Τρίτη, 17 Ιουνίου 2014

Treatment of Depression in Primary Care: Using Tools to Improve Outcomes

CME Institute: Evaluating and Monitoring Treatment Response in Depression Using Measurement-Based Assessment and Rating Scales

Madhukar H. Trivedi, MD

Department of Psychiatry and the Mood Disorders Research Program and Clinic, University of Texas Southwestern Medical Center, Dallas

Although many treatment options are available for MDD, only about 20% of patients receive adequate treatment, according to the NCS-R study (AV 1).1 Patients may require multiple treatment steps or a combination of medication and nonpharmacologic interventions, such as exercise or psychotherapy, to achieve remission and return to presymptomatic levels of functioning. When patients do not achieve a sufficient reduction in depressive symptoms, clinicians must decide how to improve partial or nonresponse and when to adjust, switch, or augment medication.

Because global clinical judgment is not always accurate, the APA guidelines2 recommend regularly and systematically assessing patient outcomes to aid in treatment planning and decision-making. To comprehensively evaluate illness course and treatment impact, clinicians should supplement their clinical judgment by using standard tools to assess depressive symptoms and implementing measurement-based care (MBC).



Assessing Depressive Symptoms
Standard methods of symptom measurement can help guide the treatment of MDD just as they do with diabetes, hypertension, and congestive heart failure. The following self-rated scales are well-suited for quick and easy use in primary care clinical practices.
AV 2. DSM-IV-TR Criterion for a Major Depressive Episode
9-Item Patient Health Questionnaire (PHQ-9). The PHQ-9 helps clinicians provide a DSM-IV criteria-based diagnosis of depression (AV 2)3 and then monitor patients symptoms throughout the course of treatment.4 The 1-page PHQ-9 is developed from the depression portion of the PRIME-MD, a diagnostic tool for common mental disorders. In practice, the PHQ-9 is relatively quick for patients to complete, is available in several languages, and generally takes clinicians less than 2 minutes to review. The patient rates the frequency of each item from not at all (0) to nearly every day (3), and the clinician totals the scores to confirm the patient’s depression severity, which ranges from none or minimal (<5) to severe (≥20). A diagnosis of major depression is suspected if the patient answers “more than half the days” for 5 or more of the 9 “A” DSM criteria-based questions, including having a depressed mood or anhedonia. A proposed threshold for treatment response is achieving a score of less than 10 and having a 50% decrease from the baseline score.4
Quick Inventory of Depressive Symptomatology (QIDS). The QIDS can aid clinicians in making MDD diagnoses and in measuring symptoms as patients complete it regularly throughout treatment phases. The QIDS, a brief version of the 30-item IDS, is comprised of 16 items that also assess the 9 DSM criteria for a depressive episode. The patient rates each item on a scale of 0 to 3 based on the presence and severity of each symptom over the previous week. Total symptom scores range from none (≤5) to very severe (≥21), with a score of 5 or less indicating remission. No additional non-DSM criteria symptoms clutter the assessment, which increases its reliability and validity. Patients can easily complete the self-report version of the QIDS in 5 to 7 minutes while waiting to see the clinician. The QIDS is also available in multiple languages.5
Beck Depression Inventory (BDI). The BDI is a 21-item, self-rated scale that features questions regarding psychological and physical symptoms, such as mood, pessimism, guilt, self-dislike, crying, social withdrawal, insomnia, appetite, and work problems. Individuals rate questions from 0 to 3, and the total score indicates the severity of depression from minimal (<10) to severe (≥30). The BDI correlates well with clinician ratings of depression and differentiates between subtypes of depression and between depression and anxiety.6 A shorter 7-item FastScreen version of the BDI is available for primary care providers.
Other tools that measure depressive symptoms, such as the HDRS and MADRS, are commonly used in antidepressant research trials. However, they must be used by specially trained clinicians, are time-consuming to administer, do not include all 9 DSM-IV criteria for MDD, and may be best used in settings other than busy primary care offices.5

