Initial Screening and Triage for Follow-up HEALTH TEAM Depression is suspected: Perform two-question screen 1,2 (box 1)* Review risk factors 1-3 (box 2) Diagnose and characterize MDE with clinical interview: DSM-5 criteria 4 or PHQ-9 or S 2 IGECAPS (box 3) History of present illness (onset and severity, functional impairment, past episodes, psychosocial stressors, comorbidities) 1-4 Differential diagnosis (e.g., anxiety, ADHD, substance use, etc.) 3 Use of appropriate, validated assessment tools to establish baseline severity 1,5 (Appendix 1) Emotions: PHQ-9 6 Functioning: SDS 7 or LEAPS 8 Cognition: BC-CCI 9 Suicide risk assessment (PHQ-9, Q9) 2 Consider emergency psychiatric consultation and in-patient treatment if persistent suicidal thoughts, recent suicide attempt, or current plan 3 If low risk, discuss and/or create safety plan (Appendix 2) 3 BOX 1 Two-question screen: 3 In the past month: 1. Have you lost interest or pleasure in things you usually like to do? 2. Have you felt sad, down, depressed or hopeless? BOX 2 High-risk groups: 1 History of depression Family history of depression Psychosocial adversity High users of medical system Chronic medical conditions Other psychiatric conditions Times of hormonal challenge (post-partum) High-risk symptom presentation: 1 Unexplained physical symptoms Pain, including chronic pain Fatigue Insomnia Anxiety Substance abuse BOX 3 S 2 IGECAPS: 3 Other investigations 1,10 Laboratory assessment when clinically indicated (TSH, Hb, metabolic workup and LFTs) Develop a specific summary and care plan Outline expected timelines with patient Outline linkages with other HCPs and expected roles (box 12) Empower patient (self-report scales, MoodFx.ca, etc) Schedule follow-up visit S S I G E C A P S Sadness (depressed mood) Sleep disturbance (insomnia, hypersomnia) Interest reduced (anhedonia) Guilt or self-blame Energy loss and fatigue Concentration problems Appetite changes (low/increased appetite or weight loss/gain) Psychomotor changes (retardation, agitation) Suicidal thoughts * If time is limited and PHQ-2 screen is positive, ensure there is no risk of suicide, and rebook for a longer mental health visit as soon as possible. Provide assessment tools for patient to self-complete and bring back at next visit (e.g., PHQ-9). Provide emergency call instructions in case of decompensation before next scheduled visit.
Confirming and Documenting Diagnosis and Mental Health Care Plan HEALTH TEAM Review PHQ-9 and other tools (if used) Review lab results Consider differential diagnoses and other tools (e.g., MDQ, ASRS, CAGE, etc) Initiate treatment based on PHQ-9 score and patient preference with the initial goal of symptom remission (PHQ-9 score <5) 1,3 Use a stepped care approach based on depression severity, patient preference and availability of resources 10 (Appendix 3) Recommended for all patients: Lifestyle / Self-care (box 4) 3 Psychoeducation (box 5) and self-management 1,3,11 Psychotherapy 1,3 CBT or IPT recommended for mild-to-moderate depression in the acute phase Can prevent relapse during maintenance phase Pharmacotherapy 1,3 Recommended for moderate-to-severe depression in the acute phase 1 (box 6) Select treatment based on clinical factors 3 (box 7) Discuss potential side effects (including suicidal ideation, sexual dysfunction) Review suicide risk and safety plan (Appendix 2) Promote antidepressant adherence (box 8) Schedule follow-up visit 1,3 Within 1-2 weeks (period of greatest risk) BOX 4 Self-care strategies: 3 Regular exercise Healthy regular meals Sleep hygiene Avoiding substance use Adequate housing Stress management Engaging in pleasurable activities Daily mood chart BOX 5 Psychoeducation: 11 Causes of depression Symptoms Treatment options Benefits and risks of treatments Potential side effects Expected onset of response Expected duration of treatment BOX 6 1st-line antidepressants: 1 SSRIs (citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline) SNRIs (desvenlafaxine, duloxetine, venlafaxine) NDRI (bupropion) Alpha-adrenergic agonist/5- HT2 antagonist (mirtazapine) Newer agents not available in 2009 SNRIs (levomilnacipran) Multimodal (vilazodone, vortioxetine) BOX 8 Address medication concerns to promote adherence: 1,3 Antidepressants are not addictive Do not stop without medical consultation, even if feeling better Take as directed Some improvement may be observed in 1-2 weeks, but typically 2-8 weeks or longer for full benefit Mild side effects (GI, headaches) are common but transient BOX 7 Clinical factors: 3 Symptom profile Medical comorbidity Psychiatric comorbidity Risk of pregnancy Patient preference Previous therapeutic response Tolerability profile Drug discontinuation symptoms Drug-drug interactions Cost
