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This Month’s Expert Working With Primary Care Physicians in Treating Depression Jay Pomerantz, MDTCPR: The way an average private practice psychiatrist might hear from a PCP is with a quick phone call: “Doc, I need help with this patient. What should I prescribe?”

Dr. Pomerantz: While we are all under time pressures, I try to first ask some basic questions about the patient. What has the patient taken in the past, if anything? What were the results and side effects? What is the family history? What are the details of the symptoms—for example, is the patient excessively anxious? A very important point for PCPs to understand is that antidepressant treatment is a process, not a one-time event. You can’t just start a patient on an antidepressant and then never see him or her again. Sometimes the first drug doesn’t work; sometimes a patient needs psychotherapy or combination treatment.

TCPR: What about patients with obvious comorbid anxiety. Do you have particular recommendations for PCPs regarding those patients?

Dr. Pomerantz: PCPs should certainly be aware that the likelihood of a patient with comorbid anxiety staying on an antidepressant is doubled if you coprescribe a benzodiazepine (Pomerantz, op.cit). Perhaps because of worries about addiction, sometimes a doctor won’t use a benzodiazepine sufficiently early on, and the patient gets discouraged and is generally miserable because the antidepressant doesn’t work quickly enough for the anxiety. So I remind PCP colleagues that they can start an AD with a benzo, and then take the patient off the anxiolytic after the antidepressant is working.

TCPR: How do you talk to PCPs about recommending psychotherapy?

Dr. Pomerantz: I think there is an impression among PCPs that therapy doesn’t work. As we know, the data for psychotherapy is often just as good as for antidepressants, and for some people it is sometimes even better (Kupfer FE et al, Am J Psychiatry 2007;164(5):761–767). The combination of medication plus psychotherapy is often particularly good (Keller MB et al, New Eng J Med 2000;342(20):1462–1470). So PCPs need to be encouraged to recommend psychotherapy as a valid treatment, either alone or most often in combination with medication.

TCPR: What do you think is PCPs’ greatest challenge when it comes to screening and treating depression?
TCPR: Dr. Pomerantz, what sparked your interest in improving psychiatry’s collaboration with primary care physicians (PCPs)?

Dr. Pomerantz: I am a private practice psychiatrist, but in addition for the past 20 years I have worked part time as an associate medical director for behavioral health for an HMO in Western Massachusetts. In this role, I have helped PCPs understand and treat their patients’ psychiatric problems.

TCPR: How much depression treatment do PCPs actually do?

Dr. Pomerantz: In terms of starting new patients on antidepressants, PCPs do most of the prescribing. In 2001, I worked with a group of researchers from MIT to look at an HMO’s data on 100,000 enrollees to understand the question of who was prescribing antidepressants and why. We found that 70% of all antidepressants were prescribed by PCPs. Another 15% were prescribed by specialists, such as rheumatologists, cardiologists, OB/GYNs, and so forth. In our data, only 15% of all new prescriptions were written by psychiatrists or psychiatric nurse prescribers (Pomerantz JM, J Clin Psychiatry 2004;65(3):395–404).

TCPR: Only 15% of antidepressants were written by psychiatrists? That’s surprising.

Dr. Pomerantz: Yes, but in an earlier in-house study of the same HMO’s data, I found that actually 48% of antidepressant prescriptions, both new and refills, were written by psychiatrists. So why the difference in data? It likely has to do with the fact that psychiatrists’ patients were staying on medication longer, implying that psychiatrists were following guidelines better, and perhaps treating more of a chronic population, or alternatively, that PCPs and other medical specialists use antidepressants short term for presentations other than depression and anxiety.

TCPR: What might PCPs be using antidepressants for, if not depression?

Dr. Pomerantz: As part of the published 2001 study, we asked prescribers that very question. In fact, depression accounted for only 50% of PCPs’ antidepressant prescriptions. Fourteen other indications showed up, like fibromyalgia, migraine and other headache types, chronic pain disorder, anorexia, bulimia, gastrointestinal disorders, sleep disturbance, bladder dysfunction, smoking cessation, nocturia, premenstrual syndrome, and premature ejaculation.

TCPR: Do you interpret your data as showing that PCPs are prescribing antidepressants inappropriately?

Dr. Pomerantz: Not necessarily. It looks like PCPs and medical specialists may be appropriately treating some conditions—like sleep disturbances and smoking cessation—with short term antidepressant therapy. They are also using short term antidepressants to treat minor depressions (when there are some depressive symptoms, but not enough to add up to an official diagnosis of MDD)—and that is a little bit problematic because we know that antidepressants, especially when you first start them, carry some risks, especially of suicidal ideation. And the data shows that most people with minor depressions will come out of this by themselves without antidepressants (Oxman TE and Sengupta A, Am J Geriatr Psychiatry 2002;10:256–264).

TCPR: What kind of screening for depression should primary care doctors be doing?