Implementing Measurement-Based Care

Assessment tools play a vital role in helping clinicians detect unresolved symptoms and measure the adequacy of treatment response. When MBC approaches are used, outcomes in primary care are comparable to outcomes in psychiatric settings (AV 3).7 Implementing MBC involves using measurement-based tools to monitor depressive symptoms, treatment adherence, and side effects (AV 4).
Monitor depressive symptoms. At each visit, patients should fill out a self-rated symptom assessment scale, such as the PHQ-9. This strategy provides consistent follow-up by allowing clinicians to compare individual symptom scores over time to determine improvement in symptom severity and treatment response. For example, patients with higher scores at baseline and minimal or no improvement in scores over time may still be in the acute phase of illness and may require dose optimization, augmentation, or switch to another medication. Improving patient response also may require using treatment strategies other than medication. For example, APA practice guidelines2 recommend psychotherapy or exercise in addition to pharmacotherapy. Patient preference should always be considered when making these decisions.
Measuring depressive symptoms on a regular, frequent basis ensures that patients do not remain symptomatic for long periods between appointments. Using critical decision points, clinicians should assess patients every 2 weeks for the first 6 weeks of treatment, followed by every 3 weeks until remission or an adequate response is achieved or until a change in treatment strategy is necessary. During the continuation phase following remission, patients should be assessed every 3 months to prevent or treat relapses.8 Some telephone or online follow-up can be incorporated to lower patient costs and minimize in-office visits.
Once patients start an antidepressant regimen, clinicians should continue to assess suicidal thoughts and behaviors, which are common in patients with MDD and may be exacerbated by certain medications. The 12-item Concise Health Risk Tracking scale (CHRT), available in both self-report and clinician-rated versions, is an easy-to-use tool that examine patients’ current suicidal thoughts and plans, perception of social support, and sense of hopelessness.9 The 17-item Concise Associated Symptoms Tracking scale(CAST), also patient- or clinician-rated, measures irritability, anxiety, mania, insomnia, and panic associated with suicidal thoughts and behaviors. Both the CHRT and CAST scales have shown good psychometric properties and usefulness as tools for monitoring suicidality.10
Monitor treatment adherence. Another aspect of MBC is monitoring patients’ adherence to their treatment regimen. If patients are not taking their medications, clinicians need to know before adjusting or changing treatment. Patients are considered nonadherent if they miss 3 or more of the last 14 days of medication.11 Reasons for nonadherence could be treatment-emergent adverse effects, lack of understanding of the importance of compliance, or forgetfulness. Patients may complete the Medication Adherence Questionnaire (MAQ) at each visit to provide an overview of their adherence and possible reasons for noncompliance. Unless nonadherence is due to intolerable side effects, clinicians should address the patients’ concerns but try to continue the current treatment and dose to see if it is effective.
Monitor side effects. Adverse events are a common cause of patient nonadherence, which is why clinicians should ask patients specifically about side effects. If adverse events are a concern, clinicians can administer the 3-item Frequency, Intensity, and Burden of Side Effects Ratings(FIBSER) self-report scale. The burden question is a good indication of what patients are willing and able to tolerate. Many decisions about maintaining or increasing medication dosage are based on how patients handle side effects, and the FIBSER can help to inform those decisions.

Conclusion

Major depression can be complex disorder to manage, particularly in primary care. To supplement clinical judgment, several assessment scales are available for evaluating depressive symptom severity and diagnosing MDD, including the PHQ-9, QIDS-SR, and BDI. These tools take little time to review and provide valuable data to help develop treatment plans. Once a diagnosis is made and treatment is initiated, clinicians should implement MBC using measurement tools to regularly and systematically assess and track patients’ symptoms, treatment adherence, suicidality, and side effects. Implementing MBC enables clinicians to make better-informed treatment decisions and tailor practice approaches that will optimize outcomes and help patients achieve remission.

Clinical Points

  • Use an assessment tool to aid in diagnosing MDD
  • Administer a self-rated assessment scale at each patient visit to track depressive symptoms
  • Follow a set visit schedule and dose titration for your patients with MDD
  • Consistently monitor patients’ depressive symptoms, suicidality, treatment adherence, and side effects to optimize treatment

Abbreviations

APA = American Psychiatric Association, BDI = Beck Depression Inventory, CAST = Concise Associated Symptoms Tracking scale, CHRT = Concise Health Risk Tracking scale, DSM = Diagnostic and Statistical Manual of Mental Disorders, FIBSER = Frequency, Intensity, and Burden of Side Effects Ratings, HDRS = Hamilton Depression Rating Scale, IDS = Inventory of Depressive Symptomatology, MADRS = Montgomery-Asberg Depression Rating Scale, MAQ = Medication Adherence Questionnaire, MBC = measurement-based care, MDD = major depressive disorder, NCS-R = National Comorbidity Survey-Replication, PRIME-MD = Primary Care Evaluation of Mental Disorders, QIDS-SR = Quick Inventory of Depressive Symptomatology–Self-Report, STAR*D = Sequenced Treatment Alternatives to Relieve Depression

References

  1. Kessler RC, Berglund P, Demler O, et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA. 2003;289(23):3095–3105. PubMed
  2. American Psychiatric Association. Practice Guideline for the Treatment of Patients With Major Depressive Disorder, Third Edition. Washington, DC: American Psychiatric Association; 2010. http://psychiatryonline.org/content.aspx?bookid=28&sectionid=1667485. Accessed January 4, 2013.
  3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000.
  4. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–613. PubMed
  5. Trivedi M. The link between depression and physical symptoms. Prim Care Companion J Clin Psychiatry. 2004;6(suppl 1):12–16. Full Text
  6. Beck AT, Steer RA, Carbin MG. Psychometric properties of the Beck Depression Inventory: twenty-five years of evaluation. Clin Psychol Rev. 1988;8(1):77–100. http://dx.doi.org/10.1016/0272-7358(88)90050-5. Accessed January 4, 2013.
  7. Gaynes BN, Rush AJ, Trivedi MH, et al. Primary versus specialty care outcomes for depressed outpatients managed with measurement-based care: results from STAR*D. J Gen Intern Med. 2008;23(5):551–560. PubMed
  8. Suehs BT, Argo TR, Bendele SD, et al. Texas Medication Algorithm Project Procedural Manual: Major Depressive Disorder Algorithms. Austin, TX: Texas Department of State Health Services; 2008.http://www.pbhcare.org/pubdocs/upload/documents/TMAP%20Depression%202010.pdf . Accessed January 4, 2013.
  9. Trivedi MH, Wisniewski SR, Morris DW, et al. Concise Health Risk Tracking scale: a brief self-report and clinician rating of suicidal risk. J Clin Psychiatry. 2011;72(6):757–764. Full Text
  10. Trivedi MH, Wisniewski SR, Morris DW, et al. Concise Associated Symptoms Tracking scale: a brief self-report and clinician rating of symptoms associated with suicidality. J Clin Psychiatry. 2011;72(6):765–774. Full Text
  11. Tackling partial response to depression treatment [Academic Highlights]. Prim Care Companion J Clin Psychiatry. 2009;11(4):155–162. Full Text
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