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Optimizing Depression Treatment to Increase the Likelihood of Remission

Alan J. Gelenberg, MD

Department of Psychiatry, Penn State College of Medicine, Hershey, Pennsylvania

The Case for Measurement-Based Care

Depression is a leading cause of disease burden worldwide, particularly in developed countries,1 yet it remains underrecognized and undertreated. Even for those patients who are correctly diagnosed with depression, treatment is often inadequate. Kessler et al2 found that, of patients experiencing a major depressive episode during the previous year, only 22% received adequate treatment. In fact, only 33% of patients with chronic MDD have ever received an adequate trial of pharmacotherapy.3

Implementing measurement-based care—a system utilizing standardized measurement tools and algorithms for screening, diagnosing, and selecting and monitoring treatment—can improve the quality of care received by patients with depression and improve their treatment outcomes. Measurement-based care in psychiatry has been found to be efficacious and is strongly endorsed by experts4 but has yet to become standard practice in the field. Many psychiatrists continue to use clinical intuition and empathy instead of objective measurement. However, measurement-based care is common in most nonpsychiatric areas of medicine. For instance, internists diagnosing and treating hypertension are expected to measure blood pressure. Likewise, psychiatrists should measure depressive symptoms with standardized screening and diagnostic tools. The revision of the APA guidelines for the treatment of MDD is expected to strongly endorse measurement-based care.

Screening

 

Routine screening for depression is easy, can enhance the detection of depression, and is recommended for all patients in psychiatric and primary care settings. Short and simple screening tools such as the PHQ-25 and the PHQ-96 elicit accurate information regarding the presence of depression. Self-rated instruments can be quickly completed by patients immediately prior to appointments, making the screening tools cost-effective time savers. By having patients answer a screening instrument before the visit, the physician gains more time during the session to communicate with the patient. Other patient-rated screening tools include the CES-D,7 the HADS,8 and the Zung SDS.9,10 When screening results are positive for the presence of depression, a thorough diagnostic evaluation should follow. See AV 1AV 1 for a list of selected measurement tools for each treatment phase for depression.

Diagnosing

Clinician- and patient-rated diagnostic instruments can be used to systematically and accurately diagnose depressive disorders (see AV 1AV 1). Many are available in electronic versions and foreign-language translations. The clinician-rated SCID-CV11 was designed to help diagnose disorders most commonly seen in clinical practice. The MINI12 is a short, clinician-rated interview designed for the diagnosis of disorders based on DSM-IV and ICD-10 criteria. Patient-rated instruments for diagnosing MDD include the PRIME-MD,13,14 which evaluates primary care patients for anxious, depressive, and alcohol-related disorders; the PDSQ,15 which screens for common DSM-IV Axis I disorders and enables easy identification of secondary disorders; and the previously mentioned PHQ-9,6,16 which can be used for both screening and diagnosis. While electronic patient-rated instruments are likely to become the standard, whichever instrument is deemed the most practical and cost-effective in the physician’s own health care setting is the best choice.

During the diagnostic process, clinicians must be sure to differentiate MDD from disorders with similar symptomatology, such as MDD with psychotic features, bipolar disorder, substance use disorders, and depression due to a medical condition. These diagnoses require different treatment than that for MDD.

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Selecting Treatment

Physicians who conduct routine screening for MDD must have a system in place to manage the patients who have depression. When selecting treatment, clinicians should consult treatment algorithms such as the TMAP algorithm for depression.17 The use of treatment algorithms in psychiatric practice has been shown to increase remission rates and help patients reach remission faster than treatment as usual, both for patients with mild-to-moderate depression and for those with depression requiring hospitalization.18,19

 

Besides the use of algorithms, collaboration among the treatment team and with the patient and his or her family is necessary to narrow the gap between the efficacy of available treatments for depression and the real-world effectiveness of those treatments. Family members can be key decision-makers with the patient after the patient leaves the physician’s office, and engaging them in the patient’s treatment is essential. Alexopoulos and colleagues20 found that, compared with usual care, collaborative care that incorporated algorithm-based treatment reduced suicidal ideation, sped response, and increased remission rates in elderly patients with MDD over 2 years (AV 2AV 2).

