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 Depression Management Tool Kit ©

The MacArthur Foundation Initiative on Depression and Primary Care has created a Depression Tool Kit, which is intended to help primary care physicians recognize and manage Major Depression. The Kit includes easy to use tools to assist with:

  • Recognizing and diagnosing depression;
  • Educating patients about depression, assessing treatment preferences, engaging their participation and explaining the process of care;
  • Using evidence-based guidelines and management tools for treating depression; and
  • Monitoring patient response to treatment.

 Overview of the Depression Care Process

Recognition& Diagnosis

Step I

  • The physician suspects that a patient may be depressed. Some patients self-identify, but many others present with somatic complaints. Most physicians rely on their general impression to recognize these patients and a few physicians use screening tools. Formal assessment follows to confirm diagnosis.
  • Patient Education

    Step II

  • If diagnosis is confirmed, the physician and staff educate the patient about depression and the care process, engage the patient and determine patient preference for treatment.
  • Treatment

    Step III

  • The physician and patient select a management approach for treating depression:
  • * watchful waiting, with supportive counseling
    * antidepressant medications
    * mental health referral for psychotherapy
    * combination of antidepressants and psychotherapy

    Monitoring

    Step IV

  • The physician and support staff monitor compliance with the plan and improvements in symptoms/function and modify treatment as appropriate.
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    ATTACHED TOOLS FOR MANAGING DEPRESSION

    APPENDIX I

    I. Recognition and Diagnostic Information
    Physician Memory Aids
    PHQ-9 Patient Questionnaire

    APPENDIX II

    II. Patient Education Materials
    •Patient Handouts
    •External Resources

    APPENDIX III

    III. Treatment Information
    •Treatment Fact Sheets
    •Drug Administration Information

    APPENDIX IV

    IV. Monitoring and Follow-Up Information
    •Monitoring Tools
    •Referral Tools

    I. RECOGNIZING DEPRESSION AND DIAGNOSTIC EVALUATION

    Some physicians rely solely on their usual routines to identify depression. Some use memory aids to assure completeness. Others use a more formal approach to diagnosis by using a patient questionnaire. APPENDIX I contains memory aids (IA) and a screening instrument (IB).


    Overview of the Screening Process
     
    Step A
    Through interview and examination, the physician may suspect depression.
    Step B
    Diagnostic criteria are explored and (if appropriate) a depression diagnosis is confirmed.
    Step C
    Rule out other causes of depressive symptoms.

    IA. RECOGNITION TOOLS: PHYSICIAN MEMORY AIDS

    Physician memory aids are briefly described below: (materials with * are backed by specific evidence from the articles cited).

    Two Question Screen (4) *

    During patient interview, two questions have been shown to be effective for identifying patients who may be depressed (see page 1, APPENDIX I).

    Interview Questions (7)

    Direct questions about patient mood and function may help physicians recognize patients who may be depressed (see page 1, APPENDIX I).

    DSM - IV Criteria for Major Depression (3)

    A list of the 9 criteria for diagnosing Major Depression, along with instruction of how to interpret patient responses (see page 1, APPENDIX I).

    Assessment Checklist

    A list of measures and historical factors that are important when evaluating a depression diagnosis. (see page 2, APPENDIX I).

    Suicide Risk Questions (11)

    Suicide risk needs to be assessed whenever a diagnosis of depression is made. Some scripted questions are provided (see page 2, APPENDIX I).

    Ruling Out Other Causes of Depressive Symptoms (10)

    A list of medications and conditions to consider when diagnosing depression (see page 4, APPENDIX I).

    IB. DIAGNOSTIC TOOLS: PHQ-9 PATIENT QUESTIONNAIRE (6) *

    PHQ-9 may be used when a physician suspects depression and/or the Two-Question Screen is positive. The PHQ-9 score also helps quantify the severity of depression. PHQ-9 can be self-administered by the patient before, during, or after the office visit. PHQ-9 can be found on page 4, APPENDIX I.

