CURRENT PRACTICES IN THE DIAGNOSIS AND TREATMENT OF DEPRESSION

1
CURRENT PRACTICES IN THE DIAGNOSIS AND TREATMENT
OF DEPRESSION

• Best Practices in Primary Care

2
Learning Objectives

• By the end of this presentation, the participants
  will be familiar with up-to-date information
  surrounding depressive disorders, including
• Current standards and guidelines for screening,
  diagnosis, and treatment
• Challenges and barriers to detection and
  treatment
• Thoughts on improving depression care

3
Introduction to Depressive Disorders

• Depressive disorders are common
• 4.88.6 of patients seen in primary care1
• 4th most common source of disability worldwide2
• The 3 most prevalent depressive disorders
  described by the DSM-IV are3
• Dysthymia
• Major depressive disorder (MDD)
• Bipolar depression (as a part of Bipolar Disorder)

• Katon W. Gen Hosp Psychiatry. 199214(4)237.
• Ustun TB. Br J Psychiatry. 2004184386.
• APA. DSM-IV-TR. Washington, DC APA 2000.

4
Introduction to Depressive DisordersSuccessful
Management of Patients

• Patient awareness
• Early and accurate detection
• Consideration of disparities in care
• Please see the accompanying module, Disparities
  in the Diagnosis and Treatment of Depression
• Cultural competence
• Please see Transcultural Issues in the Diagnosis
  and Treatment of Depression
• Thorough assessment
• Knowledge of current guidelines
• Appropriate and individualized treatment

5
Introduction to Depressive Disorders

• Diagnosis and treatment of these disorders can be
  challenging because of their complex etiologies,
  symptoms, and severity
• Diagnosis requires a careful assessment of each
  patients
• Longitudinal history of symptoms and treatments
• Current mood state
• Comorbid diseases and conditions
• Substance abuse
• Other factors (eg, socioeconomic and
  environmental stressors)

6
Dysthymia

• Chronic, less severe mood disorder
• gt2 years of depressed mood for most of the day,
  on more days than not
• Additional depressive symptoms (2 or more)
• Poor appetite or overeating
• Insomnia or hypersomnia
• Low energy or fatigue
• Low self-esteem
• Poor concentration
• Feelings of hopelessness

APA. DSM-IV-TR. Washington, DC APA 2000380.
7
Major Depressive Disorder

• Characterized by 1 or more major depressive
  episodes
• A major depressive episode consists of
• 2 weeks of depressed mood and/or loss of interest
• 4 additional symptoms nearly every day, such as
• Insomnia or hypersomnia
• Psychomotor agitation or retardation
• Fatigue or loss of energy
• Feelings of worthlessness or guilt
• Diminished ability to think or concentrate
• Recurrent thoughts of death or suicide

APA. DSM-IV-TR. Washington, DC APA 2000356.
8
Screening for Dysthymia and MDD

• Little evidence to recommend one formal screening
  tool over another
• Screen adult patients with increased risks for
  depression
• Chronic pain or illness
• Personal or family history of depression
• Stressful life events
• Potential harms of screening
• False-positive results
• Inconvenience of further work-up
• Adverse effects and costs of treatment for
  patient
• Labeling

US Preventive Services Task Force. Ann Intern
Med. 2002136760.
9
Screening for Dysthymia and MDD (cont)

• Multiple screening tools exist for adults,14
  including
• However, asking 2 questions about mood changes
  can be as effective as longer screening tools2,5

• Means-Christensen AJ. Gen Hosp Psychiatry.
  200628108.
• Thibault JM. Am Fam Physician. 2004701101.
• Pignone MP. Ann Intern Med. 2002136765.
• McIntyre RS. Can Med Assoc J. 20051731327.
• Whooley MA. J Gen Intern Med. 199712439.

