Treatment Plan
Key Points:
- The Collaborative Care Model is recommended for depression in primary care because it has demonstrated improvement in treatment adherence, patient quality of life and depression outcomes.
- Successful programs for the treatment of depression include organized treatment protocols, structured follow-up protocols, systematic monitoring of treatment adherence and effectiveness.
- When considering treatment options, the primary goal is to achieve remission.
Collaborative Care
More than 37 randomized controlled trials have demonstrated the effectiveness of the Collaborative Care Model. The work group recommends three key references (see original guideline document [A], [M]) in which primary care treatment of depression is provided by a team (depression care manager, primary physician, consulting psychiatrist, others). This model has demonstrated improvement in treatment adherence, patient quality of life, and depression outcomes. Preliminary evidence suggests the collaborative care model is also effective for depression during pregnancy and postpartum [M].
The redesign to a team-based collaborative care approach involves:
- Primary care providers using evidence-based approaches to depression care and a standard tool for measuring severity, response to treatment plan and remission
- A systematic way of tracking and reminding patients at appropriate intervals of visits with their primary care physician and monitoring of treatment adherence and effectiveness
- A team member (care manager role) to utilize the tracking system and make frequent contacts with the patients to provide further education, self-management support, and monitor for response in order to aid in facilitating treatment changes and in relapse prevention
- Communication between primary care team and psychiatry to consult frequently and regularly regarding patient under clinical supervision, as well as direct patient visits as needed [A].
See the Key Implementation Recommendations in the "Description of Implementation Strategy" field and Resources Available section in the original guideline document for suggestions and information on implementing the Collaborative Care Model.
Educate and Engage Patient
Successful care of major depression as an illness requires active engagement of each patient and his/her family and ongoing patient education, beginning at the time of diagnosis.
Often, the depressed patient's pessimism, low motivation, low energy, and sense of social isolation and guilt may lead to nonadherence with treatment [R].
Education topics should include:
- The cause, symptoms and natural history of major depression
- Treatment options and the process of finding the best fit for a given individual
- Information on what to expect during the course of treatment
- How to monitor symptoms and side effects
- Follow-up protocol (office visits and/or telephone contacts)
- Early warning signs of relapse or recurrence
- Length of treatment
- Communication with the caregiver. A patient should plan to make appointments for six months to one year. Frequency of visits will depend on depression severity. See "Establish Follow-Up Plan" further in this annotation.
Patient education should include diagnosis, prognosis, and treatment options including costs, duration, side effects, and expected benefits. Emphasize the following six points:
- Depression is a medical illness, not a character defect.
- Recovery is the rule, not the exception.
- Treatment is effective for nearly all patients.
- The aim of treatment is complete remission, not just getting better but staying well.
- The risk of recurrence is significant: 50% after one episode, 70% after two episodes, 90% after three episodes [R].
- Patient and family should be alert to early signs and symptoms of recurrence and seek treatment early if depression returns.
People of differing racial/ethnic groups can be successfully treated using currently available evidence-based interventions when differential personal elements, from biological to environmental to cultural, are considered during the treatment planning process [R].
Patient Self-Management
It is important for the patient to consider and adopt some self-care responsibilities, which may range from simply demonstrating reliable behavior in taking medications and calling the provider with side effects to agreeing to participate in sessions, journaling and completing homework, which is necessary for some cognitive behavioral therapies. Written materials are helpful to reinforce information shared during the discussion. Patients who commit to some self-care responsibilities and receive this education compared with those who do not are more likely to continue treatment, rather than prematurely abandon it, and are more likely to attain better outcomes.
Exercise
Evidence suggests that physical activity at a dose consistent with public health recommendations is a useful tool for easing major depression symptoms. Among individuals with major depression, exercise therapy is feasible and is associated with significant therapeutic benefit, especially if exercise is continued over time [A], [C], [R]. When prescribing exercise either alone or as an adjunct to medication and psychotherapy, the complexity and the individual circumstances of each patient must be considered. When prescribing an exercise prescription, several caveats apply:
- Anticipate barriers - hopelessness and fatigue can make physical exertion difficult.