    II. PATIENT EDUCATION MATERIALS

    One of the key components of depression management is helping the patient recognize that he/she is depressed, that treatment is needed to improve the quality of life for both the patient and his/her family, and to engage their participation in the care process. 10 Tools have been developed to help the physician educate the patient about depression, what effective treatments are available, what they can expect from treatment and the patient's role in managing depression. See APPENDIX II, Patient Education Materials.

    Approach to Patient Education

    Many times patients may not be willing to accept a diagnosis of depression or may begin treatment but then not continue. Physicians and their office staff can help patients by providing educational materials and support in terms that the patient can understand. For example, if the patient believes stress is a major factor, the clinician should be sensitive to the patients understanding and not over-emphasize the role of biological factors. The physician can consider including these items in their discussion with the patient: (2)

    • The cause, symptoms and natural history of Major Depression.
    • Treatment options, including indications, mechanisms of action, cost, risks and benefits.
    • Anticipated outcomes in terms of symptom relief, functional ability and quality of life.
    • Potential difficulties in complying with treatment and strategies to handle these problems.
    • Early warning signs of relapse or recurrence.

     

    Topics & Titles of Handouts How Its Used

    UNDERSTANDING DEPRESSION

    •What Is Depression

    Patient handout with concise easily understood information about depression and its treatment.

    MANAGING DEPRESSION

    •Understand the Process for Managing Depression

     Patient handout listing steps involved in the treatment process.

    ANTIDEPRESSANT THERAPIES

    • Persons Considering Medication Treatment

    • Frequently Asked Questions About Antidepressants

    Patient handout explaining how antidepressants work and steps the patient should take.

    Patient handout with common questions and answers about antidepressant medications,

    PSYCHOTHERAPY

    • Persons Considering Psychotherapy Treatment

    Patient handout listing types of mental health professionals, and what to expect from psychotherapy.

    WEB SITE MATERIALS

    •Patient Education Materials

    Links with national organizations for patient education materials

    III. TREATMENT INFORMATION

    The information in this section is based on AHCPR guidelines for Major Depressive Disorder as well as research in the field.



    Overview of the Treatment Process

    Step A
    Physician selects treatment approach with the patient, then works with patient to set goals for treatment outcomes and discusses phases of treatment (acute, continuous and maintenance).

    Step B

    Physician or support staff reassess patient symptoms and function after therapy has begun. Continues with therapies that reduce depressive symptoms or achieves remission. Adjusts therapies with partial or no response.

    Step C

    Follows Continuous/Maintenance guidelines to prevent relapse or recurrence.


    Treatment Section Format

    The information in the treatment section is organized by treatment approach. The format of the treatment section and corresponding tools in APPENDIX III are described below:

    IIIA. Supportive Counseling
    IIIB. Antidepressants
    IIIC. Referral to Psychotherapy
    IIID. Combined Treatment with Antidepressants & Psychotherapy
    IIIE. Patient Response to Treatment

    TREATMENT TOOLS IN APPENDIX III

    • Supportive Counseling Guide Sheet - Physicians who choose "office counseling" as a first line of treatment for patients will find this guide helpful. Information includes suggestions for approach, support strategies and coping strategies.
    • AHCPR Guidelines - Fact sheets with recommendations for depression treatment. Other information includes suggestions for monitoring and length of time to trial treatments.
    • Antidepressant Administration Schedule - Listing of common antidepressants used to treat depression. Information includes ranges of therapeutic dose, suggestions for initial dose and recommendations for titration. Also information is provided listing conditions/factors to consider when prescribing antidepressants.
    • Antidepressant Fact Sheets - Information about elderly patients, non-responsive patients, contraindications, discontinuing antidepressants, and a side effect management guide, with alternative drug recommendations.
    • Reassessment Tool - Instructions about how to reassess patient symptoms and function once treatment has begun.

