Scope and Target Population:
All adults greater than 18 years of age.

Clinical Highlights and Recommendations:

• 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 well the ongoing patient contacts are documented, and
  - how well the outcomes are measured and documented.
  
• Patients with any chronic condition should be screened for depression, especially those with diabetes, cardiovascular disease, or chronic pain. Presentations for major depression include:
  - multiple somatic complaints, weight gain/loss, mild dementia;
  - multiple (> 5/year) medical visits; problems in more than one organ system, with the absence of physical findings;
  - fatigue;
  - work or relationship dysfunction/changes in interpersonal relationships; and
  - sleep disturbances.
  
• Consider using a standardized instrument to document depressive symptoms. Document baseline symptoms and severity to assist in evaluating future progress, including response and remission rates.
  
• Antidepressant medications and/or referral for psychotherapy are recommended as treatment for major depression without coexisting medical conditions, substance abuse or other specific psychiatric comorbidities. Physical activity and tailored patient education are also useful tools in easing symptoms of major depression.
  
• When antidepressant therapy is prescribed, medication adherence and completion is critical. The patient should be advised of the following:
  - Most people need to be on medication at least 6-12 months after adequate response to symptoms.
  - Patients may show improvement at two weeks but need a longer length of time to really see response and remission.
  - Take the medication as prescribed, even after starting to feel better.
  - Do not stop taking the medication without calling the provider. Side effects can be managed by changes in the dosage or dose schedule.
  
• If the primary care provider is seeing incremental improvement, continue working with that patient to augment or increase medication dosage to reach remission. This can take up to three months. Don't give up on the patient whether treating in primary care or referring.
  
• The key objectives of treatment are:
  - to achieve remission of symptoms in the acute treatment phase for major depression,
  - to reduce patient relapse and reduction of symptoms, and
  - to return to previous level of occupational and psychosocial function.

Priority Aims:

1. Increase the accuracy of diagnosis of major depression.
   
2. Improve the frequency of assessment of response to treatment in patients with major depression.
   
3. Improve the outcomes of treatment for major depression.
   
4. Increase the percent of patients with major depression who continue on antidepressants for an adequate length of time.
   
5. Increase the assessment for major depression of primary care patients presenting with any additional chronic condition such as diabetes, cardiovascular disease, or chronic pain.
   
6. Improve communication between the primary care physician and the mental health care provider (if patient is co-managed).
   
7. Improve the frequency of assessment of patients with major depression for the presence of substance abuse.

Additional Background:
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 mechanism to assure that they are routinely evaluating for and documenting the presence for two weeks of at least five vegetative signs and symptoms of major depression (and that one includes sadness or loss of interest or pleasure in usual activities) in order to substantiate that the patient meets the DSM-IV TR criteria for major depression.
   
2. The clinic or medical group should have a systematic way to provide and document:
   a. Engagement Education: The patient has received information about the nature of the disease and risks/benefits of treatment options (minimally either documentation of a discussion or that patient treatment options and handouts are routinely given.)
   b. Ongoing Contacts: A documented system to assure ongoing contacts with the patient during the first six 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.)
   
3. Outcomes: The system should have a way of at least periodically monitoring outcomes of individuals and systemwide to improve individual care and the effectiveness of the clinical practice overall.