- Keep expectations realistic - some patients are vulnerable to guilt and self-blame if they fail to carry out the regime.
- Introduce a feasible plan - walking, alone or in a group, is often a good option.
- Accentuate pleasurable aspects - the specific choice of exercise should be guided by the patient's preferences, and must be pleasurable.
- A goal of 30 minutes of moderate-intensity aerobic exercise, three to five days a week is recommended for otherwise healthy adults (17.5 kcal/kg/week of total energy expenditure). For more information see the NGC summary of the ICSI guideline Prevention and Management of Obesity.
- Encourage adherence - greater antidepressant effects are seen when training continues beyond 16 weeks.
Discuss Treatment Options
When considering treatment options, the primary goal is to achieve remission or to get the patient to be virtually symptom free (i.e., a PHQ-9 score of less than five or a HAM-D score of less than seven).
Psychotherapy versus Pharmacotherapy
Pharmacologic and/or psychotherapy interventions are effective in treating depression. Factors to consider in making treatment recommendations are symptom severity, presence of psychosocial stressors, presence of comorbid conditions, and patient preferences. If the initial presentation is mild to moderate, either an antidepressant or psychotherapy (or both) is indicated. If the presenting symptoms of depression are severe, the initial recommendation is to treat with antidepressants and psychotherapy. See the table "Depression Treatment and Follow-Up Intervals Based on Severity" in the original guideline document.
It is useful to also take into consideration cultural beliefs and sufficiency of (or lack of) resources such as transportation, finances and child care when making a decision whether to treat with medication and/or psychotherapy.
Depression treatment should take health beliefs into account. Patients who perceive more self-control of their health experience greater reduction in depressive symptoms, whether treated with psychotherapy or an antidepressant [C]. Therefore, it is important to adequately assess a patient's expectations and beliefs in the controllability of depressive symptoms and functioning in order to treat major depression effectively and to minimize the risk of relapse and recurrence.
Psychotherapy
Cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), short-term psychodynamic psychotherapy (STPP) and problem-solving treatment (PST) have documented efficacy [A], [C], [D], [M]. In mild to moderate levels of depression, psychotherapy can be equally as effective as medication [A]. With severe depression, antidepressant medication may be necessary [A]. There is documentation to support lower relapse rates and outcomes among patients receiving psychotherapy [A], [M].
- Psychotherapy, especially focused psychotherapy, can significantly reduce symptoms, restore psychosocial and occupational functioning, and prevent relapse in patients with major depression [M].
- Offer a referral for psychotherapy whenever psychological or psychosocial issues are prominent, or if the patient requests it.
- Support and education in the primary care setting are critical and contribute to the likelihood of good follow-through on treatment. It may help patients understand their options and resources if the primary care clinic explains that this is not the same as a course of psychotherapy.
- Maintenance psychotherapy is useful in managing chronic forms of major depressive disorder [A].
- Because both antidepressants and psychotherapy are effective, careful consideration to patient preference for mode of treatment is appropriate [A].
Medications
Acute treatment (usually the first three months of treatment) refers to treating with antidepressant medication in order to achieve remission of major depressive symptoms. Remission is defined as having minimal residual symptoms.
For antidepressant medications, adherence to a therapeutic dose and meeting clinical goals are more important than the specific drug selected. Successful treatment often involves dosage adjustments and/or trial of a different medication at some point, to maximize response and minimize side effects [R].
When antidepressant therapy is prescribed, the following key messages should be highlighted to support medication adherence and completion:
- Side effects from medication often precede therapeutic benefit and typically recede over time. It is important to expect some discomfort prior to the benefit.
- Successful treatment often involves dosage adjustments and/or trial of a different medication at some point, to maximize response and minimize side effects.
- Most people need to be on medication at least 6 to 12 months after adequate response to symptoms.
- Patients may show improvement at two weeks but need a longer length of time to really see response and remission.
- Take the medication as prescribed, even after one feels better. Premature discontinuation of antidepressant treatment has been associated with a 77% increase in the risk of relapse/recurrence of symptoms [B]. On average, 50% to 85% of patients with a single episode of major depressive disorder will have at least one or more episode within 15 years of their first diagnosis [R]. The probability of recurrence of depressive symptoms was found to be 25% after one year, 42% after two years, and 60% after five years in one study [B]. Each episode of recurrence increased the risk of subsequent episodes by 16% [B].
