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Depression, Adult in Primary Care

Guideline Summary

Revision Date: September 2013
Sixteenth Edition

Scope and Target Population

The purpose of this guideline is to assist primary care in developing systems that support effective assessment, diagnosis and ongoing management of initial and recurrent major depression and persistent depressive disorder in adults age 18 and over and assist patients to achieve remission of symptoms, reduce relapse and return to previous level of functioning. This guideline does not address the pediatric population. Diagnoses outside the scope of this guideline include adjustment disorder and bipolar disorder.

This guideline is an evidence-based document based on best care; it has also evolved to include information on best-practice systems for implementation. A system that has embedded the elements of best practice and has capacity to effectively manage the volume should consider routine screening of all patients, based on the recommendations of the U.S. Preventive Services Task Force. Depending on resources and systems, a group or clinic might also consider an interim plan of screening high-risk patients such as those with diabetes, cancer, chronic pain, coronary artery disease and post-stroke, all perinatal patients, as well as those with a history of previous depression.

Aims

The aims and measures in this guideline are based upon evidence supporting impact of system elements and process elements, and promoting actual symptom and functional patient improvement and outcomes, and are aligned with MN Community Measurement and the DIAMOND Initiative where there is overlap.

  1. Increase the percentage of patients accurately diagnosed with major depression or persistent depressive disorder.
  2. Decrease the number of completed suicides in patients with major depression or persistent depressive disorder managed in primary care.
  3. Increase the percentage of patients with major depression or persistent depressive disorder who are assessed for the presence and severity (mild to moderate, moderate to high) and dependent on substance use.
  4. Increase the assessment for major depression or persistent depressive disorder of primary care patients presenting with additional high-risk conditions such as diabetes, cardiovascular disease, post-stroke, chronic pain and all perinatal women.
  5. Improve communication between the primary care physician and the mental health care clinician (if patient is co-managed).
  6. Increase the percentage of patients with major depression or persistent depressive disorder who have improvement in outcomes from treatment for major depression or persistent depressive disorder.
  7. Increase the percentage of patients with major depression or persistent depressive disorder who have a follow-up to assess of response to treatment.

Clinical Highlights

  • A reasonable way to evaluate whether a system is successfully functioning in its diagnosis, treatment plan and follow-up of major depression is to consider:
    - how well the diagnosis is documented
    - how well the treatment team engages and educates patients/families
    - how reliably the ongoing patient contacts occur and response/remission to treatment are documented
    - how well the outcomes are measured and documented

  • Use a standardized instrument to document depressive symptoms. Document baseline symptoms and severity to assist in evaluating future progress, including response and remission rates.
  • Additional considerations that should be taken into account:
    - Patients with a high risk of common comorbid depression conditions such as substance abuse, diabetes, cardiovascular disease and chronic pain should be screened for depression.
    - Perinatal depression treatment should involve a thorough risk-benefit assessment in order to minimize the risks of both depression and its treatment to the mother and child.
    - Older persons and the cultural experiences of patients should receive special considerations regarding risk, assessment and treatment of depression.
  • Antidepressant medications and/or referral for psychotherapy are recommended as treatment for major depression. Factors to consider in making treatment recommendations are symptom severity, presence of psychosocial stressors, presence of comorbid conditions, and patient preferences. Physical activity and active patient engagement are also useful in easing symptoms of major depression.
  • If the primary care clinician is seeing incremental improvement, continue working with the patient to increase medication dosage or augment with psychotherapy or medication to reach remission. This can take up to three months. Studies have shown that depression can be treated successfully in primary care.
    - For medication treatment, patients may show improvement at two weeks but need a longer length of time to really see response and remission. Most people treated for initial depression need to be on medication at least 6-12 months after adequate response to symptoms. Patients with recurrent depression need to be treated for three years or more.
    - For medication treatment, patients may show improvement at two weeks but need a longer length of time to really see response and remission. Most people treated for initial depression need to be on medication at least 6-12 months after adequate response to symptoms. Patients with recurrent depression need to be treated for three years or more. - For psychotherapy treatment, 8-10 weeks of regular and frequent therapy may be required to show improvement.
  • The key objectives of treatment are to: - achieve remission of symptoms in the acute treatment phase for major depression - reduce relapse and reduction of symptoms - return patient to previous level of occupational and psychosocial function

Additional Background

The U.S. Preventive Services Task Force (USPSTF) recommends routine depression screening for all adults and adolescents (age 12-18) but only in clinical practices that have systems in place with care management, staff assistance or mental health specialist involvement to assure accurate diagnosis, effective treatment and follow-up. Furthermore, the American College of Preventive Medicine (ACPM) supports this recommendation and adds that all primary care practices should have such systems of care in place. The purpose of this guideline is to assist ICSI members to develop systems that support effective diagnosis and treatment of major depression.

A reasonable way to evaluate whether a system is successfully functioning in its diagnosis, treatment and follow-up of major depression would be to consider the following:

  1. Diagnosis: The clinic or medical group should have a reliable process for routine evaluation and documentation of DSM-5 criteria for major depression.
  2. The clinic or medical group should have a systematic way to provide and document:
    a. Engagement Education: The patient and his/her family are actively engaged and participating in self-management, based on knowledge of the nature of the disease, risk/benefits of treatment options, and consideration of patient preferences.
    b. Ongoing Contacts: A documented system to assure ongoing contacts with the patient during the first 6 to 12 months of care (scheduled follow-up appointments, phone calls and some way to react and/or reach out if the patient drops out of treatment) based on use of a standardized, objective tool used at each contact to document and track treatment response.
  3. Outcomes: The system should have a way to reliably and consistently monitor outcomes of individuals and to improve systemwide individual care and the effectiveness of the clinical practice overall.

Importance of Major Depression Focus in Primary Care

Major depression is a treatable cause of pain, suffering, disability and death, yet primary care clinicians detect major depression in only one-third to one-half of their patients with major depression. Additionally, more than 80% of patients with depression have a medical comorbidity. Usual care for depression in the primary care setting has resulted in only about half of depressed adults getting treated and only 20-40% showing substantial improvement over 12 months. Approximately 70-80% of antidepressants are prescribed in primary care, making it critical that clinicians know how to use them and have a system that supports best practices.

At any given time, 9% of the population has a depressive disorder, and 3.4% has major depression. In a 12-month time period, 6.6% of the U.S. population will have experienced major depression, and 16.6 % of the population will experience depression in their lifetime.

Additionally, major depression was second only to back and neck pain for having the greatest effect on disability days, at 386.6 million U.S. days per year.

In another WHO study of more than 240,000 people across 60 countries, depression was shown to produce the greatest decrease in quality of health compared to several other chronic diseases. Health scores worsened when depression was a comorbid condition, and the most disabling combination was depression and diabetes.

A recent study showed a relationship between the severity of depression symptoms and work function. Data was analyzed from 771 depressed patients who were currently employed. The data showed that for every 1-point increase in PHQ-9 score, patients experienced an additional mean productivity loss of 1.65%. And, even minor levels of depression symptoms were associated with decrements in work function.