    Three Phases of Treatment

    It may be useful to think of depression treatment as three phases. Each phase has a specific goal: (2)

    • Acute Aims at minimizing depressive symptoms.
    • Continuous Tries to prevent return of symptoms during current episode.
    • Maintenance Focus is to prevent return of symptoms within 2 years. 

    Treatment of Major Depressive Disorder (MDD)

    According to AHCPR guidelines, Major Depressive Disorder requires treatment. Physicians formulate a treatment approach based upon AHCPR recommendations for treatment.

     

     

     

    Treatment Options by Severity of Major Depressive Disorder (2)

     Severity

     Acute Phase

     Discussion Points

    Mild

    1. watchful waiting
    2. psychotherapy
    3. antidepressant

    For mild, ambiguous or marginal cases; revisit within 2 - 4 weeks to evaluate status of symptoms.

    Moderate

    1. antidepressant or
    2. psychotherapy
    3. combined treatment

    Either antidepressants, psychotherapy or combined therapy are recommended. Clinicians should be guided by patient preference and patient response.

    Severe

    1. antidepressant
    2. combined treatment- psychotherapy with antidepressant

    Antidepressants are recommended with or without psychotherapy. Psychotherapy should not be relied on alone with severe cases.

    III A. SUPPORTIVE COUNSELING AND PROBLEM SOLVING TREATMENT

    Primary care physicians are well suited to provide supportive counseling and recommend coping strategies for depressive disorders. Patients with severe Major Depressive Disorder require antidepressant therapy, with or without psychotherapy or supporting counseling. Counseling efforts focus on solutions. The physician works with the patient using regular brief periods. "The provider empathizes with the patient while moving the dialogue towards the construction of clear, simple, specific behavioral change plans".(12) For physicians who choose supportive counseling/coping strategies, a one-page fact sheet is located on page 1 of APPENDIX III to help with counseling sessions. Physicians who would like more information about supportive counseling may find the text "The Fifteen Minute Hour" (14) useful.

    Problem Solving Treatment for Primary Care (PST-PC) is a psychological treatment for depression that may be performed by primary care physicians or staff who are formally trained. It is based on the finding that depression is associated with life problems. Patients meet with the clinician four to six 30-minute sessions over a 6 - 10 week period. The focus of PST-PC involves a) identifying and clarifying problems; b) setting realistic goals and generating solutions; c) and evaluating progress and renewing problem-solving efforts if indicated. Patients who receive PST-PC tend to be more satisfied and more likely to complete treatment than patients receiving antidepressant medications. 13 Physicians who are interested in learning more about PST-PC training for primary care physicians may contact Mark Hegel Ph.D., via email: [email protected].

    III B. TREATMENT INFORMATION: ANTIDEPRESSANTS

    Treating depression with antidepressants is a decision made jointly with the patient. AHCPR guidelines on pages 2-3 in APPENDIX III list recommendations for each treatment phase, timeframes and expected responses. The Administration Schedule for Antidepressants on page 4 is used to select type of antidepressant and dose, and lists prescribing recommendations for health conditions. Pages 5-6 in APPENDIX III contains information about contraindications, patients who are non-responsive to treatment, recommendations for discontinuing antidepressants and strategies for managing side effects. Other information for antidepressant treatment is listed below:

    Factors to Consider when Selecting Antidepressants (10)

    • Comorbid physical illnesses;
    • History of response to medication in patient or first-degree relative;
    • Patient age (elderly patients may find side effects of SSRIs easier to tolerate);
    • Patient preference;
    • Out-of-pocket costs (tricyclics may be more affordable);
    • Potentially fatal drug interactions;
    • Avoid prescribing tricyclics in patients taking antiarrhythmics
    • Given the many complex interactions, MAOIs should only be prescribed by physicians who are expert in their use.

    *** ADD PSYCHOTHERAPY TO MEDICATIONS IF: (2)

    • Patient shows partial response to medication and residual symptoms are largely psychological.
    • Patient shows partial or complete response to medication but other psychosocial problems remain significant.
    • Patient has difficulty with adherence.