- Do not stop taking the medication without calling your provider. Side effects can be managed by changes in the dosage or dosage schedule.
Patient adherence is critical. In addition to medication monitoring, clinical management of patients placed on antidepressants should include the provider's support and reassurance.
Health care providers should carefully evaluate their patient in whom depression persistently worsens, or emergent suicidality is severe, abrupt in onset, or was not part of the presenting symptoms to determine what intervention, including discontinuing or modifying the current drug therapy, is indicated.
The U.S. Food and Drug Administration (FDA) has requested that manufacturers of antidepressants include a warning statement regarding antidepressants increasing the risk compared to placebo of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults in short-term studies of major depressive disorder (MDD) and other psychiatric disorders. The full warning statement can be found at http://www.fda.gov/cder/drug/antidepressants/default.htm.
The provider should instruct the patient and the patient's caregiver to be alert for the emergence of agitation, irritability, and the other symptoms. The emergence of suicidality and worsening depression should be closely monitored and reported immediately to the health care provider.
See also Annotation #5, "Is Patient Unsafe to Self or Others?" above.
Selection of an Antidepressant Medication
Antidepressant drug selection should be based on:
- The patient's history of response to previous antidepressant medications (if any)
- The patient's comorbid psychiatric or medical conditions
- Clinician familiarity with specific antidepressants
The Texas Medication Algorithms which can be found at http://www.dshs.state.tx.us/mhprograms/disclaimer.shtm provide good overall parameters for care. The STAR*D Study has updated data on treatment response timelines and follow-ups.
There is no evidence regarding choice of brand versus generic based on adverse clinical outcomes.
While genetic differences in the metabolism of certain medications including antidepressants can be determined by genetic testing, the clinical significance and applicability to practice has not yet been established.
For up-to-date prescribing information, the work group recommends the following references:
Refer to the original guideline document for information regarding pharmaceutical and therapeutic equivalents.
Consider discussing with the patient the specific side effect profiles, costs, and benefits of different antidepressants, including generics. Cost implications for patients need to be discussed between provider and patient.
- Selective Serotonin Reuptake Inhibitor (SSRI); venlafaxine, duloxetine, mirtazapine, and bupropion
SSRIs, venlafaxine, duloxetine, mirtazapine and bupropion are frequently chosen as first-line therapy because of simplicity, side effect profiles, and community standards.
They generally lack the common adverse reactions (anticholinergic, sedative effects) of the tricyclics and cause fewer problems when taken in overdose. However, they may cause headache, nervousness, insomnia, and sexual side effects and may be more expensive because some may not yet be available as generics. Care must be taken to remain with either the brand name product or the same general product.
- Secondary Amine Tricyclics
The literature clearly supports the effectiveness of tricyclics. Because of associated side effects, they are used less frequently as first-line agents.
Secondary amine tricyclics cause less orthostatic hypotension and sedation than tertiary amine tricyclics.
These medications should be monitored cautiously in patients with heart problems, or in patients with potential for drug interactions. Monitoring blood levels and electrocardiogram (EKG) may be advised.
- Monoamine Oxidase Inhibitor (MAOI)
MAOIs, in general, should be restricted for patients who do not respond to other treatments because of their potential for serious side effects and the necessity of dietary restrictions. Patients with major depressive disorders with atypical features are one group for whom several studies suggest MAOIs may be particularly effective. However, in clinical practice, many psychiatrists start with SSRIs in such patients because of the more favorable adverse effect profile.
Medication interactions with antidepressant agents: Many antidepressant agents have clinically significant drug interactions, particularly those agents which undergo cytochrome P450 enzymatic metabolism in the liver. A complete discussion of this topic is beyond the scope of this guideline. Practitioners are advised to consult references such as the Physician's Desk Reference, American Hospital Formulary Service, Epocrates, or Micromedex for more information about drug interactions with specific agents, and to assess the significance of the interaction prior to prescribing antidepressants.
