Clinical Vignettes from the Care Management Institute: Major Depression
Price, MD, FAAFP
syndromes are commonly seen in the primary care setting. Major depression
affects 4.8% to 8.6% of the general US population in any given year; other
types of depression affect an additional 3% to 8.4% of patients.1
Total costs of depression, including direct medical costs and indirect
costs due to days lost from work, exceed $43 billion annually.1,2
In the primary
care setting, treatment of depression usually includes evaluation by a
physician, brief patient education, and either antidepressant therapy,
referral to a behavioral health specialist, or both a prescription and
a referral. Although most depressed patients can be successfully treated
by primary care clinicians, depression remains unrecognized or undertreated
in many patients.
the Kaiser Permanente Care Management Institute (CMI) revised its guideline
for evidence-based care of depressed adult outpatients in the primary
care setting.3 This article and case example highlight key
steps and recommendations from this guideline.
married, employed female computer programmer with two young children (one
aged four years, the other aged nine months) is seen for a four-week history
of fatigue, insomnia, headache, abdominal discomfort, and difficulty concentrating
at work. She denies signs and symptoms of an acute infectious process
and did not have headache or abdominal pain before the previous month.
She is breastfeeding. She has obtained intermittent relief from headache
by using acetaminophen, and she takes a multivitamin regularly. Normal
menses has resumed. She is appropriately and professionally dressed, and
her children accompany her in the examination room. She appears tired
but in no acute distress. Results of physical examination, including neurologic
screening, are normal.
you proceed toward making a diagnosis? What treatment options are available?
How should you follow this patient over time?
Definition of Major
disorder (MDD) is characterized by at least two weeks of either
depressed mood or loss of interest in previously pleasurable activities4
along with four or more additional symptoms, including:
retardation or agitation
ideation, intention, or plan4
device DIGSPACES is a helpful way to remember these key symptoms of MDD.
Diagnosis and treatment of other types of depression (eg, adjustment disorder
with depressed mood; dysthymia; minor depressive disorders; depression
with psychotic features; and bipolar disorder) are beyond the scope of
Who Should be Screened
with cancer,5 chronic pain,6 heart failure,7
diabetes,8 recent stroke,9 or a recent acute cardiac
event10 have higher rates of depression than the general population.
Elderly patients with multiple medical comorbidity may also be at increased
risk for depression.11 Patients with a prior history of MDD
are at risk for recurrence.2,12 Other patients--those with
multiple somatic complaints without known cause, women in the antenatal
and postpartum periods, victims of domestic abuse, and HIV-positive patients--may
also be candidates for screening.
indicates that one-time screening of adults 40 years of age or older may
be cost-effective from a societal perspective.1,13 However,
screening of asymptomatic adults at low risk may result in many false-positive
tests. Thus, clinicians should weigh the potential societal benefits of
screening asymptomatic low-risk adults against other clinical and operational
priorities (including depression screening of higher-risk patients).
Diagnosis of MDD
screening tools are available to assist clinicians in screening for depression
1).14-23 Many of these tools can be completed by the patient
and easily scored by the clinician or by an assistant. These tools have
similar false-positive and false-negative rates.20,22,24-32 A
"yes" answer to one of the following two questions is as sensitive
a screen for MDD as most of these screening tools.14
the past month, have you often been bothered by feeling down, depressed,
the past month, have you often been bothered by little interest or pleasure
in doing things?"
screening results should be confirmed with careful attention to possible
substance abuse, medical, and other psychological causes or comorbidity
2). The patient in the above example denied using alcohol or drugs
and denied current or past physical, sexual, or emotional abuse; in addition,
the complete blood cell count (CBC) and thyroid-stimulating hormone (TSH)
level were normal. (TSH is measured to rule out hypothyroidism, a common
postpartum condition that can cause depression.)
Severity of Depressive Symptoms
severity is an important guide to selecting proper treatment for MDD.
Many depression-screening instruments provide a range of scores corresponding
to mild, moderate, and severe depression. Patients with five or six symptoms
of MDD who have slightly impaired daily functioning are mildly depressed.
Patients with six or seven MDD symptoms and moderately impaired daily
functioning are moderately depressed. Patients with eight or nine MDD
symptoms with profoundly impaired functioning in daily activities or suicidal
intention or plans are severely depressed.
depressed patients, regardless of illness severity, should be screened
for suicidal ideation. Many patients with depression have thoughts
of suicide; asking "Have you thought about taking your life?"
