualitative market research with patients (July 2011) on patients in Canada and Europe, conducted by H. Lundbeck A/S 26 26 Mini-Mental State Exam (MMSE) and the Montreal Cognitive Assessment (MoCA) ● Common bedside tests to assess cognitive impairment ● Not very sensitive for milder degrees of cognitive impairment seen in depression 27 British Columbia Cognitive Complaints Inventory (BC-CCI) • • • • • 6 item scale that measures perceived cognitive problems. Brief, self-rated, easy to incorporate clinically, ensures standardized cognitive assessment Sensitive to cognitive complaints in patients with depression Can be used to monitor change over time Should be used in conjunction with a depression rating scale eg PHQ-9 TOTAL SCORE SEVERITY OF PERCEIVED COGNITIVE SYMPTOMS 0-4 Broadly normal 5-8 “mild” cognitive complaints 9-14 “moderate” cognitive complaints 15-18 “severe” cognitive complaints Iverson GL, Lam RW, Rapid screening for perceived cognitive impairment in major depressive disorder, Ann Clin Psychiatry, 2013 May; 25(2) 135-40 The Sheehan Disability Scale- SDS • 10-point self-rated scale • Assists clinician to monitor function in 3 domains - work, social and family functioning • Uses visuospatial, numeric and verbal descriptive anchors • Reflects change over time with effective treatment SCORING No recommended cut-off score; changeover-time useful in monitoring response Clinicians should pay attention to patients with scores over 5 in any domain Sheehan DV. The Anxiety Disease. New York. Charles Scribner and Sons, 1983. Arizona Sexual Experience Scale (ASEX) The Arizona Sexual Experience Scale (ASEX) is designed to assess five major global aspects of sexual dysfunction: • Drive • Arousal • Penile erection/vaginal lubrication • Ability to reach orgasm • Satisfaction from orgasm All of these are domains most commonly impaired by psychotropic dugs Items are rated 1-6; higher scores = greater dysfunction Sexual dysfunction is defined as: • ASEX total score 19 or 1 item 5 or 3 items 4 ASEX, Arizona Sexual Experience Scale McGahuey CA et al. J Sex Marital Ther. 2000;26(1):25-40. Prepared in response to an unsolicited request – Not for further distribution 30 Arizona Sexual Experiences Scale (ASEX) For each item, please indicate your OVERALL level during the PAST WEEK, including TODAY. How strong is your sex drive? 1 Extremely Strong 2 Very Strong 3 Somewhat Strong 4 Somewhat Weak 5 Very Weak 6 No Sex Drive 3 Somewhat Easily 4 Somewhat Difficult 5 Very Difficult 6 Never Aroused How easily are you sexually aroused? 1 Extremely Easily 2 Very Easily Male: Can you easily get and keep an erection? / Female: How easily does your vagina become moist? 1 Extremely Easily 2 Very Easily 3 Somewhat Easily 4 Somewhat Difficult 5 Very Difficult 6 Never 3 Somewhat Easily 4 Somewhat Difficult 5 Very Difficult 6 Never Reach Orgasm 3 Somewhat Satisfying 4 Somewhat Unsatisfying 5 Very Unsatisfying 6 Can’t Reach Orgasm How easily can you reach an orgasm? 1 Extremely Easily 2 Very Easily Are your orgasms satisfying? 1 Extremely Satisfying 2 Very Satisfying ASEX, Arizona Sexual Experience Scale McGahuey et al. J Sex Marital Ther. 2000;26(1):25-40. Prepared in response to an unsolicited request – Not for further distribution 31 Evaluating Comorbidity MDD Bipolar Disorder GAD Substance Use Disorder ADHD • Beck Depression Inventory • HAMD-7 • PHQ-9 • MDQ • Fear Questionnaire • GAD-7 • Hamilton Anxiety Scale • Substance Abuse and Dependence Scale • Adult ADHD Self-Report Scale (ASRS) 32 32 Mood Disorder Questionnaire “… useful screening instrument” Patient self-assessment screening tool for a broad diagnosis of the bipolar spectrum according to DSM-IV criteria 13 questions covering hypo/mania symptoms, clustering of symptoms, and impaired functioning Criteria for a diagnosis within the bipolar spectrum: 7 positive questions + clustering of symptoms + moderate-to-severe impairment 9 out of 10 correctly identified (specificity) 7 out of 10 ruled out (sensitivity) Hirschfeld RM, et al. Am J Psychiatry. 