Major Depressive Disorder (MDD) Guideline Diagnostic Nomenclature for Clinical Depressive Conditions

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1 Major Depressive Disorder Major Depressive Disorder (MDD) Guideline Diagnostic omenclature for Clinical Depressive Conditions Conditions Diagnostic Criteria Duration Major Depression 5 of the following symptoms (must include either depressed mood or anhedonia): Depressed mood Loss of interest in most activities (anhedonia) Significant change in weight or appetite Insomnia or hypersomnia Decreased concentration Decreased energy Inappropriate guilt or feelings of worthlessness Psychomotor agitation or retardation Suicidal ideation 2 weeks Dysthymia Depression OS (ot Otherwise Specified) 3 or 4 of the symptoms listed above with the addition of feelings of hopelessness and the omission of suicidal ideation (must include depressed mood) Variables: all included disorders must cause clinically significant impairment in daily functioning but fail to meet classification for MDD or dysthymia (e.g., minor depression with 2 to 4 depressive symptoms) 2 years 2 weeks Reference: VA/DoD Clinical Practice Guideline for Management of Major Depressive Disorder (MDD), May 09 DHCC Clinicians Helpline: 1 (866) DS: PDH-CPG Tool Kit Pocket Cards Version 1.0 ovember 2009

2 MDD Guideline Algorithm Page 1 Primary Care - Initial Assessment and Diagnosis 1 Patient age > 18 with suspected depression presenting to primary care? [A] Screening for MDD Brief assessment of initial presentation to assess for dangerousness [B] Unstable urgent condition? [C] Obtain relevant history, physical examination and lab tests [E] Obtain symptom score using PHQ-9 Determine and document DSM IV criteria for MDD [E] 4 Provide appropriate care or refer to stabilize and follow legal mandates [D] Over the past two weeks, how often have you been bothered by any of the following problems? 1. Little interest or pleasure in doing things 2. Feeling down, depressed, or hopeless. [A] Sidebar 1: Assessment - Medical history - Physical examination - Mental Status Exam - Relevant lab tests - Drug inventory (including over the counter and herbals) - Psychosocial history 7 Do medication(s) or 8 comorbid medical condition(s) contribute to symptoms? [F] Provide medical treatment and follow-up as indicated 9 Did depression symptoms resolve? 10 Continue medical follow-up as indicated DHCC Clinicians Helpline: 1 (866) DS: PDH-CPG Tool Kit Pocket Cards Version 1.0 December 2003

3 MDD Guideline Algorithm Page 1 (Continued) Primary Care - Initial Assessment and Diagnosis Presumptive diagnosis of MDD? History of MDD? Are there symptoms of depression or functional impairment that do not meet DSM IV criteria for MDD? [H] Are there concerns aboiut funtional ability or patient s mental health? Provide psychoeducation for self management [I] 23 Repeat screening 22 Follow up within 20 annually 4-6 weeks 13 Follow-up and consider referral to mental health specialty Assess for manic or hypomanic symptoms or family history of bipollar disorder or other psychiatric comorbidities [G] Suspected bipolar disorder? Occurrence of other major mental illnesses Continue on Page 2 Initial Treatment 15 Consider management of Bipolar Disorder 17 Referral/consult to specialty care DHCC Clinicians Helpline: 1 (866) DS: PDH-CPG Tool Kit Pocket Cards Version 1.0 ovember 2009

4 MDD Guideline Algorithm Page 2 Primary Care - Initial Treatment Patient with presumptive diagnosis or history of MDD, meets DSM-IV diagnostic criteria for MDD? Determine level of severity of MDD symptoms and functional impairment [J] Discuss treatment options and patient s preferences. Arrive at shared decision regarding treatment goals and plan [K] Sidebar 2: DSM-IV Diagnostic Criteria for MDD MDD diagnosis requires the presence of symptom 1, 2, or both; and at least 5 of 9 symptoms that persist for at least 2 weeks: 1. Depressed mood nearly every day for most of the day, based on self-report or observation of others 2. Marked reduction or loss of interest or pleasure in all or nearly all, activities for most of the day, nearly every day. 3. Significant non-dieting weight loss or weight gain (>5% change in body weight) 4. Insomnia or hypersomnia nearly every day 5. Psychomotor agitation or retardation (should be observable by others) 6. Fatigue/loss of energy nearly every day 7. Feelings of worthlessness or excessive/inappropriate guilt nearly every day 8. Diminished cognitive function (reduced ability to think or concentrate) nearly every day 9. Recurrent thoughts of death and/or suicide, suicide planning, or a suicide attempt DHCC Clinicians Helpline: 1 (866) DS: PDH-CPG Tool Kit Pocket Cards Version 1.0 ovember 2009

