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Supportive Counseling Fact Sheet For Physicians

 

Physician Approach to Office Counseling

Some patients benefit from supportive counseling with the physician and/or knowledgeable support staff. Brief sessions where counseling is provided using these techniques:

Focus on Solutions

Empathize with the patient, while moving the dialogue towards the construction of clear, simple, specific behavioral change plans:

Focus on Coping Strategies

"Use of active coping strategies buffers the impact of stress and helps lessen symptoms of depression". (Burns, et al. 1991). Some helpful coping strategies that may be suggested to patients are listed below:

 

Coping Strategy Suggestions

 

1. Participate in pleasurable activities, especially those that help improve your mood.
2. Participate in activities that boost your confidence.
3. Simply be aware of an uncomfortable thought, feeling or emotion without struggling with it.
4. Participate in activities that help you relax.
5. Use problem-solving techniques for problems you are having in life, such as problems with your job or relationships.
6. Notice negative thoughts and replace them with more positive thoughts.

 

Process For Developing/Monitoring Coping Strategies

1. Identify two to three coping strategies that may be helpful for the patient and clarify if the strategies will be consistent with their personality and lifestyle.
 
2. Create a list of these coping strategies, giving one to the patient and the other to keep in the medical record.
 
3. Have the patient keep track of both the problems and coping strategies that occur over the next week/couple of weeks. Have patient bring a summary to the next office visit.
  • 4. Assess coping strategies the patient used, reinforcing strategies that are effective and making suggestions when improvements are needed.

     

  • AHCPR Treatment Guidelines - Table Format

    IA. ANTIDEPRESSANT TREATMENTS (2)ACUTE PHASE TREATMENT - AIM: Removing All Symptoms

     

    Acute Phase - Expected Response

     

    Resume Treatment

     

    Modify Treatment

    Every 1-2 weeks monitorpatient compliance and symptoms

     

    4-6 week trial - 50% reduction in symptoms

     

    10-12 week trial - near full response

     

     

     

    If partial response by 5-6 weeks, continue with same antidepressant for another 5-weeks

     

     

     

    * If no response by 6 weeks - increase dose or switch drugs

     

    * If partial response by 12 weeks - increase dose or switch drugs

    CONTINUOUS/MAINTENANCE PHASE TREATMENT - Preventing Relapse/Recurrence

     

    Type of Patient

     

    Continuous Treatment

     

    Maintenance Treatment

     

    Initial Episode

     

    4 to 9 months after return to well state

     

    Discuss with patient the Pros/Cons of continuing antidepressant therapy Maintenance phase treatment is optional

     

    Recurrent Episode

    who have 2 or more episodes of Major depression in a 5 year period

     

    At least 9 months

     

     

     

    Continue long-term maintenance therapy Consult AHCPR guidelines for details about Maintenance treatment

     

    IB. PSYCHOTHERAPY TREATMENTS (2)

    ACUTE PHASE TREATMENT - AIM Removing All Symptoms

    CONTINUOUS/MAINTENANCE PHASE TREATMENT - Preventing Relapse/Recurrence

     

    Severity of MDD

     

    Initial Psychotherapy

     

    Continue Psychotherapy

     

    Modify Treatment Plan

     

    Mild or Moderate

     

    6-8 week trial - partial remission of symptoms

     

    If psychosocial function has not been fully restored

     
    No improvement after 6-8weeks
    Only partial improvement after 12 weeks

     

    Severe

     

    Psychotherapy should be used only in conjunction with antidepressants

     

    Prevents subsequent relapses and recurrences once treatment with antidepressants ends

     

     

     

    2. Depression Guideline Panel. Depression in Primary Care: Volume 2. Treatment of Major Depression. Clinical Practice Guideline, Number 5. Rockville, MD. U.S. Department of Health and Human Services. Public Health Service, Agency for Health Care Policy and Research

     

     

    AHCPR Treatment Guidelines - Narrative Format

     

     

    Antidepressant Administration Schedule

     

    Physician Antidepressant Fact Sheet

     

    Extended Use of Minor Tranquilizers to Treat Depression Is Contraindicated (10)

     

    Treating Elderly Patients With Antidepressants (10)

     

    Discontinuing Antidepressant Therapy (10)

    While antidepressant medications are generally considered safe, they should be discontinued if they are not required. For first episodes of depression, it may be appropriate to discontinue medication after 4-9 months of continuation phase treatment since only 50% will have another episode of depression. Tricyclic antidepressants and other drugs listed on page 3 of the administration schedule should be tapered if the patient has had exposure at therapeutic dosages for 3 months or more. A tapering schedule of tricyclics over 2 to 4 weeks is recommended.