Monitoring Treatment

 

Once treatment has been initiated, symptom severity, adverse events, and suicidality should be regularly monitored. With remission as the goal of treatment, many patients with depression may require dose optimization, medication switching, or antidepressant augmentation to achieve remission. Objectively tracking patients’ symptomatology allows clinicians to adjust treatment strategies as necessary in a timely manner to help patients reach full remission without residual symptoms, which is crucial to avoiding relapse. A 2-year follow-up study21 found that patients who remitted from MDD were significantly less likely to relapse if they had achieved full remission than if they had residual symptoms at remission (P<.0001). Similarly, Paykel and colleagues22 found that, during the 15 months after remission of MDD, 3 times as many patients with residual symptoms relapsed than those who did not have residual symptoms (AV 3AV 3).

Available monitoring tools include the HDRS,23 which evaluates DSM-IV symptom severity for depression and comorbid anxiety; the MADRS,24 which was designed to be sensitive to antidepressant treatment effects; the IDS25; the QIDS,26 the HADS,8 and the BDI,27 among others (see AV 1AV 1). The FIBSER28 is useful in monitoring the severity and frequency of adverse events, and the C-SSRS29 can be used to track suicidality (see AV 1AV 1).

Summary

To improve the care of patients with depression and to reduce the chronicity and overall burden of MDD as much as possible, physicians must screen for and diagnose depression, individualize treatment, monitor response, collaborate with the patients and others involved in treatment, and strive for remission. The use of measurement-based care at all phases of the treatment process, from screening to response assessment, can improve treatment outcomes for patients suffering from depression. Standardized measurement tools and treatment algorithms are widely available and are easy to implement in practice; making measurement-based care the treatment standard in psychiatry should be a priority for everyone in the field.

For Clinical Use

  • Screen all patients in psychiatric and primary care settings for depression
  • Use measurement-based care, including treatment algorithms, for all phases of the treatment process

Abbreviations

APA=American Psychiatric Association; BDI=Beck Depression Inventory; CES-D=Center for Epidemiologic Studies Depression scale; C-SSRS=Columbia Suicide Severity Rating Scale; DSM-IV=Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; FIBSER=Frequency, Intensity, and Burden of Side Effects Rating scale; HADS=Hospital Anxiety and Depression Scale; HDRS=Hamilton Depression Rating Scale; ICD-10=International Classification of Diseases and Related Health Problems, 10th Revision; IDS=Inventory of Depressive Symptomatology; MADRS=Montgomery-Åsberg Depression Rating Scale; MDD=major depressive disorder; MINI=Mini International Neuropsychiatric Interview; PDSQ=Psychiatric Diagnostic Screening Questionnaire; PHQ-2=2-item Patient Health Questionnaire; PHQ-9=9-item Patient Health Questionnaire; PRIME-MD=Primary Care Evaluation of Mental Disorders; QIDS=Quick Inventory of Depressive Symptomatology; SCID-CV=Structured Clinical Interview for DSM-IV Axis I Disorders, Clinician-rated version; TMAP=Texas Medication Algorithm Project; Zung SDS=Zung Self-Rating Depression Scale

