DEPRESSION Depression Assessment PHQ-9 Screening tool Depression treatment Treatment flow chart Medications Patient Resource

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1 E-Resource March, 2015 DEPRESSION Depression Assessment PHQ-9 Screening tool Depression treatment Treatment flow chart Medications Patient Resource Depression affects approximately 20% of the general population and 10% of patients seen in the primary care setting. The following provides useful information and guidelines for detecting and managing depression in primary care Though depression symptoms are commonly seen in the primary care setting, the detection rate of depression in primary care is much lower than in behavioral health settings. This may be attributed to the fact that the presentation of depression often differs between the two settings. Depression seen in primary care is often less severe and less impairing and is more likely to spontaneously improve over a 12- month follow-up period. Depressive episodes in primary care are more likely to be associated with recent stressful life events while in behavioral health settings, depression is more frequently unrelated to life events. Comorbidity is more common among depressed primary care patients. Common comorbidities of depression include anxiety, alcohol abuse, hypertension, arthritis, diabetes and cardiac disease. There is also a greater association of somatic symptoms with depression in primary care; many depressed patients do not present with depression in primary care, but rather present with somatic symptoms, including chronic pain, insomnia, fatigue, headache, weight change, anxiety, irritability and apathy. Depression detection and diagnosis Depression is most effectively detected through clinical interview. Two effective questions for detecting depression include: During the past month, have you been bothered by feeling down, depressed, or hopeless? During the past month, have you been bothered by having little interest or pleasure in doing things? If the patient answers yes to either of these questions, the PHQ-9 should be utilized to assess depression severity (see page 2). All patients who present with depression should be assessed for suicidality. Providers should directly address current suicidal plan or ideation, past history of suicide attempts and level of remorse about unsuccessful attempts, access to a means for suicide (pills, firearms, etc.), presence of a substance use disorder, and disruption of important relationships. If a patient is suicidal, consult a behavioral health specialist immediately or refer the patient to an emergency department for immediate evaluation. It is also important to screen for potential medical conditions that mimic or exacerbate depression including alcohol/substance use, medical comorbidity (cancer, heart disease, stroke, diabetes), metabolic disorder or comorbid psychiatric disorder. Taking some medications may also lead to depressive symptoms so it is important to get a complete medical history from the patient. Depression treatment There are three phases of depression treatment: Acute phase (8-12 weeks): eliminate symptoms/approach baseline Continuation phase (16-20 weeks): prevention of relapse Maintenance phase (as needed): prevention of future episodes Steps of depression treatment: 1. Develop a treatment plan with patient (and family if appropriate) 2. Select appropriate acute phase treatment Medication: medication is the first line of treatment for most patients (see page 3) Education: helps improve patient compliance and enhance treatment outcomes Psychotherapy: cognitive behavioral therapy and interpersonal therapy are effective in treating depression 3. Select medication: consider side effects, patient history of response/non-response to previous medications, drug/drug and drug/ disease interactions, patient age, medication cost (see page 4) 4. Evaluation of treatment response Monitor adherence and tolerance to medication (Nurse telephone follow-up within 1-2 weeks of treatment initiation; physician follow-up 4 weeks after treatment initiation) Monitor adverse effects and adjust medication if necessary Asses patient mood and vegetative symptoms Assess patient suicidality or other at-risk behaviors Repeat PHQ-9 (within 3 months of treatment initiation) For patients with no improvement at 4-week evaluation, review that diagnosis is correct, evaluate compliance with medication, consider increasing dose or changing medication, or recommend adding psychotherapy to treatment. 5. Continuation phase: maintain medication at acute phase dose and monitor for adherence. (every 1-3 months) 6. Evaluate need for maintenance treatment: consider for patients who have had 3 or more episodes of major depression When to refer to a specialist: Case is overly complex Patient fails to respond to two adequate medication trials Patient may meet criteria for bipolar disorder Patient may benefit from formal psychotherapy or specialized treatments such as ECT or light therapy Patient shows chronic psychosocial problems Patient or clinician requests a second opinion When to refer for emergency evaluation: Patient is actively suicidal Patient is actively psychotic Patient may require psychiatric hospitalization About the Virtual Guidance Program JPS Health Network is proud to offer a new behavioral health clinical guidance resource to all primary care providers in our region. The JPS Behavioral Health Virtual Resource service offers: Telephone consultation with a behavioral health clinical team member Referral to community resources benefiting behavioral health patients Online reference library of behavioral health education materials Educational opportunities to increase provider understanding and comfort level in treating behavioral health conditions. Call or Visit for more information and to access a free virtual consultation for your patient

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3 PHQ-9 Depression Screening Scoring and Treatment Recommendations PHQ-9 scores can be used to plan and monitor treatment. To score the instrument, tally each response by the number value under the answer headings, (not at all=0, several days=1, more than half the days=2, and nearly every day=3). Add the numbers together to total the score on the bottom of the questionnaire. Interpret the score by using the guide listed below. Score: Interpretation: Treatment Recommendation 0-4 The score suggests the patient may not need depression treatment Support, educate to call if worsens, follow up in one month Mild to Moderate Depression Dysthymia Support, community resources and education May need Antidepressant therapy Score>9 initiates treatment planning and follow up related to depression Virtual Psychiatric Guidance Moderate major depressive disorder Antidepressant and/or psychotherapy Score>9 initiates treatment planning and follow up related to depression Virtual Psychiatric Guidance Referral to Psychiatry if warranted 20 or higher Severe major depressive disorder Antidepressant, Possible augmentation Regular Follow up Virtual Psychiatric Guidance Referral to Psychiatry if warranted

4 Treatment of Depression Tufts Health Plan. (2005), Clinical Guideline for the Treatment of Depression in the Primary Care Setting.

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