Depression Practice Guidelines

Practice Guideline Training Module One

March, 2008

TREATING MAJOR DEPRESSIVE DISORDER

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This presentation was created with the assistance of the University of Washington’s Psychiatric Residency Training Program – Spokane Track. Special thanks are directed to Matt Layton, MD (Program Director) and Michael Wu, MD (Chief Resident).

Acknowledgement

Greater Columbia Behavioral Health selected two practice guidelines in 2007 based upon the recommendations of the Mental Health Division (MHD) and the External Quality Review Organization (EQRO). The two practice guidelines selected include:

- THE GENERAL ADULT PSYCHIATRIC EVALUATION - TREATING PATIENTS WITH MAJOR DEPRESSIVE DISORDER

The following practice guideline is not a directive but serves as a guide in the provision of treatment to assist the clinical staff in reaching the best possible outcomes for consumers.

Interspersed throughout this presentation, you will find colored notations based on the GCBH Clinical Review process. These “GCBH Comments” are intended to be helpful hints as to how you might apply the principles contained within the Practice Guideline in your day-to-day clinical activities….

Self-administered clinical training

Following this training, you will be asked to complete a training post-test. This test will consist of 10 questions taken from the Power Point presentation. You may use the page up or page down buttons to review the training materials. Once the post-test is completed, please complete the attached word document attesting to successful completion of the training and post-test and retain it and your completed Quiz as evidence that you completed this module. Also, please inquire of your Human Resources office as to whether a copy of these items should be placed into your training/personnel file.

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General Overview and Reference

This Power Point training presentation is fully automated. To manually view this training, you may use the <PAGE UP> or <PAGE DOWN> keys

This training is based on Practice Guideline for the Treatment of Patients With Major Depressive Disorder, Second Edition, originally published in April 2000. A guideline watch, summarizing significant developments in the scientific literature since publication of this guideline, may be available in the Psychiatric Practice section of the APA web site at www.psych.org.

Introduction to this training

In 2007 the Board of Greater Columbia Behavioral Health adopted two Practice Guidelines, including this one addressing the treatment of Depression.

As a service to the community, this Guideline has been organized into a self examination format so that you can review its content and then complete a self-assessment exam.

Copies of the completed exam and the attestation (attached as a word document) should be retained for your training records – and may be also placed into your agency personnel file as evidence that you completed this program.

More importantly, it is hoped that you will adopt aspects of this training into your clinical practice as discussed in the next slide….as noted earlier, GCBH has included “Comments” drawn from our Clinical Review process which are intended to provide you some ideas about how to incorporate this Practice Guideline into your day-to-day clinical activities.

What is a Practice Guideline ?

The American Psychiatric Association (APA) Practice Guidelines and the Quick Reference Guides are not intended to be construed or to serve as a standard of medical care. This guideline serves as an overview of a general adult psychiatric evaluation made for purposes of education and review.

Standards of medical care are determined on the basis of all clinical data available for an individual patient and are subject to change as scientific knowledge and technology advance and practice patterns evolve.

These parameters of practice should be considered guidelines only. Adherence to them will not ensure a successful outcome for every individual, nor should they be interpreted as including all proper methods of care or excluding other acceptable methods of care aimed at the same results.

This practice guideline presumes familiarity with basic principles of psychiatric diagnosis and treatment planning. Psychiatric evaluations vary according to their purpose and the specific emphasis of an evaluation will vary according to its purpose and the patient’s presenting problem. Documentation is an integral part of an evaluation, detail of clinically appropriate documentation also will vary with the patient, setting, clinical situation, and confidentiality issues.

The ultimate judgment regarding a particular clinical procedure or treatment plan must be made by clinical staff in light of the clinical data presented by the patient and the diagnostic and treatment options available.

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Outline of This Presentation

Training objectives-Participants of this training will:

Develop an understanding of the clinical considerations for a comprehensive Assessment, development of an Individualized Treatment Plan, and documenting progress following the TREATMENT TREATMENT OF DEPRESSION practice guidelinesOF DEPRESSION practice guidelines. This understanding will be assessed and demonstrated by taking a ten question quiz which will be submitted to the employer and to Greater Columbia Behavioral Health.

