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:
Overview of the Depression Care Process
ATTACHED TOOLS FOR MANAGING DEPRESSION
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).
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).
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)
Topics & Titles of Handouts How Its Used
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
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:
TREATMENT TOOLS IN APPENDIX III
Three Phases of Treatment
It may be useful to think of depression treatment as three phases. Each phase has a specific goal: (2)
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)
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)
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)
III D. USING COMBINED TREATMENT: ANTI-DEPRESSANTS AND PSYCHOTHERAPY
Combined treatment with psychotherapy and antidepressants are recommended for: (2)
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:
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:
Scheduling Follow-Up Appointments After Initial Management (Depression Symptoms Present)
At follow up visits, typical functions the physician and/or support staff will perform include:
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:
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
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:
3. Monitoring Status of Mental Health Referrals
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.
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.