10
Screening for Dysthymia and MDD (cont)

• How effective are screening instruments in
  detecting depression?
• Meta-analysis of 18 studies comparing the
  effectiveness of screening instruments in primary
  care settings
• Revealed an overall average sensitivity of 84
  and a specificity of 72
• BDI, CES-D, GHQ, HSCL, MOS-D, ID, PRIME-MD,
  SDDS-PC, and
• SDS instruments were compared

BDI Beck Depression Inventory CES-D Center
for Epidemiologic Studies Depression Screen GHQ
General Health Questionnaire HSCL Hopkins
Symptoms Checklist MOS-D Medical Outcomes Study
Depression Screen ID Popoff Index of
Depression PRIME-MD Primary Care Evaluation of
Mental Disorders SDDS-PC Symptom Driven
Diagnostic System-Primary Care SDS Zung
Self-Assessment Depression Scale
Mulrow CD. Ann Intern Med. 1995122912.
11
Screening for Dysthymia and MDD (cont)

• Does screening improve outcomes?
• A systematic review for the US Preventive
  Services Task Force analyzed studies to determine
  if screening in primary care settings improves
  recognition, treatment, and clinical outcomes
• Results indicated an overall reduction in risk
  for persistent depression
• Instruments compared BDI, CES-D, GHQ, MOS-D,
  PRIME-MD, SDDS-PC, SDS, 2-item instrument

Pignone MP. Ann Intern Med. 2002136765.
12
Screening for Dysthymia and MDD (cont)

• Patient Health Questionnaire-2 (PHQ-2)1
• Adapted from the PRIME-MD screening tool1,2
• Used as an initial screening tool to detect
  depressive disorders1,2
• 2 versions1,2
• Yes/no questions Over the past 2 weeks, have
  you felt down, depressed, or hopeless? and Over
  the past 2 weeks, have you felt little interest
  or pleasure in doing things?
• Sensitivity, 96 specificity, 57
• Rating scale (03) and different time frames,
  responses, and scoring, for greater accuracy
• A score 3 points sensitivity, 83 specificity
  92, for MDD
• A positive PHQ-2 screen calls for diagnosis
  confirmation with the PHQ-91

• Thibault JM. Am Fam Physician. 2004701101.
• Whooley MA. J Gen Intern Med. 199712439.

13
Screening for Dysthymia and MDD (cont)

• Patient Health Questionnaire-9 (PHQ-9)
• 9-item questionnaire consisting of the 9 criteria
  for diagnosing disorders contained in the
  DSM-IV-TR,1 including
• MDD
• Anxiety disorder
• Panic disorder
• Alcohol abuse
• Somatoform disorders
• Multi-purpose instrument1,2 successful in
• Diagnosing certain mental disorders, including
  depressive disorders, according to DSM-IV-TR
  criteria
• Assessing depression severity over time

• Kroenke K. J Gen Intern Med. 200116606.
• Thibault JM. Am Fam Physician. 2004701101.

14
Screening for Dysthymia and MDD (cont)

• PHQ-9 (cont)
• Comparable sensitivity and specificity to longer
  questionnaires1,2
• Overall sensitivity1 84
• Overall specificity1 72
• Feasible for primary care due to brevity and low
  time requirement during office visits1,2
• In combination with the PHQ-2 screening tool, the
  PHQ-9 demonstrates a 95.1 accuracy in diagnosing
  a major depressive episode.2

• Kroenke K. J Gen Intern Med. 200116606.
• Thibault JM. Am Fam Physician. 2004701101.

15
Screening for Dysthymia and MDD (cont)

• Anxiety and Depression Detector (ADD)
• Succinct 5-question screening instrument for
  depression, anxiety, panic disorder, social
  phobia, and posttraumatic stress disorder
• Successful in screening for depressive disorders
  regardless of age, gender, or ethnicity
• Useful and valid
• Sensitivity 9296
• Specificity 5782
• Increased likelihood of use for screening
  patients in primary care settings because of its
  brevity

Means-Christensen AJ. Gen Hosp Psychiatry.
200628108.
16
Screening for Dysthymia and MDD Across Racial and
Ethnic Populations

• Physicians must be aware that
• Disease may present as a culture-bound syndrome1
• Variable presenting symptoms, influenced by
  culture
• Depression screening instruments may not reflect
  the language and culture of African Americans,
  Hispanics, Asians, and other racial and ethnic
  groups2
• Verbal descriptions of depression-associated
  emotional concepts tend to be unique to
  particular cultures2
• See Disparities in the Diagnosis and Treatment of
  Depression for more information

• APA. DSM-IV-TR. Washington, DC APA 2000.
• Rait G. Age Aging. 199827271.