Outline of This Presentation

Psychiatric Management Acute Phase Treatment Continuation Phase Maintenance Phase Discontinuation of Active Treatment

Psychiatric Management

GCBH Commentary…

All eligible Medicaid recipients are entitled to an Intake Assessment to: Establish Medical Necessity Develop a multifaceted clinical formulation Provide a guide for the development of an individualized

Treatment Plan Aid the clinician in maintaining focus during treatment (continuity

of care)


Throughout the formulation of a treatment plan and all subsequent phases of treatment, the following principles of psychiatric management should be kept in mind:

Perform a diagnostic evaluation. Determine whether the diagnosis is depression. Determine whether there is psychiatric and general medical

comorbidity. Include the general domains of an evaluation, refer to the general

psychiatric evaluation of an adult.


GCBH Commentary:

The assessment contains:Current Status: age, ethnicity, gender, comment about living situation, parent/legal guardian status, marital status, referral source, reason for referral, and other very brief information that may be expanded on later in the assessment.Consumer statements of presenting problems/concerns and clinical formulationCultural considerations: include culture, ethnicity, and disability and whether consumer identifies with this culture.Social HistoryCurrent Living ArrangementSexual orientation- This is a reportable data element to the state MHD, and is a consideration in providing culturally appropriate services.Work/Education - Summarize consumer's history of functioning in these settings and how successful they have been.Medical - Basic medical information to include a statement of significant health history or lack thereof.Developmental History


Evaluate the safety of the patient and others. Assessment of suicide risk is essential, consider:

Presence of suicidal or homicidal ideation, intent, or plans Access to means for suicide and the lethality of those means Presence of psychotic symptoms, command hallucinations, or

severe anxiety Presence of alcohol or substance use History and seriousness of previous attempts Family history of or recent exposure to suicide


•If the patient demonstrates suicidal or homicidal ideation, intention, or plans, close monitoring is required.•Hospitalization should be considered if risk is significant.•Note, however, that the ability to predict attempted or completed suicide is poor

•Establish and maintain a therapeutic alliance.•It is important to pay attention to the concerns of the patient and his or her family.•Be aware of transference and countertransference issues.


•Evaluate and address functional impairments.

•Impairments include deficits in interpersonal relationships, work and living conditions, and other medical- or health-related needs.•Address identified impairments (e.g., scheduling absences from work).


Determine the appropriate treatment setting considering:

• Clinical condition (including symptom severity, comorbidity, suicidality, homicidality, and level of functioning)• Available support systems• Ability of the patient to adequately care for self, provide reliable feedback to the psychiatrist, and cooperate with treatment• Consider hospitalization if a serious threat of harm to self or others exists, if patient is severely ill, lacks adequate supports or has severe comorbid medical problems or poor response to outpatient treatment.


GCBH Commentary:

• An Individualized Treatment Plan (ITP) is designed for each consumer and is based on the Assessment including strengths and needs and information gathered from other resources.

• The clinician develops the plan with the consumer; the family; or the guardian/care giver. The plan sets goals and identifies treatment and services to meet the needs of consumer.

• Services/supports are based on information gathered in the Assessment. The consumer and the clinician prioritize goals to address needs within all aspects of the consumer’s life.The ITP will be coordinated with other support systems, both formal and informal.


•Monitor psychiatric status and safety.•Monitor the patient for changes in destructive impulses to self and others.•Be vigilant in monitoring changes in psychiatric status, including major depressive symptoms and symptoms of potential comorbid conditions.•Consider diagnostic reevaluation if symptoms change significantly or if new symptoms emerge.