Monitoring & Follow-up Week 0-2 after antidepressant initiation Review depression severity based on PHQ-9 (can be completed in waiting room) to assess for early symptom improvement ( 20% reduction) 1,3,5 Review response to treatment: Failure to achieve 20% reduction at 2-4 weeks is strongly suggestive that initial therapy will not result in long-term remission 5,12 Assess adherence 1 and tolerability (FISBER scale) 13 Adjust treatment plan as needed (e.g. optimize antidepressant dosage) 1 HEALTH TEAM Week 3-4 after antidepressant initiation Review depression severity based on PHQ-9 (can be completed in waiting room) to assess for early symptom improvement 1,3,5 Adequate treatment trial is 2-8 weeks at maximum dose 1,3 Assess adherence 1 and tolerability (FIBSER scale) 13 Adjust treatment plan as needed If <20% reduction in symptom severity 1,5 Optimize antidepressant dosage 1,5 Consider switch to agent with evidence for superiority (box 9) 1 Consider adjunct therapy (box 10) 5 If 20% reduction in symptom severity 1,5 Continue index antidepressant and dose 1,5 If not in remission, consider adjunct therapy (box 10) 5 Follow-up as needed (e.g., every 2-4 weeks) after antidepressant initiation Depending on severity and response, can be longer 1 Use MBC to assess response across all domains of depression 1,5 Upload MBC scores into EMR Assess adherence and tolerability 1 Other healthcare team members can support (box 12) Assess suicide risk at every visit 3 Maintain therapy for at least 6-9 months after full remission of symptoms 1,3 Depending on severity and response, can be longer (box 11) 1 Continue frequent follow-ups for 6 months after discontinuation 3 BOX 9 Agents with evidence of superiority: 1 Duloxetine Escitalopram Mirtazapine Sertraline Venlafaxine Newer agents not available in 2009 Levomilnacipran vilazodone vortioxetine BOX 10 Recommended add-on therapies: 1 1st-line: aripiprazole, lithium, olanzapine, risperidone 2nd-line: bupropion, mirtazapine, quetiapine, triiodothyronine, other antidepressant 3rd-line: buspirone, modafinil, stimulants, ziprasidone BOX 11 Risk factors for long-term therapy (2 years to lifetime): 1 Older age Recurrent episodes ( 3) Chronic episodes Psychotic episodes Severe episodes Difficult to treat episodes Significant comorbidity Residual symptoms History of recurrence during discontinuation
Monitoring & Follow-up(continued) BOX 12 Supportive Healthcare Team Members and Responsibilities Pharmacist Psychoeducation Adherence support & documentation Tolerability assessment & documentation (FIBSER) Medication review Phone calls Clinic nurse Follow-up emotional, functional, cognitive assessment scales administration to assess response Phone calls to review adherence and progress Documentation into EMR Psychoeducation EMR support system Add-on email/text reminder system to help: -Remind patients of appointments -Recall patients who have not been booked for follow-up -Educate and support adherence -Ensure patients are not lost through follow-up Patient information portal Education Email reminder system Repository for self-report scales and tools (e.g., Apps such as MoodFx.ca, PHQ-9) Links to community resources References 1. CANMAT. Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical Guidelines for the Management of Major Depressive Disorder in Adults. J Affect Disord. 2009; 117: S1-S64. 2. Mitchell J, et al. Institute for Clinical Systems Improvement. Adult Depression in Primary Care. Updated September 2013. 3. Guidelines and Protocols Advisory Committee. Major Depressive Disorder in Adults - Diagnosis and Management. December 2013. Available at http://www2.gov.bc.ca/gov/downloadasset? assetid=c436972318f54b499636c2a121213e1a&filename=depression_full_guideline.pdf 4. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, Fifth Edition. Washington, DC: American Psychiatric Association; 2013. 5. Kudlow PA, et al. Predicting treatment response in major depressive disorder: the impact of early symptomatic improvement. Can J Psychiatry. 2009;57(12):782-8. 6. Kroenke K, et al. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-613. 7. Sheehan DV. The Anxiety Disease. New York: Carles Scribner & Sons, 1983. 8. Lam RW, et al. A new clinical rating scale for work absence and productivity: validation in patients with major depressive disorder. BMC Psychiatry. 2009;9:78. 9. Iverson GL & Lam RW. Rapid screening for perceived cognitive impairment in major depressive disorder. Ann Clin Psychiatry. 2013;25:135-40. 10. National institute for Health and Clinical Excellence. Depression in adults: The treatment and management of depression in adults. October 2009. Available at guidance.nice.org.uk/cg90. 11. To A, et al. Treatment of depression in primary care Part 1: Principles of acute treatment. BCMJ. 2002;44:473-8. 12. Szegedi A, et al. Early improvement in the first 2 weeks as a predictor of treatment outcome in patients with major depressive disorder: a meta-analysis including 6562 patients. J Clin Psychiatry. 2009;70:344-53. 13. Wisniewski SR, et al. Self-rated global measure of the frequency, intensity, and burden of side effects. J Psychiatr Pract. 2006;12:71-9.
