SPOTLIGHT ON MENTAL HEALTH Yelizaveta Sher M D

SPOTLIGHT ON MENTAL HEALTH Yelizaveta Sher, M. D. Department of Psychosomatic Medicine Meg Dvorak, LCSW Adult CF Social Worker

TIDES: The International Depression Epidemiological Study • 154 cystic fibrosis centers in 9 countries (Europe & US) • 6, 088 patients w/ CF (12 yo & up), and 4, 102 caregivers of children w/ CF, birth-18 yo • ↑depression in 10% of adolescents, 19% of adults, 37% of mothers and 31% of fathers. • ↑ anxiety in 22% of adolescents, 32% of adults, 48% of mothers and 36% of fathers. • Elevations 2– 3 times ↑ those of community samples. Quittner AL, Goldbeck L, Abbott J, et al. Thorax 2014

Cystic Fibrosis & Mental Health • Study comparing • Psychological distress adolescents with CF & in CF is associated with: • ↓pulmonary function • ↑ hospitalizations • ↑ healthcare costs • ↓ health-related quality of life depression vs no dep: • Those who were depressed were 3 X more likely to be hospitalized for a pulmonary exacerbation, and incurred ↑healthcare costs over 2 years Quittner AL, Goldbeck L, Abbott J, et al. Thorax 2014

CFF and ECFS International Committee on Mental Health in CF (ICMH) Guidelines • Prevention: – Ongoing education & preventative, supportive interventions – Behavioral approaches be used to reduce the risk of distress • Screening – Annual screening for adolescents and adults with CF (ages 12–adulthood) with PHQ-9 and GAD-7 – Annual screening of caregivers of children and adolescents – Screening of children (<12) if one caregiver is depressed or there is concern Quittner A et al, Thorax 2015

CFF and ECFS International Committee on Mental Health in CF (ICMH) Guidelines • Clinical Assessment/Intervention: – Clinically evaluate elevated scores and refer to PCP/MH as needed – Use flexible, stepped care model of clinical intervention – Based on severity and availability, use evidencebased psychological interventions and/or pharmacotherapy Quittner A et al, Thorax 2015

MDD Dysthymia Substance. Induced Mood Disorder Demoralization Adjustment Disorder w/ Depressed Mood Depression 2/2 Medical Illness Bipolar Disorder, Depressed Normal Reaction to Stress

5 + symptoms x 2 weeks: MDD Dysthymia • depressed mood Adjustment disorder w/ depressed mood • ↓ interest/pleasure • Changes in appetite and/or sleep Substance- Induced changes • psychomotor • low. Mood energy Depression Disorder or guilt • worthlessness Bipolar Disorder, Depressed • ↓concentration • thoughts of death, suicidal ideations, attempt Demoralization Depression 2/2 Medical Illness Normal Reaction to Stress

MDD Dysthymia Substance. Induced Mood Disorder Demoralization Adjustment Disorder w/ Depressed Mood Depression Bipolar Symptoms within 3 months. Disorder, of the stressor onset Depressed Marked distress in excess of expected and significant impairment in functioning Depression 2/2 Medical Illness Normal Sxs do not persist 6 months after stressor Reaction to termination Stress

MDD Dysthymia Depressed Mood Substance. Induced Mood Disorder Demoralization Adjustment Disorder w/ Depression Bipolar Disorder, Depressed • Episodes of mania or hypomania in addition to Normal depressed episodes • Depression Reaction to Depression may be characterized by hypersomnia, 2/2 Medical Stress hyperphagia, mood reactivity Illness • Very different treatment from unipolar depression

GAD Adjustment do w/ anxious mood PTSD Panic Disorder Anxiety Phobias OCD American Psychiatric Association, 2013, DSM 5 Medical Conditions: Hypoxia Metabolic Infection Tumor Medications: Steroids Albuterol Thyroid meds Stimulants Theophylline

GAD Adjustment do w/ anxious mood PTSD Excessive anxiety and worry x 6 months about few things Associated with 3+: Restlessness Panic Easily fatigued Disorder Diff concentrating Irritability Muscle tension Sleep disturbance Impairment Phobias Not due to effects of substance or illness Anxiety OCD American Psychiatric Association, 2013, DSM 5 Medical Conditions: Hypoxia Metabolic Infection Tumor Medications: Steroids Albuterol Thyroid meds Stimulants Theophylline

Presence of obsessions, compulsions or both Obsessions – recurrent thoughts, urges, images Compulsions – repetitive behaviors in response to Panic to obsession decrease Disorder anxiety Time-consuming or cause sign distress (1+ hr/day) Not due to effects of substance or medical illness GAD Adjustment do w/ anxious mood PTSD Anxiety Phobias OCD American Psychiatric Association, 2013, DSM 5 Medical Conditions: Hypoxia Metabolic Infection Tumor Medications: Steroids Albuterol Thyroid meds Stimulants Theophylline

Recurrent unexpected panic attacks AND Attack(s) followed by 1 month of 1+ of following: GAD Persistent concern about having additional attacks Worry about the implications of the attack Significant change in behavior related to the attacks Adjustment do w/ anxious mood +/- Agoraphobia Impairment Not due to effects of substance or illness PTSD Panic Disorder Anxiety Phobias OCD American Psychiatric Association, 2013, DSM 5 Medical Conditions: Hypoxia Metabolic Infection Tumor Medications: Steroids Albuterol Thyroid meds Stimulants Theophylline

American Psychiatric Association, 2013, DSM 5 GAD Adjustment do w/ anxious mood PTSD A. Exposure to actual/threatened death, serious injury or sexual Panic violence B. Disorder Intrusion Sxs Anxiety Intrusive thoughts Nightmares Flashbacks Psychological and/or physiologic distress with reminders Phobias C. Avoidance of stimuli and numbing D. Negative alterations in mood and cognitions E. Changes in arousal and reactivity F. Lasts for > 1 month OCD Medical Conditions: Hypoxia Metabolic Infection Tumor Medications: Steroids Albuterol Thyroid meds Stimulants Theophylline

Treatment • Diet • Exercise • Physical health • Support • Psychotherapy • Medications

Treatment: Psychotherapy • Psychodynamic Therapy – Understanding of how one’s past shapes today • Motivational Interviewing – Patient-focused; eliciting talk of change from the patient • Cognitive Behavioral Therapy – relationship between thoughts, emotions, and behaviors • Interpersonal Therapy – social support; changes in role functioning ; resolution of grief • Existential Psychotherapy – Meaning of life; dealing with death and grief • Mindfulness – Staying in the moment; focus on now • Supportive Psychotherapy – Active listening; problem solving

Pharmacotherapy • • • MAOIs TCAs SSRIs SNRIs Atypicals: mirtazapine, buproprion, vilazodone Augmentors: lithium, thyroid, aripiprazole

Percent of Patients 18 Years and Older with Depression, 2005 -2014

Percent of Patients 18 Years and Older with Depression in 2014 , by Center

Adult Mental Health Coordinator • • 3 year grant through CFF Faculty psychiatrist embedded in CF clinic Expertise in CF, lung txp, psychosomatic medicine Work closely with LCSW to improve screening process

Bridging the Mental Health Gap Access to MH services now • • • MH screening, referral MH system broken Medi-Cal, GHPP Private insurance Patients – Depression as barrier – CF as barrier • Providers – Expensive – Don’t take insurance Improvements with MHC • Services embedded in CF clinic • Evidenced based interventions in your clinic appointment * • Access to medications • Increased focus on MH • Improved data tracking for research and QI • Psychiatrist with CF expertise