Elderly patients: Because of the potential for decreased renal and hepatic function, concomitant diseases and medications, the elderly are at higher risk of significant side effects or drug interactions with antidepressant medications. For elderly patients with moderate to severe depression, tricyclic antidepressants (TCAs) such as nortriptyline continue to be regarded as the most effective treatment [A], [C]. Consider starting at the lowest possible dose and increasing slowly to effective dose or until side effects appear. Tertiary amine tricyclics should generally be avoided in elderly patients because of the high incidence of orthostatic hypotension, sedation, cognitive problems, and cardiac effects with these agents.
Perinatal Depression Treatment
- Patient participation in shared treatment decision-making improves depression treatment adherence and clinical outcomes in depressed patients [C].
- Evidence of treatment success using psychotherapy alone [M].
- In order to assure optimal dosing and safety, medication management in the perinatal patient is best handled by a health professional with this specific expertise.
See the "Resources Available" section in the original guideline document for Wisner's Model and risk-benefit analysis decision-making tool.
Approximately 5% to 14% of women experience significant mood or anxiety symptoms during pregnancy [C]. Physicians must help patients weigh the risk of prenatal exposure to psychotropic medications against the risks of untreated psychiatric illness. The first line of treatment for mild to moderate depression includes increased instrumental support, which includes household tasks, childcare, etc., as well as interpersonal psychotherapy. When these non-medication options have failed or if patients have severe major depression or other Axis I (clinical disorders, other conditions that may be a focus of clinical attention) diagnoses, then the risks of untreated illness may outweigh the potential detrimental effects of certain antidepressant medications.
Risks of untreated maternal depression during pregnancy include:
- Preterm labor through increases in hormones [B]
- Preeclampsia – one study found depression was associated with a 2.5-fold increased risk [C]
- Increased risk of spontaneous abortion due to imbalance of nervous and endocrine systems [D], [R]
Maternal depression and impact on children [A], [C], [R]:
- Parental depression is among the most consistent and well-replicated risk factors for depression, anxiety and disruptive disorders in children. The best data thus far comes from the STAR*D Child Report, where untreated depressed mothers showed an 8% increase of psychiatric diagnoses in their children ages 7 to 17 years versus an 11% reduction in rates of psychiatric diagnoses when mothers were treated and reached remission. There was no improvement at all before mothers responded to treatment (response equals 50% reduction in symptoms) and more improvement as a mother reached remission. This highlights another important reason to treat depressed mothers and to treat remission.
Information is limited about the long-term neurobehavioral effects on children exposed in utero to antidepressants. Two studies have found that preschool children who had been exposed in utero to SSRIs or TCAs during the first trimester or throughout pregnancy had no difference in language, behavioral or intellectual development compared to non-exposed children.
There is no evidence that the tricyclic antidepressants or the SSRIs increase the risk of intrauterine death, fetal malformations, pregnancy complications or behavioral toxicity, except possibly paroxetine. Therefore, decisions regarding the treatment of depression during pregnancy must balance the risk to the mother and fetus secondary to untreated depression with the relative (although not absolute) safety of antidepressant treatment for this condition. Fetal or infant exposure to maternal depression may represent a stressful life event and increase the risk of future psychopathology in children [R].
Patients commonly underestimate the risks of untreated maternal psychiatric illness while over emphasizing the risks of their psychotropic medications. In a recent prospective study of women with a history of depression, 43% relapsed during their pregnancy. Half of these relapses occurred during the first trimester. Women who discontinued their antidepressant medication during the study period had a fivefold risk of relapse during their pregnancy compared to women who continued their antidepressant [B].
Misperception about risk can lead both providers and patients to terminate otherwise wanted pregnancies or avoid needed pharmacotherapy. By informing patients about the nature and magnitude of medication risks as well the risks of untreated illness, providers can help patients reach their own decisions. The clinician's goal is to provide a thorough risk-benefit assessment in order to minimize the risks of both depression and its treatment to the mother and child [R].
U.S. FDA Pregnancy Risk Categories:
(A) Controlled studies show no risk. Adequate, well-controlled studies in pregnant women have failed to demonstrate risk to the fetus. No currently available antidepressant medication is rated A.
