Practice Guideline Training Module One

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Practice Guideline Training Module One

• March, 2008

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TREATING MAJOR DEPRESSIVE DISORDER Press the
ltPAGE DOWNgt Button to continue
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This presentation was created with the assistance
of the University of Washingtons Psychiatric
Residency Training Program Spokane Track.
Special thanks are directed to Matt Layton, MD
(Program Director) and Michael Wu, MD (Chief
Resident).
Acknowledgement
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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 DISORDERThe 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.
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Self-administered clinical trainingFollowing
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.Press ltPAGE
DOWNgt to continue
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General Overview and ReferenceThis Power Point
training presentation is fully automated. To
manually view this training, you may use the
ltPAGE UPgt or ltPAGE DOWNgt 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.

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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.

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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 patients
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
  OF 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.

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Outline of This Presentation

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

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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)

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Psychiatric Management

• 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.

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Psychiatric Management

• 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 formulation
• Cultural considerations include culture,
  ethnicity, and disability and whether consumer
  identifies with this culture.
• Social History
• Current Living Arrangement
• Sexual 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

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Psychiatric Management

• 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

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Psychiatric Management

• 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.

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Psychiatric Management

• 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).

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Psychiatric Management

• 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.

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Psychiatric Management

• 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 consumers life.
• The ITP will be coordinated with other support
  systems, both formal and informal.

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Psychiatric Management

• 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.

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Psychiatric Management

• 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

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Psychiatric Management

• 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.

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Psychiatric Management

• 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.

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Psychiatric Management

• 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)

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Quiz questions- True or False

• Suicidal or homicidal ideation is a factor to
  consider in the Psychiatric Management phase of
  treatment.
• Although important, establishing a therapeutic
  alliance is not a primary consideration in
  following this practice guideline.
• Press ltPAGE DOWNgt to continue

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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

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Acute Phase Treatment

• 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

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Acute Phase Treatment

• 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

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Acute Phase Treatment

• 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)

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Acute Phase Treatment

• 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.

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Acute Phase Treatment

• 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

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Acute Phase Treatment

• 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)

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Acute Phase Treatment

• Implementation of Antidepressant Therapy
• Generally start at dosage levels suggested
• Titrate to full therapeutic dosage, taking the
  following considerations into account
• Side effects
• Patients 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,
• patients cooperation with treatment,
  availability of social supports, and
• presence of comorbid general medical problems.

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Acute Phase Treatment

• 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).

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Acute Phase Treatment

• 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).

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Acute Phase Treatment

• 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

36
Acute Phase Treatment

• 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

37
Acute Phase Treatment
Choice of Medication Plus Psychotherapy Consider
the same issues that influence the choice of
medication If 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.
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Acute Phase Treatment
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.
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Quiz questions-True or False

• 3. Relapse may be preventable if the clinical
  staff monitor the consumers 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.
• Press ltPAGE DOWNgt to continue

40
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.

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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.

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Quiz questions-True or False

• 7. It is best to discontinue medications as early
  as possible in the treatment of depression.
• Press ltPAGE DOWNgt to continue

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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.

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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).

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Quiz questions-True or False

• 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.
• Press ltPAGE DOWNgt to continue

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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

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Discontinuation of Active Treatment

• 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.

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Discontinuation of Active Treatment

• 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

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Discontinuation of Active Treatment

• When discontinuing psychotherapy, the best
  method depends on the patients needs and type of
  psychotherapy, the duration of treatment, and the
  intensity of treatment.

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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
shorterhalf-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.
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Quiz questions- True or False

• 10. When deciding to discontinue treatment, the
  BHO authorization period is the primary
  consideration.
• Press ltPAGE DOWNgt to continue

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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 consumers 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)

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Upon completion of this module

• 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.

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For additional information or questions..

• Please contact
• Glenn Lippman, MD (lipberry2_at_msn.com)