     

    Expected Course For Patients Who are Non-Responsive to Antidepressants (2)

    The following approaches may be useful with non-responsive patients: 

    Phases

    Patient Response

    Expected Outcome

    Acute Phase

    Partial Symptom Reduction

    More symptoms during continuation phase

    Continuation Phase

    Poor Symptom Control

    Higher chance of earlier relapse & higher recurrence once treatment is discontinued

    Managing Side Effects

    This tool provides information about 1) types of side effect, 2) the recommended action to minimize or eliminate the side effect and 3) alternative drugs to consider if the patient cannot tolerate the side effect.

     

     

    Physician Antidepressant Fact Sheet

     

    Strategies for Managing Antidepressant Side Effects

    1. Allow patient to verbalize his/her complaint about side effects.

    2. Wait and support. Some side effects (i.e., GI distress with SSRIs) will subside over 1-2 weeks of treatment.

    3. Lower the dose temporarily.

    4. Treat the side effects (see below).

    5. Change to a different antidepressant.

    6. Discontinue medications and start Psychotherapy.

     

    Side Effect Management Strategy Alternative Drugs

     

    Sedation

     
    Give medication at bedtime
    Try caffeine

     

    citalopram, sertraline,

    fluoxetine, venlafaxine,

    bupropion

     

    Orthostatic Hypotension-

    Dizziness

     
    Consider switching to a different antidepressant
    Increase hydration
    Sit-stand-get up slowly
    Support hose

     

    SSRI or other new

    agents

     

    Anticholinergic

    Dry mouth/eyes, constipation, urinary retention, tachycardia

     
    Consider switching to a different antidepressant
    Increase hydration
    Sugarless gum/candy
    Dietary fiber
    Artificial tears
    Bethanechol 10 - 20 mg bid - tid
    If confusion - stop medication and R/O other causes

     

    SSRI or other new

    agents

     

    GI Distress/Nausea

     
    This often improves 1-2 weeks after medication started
    Take with meals
    Consider antacids or H2 blockers

     

     

    Restlessness

    Jitters/

    Tremors

     
    Start with small doses (especially with underlying anxiety disorder)
    Reduce dose temporarily
    Add buspirone 10 - 20 mg bid-tid
    Add beta blocker (propranolol 10-20 mg bid/tid
    Consider short term trial of benzodiazepine

     

     

    Headache

     
    Lower dose
    Acetaminophen

     

     

    Insomnia

     
    Trazodone 25 - 100 mg po qhs (can cause orthostatic hypotension and priapism)
    Make sure antidepressants are take in am

     

     

    Sexual Dysfunction

     
    May be part of depression or medical disorders
    Decrease dose
    Try adding bupropion 75 mg qhs or bid
    Try adding buspirone 10-20 mg bid - tid
    Try adding cyproheptadine 4 mg 1-2 hrs before sex
    Consider a trial of Viagra

     

    Bupropion or nefazodone

    11. Impact Study, a multicenter study sponsored by the John A. Hartford Foundation and the California Health Care Foundation. (www.impact.edu)

     

     

     

    Assessing Patient Symptoms and Functions

     

    After the patient has started treatment, it is helpful to reassess symptoms and function to determine the effectiveness of treatment. PHQ-9 scores at the time of diagnosis are compared to scores after treatment has begun. This approach helps quantify how much the patient is improving.

     

    Instructions for Scoring Patient Symptoms and Function Using PHQ-9 (4)

    Tally patient responses on the PHQ-9 patient questionnaire that is given once treatment has begun. Add patient responses using the numbers 0,1,2 and 3 for each question the patient answered:

    Question

    Score

    Not at all
    Several Days
    More than half the day
    Nearly every day

    Score patient's response by adding 0,1,2, or 3 for each response

    0
    1
    2
    3

    Cut points of 5, 10, 15, and 20 identify patients with mild, moderate, major and severe depressive symptoms. For patients with major depression, a preliminary suggestion (pending validation in prospective clinical trials) would be to consider a PHQ-9 of less than 15 as a response, and less than 10 as remission. Also, a 50% reduction in the baseline PHQ-9 score (in those with very high scores) might be considered a good treatment response.

     

    For those who wish to follow the number of depressive symptoms, the PHQ-9 does inquire about the nine symptom criteria for depressive disorders. One can use as a depressive symptom count the total number of symptoms checked by the patient as still present "more than half the days" or "nearly every day" (a 2 or 3 score).

     

    Reassessment Schedule

    Regardless of approach, patient symptoms and function needs to be periodically evaluated, through patient interviews or formal assessment using PHQ-9. It takes an average of 1 minute to score and compare patient's PHQ-9scores to earlier scores. Copies of each PHQ-9 Patient Questionnaire may be stored in the patient's medical record.

    Documenting patient improvements on a flow sheet in the medical record can help keep track of patient progress. (see APPENDIX IV).