does not make patients more prone to attempt suicide. Patients with current
suicidal ideation should be asked about their intentions ("Do you
think you will commit suicide?") and if they have a plan ("Have
you thought about how you would kill yourself?" "Do you plan
to kill yourself? If so, when?"). Clinicians should elicit a promise
from actively suicidal patients not to harm themselves and should assess
adequacy and availability of patient support systems (family, friends,
and clergy). A behavioral health specialist should be contacted immediately
in these cases. Risk factors for suicide include: recent loss; medical
hospitalization within the past year; history of psychiatric hospitalization
or suicide attempts; living alone; severe vegetative symptoms; severe
hopelessness; comorbid substance abuse; and other comorbid psychiatric
conditions. Patients with these risk factors should be closely monitored.33-36
Although men are statistically more likely than women to successfully
commit suicide, women attempt suicide more often.37
Treatment of MDD
most mildly or moderately depressed adult primary care outpatients, medication
and psychotherapy are equally effective,38-41 although psychotherapy
might be slower to take effect.40,41 A shared decision-making
approach describing the pros and cons of each option should be used with
these patients to help them select initial treatment options consistent
with their values and concerns. One study41 found that patients
who select psychotherapy achieve better outcomes than patients who are
"assigned" to it. Another study42 found that patients
of different cultural backgrounds often prefer psychotherapy to medication.
A shared decision-making approach in patients with other conditions has
been shown to improve patient knowledge and to decrease patient uncertainty
about type of treatment.43-45 This approach can also help instill
a sense of control in depressed patients, who often feel "lost"
as a result of their depression.
depressed patients may respond better to medication than psychotherapy46
and may respond better to the combination of medication and psychotherapy.46,47
Consultation with a psychiatrist or other behavioral health specialist
is recommended for severely depressed patients seen in the primary care
of Antidepressant Medication
antidepressant classes appear to be equally effective in depressed patients
regardless of their age48 and regardless of whether they are
affected by any of the following conditions: diabetes;49,50
cancer;51,52 recurrent, chronic, or refractory depression;53-59
or mixed anxiety and depression.59-65 The CMI Depression Guideline
group did not find high-quality studies comparing the effectiveness of
different antidepressants in patients of different ethnic groups.
In the first
six to 12 weeks of therapy, selective serotonin reuptake inhibitors (SSRIs)
are somewhat better tolerated than tricyclic agents (TCAs) (number needed
to treat, 20-33).66,67 Risk of death by overdose is greater
with TCAs than with SSRIs, although rate of suicide from all causes does
not differ on the basis of type of antidepressant.59,68,69
However, given the lethality of TCAs when overdosed, the CMI guideline
workgroup strongly recommends that TCAs be avoided by patients who are
suicidal. Antidepressant agents have different side effect profiles that
clinicians should consider when prescribing for patients with other comorbidities;
patients may express a preference for a type of medication on the basis
of discussing class-specific side effects with the clinician.
successfully treated for depression with a particular antidepressant in
the past should be offered that agent again. Partly on the basis of favorable
pricing obtained from the manufacturer, fluoxetine is now Kaiser Permanente's
(St John's wort) has been shown to be as effective as low-dose TCAs or
SSRIs in treatment of mildly depressed adults and is better tolerated
than TCAs.59,70-75 However, the CMI depression guideline workgroup
has several concerns regarding the trials studying St John's wort, including
difficulty in blinding as well as lack of standardized preparations across
trials. The US Food and Drug Administration (FDA) does not regulate St
John's wort, and the amount of active ingredient may vary widely between
and within brands. For these reasons, the CMI guideline workgroup recommends
caution in prescribing St John's wort for treatment of depression. Clinicians
should consider discussing these concerns with patients who wish to use
St John's wort. This substance should not be used in combination with
other antidepressant agents.
The acute phase of treatment for MDD is defined as the period extending
from the start of treatment that achieves symptom remission for a period
of three months. No scientific evidence suggests an optimal frequency
of follow-up during the acute phase, but Health Plan Employer Data Information
Set (HEDIS) criteria require three follow-up contacts (including one face-to-face
contact with a prescribing provider) in the first 12 weeks of treatment.76
The risk of patients discontinuing treatment is highest in the first months
of treatment;67 therefore, follow-up is needed to assess patient
adherence to therapy, symptom remission, and, if medication is chosen,
presence of worrisome or unacceptable side effects.
options are available for patients who do not achieve symptom remission
within 6 to 12 weeks. The diagnosis should be reevaluated, and possible
presence of other untreated comorbid conditions should be considered.
Adherence to treatment regimen should be assessed and reinforced. Dosage
of medication may be increased or the medication can be changed. Psychotherapy
and medication can be combined, or a second, low-dose antidepressant from
a different class can be added. At this point, referral to a behavioral
health specialist is also an available option for patients who do not
respond to prescribed medication.
the acute phase has ended, patients should continue treatment for an additional
4 to 12 months. Terminating treatment sooner is associated with early
recurrence of symptoms.77 No available data exist to suggest
an optimal frequency of patient follow-up during the continuation phase.