GCBH Commentary:

When required, a current crisis plan will be developed with the consumer; family; and supports that includes: How and when the plan will be activated The steps that will be taken Supports to help avoid a more restrictive level of care, and The consumer, family, and supports have a copy of the crisis

plan


•Enhance medication adherence.•Emphasize and clarify medication schedule, the typical time course for treatment response, need to continue medication, need to consult with the prescribing doctor before medication discontinuation, and what to do if problems arise.•Improve adherence in elderly patients by simplifying the medication regimen and minimizing cost.•Consider psychotherapeutic intervention for serious or persistent nonadherence.


•Address early signs of relapse.•Inform the patient (and, when appropriate, the family) about the significant risk of relapse.•Educate the patient (and the family) about how to identify early signs and symptoms of new episodes.•Emphasize seeking help if signs of relapse appear, to prevent full blown exacerbation.


GCBH Commentary:

The clinical record demonstrates congruent treatment; i.e., there is an interactive relationship between person circumstances, treatment provision, and treatment planning: Progress notes show that treatments are in accordance with the

ITP The case record documents consumer progress toward

treatment goals. Progress notes show when extraordinary treatments occur

(compared with the treatment plan)

Quiz questions- True or False

1. Suicidal or homicidal ideation is a factor to consider in the Psychiatric Management phase of treatment.

2. Although important, establishing a therapeutic alliance is not a primary consideration in following this practice guideline.


Acute Phase Treatment

Choice of Initial Treatment Modality: Pharmacotherapy alone

Pharmacotherapy according to severity of depressive episode Mild

Antidepressants if preferred by patient Moderate to severe

Antidepressants are treatment of choice (unless electroconvulsive therapy [ECT] is planned)

With psychotic features Antidepressants plus antipsychotics or ECT


Features suggesting that medication may be the preferred treatment include the following:

History of prior positive response Severe symptomatology, significant sleep or appetite

disturbances or agitation Anticipation of need for maintenance therapy Patient preference Lack of available alternative treatment modalities


Psychotherapy Alone If the severity of the depressive episode is mild to moderate, use

psychotherapy if preferred by the patient. Features suggesting the use of psychotherapeutic interventions

include the following: Presence of significant psychosocial stressors Intrapsychic conflict Interpersonal difficulties Comorbid personality disorder Pregnancy, lactation, or wish to become pregnant Patient preference


Combined Pharmacotherapy and Psychotherapy Consider the use of combined pharmocotherapy and

psychotherapy if the severity of the major depressive episode is mild to severe with clinically significant psychosocial issues, interpersonal problems, or a comorbid personality disorder.

Other features suggesting combination treatment include the following:

History of only partial response to single treatment modalities

Poor adherence to treatments (combine medication with a psychotherapeutic approach that focuses on treatment adherence)


Electroconvulsive Therapy Consider ECT if any of the following features are present:

Major depressive episode with a high degree of symptom severity and functional impairment

Psychotic symptoms or catatonia Urgent need for response (e.g., suicidality or nutritional

compromise in a patient refusing food) ECT may be the preferred treatment when

The presence of comorbid medical conditions precludes the use of antidepressant medications,

there is a prior history of positive response to ECT, or the patient expresses a preference for ECT.


Choice of Antidepressant Principles of Choosing an Initial Antidepressant

Because there is comparable efficacy between and within classes of medications, the initial selection is based largely on the following considerations:

Anticipated side effects Safety or tolerability of side effects for individual patients Patient preference Quantity and quality of clinical trial data Cost


Based on these factors, the following medications are likely to be effective for most patients: selective serotonin reuptake inhibitors (SSRIs), desipramine, nortriptyline, bupropion, venlafaxine, and mirtazapine.

Consider other features, including the following: History of prior response with a particular antidepressant Presence of comorbid psychiatric or general medical

conditions (e.g., tertiary amine tricyclic antidepressants [TCAs] may not be optimal in patients with cardiovascular conditions or acute-angle glaucoma)


Implementation of Antidepressant Therapy Generally start at dosage levels suggested Titrate to full therapeutic dosage, taking the following considerations into

account: Side effects Patient’s age Comorbid illnesses (e.g., starting and therapeutic doses should be

reduced [generally to half] in elderly or medically frail patients) Determine the monitoring frequency. Frequency depends on:

suicide risk, side effects or drug interactions, patient’s cooperation with treatment, availability of social supports,

and presence of comorbid general medical problems.