17
Diagnosis of Dysthymia and MDD

• A positive screening test result should lead to a
  full diagnostic interview
• Prevailing standard for diagnosis DSM-IV-TR
  criteria
• The psychiatric interview includes

US Preventive Services Task Force. Ann Intern
Med. 2002136760.
18
Diagnosis of Dysthymia and MDD (cont)

• Psychiatric review of symptoms
• The mnemonic Depressed patients seem anxious, so
  claim psychiatrists can help physicians remember
  to screen for other/comorbid psychiatric
  disorders
• Depression
• Personality disorders
• Substance abuse disorders
• Anxiety disorders
• Somatization disorders
• Cognitive disorders
• Psychotic disorders

19
Diagnosis of Dysthymia and MDD (cont)

• Mnemonic for symptoms of major depression and
  dysthymia
• SIGECAPS
• Sleep disturbance
• Interest loss
• Guilt
• Energy deficit
• Concentration deficit
• Appetite disturbance
• Psychomotor retardation or agitation
• Suicidality

20
Benefits of Diagnosis and Treatment

• Effective diagnosis and treatment may
• Halt or slow progression of disease1
• Help avoid long-term interpersonal and
  psychosocial problems1
• Decrease the risk for comorbid illness1,2
• Help avoid substance abuse and suicidal behavior1
  
• Improve daily functioning1

• Saluja G. Arch Pediatr Adolesc Med. 2004158760.
  
• Aina Y. J Am Osteopath Assoc. 2006106S9.

21
Barriers to Detection and Treatment of Depressive
Disorders

• Patients
• May be mistrustful of hospitals, institutions,
  and physicians1,2
• May not accept diagnosis or may resist treatment
  (especially with mild depression)3
• May perceive a poor relationship with their
  physician1
• May have a low level of health literacy1
• May feel that a stigma surrounds psychiatric
  diagnoses1,3
• May have decreased access to appropriate mental
  health care due to socioeconomic factors and
  geographic factors1

• US Dept. of Health and Human Services. Mental
  Health Culture, Race, and Ethnicity
  A Supplement to Mental Health
  A Report of the Surgeon General. Rockville, MD
  2001.
• Boulware LE. Public Health Rep. 2003118358.
• Klinkman MS. J Clin Psychiatry. 20036419.

22
Barriers to Detection and Treatment of Depressive
Disorders

• Physicians
• May adopt a wait-and-see attitude1
• May not have adequate time for thorough
  assessment1
• May not be reimbursed for psychiatric-based
  office visits1
• May exhibit prejudice or have a stereotypical
  attitude toward certain patients2
• May have difficulty managing depressive disorders
  in the primary care setting because of patients
  multiple health problems and demands1,2
• May be unfamiliar with cultural variations in
  disease presentation and response to treatment1

• Klinkman MS. J Clin Psychiatry. 20036419.
• US Dept. of Health and Human Services. Mental
  Health Culture, Race, and EthnicityA Supplement
  to Mental Health A Report of the Surgeon
  General. Rockville, MD 2001.

23
Barriers to Detection and Treatment of Depressive
Disorders

• Physicians may not rely on practice guidelines
  for diagnosis, evaluation, and treatment1-4
• Differences exist among health care facilities
  and practitioners with respect to preferred
  treatment types1-3
• Need for standardized approaches to patient
  assessment, referral, and treatment2-4

• Burman ME. J Am Acad Nurse Pract. 200517370.
• Charbonneau A. Am J Manag Care. 200410846.
• Robinson WD. J Am Board Fam Pract. 20051879.
• Rollman BL. Adm Policy Ment Health. 20063343.

24
Avoiding Misdiagnoses and Missed Diagnoses

• Rule out other psychiatric illnesses1
• Look for underlying medical conditions that may
  cause symptoms resembling depression1
• Be aware of substances and medications that may
  cause depressive symptoms1
• Know that physician-patient interactions and
  disease presentation may vary2
• Cultural differences may present a barrier to
  communication (eg, language, expression,
  mannerisms, views)

• Karasu TB. 2000. Practice Guideline for the
  Treatment of Patients With Major Depressive
  Disorder, 2nd Edition. http//www.psych.org/psych_
  pract/treatg/pg/prac_guide.cfm.
• Juckett G. Am Fam Physician. 200572(11)2267.