     

     

    III C. TREATMENT INFORMATION: REFERRAL TO PSYCHOTHERAPY (2)

    Individuals with mild to moderate Major depression, can be treated with time-limited psychotherapies. Cognitive Behavioral Therapy and Interpersonal Therapy (8-20 visits) have been shown to be equally efficacious to antidepressant medication, although improvement is initially slower than with medication. AHCPR guidelines for psychotherapy treatment are listed on page 2-3 in APPENDIX III.

    Factors to Consider when Selecting Psychotherapy (10)

    • Referred for medication management in addition to psychotherapy?

      If yes: consider referral to psychiatrist or other psychopharmacology expert

    • Patient preference
    - Has a specific therapist in mind
    - Prefers therapist of specific gender
    - May prefer therapist who counsels from a religious perspective
    • Health plan restrictions 
    • Patient's out-of-pocket costs

    **** ADD MEDICATIONS TO PSYCHOTHERAPY IF: (2)

    Patient show poor response to psychotherapy after 6 weeks or only a partial response after 12 weeks: If no response at all to psychotherapy after 12 weeks, antidepressant medication is recommended.

    III D. USING COMBINED TREATMENT: ANTI-DEPRESSANTS AND PSYCHOTHERAPY

    Combined treatment with psychotherapy and antidepressants are recommended for: (2)

    • Patients who have partial response to either type of treatment alone;
    • Patients with personality disorders;
    • Patients with complex psychosocial problems;
    • Patients who prefer psychotherapy, but have severe depression;
    • Prior course of illness is chronic or characterized by poor inter-episode recovery.

    III E. TREATMENT INFORMATION: MONITORING PATIENT RESPONSE TO TREATMENT (2)

    It is essential to monitor patient response to treatment. Management plans frequently need adjustment to optimize response. Many patients require significant support to maintain compliance.

    Intervals for monitoring patients are dependent upon the severity of depression and the treatment approach taken. Each patient differs in the timing of treatment response. However, typical response is 2 to 8 weeks for medication and 2 to 12 weeks for psychotherapy. Patient response to treatment is categorized as: 1) full symptom reduction, 2) partial symptom reduction and 3) no symptom reduction. Physicians may use AHCPR recommendations for follow-up monitoring. Tools to support monitoring and monitoring intervals are provided in Section IV B. Establishing A Monitoring Schedule.

    IV. IMPLEMENTING SYSTEMS FOR MONITORING AND REFERRALS

    An important part of depression management concerns office systems and staff roles in depression care. The systems used by physician offices may include: 1) using support staff to help care for depressed patients, 2) establishing a monitoring schedule to track patient response to treatment at regular intervals and 3) processing referrals for counseling. Some tools for helping offices change systems are located in APPENDIX IV Office Tools for Monitoring.

    IV A. USE OF SUPPORT STAFF

    Primary care physicians can benefit by asking a nurse or support staff to help educate and monitor patients with depression. Functions that can be delegated include:

    • Administer and score the PHQ-9 instrument;
    • Share educational resources with patients and answer questions;
    • Explain the steps involved in the process of care that will be used to treat the patient and what he/she can expect;
    • Review side effect strategies and discuss when the physician needs to be notified;
    • Schedule follow-up visits and establish systems for maintaining patient compliance and monitoring response to treatment;
    • Assist with the referral process for psychotherapy services.

    IV B. ESTABLISHING A MONITORING SCHEDULE

    Depression is often a chronic condition and requires close initial monitoring until symptoms are eliminated and then periodic monitoring to make sure a relapse or recurrence doesn't occur. Depression is like other chronic conditions, diabetes, heart disease, or hypertension and can benefit from establishing regularly scheduled visits with the patient.

    Recommendations For Follow Up Visits

    The AHCPR guidelines provide recommendations for Major Depressive Disorder. Specific frequencies depend on many factors, including the severity of depression. The following consensus guidelines may be useful for establishing intervals of follow up, until more evidence about specific frequencies is available.

