Major Depression in Adults in Primary Care

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Source: Institute for Clinical Systems Improvement (ICSI). Major depression in adults in primary care. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2008 May. 84 p. Major Depression in Adults in Primary Care Suspect and screen for major depression: (see also box #1a) *Presentations (in addition to obvious sadness). *Risk Factors. Use measurable tool at screening for baseline intensity and at follow-up for adequate response. A The two-question screen: Over the past month have you been bothered by: 1. Little interest or pleasure in doing things? 2. Feeling down, depressed, or hopeless? Diagnose and characterize major depression with clinical interview to include: *DSM-IV TR criteria (see box #2a). *History of present illness. (Onset and severity of symptoms, functional impairment, past episodes and psychosocial stressors). *Pertinent medical history, especially illness that can cause depression. *Assess for current substance abuse, withdrawal or medications that can cause depression. A DSM-IV TR Criteria for Major Depressive Episode: Must have a total of 5 symptoms for at least 2 weeks. One of the symptoms must be depressed mood or loss of interest. 1. Depressed mood. 2. Markedly diminished interest or pleasure in all or almost all activities. 3. Significant (greater than 5% body weight) weight loss or gain, or increase or decrease in appetite. 4. Insomnia or hypersomnia. Greater than or equal to 5 DSM-IV TR criteria present? A Consider other mood and anxiety disorders or somatoform disorders. A 5. Psychomotor agitation or retardation. 6. Fatigue or loss of energy. 7. Feeling of worthlessness or inappropriate guilt. 8. Diminished concentration or indecisiveness. 9. Recurrent thoughts of death or suicide. *Use your organization's protocol to assess and minimize suicide risk. *Consider hospitalization. *Out of guideline. Is patient unsafe to self or others? A Involve behavioral/chemical health. A Assess need for additional resources: substance abuse or psychiatric comorbidity, especially bipolar disorder? A Additional considerations? (medical comorbidity, cultural considerations, special populations). A Address secondary causes and/or adapt a plan for the special population. A Treatment Plan *Collaborative care. *Educate and engage patient. *Discuss treatment options. *Establish follow-up plan. *Use measurable tool at screening for baseline intensity and at follow-up for adequate reponse. A Is patient responding adequately? A Continuation and maintenance treatment duration based on episode. A Evaluate dose, duration, type and adherence with medication and/or psychotherapy. Reconsider accuracy of diagnosis or impact of comorbidities. A Consider other strategies: *Augmentation therapy. *Hospitalization. *Light therapy. *Electroconvulsive treatment (ECT). A A = Annotation All copyrights are reserved by the Institute for Clinical Systems Improvement, Inc.