2000;157(11);1873-75. Lifecycle of ADHD Drop out of school Relationship Issues Job performance Parent Alcohol/Substance Abuse Accidents Hyperactive as child 34 When to Screen? Patients presenting with: Major Mood and Anxiety D/O (including poor response to treatment) Drug abuse or drug dependence Family history or children with ADHD Poor school performance as a child (not reaching potential) Frequent job changes or moving often Frequent driving infractions Higher number of accidents than average population Forgetfulness (missed appointments, trouble with adherence to medications) History of maternal smoking during pregnancy 35 Questions for Suspected ADHD Have you ever been diagnosed with ADHD? Do you have a family history of ADHD (siblings, children, parents or extended family)? Did you have any difficulty in school? Did you daydream or have difficulty paying attention? Did you get your homework done on time? Were you disruptive? Anything positive – move to Step 2 Do you currently have substantial difficulties with forgetfulness, attention, impulsivity or restlessness that are interfering with your relationships or your success at work? Anything positive – move to Step 3 Complete ASRS & Complete Diagnostic Interview McIntosh D, Kutcher S, Binder C, et al. Neuropsychiatr Dis Treat. 2009. 36 • A checklist of 18 questions about symptoms that are based on the diagnostic criteria for ADHD from the DSM-IV • Developed in conjunction with the World Health Organization and the Workgroup on Adult ADHD. Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist 1. How often do you have trouble wrapping up the final details of a project, once the challenging parts have been done? 2. How often do you have difficulty getting things in order when you have to do a task that requires organization? 3. How often do you have problems remembering appointments or obligations? 4. When you have a task that requires a lot of thought, how often do you avoid or delay getting started? 5. How often do you fidget or squirm with your hands or feet when you have to sit down for a long time? 6. How often do you feel overly active and compelled to do things, like you were driven by a motor? 7. How often do you make careless mistakes when you have to work on a boring or difficult project? 8. How often do you have difficulty keeping your attention when you are doing boring or repetitive work? 9. How often do you have difficulty concentrating on what people say to you, even when they are speaking to you directly? 10. How often do you misplace or have difficulty finding things at home or at work? 11. How often are you distracted by activity or noise around you? 12. How often do you leave your seat in meetings or other situations in which you are expected to remain seated? 13. How often do you feel restless or fidgety? 14. How often do you have difficulty unwinding and relaxing when you have time to yourself? 15. How often do you find yourself talking too much when you are in social situations? 16. When you're in a conversation, how often do you find yourself finishing the sentences of the people you are talking to, before they can finish them themselves? 17. How often do you have difficulty waiting your turn in situations when turn taking is required? 18. How often do you interrupt others when they are busy? Very Often Often Sometimes Please answer the questions below, rating yourself on each of the criteria shown using the scale on the right side of the page. As you answer each question, place an X on the box that best describes how you have felt and conducted yourself over the past 6 months. Please give this completed checklist to your healthcare professional to discuss during today’s appointment. Today’s Date: Rarely Your Name: Never The Adult ADHD Self-Report Scale (ASRS-V1.1)1 Symptom Checklist Part A Part B 37 1. ASRS-v1.1 Screener COPYRIGHT ©2003 World Health Organization (WHO). Reprinted with permission of WHO. All rights reserved. ASRS-v1.1 Screener COPYRIGHT ©2003 World Health Organization (WHO). Reprinted with permission of WHO. All rights reserved. Defining Treatment Goals Outcomes are now here Ideal outcome should be here Outcomes were here Remission Response 50% improvement in a validated depression rating scale from baseline (e.g., HAM-D) Not officially defined; varies between studies (e.g., HAM-D <7-10) Functional Recovery Adapted from: Nierenberg & DeCecco. J Clin Psychiatry 2001;62 (Suppl 16):5-9. Defining “remission” from a patient’s perspective Factors identified as very important, in rank order: 1. Presence of positive mental health (e.g. optimism, vigour, self-confidence) 2. Feeling like your usual, normal self 3. Return to usual level of functioning at work, home or school 4. Feeling in emotional control 5. Participating in, and enjoying, relationships with family and friends 6. Absence of symptoms of depression Zimmerman et al. Am J Psychiatry 2006; 163:148-150 Thanks! Q&A Time!