5 MDD Guideline Algorithm Page 2 (Continued) Primary Care - Initial Treatment 27 Is there indication for referral 28 to mental health specialty? [L] Initiate treatment strategies effective for depression [See sidebar 4] [M] Address psychosocial needs [] Refer to Mental Health Specialty Care SEVERIT Mild Sidebar 3: Indications for Referral to Mental Health - Unclear diagnosis - Evidence of psychotic features, past-mania or hypomania - Signs of comorbid psychiatric conditions - Unable to treat patient in primary care - eed for psychosocial interventions - Patient preference Sidebar 4: Initial Treatment Strategies for MDD PHQ-9 SCORE FUCTIOAL IMPAIRMET Mild IITIAL STRATEG Monotherapy-antidepressants or psychotherapy or, possibly combination 31 Schedule follow-up in 4-6 weeks Moderate Moderate Antidepressants or psychotherapy or, combination Continue on Page 3 Treatment Management and Follow-up Severe 20 Severe May start with antidepressants or psychotherapy but should prefer combination or multiple antidepressants Psychoeducation and self-management should be provided for all severity levels DHCC Clinicians Helpline: 1 (866) DS: PDH-CPG Tool Kit Pocket Cards Version 1.0 ovember 2009

6 Major Depressive Disorder MDD Guideline Algorithm Page 3 Primary Care - Treatment Management and Follow-up Patient with a diagnosis of MDD on treatment Complete assessment (see sidebar 5) Review current medication Assess for dangerousness [O] Unstable or dangerous condition? [C] Is patient condition improving and current treatment strategy tolerable? [P] Provide appropriate care or refer to stabilize and follow legal mandates [D] 37 Continue current treatment strategy. Reassess by 4-6 weeks [Q] Full remission? [R] Sidebar 5: Assessment of Treatment Response - Symptoms severity (PHQ9) and risk for suicide - Tolerability to treatment (Adverse effects) - Adherence to treatment - Medical problems influencing recovery - Psychosocial barriers to therapy - Revaluate diagnosis and appropriate treatment Sidebar 6: Treatment Strategies Monotherapy (Psych. or Drugs) Combine psych and pharmacotherapy Complex psychopharmacology Somatic interventions Inpatient/residential Sidebar 7: Indication for Consultation or Referral to Mental Health Specialty Care - Primary care out of comfort zone - Complicated depression with comorbidity - Lack of resources - Treatment resistance - Patient request DHCC Clinicians Helpline: 1 (866) DS: PDH-CPG Tool Kit Pocket Cards Version 1.0 ovember 2009

7 MDD Guideline Algorithm Page 3 (Continued) Primary Care - Treatment Management and Follow-up 44 Adjust/modify treatment: - Consider longer duration - Consider increasing dose - Consider augmentation - Consider switching to another agent - Consider modifying treatment strategy (See sidebar 6,7) [U] Continue treatment to prevent relapse [S] Sustained remission? 45 Schedule follow-up Relapse 41 Continue maintenance therapy in Primary Care [T] 42 Sustained remission? Recurrence 43 Return to Box 32 Screen annually DHCC Clinicians Helpline: 1 (866) DS: PDH-CPG Tool Kit Pocket Cards Version 1.0 ovember 2009

8 MDD Guideline Algorithm ICD-9 and DSM-IV Codes ICD-9 Code Diagnosis DSM-IV Code Diagnosis 296.2x Major Depressive Disorder, Single Episode 296.2x Major Depressive Disorder, Single Episode 296.3x Major Depressive Disorder, Recurrent Episode 296.3x Major Depressive Disorder, Recurrent Dysthymic Disorder Dysthymic Disorder 311 Depressive Disorder, ot elsewhere classified 311 Depressive Disorder OS ICD-9 and DSM-IV 5th Digit Subclassification Codes: x in x 0 Unspecified 1 Mild 2 Moderate 3 Severe, o Psychotic Behavior 4 Severe, with Psychotic Behavior 5 In Partial or Unspecified Remission 6 Full Remission DHCC Clinicians Helpline: 1 (866) DS: PDH-CPG Tool Kit Pocket Cards Version 1.0 ovember 2009

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