    If treatment is initiated, the patient should be contacted by phone or office visit within 1 - 2 weeks of diagnosis as a first step, regardless of severity. Contact with the patient early after treatment begins may foster better patient compliance. Conversation with the patient may include:

    • Answering any questions the patient may have about his/her diagnosis or treatment;
    • Verifying if the patient has followed recommendations:
      • For supportive counseling;
      • Referral to counseling or psychotherapy;
      • Compliance with medication.
    • Identifying problems with medications and either:
      • Give support to continue with known side effects;
      • Have physician prescribe another medication.

    Scheduling Follow-Up Appointments After Initial Management (Depression Symptoms Present)

    Mild - Major Depressive Disorder .......................Visit or phone contact every month.
    PHQ-9 score of 5-14 and less than 5 symptoms endorsed as present "more than half the days"
     
    Moderate - Major Depressive Disorder .................Visit or phone contact every 2 weeks.
    PHQ-9 score of 15-19 or 5 or 6 symptoms endorsed as present at least "more than half the days"
     
    Severe - Major Depressive Disorder .......................Visit or phone contact at least every week.
    PHQ-9 score of >20 or 7 to 9 symptoms endorsed as present at least "more than half the days".

    At follow up visits, typical functions the physician and/or support staff will perform include:

    • Reassessing the diagnosis of depression;
    • Measuring changes in depression scores and patient function;
    • Making changes in treatment recommendations if improvements are not noted.

     Scheduling Follow-Up Appointments (After Symptom Resolution)

    Physicians need to contact patients regularly after their symptoms have resolved to assure patients complete the course of recommended treatment and that there is no symptom breakthrough:

     Patient on Antidepressant Medications and/or Psychotherapy

    Visit or phone contact every month, for 6 months following symptom remission.

    Patients Participating in No Active Treatment

    Visit or phone contact every three months for 6 months following symptom remission.

    Periodic Monitoring

    Because depression is a chronic condition, 50% of depressed patients will experience a new episode of depression within two years following continuation treatment. With recurrent depressions, the rate may approach 75%. Unfortunately, many of these patients will not seek help from their primary care doctor as soon as symptoms reappear. This situation makes it critical for the primary care physician to actively monitor the mental health status of patients with a history of depression in periodic checkups once a year. In addition, it is useful to have an increased level of suspicion regarding depression when these patients are seen in the interim for other problems.

    Documenting Progress In the Medical Record

    A Flow sheet is located on page 1 in APPENDIX IV for documenting patient symptoms, functions, PHQ-9 scores and treatment. Ongoing monitoring is an important step in depression care. Physicians may choose to keep the flow sheet on top of other medical record documents, such as the inside flap of the manila folder.

    IV C. PSYCHOTHERAPY REFERRALS

    Two functions the office staff can perform in this area include 1) coordinating referrals for psychotherapy and 2) monitoring the status of referrals:

    1. Coordinating Referrals for Psychotherapy

     Types of tasks the office helps with for referrals and the tools used in the process:

     Tasks for Monitoring Tool to Assist Process

    • Was the referral able to accept patient?
    • Did patient schedule appointment? Office Monitoring Systems
    • Did patient keep appointment?

    2. Facilitating Communication - Primary Care Physician and Consultants

    When depressed patients require psychotherapy, the primary care physician needs to talk with the psychotherapist. Types of monitoring tasks and tools to help monitor the process includes:

     Support Staff Monitoring

    • Did the physician establish initial communication with the psychotherapist?
    • Has the psychotherapist's impression been communicated back to PCP?
    • Is patient continuing with psychotherapy sessions as scheduled?
    • Is patient improving?

     Tool to Assist Process

    Referral for Psychotherapy Form

    Psychotherapy Communication Form

    3. Monitoring Status of Mental Health Referrals

     Office systems in the physician office need to monitor patient activities when referrals are made to mental health professionals. These tracking systems:

    • can be manual, (such as a tickler file) or;
    • can be computerized, where reminders and communications are printed out and reviewed.