25
Treatment of Dysthymia and MDD

• Psychiatric management is necessary throughout
  all treatment phases and includes
• Establishing and maintaining a therapeutic
  alliance
• Diagnostic evaluation
• Evaluating and monitoring the psychiatric status
  of the patient, and the safety of the patient and
  others
• Evaluating the level of functional impairments
• Determining a treatment setting
• Providing education to patients and families
• Enhancing treatment adherence
• Working with patients to address early signs of
  relapse

Karasu TB. 2000. Practice Guideline for the
Treatment of Patients With Major Depressive
Disorder, 2nd Edition. http//www.psych.org/psych_
pract/treatg/pg/prac_guide.cfm.
26
Treatment of Dysthymia and MDD (cont)

• Treatment Phases1,2
• Major Therapeutic Modalities1
• Psychotherapy
• Pharmacologic therapy
• Combination therapy
• Electroconvulsive therapy
  (ECT)

Acute Remission is induced
Continuation Remission is preserved
Maintenance Protection against recurrence

• Karasu TB. 2000. Practice Guideline for the
  Treatment of Patients With Major Depressive
  Disorder, 2nd Edition. http//www.psych.org/psych_
  pract/treatg/pg/prac_guide.cfm.
• Reimherr FW. Am J Psychiatry. 19981551247.

27
Treatment of Dysthymia and MDDPsychotherapy

• May be primary treatment for patients who refuse
  or cannot tolerate pharmacologic therapy
• Equal efficacy when compared with antidepressants
• May be preferred for certain populations
• Pregnancy
• Acute medical conditions (eg, recent MI)
• Commonly implemented types
• Interpersonal therapy
• Cognitive behavioral therapy
• Cognitive therapy
• Behavioral therapy

Goldberg RJ. St. Louis, MO Mosby199881.
28
Treatment of Dysthymia and MDDPharmacologic
Therapy
Karasu TB. 2000. http//www.psych.org/psych_pract/
treatg/pg/prac_guide.cfm.
29
Treatment of Dysthymia and MDDPharmacologic
Therapy (cont)

• The APA recommends considering the following when
  choosing an initial antidepressant
• Anticipated side effects
• Safety/tolerability of side effects for
  individual patients
• Patient preference
• Quantity and quality of clinical trial data
• Cost
• Other important considerations include
• History of prior response
• Presence of comorbid psychiatric/medical
  conditions

Karasu TB. 2000. Practice Guideline for the
Treatment of Patients With Major Depressive
Disorder, 2nd Edition. http//www.psych.org/psych_
pract/treatg/pg/prac_guide.cfm.
30
Treatment of Dysthymia and MDDPharmacologic
Therapy (cont)

• Effective first-line therapy for most patients
• SSRIs
• Desipramine
• Nortriptyline
• Bupropion
• Venlafaxine
• MAOIs Second-line therapy
• Are recommended for patients who are
  nonresponsive to other treatments
• Have dietary reactions and serious side effects

Karasu TB. 2000. Practice Guideline for the
Treatment of Patients With Major Depressive
Disorder, 2nd Edition. http//www.psych.org/psych_
pract/treatg/pg/prac_guide.cfm.
31
Treatment Algorithm for Dysthymia and MDD
Select treatment

• After remission
• Continue medication for 1620 weeks
• Maintenance therapy vs discontinuation should be
  based on
• Risk for recurrence
• Patient preferences
• Severity of episodes
• Treatment side effects

Monitor acute treatment 12 weeks
Reassess response to treatment 48 weeks
Partial Response Adjust dosage, psychotherapy
Full Response Continue treatment for 6 more
weeks
No Response Adjust dosage or change treatment
psychotherapy
Karasu TB. 2000. http//www.psych.org/psych_pract/
treatg/pg/prac_guide.cfm.
32
Treatment of Dysthymia and MDD

• Serious adverse events
• Antidepressant treatment may increase suicidal
  thoughts in adolescents and childrenFDA black
  box warning on all antidepressants1
• Hepatic failure seen with nefazodone useFDA
  black box warning1
• Serotonin Syndrome2
• Seen with several drugs, including SSRIs and
  MAOIs increased when combinations of SSRIs or
  SSRIs MAOIs are given
• Rapid onset of symptoms ranging from mild to
  life-threatening, including fever, hypertension,
  diaphoresis, tachycardia, hyperreflexia, and shock

• Boyer EW. N Engl J Med. 20053521112.
• Fochtmann LJ. 2005. Guideline Watch Practice
  Guideline for the Treatment of Patients With
  Major Depressive Disorder, 2nd Edition.
  http//www.psych.org/psych_pract/treatg/pg/prac_gu
  ide.cfm.