Appendix 1: Measurement-based care (MBC) scales Patient Health Questionnaire (PHQ-9) Kroenke K, et al. J Gen Intern Med. 2001;16(9):606-613
Appendix 1: MBC scales Sheehan Disability Scale (SDS) SCORING: The numerical ratings of 0-10 can be translated into a percentage, if desired The 3 items can also be summed into a single dimensional measure of global functional impairment that ranges from 0 (unimpaired) to 30 (highly impaired) There is no recommended cutoff score; however, change-over-time in scores can help monitor response to treatment It is recommended that clinicians pay special attention to patients who score 5 or greater on any of the three scales, because such high scores are associated with significant functional impairment Sensitivity: 83% Specificity: 69% Sheehan DV. The Anxiety Disease. New York: Carles Scribner & Sons, 1983. Rush JA et al. Handbook of Psychiatric Measures, 2000 American Psychiatric Association, 113-115.
Appendix 1: MBC scales Lam Employment Absence and Productivity Scale (LEAPS) Score Work Impairment 0-5 None to minimal 6-10 Mild 11-16 Moderate 17-22 Severe 23-28 Very severe Lam RW, et al. BMC Psychiatry. 2009;9:78
Appendix 1: MBC scales The British Columbia Cognitive Complaints Inventory (BC-CCI) The British Columbia Cognitive Complaints Inventory (BC-CCI) Description and Clinical Application The BC-CCI is a rapid screening tool that assesses perceived cognitive difficulties specifically in patients with MDD and related mood disorders. It takes <3 min for patients to complete. It helps quantify perceived cognitive function stemming from depression. The BC-CCI is not a diagnostic tool and should therefore be used in conjunction with a symptom rating scale such as the PHQ-9. However, the BC-CCI total score can provide a quick measure of perceived cognitive difficulties that can be used to monitor changes in these symptoms over time. Using a validated tool such as the BC-CCI can also save time during clinical assessment and ensure these symptoms are assessed in a standardized way. Monitoring the cognitive dimension of MDD during treatment is becoming increasingly important with evolving evidence showing that individuals with MDD continue to experience cognitive difficulties despite the remission of other depressive symptoms. In these cases, it may be especially important to monitor the cognitive symptoms of MDD over time. Please rate your problems with memory, thinking skills and concentration during the past 7 days Not at all (0) Some (1) Quite a bit (2) Very much (3) 1 Forgetfulness / memory problems 0 1 2 3 2 Slow thinking speed 0 1 2 3 3 Trouble expressing my thoughts 0 1 2 3 4 Trouble finding the right word 0 1 2 3 5 Poor concentration 0 1 2 3 6 Trouble figuring things out or solving problems 0 1 2 3 ADD COLUMNS TOTAL BC-CCI SCORE BC-CCI: FUNCTIONAL IMPAIRMENT Please answer the questions below regarding how you have felt in the past 7 days. The symptoms I noted above make it difficult for me to do my work / school work. False, Not at all true Slightly True Mainly True Very True The symptoms I noted above make it difficult for me to have good relationships with my family and friends. False, Not at all true Slightly True Mainly True Very True The symptoms I noted above make it difficult for me to enjoy social activities, recreational activities, or hobbies. False, Not at all true Slightly True Mainly True Very True Scoring The scale consists of 6 items assessing perceived problems with concentration, memory, expressing thoughts, word finding, slow thinking, and difficulty solving problems in the past 7 days. There is an additional component to the BC-CCI to help healthcare practitioners speak with individuals regarding how they perceive these impairments are affecting psychosocial and occupational function. 0-4 Broadly normal 5-8 Mild cognitive complaints 9-14 Moderate cognitive complaints 15-18 Severe cognitive complaints Iverson GL & Lam RW. Rapid screening for perceived cognitive impairment in major depressive disorder. Ann ClinPsychiatry 2013; 25:135.