(B) No evidence of risk in humans. Either animal findings show risk, but human findings do not; or if no adequate human studies have been done, animal findings are negative. Bupropion and maprotiline are rated B.
(C) Risk cannot be ruled out. Human studies are lacking, and animal studies are either positive for fetal risk or lacking. However, potential benefits may justify the potential risks. Amitriptyline, amoxapine, protriptyline, sertraline, trazodone, trimipramine, venlafaxine are rated C.
(D) Positive evidence of risk. Investigational or postmarketing data show risk to the fetus. Nevertheless, potential benefits may outweigh the potential risks. If needed in a life-threatening situation or a serious disease, the drug may be acceptable if safer drugs cannot be used or are ineffective. Imipramine and nortriptyline are rated D.
(X) Contraindicated in pregnancy. Studies in animals or human, or investigational or postmarketing reports have shown fetal risk which clearly outweighs any possible benefit to the patient. None of the currently available antidepressant medications are rated X.
The most reproductive safety information is available for the tricyclic antidepressants (TCAs) and SSRIs [B], [R]. Among the available pregnancy data, there is no evidence that these medications are associated with an increased risk of major congenital malformations. This is also true for sertraline, paroxetine, fluvoxamine, venlafaxine, and bupropion; however, there are fewer documented pregnancies with these medications.
In 2006 the FDA issued a warning for paroxetine due to an increased risk for cardiovascular malformations, primarily ventricular and atrial septal defects, compared to other antidepressants. Only first-trimester exposure to paroxetine at doses greater than 25 mg a day was associated with a greater risk of cardiac malformations in one study. Daily doses lower than 25 mg of paroxetine were not found to have an increased risk of any malformations in this study. Women of child-bearing age on paroxetine should be advised of the potential risk and other treatment options should be considered. The risk to infants exposed to paroxetine ranged from 1.5% to 2% compared to 1% in control groups [C], [R].
There have been many case reports of perinatal syndromes with TCAs (e.g., jitteriness, irritability, bowel obstruction, urinary retention) as well as different SSRIs. Other studies have found an association between prenatal SSRI exposure and preterm delivery. In general, these reports have been limited to case reports and small case series. There is also concern about the lack of control groups in these studies. In effect, some neonates in these reports may be exhibiting symptoms due to SSRI toxicity or withdrawal at birth, or alternatively, be more irritable and difficult to settle due to maternal depression and anxiety [B], [C], [R]. To avoid perinatal withdrawal syndromes, some support slowly tapering antidepressants in the weeks prior to delivery. This is a debated treatment strategy since it also theoretically withdraws antidepressants just as women are entering the postpartum period, a time of increased risk for mood or anxiety symptoms. There is currently no clear evidence to suggest that reducing or discontinuing antidepressants in late pregnancy will reduce adverse neonatal effects [R].
Persistent pulmonary hypertension (PPHN) was not found to be a risk of SSRIs or non-SSRIs by mothers prior to the 20th week of gestation. However, use of SSRIs in late pregnancy may increase the risk of PPHN. The absolute risk of developing PPHN is relatively small (6 to 12/1,000). Further studies are needed to evaluate the true risk of this potential complication [C], [R].
Exposure to SSRIs in pregnancy may be associated with adverse neonatal effects [R]. However, these are predominantly mild and short lived. Discontinuing antidepressants in women with a history of recurrent or severe depression is also associated with potentially adverse outcomes for both the mother and infant. Women with a history of depression who are planning to become pregnant should carefully consider the choice and timing of an antidepressant [B]. It is recommended that throughout the pregnancy if a medication is continued, the minimum effective dose of an antidepressant needed to get remission should be used with ongoing maternal monitoring [R]. The decision to continue treatment during the pregnancy should balance the risks and benefits to the mother and child and should be made on case-by-case basis [B], [C], [R].
Lactation: Current knowledge on the use of antidepressants during lactation is insufficient. No randomized controlled trials have been completed due to ethical concerns. Existing knowledge is based on case reports, case series and pharmacokinetic studies. Adverse events may be more likely to be reported than non-effects [R].