33
Treatment of Dysthymia and MDD

• Switching medications safely
• Minimum washout period necessary when switching
  antidepressants
• For a drug with long half-life metabolites, when
  switching to an MAOI5 weeks
• Fluoxetine
• For a drug without long half-life metabolites, or
  for an MAOI, when switching to a (different)
  MAOI2 weeks
• TCAs
• Paroxetine
• Fluvoxamine
• Venlaxifine

Fochtmann LJ. 2005. Guideline Watch Practice
Guideline for the Treatment of Patients With
Major Depressive Disorder, 2nd Edition.
http//www.psych.org/psych_pract/treatg/pg/prac_gu
ide.cfm.
34
Treatment of Dysthymia and MDDOther
Considerations

• Ethnopsychopharmacology1 the response to
  treatment agents for depressive disorders varies
  on an individual, racial, and ethnic basis
  because of genetic, physiologic, environmental,
  and cultural factors
• These variations can alter drug efficacy, side
  effects, and plasma levels1,2
• When prescribing medication1
• Consider individual polymorphisms in drug
  metabolizing enzymes, pathways, and target
  receptors
• Educate the patient
• Monitor the patient at each follow-up visit (eg,
  for symptomatic improvement and side effects)

• Smith, MW. Ethnopsychopharmacology. In Lim
  RF(ed). Clinical Manual of Cultural Psychiatry.
  Arlington, VA AP Publishing, Inc. 2006.
• Malhotra A. Am J Psychiatry. 2004161780.

35
Treatment of Dysthymia and MDDOther
Considerations (cont)

• Patients may use complementary and alternative
  medicines
• Eg, St. Johns Wort and other herbal remedies,1
  non-prescribed vitamin supplements,2 cod liver
  oil,2 garlic preparations,2 S-adenosylmethionine
  (SAMe)3
• Physicians should inquire about use of these
  medicines and discuss their potential
• Effectiveness
• Drug interactions with prescribed antidepressants
  and other medications
• Toxicities

• Dasgupta A. Arch Pathol Lab Med. 2006130521.
• Burroughs VJ. National Pharmaceutical Council,
  2002. http//www.npcnow.org/resources/PDFs/Cultura
  lFINAL.pdf.
• Jorm AF. MJA. 2006185368.

36
Treatment of Dysthymia and MDDElectroconvulsive
Therapy (ECT)

• Highly effective treatment for depression1,2
• Controlled seizure causes neurochemical release
• Exact mechanisms for therapeutic effects unknown
• Appropriate use of ECT1,3
• Recurrent or treatment-resistant depression that
  has failed medication and combination treatments
• Intolerable side effects to medication or
  increased risk/experience of adverse effects
• Need for acute care due to extreme suicidal
  behavior

• Goldberg RJ. St. Louis, MO Mosby 1998264.
• Gagne GG. Am J Psychiatry. 20001571960.
• Karasu TB. 2000. Practice Guideline for the
  Treatment of Patients With Major Depressive
  Disorder, 2nd Edition. 2000. http//www.psych.org/
  psych_pract/treatg/pg/prac_guide.cfm.

37
American Psychiatric Association Treatment
Algorithm for MDD Summary
Karasu TB. 2000. http//www.psych.org/psych_pract/
treatg/pg/prac_guide.cfm.
38
Managing Depressive DisordersReferral

• When should primary care physicians refer a
  patient to a psychiatrist?1,2
• There are no available guidelines for referral
• Factors to consider include
• Perceived severity/complexity of the illness
• Perceived ability to manage the illness correctly
  (eg, interest and expertise)
• Inadequate time to manage mental health problems
  due to the presence of multiple/complex comorbid
  disease(s)
• Patient preferences for evaluation and treatment
• Availability and cost of mental health services
• Failed trials of psychotropic medications under
  primary care supervision

• Klinkman MS. J Clin Psychiatry. 20036419.
• Bea SM. Cleveland Clin J Med. 200269113.

39
Diagnosis of Bipolar Disorders

• Bipolar disorder (BD)1
• Manic-depressive disorder
• Manic episode
• Period of abnormal and persistent elevated,
  expansive, or irritable mood and 3 of the
  following symptoms
• Depressive episode
• With symptoms like those of a major depressive
  episode, these periods are generally more
  numerous than, and longer in duration than, manic
  episodes2
• Most suicides occur during depressive episodes2,3

• APA. DSM-IV-TR. Washington, DC APA 2000362.
• Thase ME. Harv Rev Psychiatry. 200513257.
• Das AK. JAMA. 2005293956.