Appendix 1: MBC scales Frequency, Intensity, and Burden of Side Effects Ratings (FIBSER) Scoring: The response to Question 3 may suggest that a change in treatment is necessary. Q3 score 0-2: Treatment should continue unless concerns exist about safety or symptom severity. Q3 score 3-4: The side effect should be addressed (e.g. decrease dose) Q3 score 5-6: Change treatment (e.g. decrease dose or switch medication) Wisniewski SR, et al. J Psychiatr Pract. 2006;12:71-9. Trivedi MH. J Clin Psychiatry 2009;70(Suppl 6):S26-31.
Appendix 1: Patient Safety Plan Example ResouRces n n n n Download this card and additional resources at http://wwww.sprc.org Resource for implementing The Joint Commission 2007 Patient Safety Goals on Suicide http://www.sprc.org/library/jcsafetygoals.pdf safe-t drew upon the American Psychiatric Association Practice Guidelines for the Assessment and Treatment of Patients with Suicidal Behaviors http://www.psychiatryonline.com/ pracguide/pracguidetopic_14.aspx Practice Parameter for the Assessment and Treatment of Children and Adolescents with Suicidal Behavior. Journal of the American Academy of Child and Adolescent Psychiatry, 2001, 40 (7 Supplement): 24s-51s AcKNoWLeDGMeNTs n Originally conceived by Douglas Jacobs, MD, and developed as a collaboration between Screening for Mental Health, Inc. and the Suicide Prevention Resource Center. n This material is based upon work supported by the Substance Abuse and Mental Health Services Administration (SAMHSA) under Grant No. 1U79SM57392. Any opinions/findings/conclusions/ recommendations expressed in this material are those of the author and do not necessarily reflect the views of SAMHSA. National Suicide Prevention Lifeline 1-800-273-TALK (8255) SAFE-T Suicide Assessment Five-step Evaluation and Triage 1 IDeNTIFY RIsK FAcToRs Note those that can be modified to reduce risk 2 IDeNTIFY PRoTecTIVe FAcToRs Note those that can be enhanced 3 conduct suicide INQuIRY Suicidal thoughts, plans, behavior, and intent 4 DeTeRMINe RIsK LeVeL/INTeRVeNTIoN Determine risk. Choose appropriate intervention to address and reduce risk http://www.sprc.org 5 DocuMeNT Assessment of risk, rationale, intervention, and follow-up HHS Publication No. (SMA) 09-4432 CMHS-NSP-0193 Printed 2009 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration www.samhsa.gov
Appendix 1: Patient Safety Plan Example Suicide assessments should be conducted at first contact, with any subsequent suicidal behavior, increased ideation, or pertinent clinical change; for inpatients, prior to increasing privileges and at discharge. 1. RISK FACTORS 3 suicidal behavior: history of prior suicide attempts, aborted suicide attempts, or self-injurious behavior 3 current/past psychiatric disorders: especially mood disorders, psychotic disorders, alcohol/substance abuse, ADHD, TBI, PTSD, Cluster B personality disorders, conduct disorders (antisocial behavior, aggression, impulsivity) Co-morbidity and recent onset of illness increase risk 3 Key symptoms: anhedonia, impulsivity, hopelessness, anxiety/panic, global insomnia, command hallucinations 3 Family history: of suicide, attempts, or Axis 1 psychiatric disorders requiring hospitalization 3 Precipitants/stressors/Interpersonal: triggering events leading to humiliation, shame, or despair (e.g, loss of relationship, financial or health status real or anticipated). Ongoing medical illness (esp. CNS disorders, pain). Intoxication. Family turmoil/chaos. History of physical or sexual abuse. Social isolation 3 change in treatment: discharge from psychiatric hospital, provider or treatment change 3 Access to firearms 2. PROTECTIVE FACTORS Protective factors, even if