The CMI guideline panel consensus opinion recommends at least one follow-up
during the fifth or sixth month of treatment to assure continued remission
of symptoms and patient adherence to treatment as well as to determine
necessity of adjusting treatment. More frequent follow-up can be scheduled
on the basis of clinical judgment and patient preference.
successfully completing treatment in the acute and continuation phases,
patients for whom the treated episode was the first should be offered
a trial of medication discontinuation.12 Fluoxetine regimens
of less than 20 mg daily can be stopped; higher fluoxetine doses and other
medications should be tapered over a two- to four-week period.78,79
Because a single episode of MDD is associated with a 50% lifetime risk
of recurrence,2 patients with MDD should be educated about
this risk and instructed to call their clinician at the first signs or
symptoms of recurrent MDD. Data suggest that risk of recurrence is highest
during the first year after medication is discontinued.12 The
CMI guideline panel suggests that patients be reassessed three months
after discontinuing medication and again at 12 months.
who have had three or more episodes of MDD have a 90% lifetime risk of
recurrence after medication discontinuation.2 Studies12,80
suggest that continuing medication for at least five years is beneficial
for these patients because it decreases risk of relapse. No available
data exist to suggest an optimal frequency of patient follow-up during
maintenance treatment. The CMI guideline recommends at least one annual
contact with the patient to detect symptom relapse and to determine need
for treatment adjustment.
is available to indicate the best therapeutic approach (maintenance vs
discontinuation) for patients who have had two episodes of MDD. Expert
opinion81 suggests that if these patients have a history of
suicide attempt, substance abuse, or psychiatric comorbidity, they should
continue maintenance therapy. For patients experiencing their second episode
of MDD without these types of comorbidity, a shared decision-making approach
should be used for selecting maintenance or discontinuation of treatment.
For these patients, the lifetime risk of MDD recurrence is approximately
70%;2 therefore, these patients should receive both follow-up
and patient education on symptom relapse.
a trend toward increasing acceptance, many patients still feel stigmatized
by the diagnosis of MDD. Therefore, clinicians should explain to these
patients that MDD is a real illness and is not "all in their head."
Comparison with diabetes may be helpful (Table
3). Patients choosing medication should be informed about side effects
and given instructions designed to enhance compliance with prescribed
medication regimens (Table
4).82 Patients should also be educated about the signs
and symptoms of relapsing or worsening depression.
Depression Guideline workgroup recommends referral or consultation with
a behavioral health specialist for the situations listed in Table
and Treatment Approach
to sleep disturbance, decreased energy, and difficulty concentrating,
the patient in the above example admitted being sad and tearful as well
as feeling guilty and worrying about her parenting skills, and she had
lost interest in socializing. She also admitted to worrying about work
performance and being somewhat irritable with her husband. She was not
suicidal and had no prior history of depression or other psychiatric illness,
but she thought her mother may have been depressed. Other medical comorbidity
was excluded, and she was diagnosed with MDD, first episode, with secondary
anxiety (not meeting criteria for generalized anxiety disorder). After
participating in a shared decision-making approach, she selected pharmacotherapy
with a SSRI and started fluoxetine, 10 mg daily, the next morning. At
two-week follow-up, her depressed mood and energy were "50% better,"
but she was still having trouble concentrating and sleeping and was still
irritable. The dose of fluoxetine was increased to 20 mg in the morning,
and 50 mg of trazodone was added at bedtime. At six-week follow-up, she
was sleeping better, and her depressed mood and guilt about parenting
were "almost gone." Her energy was "returning to normal,"
but she still worried about her work performance and reported having continued
irritability with her husband. She elected not to change her medication
regimen or to add psychotherapy and, at 12-week follow-up, reported total
on medication, without further symptoms, for one year (three months of
acute-phase treatment plus nine months of continuation-phase treatment).
She was then offeredand electeda trial of medication discontinuation.
Follow-up calls at three weeks and at three months revealed continued
absence of symptoms. During a health maintenance visit one year after
medication discontinuation, she reported slight decrease in appetite as
well as increase in worry and irritability, which she attributed to job
stress. Repeat screening was not diagnostic for recurrent MDD or anxiety.
The patient was reeducated on the symptoms of MDD and elected to monitor
symptoms without resuming medication. At follow-up three months, six months,
and 12 months later, the symptoms had resolved, and the patient remained
completed an extensive, evidence-based revision of the adult depression
guideline,3 which also discusses different cultural backgrounds,
the elderly, and (briefly) depression among adolescents. The guideline
group views the depression guideline as a work in progress: Future revisions
will update current evidence and explore evidence in areas not covered
in the current guideline. The full document will be available on the Permanente
Knowledge Connection Web site: http://pkc.kp.org/national/cmi/programs/depression/DP_Guidelines.html.
you to Trina Histon, PhD, at CMI, for her help in compiling the reference
list and for her expert facilitation of the Depression Guideline process
in her role as project manager.
you to Erin Stone, MD, for his methodologic expertise during the Depression
you to the members of the guideline work group for their hard work during
the guideline development process. A complete list of guideline work group
members can be found in the Depression Guideline, available online at
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