40
Diagnosis of Bipolar Disorders

• Bipolar disorder (BD)1
• Bipolar I disorder manic and depressive episodes
• Bipolar II disorder predominantly depressive
  swings with occasional hypomanic episodes
• Should always be considered in the differential
  diagnosis for depression because of the presence
  of depressive episodes
• Frequently misdiagnosed as MDD2,3
• Antidepressant treatment for bipolar disorder can
  precipitate mania and rapid cycling3

• APA. DSM-IV-TR. Washington, DC APA 2000362.
• Thase ME. Harv Rev Psychiatry. 200513257.
• Das AK. JAMA. 2005293956.

41
Treatment of Bipolar Depression

• Specific goals of management
• Form a therapeutic alliance
• Monitor psychiatric status
• Provide education on bipolar disorder
• Enhance treatment adherence
• Promote regular sleep and activity patterns
• Anticipate stressors
• Identify new episodes early
• Minimize functional impairments

Hirschfeld RMA. 2002. Practice Guideline for the
Treatment of Patients With Bipolar Disorder,
Second Edition. http//www.psych.org/psych_pract/t
reatg/pg/prac_guide.cfm.
42
Treatment of Bipolar DepressionPharmacologic
Therapy

• Antidepressant monotherapy not recommended1,2
• 1st line lithium,1,2 valproate/divalproex,2 or
  lamotrigine1,2
• Alternative lithium antidepressant1,2
• SSRIs and bupropion equally efficacious as
  antidepressant adjuncts
• Treatment options for resistant depressive
  episodes1
• Add lamotrigine, bupropion, or paroxetine
• Add other newer SSRI
• Add MAOI
• Consider ECT for patients with life-threatening
  inanition, suicidality, or psychosis

• Hirschfeld RMA. 2002. Practice Guideline for the
  Treatment of Patients With Bipolar Disorder,
  Second Edition. http//www.psych.org/psych_pract/t
  reatg/pg/prac_guide.cfm.
• Thase ME. Harv Rev Psychiatry. 200513257.

43
Treatment of Bipolar DepressionNew
Pharmacologic Therapies (cont)

• Lamotrigine
• Newer anticonvulsant approved for maintenance
  therapy1-3
• Effective for prolonging time to intervention for
  depressive, manic, hypomanic, and mixed
  episodes1-3
• Greater efficacy than lithium in preventing
  depressive episodes1,2
• Side effects equivalent to that of placebo in
  studies1,2
• Adverse effect Stevens-Johnson syndromea severe
  dermatologic and systemic reaction that is
  potentially fatal1,3

• Hirschfeld RMA. 2002. Practice Guideline for the
  Treatment of Patients With Bipolar Disorder,
  Second Edition. http//www.psych.org/psych_pract/t
  reatg/pg/prac_guide.cfm.
• Goodwin GM. J Clin Psychiatry. 200465432.
• Thase ME. Harv Rev Psychiatry. 200513257.

44
Treatment of Bipolar DisordersPsychosocial
Interventions

• Effective when combined with pharmacologic
  treatment1,2
• Enhances drug adherence
• Decreases frequency of episodes
• Reduces likelihood of recurrence
• Enhances post-episode symptomatic adjustment
• Psychosocial interventions1 include
• Cognitive therapy
• Group therapy
• Family therapy
• Interpersonal and social rhythm therapy (IPSRT)
• Creates routines in everyday life to improve
  circadian imbalances linked
• with bipolar disorder3

• Hirschfeld RMA. 2002. Practice Guideline for the
  Treatment of Patients With Bipolar Disorder,
  Second Edition. http//www.psych.org/psych_pract/t
  reatg/pg/prac_guide.cfm.
• Thase ME. Harv Rev Psychiatry. 200513257.
• Frank E. Arch Gen Psychiatry. 200562996.