    Acknowledgements

    The Initiative on Depression and Primary Care has been supported by the John D. and Catherine T. MacArthur Foundation since 1995. The Initiative has pursued the mission of enhancing recognition and management of patients suffering from depression in primary care. We have studied current approaches to depression care, developed and tested educational and office system-based interventions that could improve these approaches, and established close working relationships with dissemination partners including specialty organizations, leaders interested in high quality depression care and other researchers.

    This tool kit has been developed through the Initiative to aid primary care physicians in caring for their patients who suffer from major depression. The care management process recommended here builds on the Agency for Health Care Policy and Research (AHCPR) guidelines (1,2) and other evidence-based sources. Tools have been adopted from recently published and current studies. Tools in the Appendices are backed by either specific efficacy studies and noted with an asterisk* or backed by consensus. In addition, we are grateful to David Brody, Kathryn Rost and Jeffrey Smith for developing prototypes that guided this work. References to published work are provided on the bibliography page in the back of this Tool Kit. Copyright is held by the authors of specific tools and the MacArthur Foundation Initiative on Depression and Primary Care.

    Copyright 2000 Trustees of Dartmouth College. No part of these materials (including text, charts, adhesive notes, flow sheets, questionnaires, etc.) may be reproduced, altered, stored in a retrieval system, or transmitted, in any form or by any means (electronic, mechanical, photocopying, or otherwise) without the express written permission of Trustees of Dartmouth College or the authors of tools as specified. Requests for permission to reproduce these materials should be directed to: Allen Dietrich, MD, Dartmouth Medical School, Department of Community and Family Medicine.

     

     Bibliography

    1. Depression Guideline Panel. Depression in Primary Care: Volume 1. Detection and Diagnosis of Depression. Clinical Practice Guideline, Number 5. Rockville, MD. U.S. Department of Health andHuman Services, Public Health Service, Agency for Health Care Policy and Research

    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

    3. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, FourthEdition. Washington DC. American Psychiatric Association, 1994.

    4. Whooley MA, Avins Al, et al. Case finding instruments for depression. Two questions are as good as many. Journal of General Internal Medicine. 1997 July; 12 (7): 439 - 445.

    5. Williams JW, Mulrow CD, Kroenke, K et al. Case finding for depression in primary care: a randomized trial. American Journal of Medicine. 1999 Jan; 106 (1): 36 - 43

    6. Spitzer R, Kroenke K, Williams J. et al. Validation and utility of a self-report version of PRIME-MD. The PHQ primary care study. Journal of American Medical Association.1999 November; 282 (18):1737 -1744.

    7. Cole S. DEP Monograph. General Hospital Psychiatry. In Press.

    8. Tanielian T, Pincus, H, Dietrich A, Williams J, Oxman T, Nutting P, Marcus S. Referrals to Psychiatrists: Assessing the communication interface between psychiatry and primary care. Psychometrics. In Press.

    9. Brody D. Depression in Primary Care Tool Kit (Prototype). International Journal of Psychiatry in Medicine 2000; 30(2): in press.

    10. Rost K. Depression Tool Kit For Primary Care " NIMH grant MH54444. (Prototype)

    11. John A. Hartford Foundation and California Health Care Foundation. Impact study (improved mood:promoting access to collaborative treatment for late life depression. www.impact.ucla.edu.

    12. Robinson P, Wischman C, et al. Treating depression in primary care. A manual for primary care and mental health providers. Context Press, Reno, Nevada, 1996.

    13. Mynors-Wallis L, Gath D, Lloyd-Thomas A Tomlinson D. Randomised controlled trial comparing problem solving treatment with amitriptyline and placebo for major depression in primary care. British Medical Journal. 1995 February; 441-5.

    14. Stuart M, Lieberman J. The Fifteen Minute Hour. Praeger Publishers. Westport, CT.1993.