TREATING MAJOR DEPRESSIVE DISORDER Press the <PAGE DOWN> Button to continue
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. Press <PAGE DOWN> to continue
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.
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. ► ► ► ► ► ► ► ► ►
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.
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.
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.
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.
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.
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)
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)
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).
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
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.
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.
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.
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
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