present, may not counteract significant acute risk 3 Internal: ability to cope with stress, religious beliefs, frustration tolerance 3 external: responsibility to children or beloved pets, positive therapeutic relationships, social supports 3. SUICIDE INQUIRY Specific questioning about thoughts, plans, behaviors, intent 3 Ideation: frequency, intensity, duration in last 48 hours, past month, and worst ever 3 Plan: timing, location, lethality, availability, preparatory acts 3 Behaviors: past attempts, aborted attempts, rehearsals (tying noose, loading gun) vs. non-suicidal self injurious actions 3 Intent: extent to which the patient (1) expects to carry out the plan and (2) believes the plan/act to be lethal vs. self-injurious. Explore ambivalence: reasons to die vs. reasons to live * For Youths: ask parent/guardian about evidence of suicidal thoughts, plans, or behaviors, and changes in mood, behaviors, or disposition * Homicide Inquiry: when indicated, esp. in character disordered or paranoid males dealing with loss or humiliation. Inquire in four areas listed above 4. RISK LEVEL/INTERVENTION 3 Assessment of risk level is based on clinical judgment, after completing steps 1 3 3 Reassess as patient or environmental circumstances change RISK LEVEL RISK/PROTECTIVE FACTOR SUICIDALITY POSSIBLE INTERVENTIONS High Moderate Low Psychiatric diagnoses with severe symptoms or acute precipitating event; protective factors not relevant Multiple risk factors, few protective factors Modifiable risk factors, strong protective factors Potentially lethal suicide attempt or persistent ideation with strong intent or suicide rehearsal Suicidal ideation with plan, but no intent or behavior Thoughts of death, no plan, intent, or behavior Admission generally indicated unless a significant change reduces risk. Suicide precautions Admission may be necessary depending on risk factors. Develop crisis plan. Give emergency/crisis numbers Outpatient referral, symptom reduction. Give emergency/crisis numbers (This chart is intended to represent a range of risk levels and interventions, not actual determinations.) 5. DOCUMENT Risk level and rationale; treatment plan to address/reduce current risk (e.g., medication, setting, psychotherapy, E.C.T., contact with significant others, consultation); firearms instructions, if relevant; follow-up plan. For youths, treatment plan should include roles for parent/guardian.
Appendix 3: Stepped Care Approach FOCUS OF INTERVENTION NATURE OF INTERVENTION STEP FOUR Severe and complex depression Risk to Life Severe self neglect Highly specialized treatment: Medication High intensity psychological interventions Combined treatments Multiprofessional and inpatient care Crisis services Electroconvulsive therapy STEP THREE Persistent sub threshold depressive symptoms Mild to moderate depression that has not responded to low intensity intervention Initial presentation of moderate to severe depression CBT IPT Behavioural activation Behavioural couples therapy Counselling Short term psychodynamic psychotherapy Antidepressants Combined interventions Collaborative care Self help groups STEP TWO Persistent sub threshold depressive symptoms Mild to moderate depression Individual facilitated self help Computerized CBT Structured physical activity Self help groups Antidepressants STEP ONE Known and suspected presentations of common mental health disorders Identification Assessment Psychoeducation Active monitoring Referral for further assessment and interventions National institute for Health and Care Excellence. Depression in adults: The treatment and management of depression in adults. October 2009. Available at guidance.nice.org.uk/cg90