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References

  1. World Health Organization. The Global Burden of Disease: 2004 Update. Geneva, Switzerland: WHO Press; 2008. http://www.who.int/healthinfo/global_burden_ disease/2004_report_update/en/. Accessed March 3, 2010.
  2. 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.
  3. Kocsis JH, Gelenberg AJ, Rothbaum B, et al. Chronic forms of major depression are still undertreated in the 21st century: systematic assessment of 801 patients presenting for treatment. J Affect Disord. 2008;110(1–2):55–61.
  4. Trivedi MH. Tools and strategies for ongoing assessment of depression: a measurement-based approach to remission. J Clin Psychiatry. 2009;70(suppl 6):26–31.
  5. Pfizer Incorporated. Patient Health Questionnaire-2 (PHQ-2). http://www.cqaimh.org/tool_depscreen.html. Published 1999. Accessed March 3, 2010.
  6. Pfizer Incorporated. Patient Health Questionnaire (PHQ-9). http://www.cqaimh.org/tool_depscreen.html. Published 2005. Accessed March 3, 2010.
  7. Radloff LS. The CES-D Scale: a self-report depression scale for research in the general population. Appl Psychol Meas. 1977;1(3):385–401.
  8. Zigmond A, Snaith R. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand. 1983;67(6):361–370.
  9. Zung WWK. A self-rating depression scale. Arch Gen Psychiatry. 1965;12(1):63–70.
  10. Guy W. ECDEU Assessment Manual for Psychopharmacology. US Dept Health, Education, and Welfare publication (ADM) 76-338. Rockville, MD: National Institute of Mental Health; 1976.
  11. First MB, Spitzer RL, Gibbon M, et al. Structured Clinical Interview for DSM-IV Axis I Disorders, Clinician Version (SCID-CV). Washington, DC: American Psychiatric Publishing, Inc; 1996.
  12. Sheehan DV, Lecrubier Y, Sheehan KH, et al. The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry. 1998;59(suppl 20):22–33.
  13. Spitzer RL, Williams JB, Kroenke K, et al. Utility of a new procedure for diagnosing mental disorders in primary care: the PRIME-MD 1000 study. JAMA. 1994;272(22):1749–1756.
  14. Kobak KA, Taylor LH, Dottl SL, et al. A computer-administered telephone interview to identify mental disorders. JAMA. 1997;278(11):905–910.
  15. Zimmerman M, Mattia JI. The reliability and validity of a screening questionnaire for 13 DSM-IV Axis I disorders (the Psychiatric Diagnostic Screening Questionnaire) in psychiatric outpatients. J Clin Psychiatry. 1999;60(10):677–683.
  16. 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.
  17. 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.dshs.state.tx.us/mhprograms/ disclaimer.shtm. Accessed March 3, 2010.
  18. Bauer M, Pfennig A, Linden M, et al. Efficacy of an algorithm-guided treatment compared with treatment as usual: a randomized, controlled study of inpatients with depression. J Clin Psychopharmacol. 2009;29(4):327–333.
  19. Yoshino A, Sawamura T, Kobayashi N, et al. Algorithm-guided treatment versus treatment as usual for major depression. Psychiatry Clin Neurosci. 2009;63(5):652–657.
  20. Alexopoulos GS, Reynolds CF 3rd, Bruce ML, et al, for the PROSPECT Group. Reducing suicidal ideation and depression in older primary care patients: 24-month outcomes of the PROSPECT Study. Am J Psychiatry. 2009;166(8):882–890.
  21. Pintor L, Gastó C, Navarro V, et al. Relapse of major depression after complete and partial remission during a 2-year follow-up. J Affect Disord. 2003;73(3):237–244.
  22. Paykel ES, Ramana R, Cooper Z, et al. Residual symptoms after partial remission: an important outcome in depression. Psychol Med. 1995;25(6):1171–1180.
  23. Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960;23(1):56–62.
  24. Montgomery SA, Åsberg M. A new depression scale designed to be sensitive to change. Br J Psychiatry. 1979;134(4):382–389.
  25. Rush AJ, Gullion CM, Basco MR, et al. The inventory of depressive symptomatology (IDS): psychometric properties. Psychol Med. 1996;26(3):477–486.
  26. Rush AJ, Trivedi MH, Ibrahim HM, et al. The 16-item Quick Inventory of Depressive Symptomatology (QIDS), Clinician Rating (QIDS-C), and Self-Report (QIDS-SR): a psychometric evaluation in patients with chronic major depression. Biol Psychiatry. 2003;54(5):573–583.
  27. Beck AT, Ward CH, Mendelson M, et al. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4(6):561–571.
  28. Wisniewski SR, Rush AJ, Balasubramani GK, et al. Self-rated global measure of the frequency, intensity, and burden of side effects. J Psychiatr Pract. 2006;12(2):71–79.
  29. Posner K, Brent DA, Lucas C, et al. Columbia Suicide Severity Rating Scale (C-SSRS). New York, NY: New York State Psychiatric Institute; 2009. http://www.maps.org/mdma/mt1_docs/c-ssrs1-14-09-baseline.pdf. Accessed March 19, 2010.