Monitor to assess the following: Treatment response Side effects Clinical condition Safety

Monitor adults closely for worsening of depression and for increased suicidal thinking or behavior, as some evidence suggests that antidepressant treatment may increase suicidality in children and adolescents (see web sites of the FDA [http://www.fda.gov], the American Academy of Child and Adolescent Psychiatry [http://www.aacap.org], and the APA [http://www.psych.org]).


Revise the treatment plan and consider the following options if needed: Maximize the initial therapeutic treatment dose.

For partial responders, extend the trial (e.g., by 2 to 4 weeks). For nonresponders on moderate doses or those with low serum

levels, raise the dose and monitor for increased side effects. Add, change, or increase the frequency of psychotherapy. Switch to another non-MAOI medication in either the same class or a

different class, particularly if there is lack of partial response. Especially if there is partial response, augment with

a non-MAOI antidepressant from a different class (be alert to drug-drug interactions) To avoid polypharmacy the GCBH recommendation is that documentation be present to explain the use of two or more medications of the same class for the same diagnosis, or

another adjuvant medication (e.g., lithium, thyroid hormone, anticonvulsants, psychostimulants).


Switch to an MAOI. Institute ECT.

Choice of Psychotherapy Principles of Choosing a Psychotherapy

Choose the modality of therapy: Cognitive behavior therapy and interpersonal therapy have the best

research-documented efficacy. Psychodynamic psychotherapy, supported by broad clinical

consensus, is usually oriented toward both symptomatic improvement and broader personality issues.

Consider other factors: Patient preference Availability of clinicians with appropriate training and expertise in the

specific approach


•Psychotherapy Implementation•Determine the frequency of psychotherapy.

•Frequency generally ranges from once to several times per week in the acute phase and depends on specific type and goals of psychotherapy,

•need to create and maintain a therapeutic relationship,•need to ensure treatment adherence, and•need to monitor and address suicidality.

•In situations with more than one treating clinician, maintain ongoing contact with the patient and other clinicians.•If the patient does not show at least moderate improvement after 4 to 8 weeks, conduct a thorough review and reappraisal


Choice of Medication Plus Psychotherapy

Consider the same issues that influence the choice of medicationIf the patient does not show at least moderate improvement after 4 to 8 weeks, conduct a thorough review, including of adherence and pharmacokinetic/pharmacodynamic factors.


If the patient does not show at least moderate improvement after an additional 4 to 8 weeks following a change, conduct another thorough review and consider consultation or possibly ECT.

Assessing Adequacy of Treatment Response

Do not conclude acute phase treatment if the patient shows only partial response. Partial response is associated with poor functional outcome.

Quiz questions-True or False

3. Relapse may be preventable if the clinical staff monitor the consumer’s response to treatment.

4. It may be adequate to treat depression with psychotherapy only.

5. General medical conditions play minimal role in diagnosis and treatment of depression.


Continuation Phase

The continuation phase is defined as the 16- to 20-week period after sustained and complete remission from the acute phase.

To prevent relapse, continue antidepressant medication at the same dose used during the acute phase.

Consider the use of psychotherapy to help prevent relapse. Consider providing ECT if medication or psychotherapy has not

been effective. Set frequency of visits depending on clinical condition and specific

treatments used. Frequency can vary from once every 2 to 3 months to multiple times per week.

Continuation Phase

GCBH Commentary:

Progress notes show that the treatment provider has regular contact with natural supports.

For persons with inpatient admissions, the chart shows that the provider observed principles of continuity and coordination of care.


7. It is best to discontinue medications as early as possible in the treatment of depression.


Maintenance Phase

The goal during the maintenance phase is to prevent recurrences of major depressive episodes. Considerations in the decision to use maintenance treatment include, risk of recurrence, severity of episodes, risks of suicide, side effects experienced with continuous treatment and patient preferences

Continue using the treatment that was effective in the acute and continuation phases.