45
American Psychiatric Association Treatment
Algorithm for BD Summary
McIntyre JS. 2002. http//www.psych.org/psych_prac
t/treatg/pg/prac_guide.cfm.
46
ConclusionsCurrent Practices in Diagnosis and
Treatment of Depression

• Depressive disorders can almost always be treated
  successfully with medication, psychotherapy, or a
  combination of both
• Not all patients respond to the same treatment
• Effective interventions decrease symptoms and
  morbidity earlier than would occur naturally in
  the course of the illness

Depression Guideline Panel. Clinical Practice
Guideline, Number 5. 1993. http//www.ncbi.nlm.nih
.gov/books/bv.fcgi?ridhstat6.chapter.15593.
47
ConclusionsCurrent Practices in Diagnosis and
Treatment of Depression (cont)

• The key initial objectives of treatment1,2 are
• Achieve remission of signs and symptoms of the
  depressive syndrome
• Restore occupational and psychosocial function to
  that of the asymptomatic state
• Reduce the likelihood of relapse and recurrence

• Depression Guideline Panel. Clinical Practice
  Guideline, Number 5. 1993. http//www.ncbi.nlm.nih
  .gov/books/bv.fcgi?ridhstat6.chapter.15593.
• ICSI. Health Care Guideline Major Depression in
  Adults in Primary Care. 2006. http//www.icsi.org/
  knowledge/detail.asp?catID29itemID180.

48
Clinical Practice Guidelines Algorithm for
Depressive DisordersAgency for Health Care
Policy and Research

• Maintain a high index of suspicion and evaluate
  risk factors
• Detect depressive symptoms with a clinical
  interview
• Diagnose the mood disorder using clinical history
  and interview
• Evaluate patients with a complete medical history
  and physical examination
• Identify and treat potential known causes (if
  present) of mood disorder

Depression Guideline Panel. Depression in Primary
Care Detection, Diagnosis, and Treatment. Quick
Reference Guide for Clinicians, Number
5. 1993. http//www.ncbi.nlm.nih.gov/books/bv.fcgi
?ridhstat6.section.33088.
49
Clinical Practice Guidelines Algorithm for
Depressive DisordersAgency for Health Care
Policy and Research (cont)

• Re-evaluate for mood disorders
• Develop a treatment plan with the patient
• Select the most appropriate acute phase treatment
• If medication is used, select the type dose
  best suited to the patient
• Evaluate treatment response
• Proceed to continuation phase treatment
• Evaluate the need for maintenance phase treatment
• Seek consultation

Depression Guideline Panel. Depression in Primary
Care Detection, Diagnosis, and Treatment. Quick
Reference Guide for Clinicians, Number
5. 1993. http//www.ncbi.nlm.nih.gov/books/bv.fcgi
?ridhstat6.section.33088.
50
Thoughts on Improving Depression Care

• To better manage depressive disorders, physicians
  should
• Screen for depression regularly, especially in
  patients with risk factors1
• Provide accurate, early diagnosis2
• Recognize disparities in care3
• To accurately rate depression severity,
  physicians should
• Perform a thorough psychiatric interview using
  DSM-IV-TR criteria2
• Have an understanding of the usefulness and
  limitations of depression severity scales4

• US Preventive Services Task Force. Ann Intern
  Med. 2002136760.
• Karasu TB. 2000. http//www.psych.org/psych_pract/
  treatg/pg/prac_guide.cfm.
• US Dept. of Health and Human Services. Mental
  Health Culture, Race, and EthnicityA Supplement
  to Mental Health A Report of the Surgeon
  General. Rockville, MD2001.
• Thibault JM. Am Fam Physician. 2004701101.

51
Thoughts on Improving Depression Care (cont)

• Treatment areas needing enhancement to improve
  outcomes include
• Adherence to practice guidelines1,2Physicians
  should consciously review recommendations and
  guidelines as they are published
• Awareness of new guidelinesAPA and other expert
  groups publish updates to previous guidelines to
  keep physicians informed of newer treatment
  options and adverse effects
• Appropriate use of supportive psychotherapy3
• Consideration of ethnopsychopharmacology4
• More accessible guidelines specific to long-term
  management of depressive disorders in primary
  care are needed5

• Burman ME. J Am Acad Nurse Pract. 200517370.
• Charbonneau A. Am J Manag Care. 200410846.
• Robinson WD. J Am Board Fam Pract. 20051879.
• Smith, MW. Ethnopsychopharmacology. In Lim
  RF(ed). Clinical Manual of Cultural Psychiatry.
  Arlington, VA AP Publishing, Inc. 2006.
• Klinkman MS. J Clin Psychiatry. 20036419.

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