Antidepressants may appear in breast milk in low concentrations. Because of the long half-life of these drugs and their metabolites, nursing infants may have measurable amounts in their plasma and tissues, such as the brain. This is particularly important during the first few months of life, with immature hepatic and renal function. Because these drugs affect neurotransmitter function in the developing central nervous system, it may not be possible to predict long-term neurodevelopmental effects. Use only when clearly needed and potential benefits outweigh the risks to the nursing infant. (Adapted from American Academy of Pediatrics (AAP) Policy Statement, Transfer of Drugs and Other Chemicals Into Human Milk, Pediatrics 2001;108:776-789). Breast-feeding offers several advantages: a) Breast-fed infants have lower rates of gastrointestinal disease, anemia, respiratory ailments, and otitis media compared to formula-fed infants; b) Nursing provides a unique opportunity for maternal-infant bonding. At the same time, the postpartum period (first 3 months following childbirth) is a particularly vulnerable period for psychiatric illness in women. Issues to be addressed when assessing the risks and benefits of psychotropic drug use during breast-feeding include the documented benefits of nursing, the potential adverse impact of untreated maternal mental illness on infant attachment and cognitive and behavioral development, and the effects of untreated mental illness on the mother.
Depression in the postpartum period can be disabling. Trials of cognitive behavioral therapy or interpersonal therapy, while safe, may not be effective--resulting in the need for antidepressant trials and/or electroconvulsive therapy (ECT). The use of antidepressants by nursing mothers is often acceptable as long as the mother-infant pair is monitored for the emergence of adverse effects or complications. Tricyclic antidepressants appear to be safe. However, there was one case report of respiratory distress in an infant of a mother treated with doxepin suggesting that this antidepressant should be avoided during lactation. Data on the SSRIs suggest that sertraline and paroxetine are safe to use in nursing mothers suffering from depression.
There have been isolated case reports of infant toxicity in nursing mothers taking either doxepin or fluoxetine; however, studies have not revealed a consistent association between infant toxicity and any specific TCAs or SSRIs. The lack of adverse effects in 180 infants exposed to fluoxetine justifies its use especially if prescribed during the pregnancy or if there is a preferential history of response to this medication. Data on citalopram, fluvoxamine, bupropion and venlafaxine are more limited and their use cannot be recommended during breast-feeding at this time. Based on multiple case series, some researchers have recommended that the SSRI sertraline be considered the first-line treatment for nursing mothers with depression; however, sertraline may also carry risk in some mothers as demonstrated in one case report of an excessively high infant sertraline level in one mother-infant pair. Among the TCAs, nortriptyline has been the most studied treatment for nursing mothers, and no evidence of infant toxicity has been reported. Few studies have been done to evaluate the long-term consequences in children following antidepressant exposure through breast milk. One study followed children whose mothers nursed while taking TCAs. At preschool age these children were developmentally similar to non-exposed children. There have been no similar studies following children whose mother nursed while taking SSRIs [C], [R].
Herbals and Dietary Supplements
Caution: many drugs interact with St. John's wort, including other antidepressants, warfarin, oral contraceptives, antiretroviral, anti-cancer and anti-rejection drugs. Care should be taken to ask all patients what medications they are taking, including over-the-counter and supplements, to avoid these interactions.
Hypericum perforatum (St. John's wort) is popularly thought to be an herbal remedy for depression. The Hypericum Depression Trial Study Group concluded that the data does not support the use of Hypericum perforatum instead of antidepressants or psychotherapy. It has no proven efficacy in standard clinical care of patients with major depression.
SAM-e (S-adenosyl methionine). S-Adenosyl - L-methionine (SAM-e) is a natural compound that has been studied as a treatment option for depression. As of 2002, there were 11 controlled against placebo studies, 14 controlled against tricyclic antidepressant studies, and 2 meta-analyses. Essentially these studies show that SAM-e is superior to placebo and comparable to tricyclics in the treatment of outpatients with major depression. Effective oral doses seem to be in the 400 to 1,600 mg a day range as compared to doses of 400 mg a day of tricyclics. Side effects are less common than with tricyclics (7% with oral and intramuscular SAM-e versus 28% with oral tricyclic) and include mild insomnia, lack of appetite, constipation, nausea, dry mouth, diaphoresis, dizziness, and nervousness. Increased anxiety and hypomania have been reported in patients with bipolar depression. Interactions with other medications have not been studied and are unknown. Comparisons to newer antidepressants have not yet been done.