Employ the same full antidepressant medication dosages used in prior phases of treatment.

Maintenance Phase

Set the frequency of visits according to clinical condition and specific treatments used. Frequency can range from as low as once every 2 to 3 months

for stable patients to as high as multiple times per week for those in psychodynamic psychotherapy.

Consider ECT maintenance for patients who have repeated moderate or severe episodes despite adequate pharmacological treatment (or who are unable to tolerate maintenance medication).


8. The Maintenance Phase of treatment requires that clinical staff continue therapies that worked previously.

9. Setting frequency of visits are determined by the clinical condition and specific treatments used.


Discontinuation of Active Treatment

GCBH Commentary…

A review of progress in relation to agreed treatment outcomes has occurred at least once in the past 180-days, including a review of level of care, effectiveness of the plan of treatment, ongoing needs and outcomes, and the development of new goals

Level of care, frequency, duration, and type(s) of treatment provided are reviewed every 90 days to check clinical efficiency and effectiveness


GCBH Commentary…

The chart documents whether, in the last six months, the individual has increased the level of normal daily activities. For children, examples are: Increased school attendance,

improved grades, increased involvement in recreation or hobbies, increased social interaction.

For Adults, examples are: Shopping regularly, participation in education, participation in social activities (such as clubs, attending church, social activity programs), participating in recreation, using library facilities, or engaging in other enjoyable activities.


Consider whether to discontinue treatment based on the same factors considered in the decision to initiate maintenance treatment. For example, consider the probability of recurrence and the frequency and severity of past episodes. As well, consider risk factors for recurrence including persistence of dysthymic symptoms after recovery, presence of an additional nonaffective psychiatric diagnosis and presence of a chronic general medical condition


When discontinuing psychotherapy, the best method depends on the patient’s needs and type of psychotherapy, the duration of treatment, and the intensity of treatment.

Discontinuation of Active Treatment Continued

To discontinue pharmacotherapy, taper the dose over at least several weeks.

Facilitates more rapid return to a full dose if symptoms recur.

Minimizes the risk of antidepressant discontinuation syndromes (more likely with shorter–half-life antidepressants).

Establish a plan to restart treatment in case of relapse.

If the patient experiences a relapse when medication is discontinued, resume the previously successful treatment.

Quiz questions- True or False

10. When deciding to discontinue treatment, the BHO authorization period is the primary consideration.


Self-Administered Test Answers

The correct answers for the quiz questions are as follows:

1. Suicidal or homicidal ideation is a factor to consider in the Psychiatric Management phase of treatment. TRUE (SLIDE 14)

2. Although important, establishing a therapeutic alliance is not a primary consideration in following this practice guideline. FALSE (SLIDE 18)

3, Relapse may be preventable if the clinical staff monitor the consumer’s response to treatment. TRUE (SLIDE 22)

4. It may be adequate to treat depression with psychotherapy only. TRUE (SLIDE 27)5. General medical conditions play minimal role in diagnosis and treatment of depression. FALSE

(SLIDE 29)6. If the consumer does not show improvement in 4 to 8 weeks, the clinician should conduct a

thorough review and reappraisal and if necessary choose a different course of treatment. TRUE (SLIDE 36)

7. It is best to discontinue medications as early as possible in the treatment of depression. FALSE (SLIDE 48)

8. The Maintenance Phase of treatment requires that clinical staff continue therapies that worked previously. TRUE (SLIDE 43)

9. Setting frequency of visits are determined by the clinical condition and specific treatments used. TRUE (SLIDE 32)

10. When deciding to discontinue treatment, the BHO authorization period is the primary consideration. FALSE (SLIDE 48)

Please review and sign the attached attestation form and retain it and your completed Quiz as evidence that you completed this module.

Also, please inquire of your Human Resources office as to whether a copy of these items should be placed into your training/personnel file.

Upon completion of this module…

For additional information or questions…..

Please contact:

Glenn Lippman, MD ([email protected])

Documents

Depression Practice Guidelines