Dr. Pomerantz: I recommend both the PHQ-2 and the PHQ-9 as depression screening tools for PCPs. The PHQ-2 asks two very simple questions: 1. During the past month have you often been bothered by feeling down, depressed, or hopeless? 2. During the past month have you often been bothered by little interest or pleasure in doing things? The PHQ-9 goes through all the symptoms of major depression. Both of these can be filled out in the waiting room of the primary care office.

TCPR: And then what? What results would indicate the PCP should start a patient on antidepressants?

Dr. Pomerantz: I have developed a treatment algorithm, based on the PHQ-9 score, which can range from zero for not depressed to 27 for severe depression. In general with a score less than seven, they might not even treat, and just have the patient come back in two to three weeks to see if he or she is getting better on his or her own. With a score of 10 to 19, they may start an antidepressant and have the patient come back for follow-up in a few weeks. For a score higher than 19, they may want to refer the patient to a mental health specialist. [Ed Note: You can access Dr. Pomerantz’s treatment algorithm at www.thecarlatreport.com/DepressionAlgorithm]

TCPR: That sounds helpful. What else do you recommend?

Dr. Pomerantz: I encourage physicians to go beyond the PHQ scores, and to not prescribe medicines without first taking a complete personal and family history of depression. How long do these depressive episodes last? Are they anxious? What has worked, and what hasn’t in the past? I also think all patients who present with depression should be screened for bipolarity. PCPs need to ask: Is there bipolar disorder in the family? Do you have periods of highs and lows? Obviously, these screening questions can’t make the diagnosis of bipolar disorder, but they can raise a red flag and prompt a referral.

TCPR: The way an average private practice psychiatrist might hear from a PCP is with a quick phone call: “Doc, I need help with this patient. What should I prescribe?”

Dr. Pomerantz: While we are all under time pressures, I try to first ask some basic questions about the patient. What has the patient taken in the past, if anything? What were the results and side effects? What is the family history? What are the details of the symptoms—for example, is the patient excessively anxious? A very important point for PCPs to understand is that antidepressant treatment is a process, not a one_time event. You can’t just start a patient on an antidepressant and then never see him or her again. Sometimes the first drug doesn’t work; sometimes a patient needs psychotherapy or combination treatment.

TCPR: What about patients with obvious comorbid anxiety. Do you have particular recommendations for PCPs regarding those patients?

Dr. Pomerantz: PCPs should certainly be aware that the likelihood of a patient with comorbid anxiety staying on an antidepressant is doubled if you coprescribe a benzodiazepine (Pomerantz, op.cit). Perhaps because of worries about addiction, sometimes a doctor won’t use a benzodiazepine sufficiently early on, and the patient gets discouraged and is generally miserable because the antidepressant doesn’t work quickly enough for the anxiety. So I remind PCP colleagues that they can start an AD with a benzo, and then take the patient off the anxiolytic after the antidepressant is working.

TCPR: How do you talk to PCPs about recommending psychotherapy?

Dr. Pomerantz: I think there is an impression among PCPs that therapy doesn’t work. As we know, the data for psychotherapy is often just as good as for antidepressants, and for some people it is sometimes even better (Kupfer FE et al, Am J Psychiatry 2007;164(5):761–767). The combination of medication plus psychotherapy is often particularly good (Keller MB et al, New Eng J Med 2000;342(20):1462–1470). So PCPs need to be encouraged to recommend psychotherapy as a valid treatment, either alone or most often in combination with medication.

TCPR: What do you think is PCPs’ greatest challenge when it comes to screening and treating depression?

Dr. Pomerantz: Time limitations—and the results can be deadly. In a review of studies on completed suicides, approximately one-half to two-thirds of individuals who committed suicide visited physicians less than one month before taking their lives; 10% to 40% visited in the week before; and almost none discussed or were asked about their mental states (Luoma JB et al, Am J Psychiatry 2002;159(6):909–916). So, the possibility for prevention is slipping through the cracks. Therefore, PCPs need to ask about depression and sometimes even about wishes to die and suicidality. I like to work with PCPs and their staff on screening for depression and suicidality (with or without a formal depression scale), completing the evaluation simply, smoothly, and without wasting precious time.

TCPR: How can you do that in the few minutes a PCP has?

Dr. Pomerantz: I discourage PCPs from asking open-ended questions, and tell them to get to the point: for any patient who seems to be seriously depressed, I urge them to ask the following questions: “How bad do you feel? Are you feeling so badly that you sometimes wish to die? Have you any thoughts about killing yourself? Do you have a suicide plan? Do you have guns or other weapons available to you?” In the unlikely event that there is serious intent and a plan, I suggest that the PCPs have a protocol that arranges for an expedited referral to a mental health specialist or even, if necessary, a plan for getting the patient to an emergency room.

TCPR: Thank you, Dr. Pomerantz.

 



APA Reference
The CarlatPsychiaty Report. (2013). This Month’s Expert: Working With Primary Care Physicians in Treating Depression by Jay Pomerantz, MD. Psych Central. Retrieved on October 21, 2014, from http://pro.psychcentral.com/this-months-expert-working-with-primary-care-physicians-in-treating-depression-by-jay-pomerantz-md/004831.html

    Last reviewed: By John M. Grohol, Psy.D. on 6 Oct 2013