Other herbal remedies and dietary supplements, such as kava-kava, Omega-3 fatty acid, (docosahexaenoic acid) and valerian root, have not been proven effective for the treatment of depression and may or may not be safe [M], [R].
Herbal products and nutritional supplements are not evaluated or regulated by the U.S. Food and Drug Administration for safety, efficacy or bioavailability.
Establish Follow-Up Plan
Proactive follow-up contacts (in person, telephone) based on the Collaborative Care Model has been shown to significantly lower depression severity [A]. In the available clinical effectiveness trials conducted in real clinical practice settings, even the addition of a care manager leads to modest remission rates [A]. Interventions are critical to educating the patient regarding the importance of preventing relapse, safety and efficacy of medications and management of potential side effects. Establish and maintain initial follow-up contact intervals (office, phone, other) [A].
Depression Treatment and Follow-Up Based on Severity
Patient Health Questionnaire (PHQ-9) Score |
Depression Severity |
Treatment Recommendation |
Follow-up Interval |
10-14 |
Moderate |
Education, pharmacotherapy or
psychotherapy
Start treatment and follow-up plan, regularly re-evaluate and revise treatment plan
|
All depressed patients initially need weekly follow-up (phone or in person) for engagement in treatment, determining if following treatment plan, addressing side effects, and check if following through on any referrals.
If patient is responding, contacts can extend as far as monthly.
|
15-19 |
Moderately severe |
Education, pharmacotherapy and/or psychotherapy
Start treatment and follow-up plan, regularly re-evaluate and revise treatment plan
|
All depressed patients initially need weekly follow-up (phone or in person) for engagement in treatment, determining if following treatment plan, addressing side effects, and check if following through on any referrals.
If patient is responding, contacts can extend to every 2 to 4 weeks.
|
>20 |
Severe |
Education, pharmacotherapy and psychotherapy
Start treatment and follow-up plan, regularly re-evaluate and revise treatment plan
|
All depressed patients initially need weekly follow-up (phone or in person) for engagement in treatment, determining if following treatment plan, addressing side effects, and check if following through on any referrals.
Until significant response is achieved, contacts should remain weekly. Referral to mental health specialist may be warranted by primary care physician (PCP) or psychiatrist.
|
Adapted from Kroenke and Spitzer, Psychiatric Annals 32:9 / September 2002
If the primary care provider is seeing some improvement, continue working with that patient to augment or increase medication dosage to reach remission. This can take up to three months. Don't give up on the patient whether treating in primary care or referring. Stay connected through consultation or collaboration and take the steps needed to get the patient to remission. This can take longer and can take several medication interventions or other steps. The STAR*D studies have shown that primary care can be just as successful as specialty care [A].
Relapse Prevention
The prevention of relapse is of primary importance in the treatment of major depression. From 50% to 85% of people who suffer an episode of major depression will have a recurrence, usually within two or three years. Patients who have had three or more episodes of major depression are at 90% risk of having another episode. Relapse prevention interventions resulted in 13.9 additional depression-free days during a 12 month period [A].
Focused psychotherapy through cognitive-behavioral therapy can reduce relapse by assisting patients with their depression-related beliefs [A].
One study found that improving attitudes towards antidepressant medications along with the patient's ability to handle medication side effects are key factors in promoting greater adherence to maintenance treatment and thus greater likelihood of preventing relapse [A].
Collaboration with Mental Health
Consider collaborating with a behavioral health care provider for the following:
- Patient request for psychotherapy
- Presence of severe symptoms and impairment in patient, or high suicide risk
- Presence of other psychiatric condition (e.g., personality disorder, history of mania)
- Suspicion or history of substance abuse
- Clinician discomfort with the case
- Medication advice (psychiatrist or other mental health prescriber)
- Patient request for more specialized treatment