Improving Patient Outcomes in Depression Through Guideline-Concordant, Measurement-Based Care
Larry Culpepper, MD, MPH
Department of Family Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
Primary care physicians have improved their recognition and treatment of MDD over the past 2 decades, but many use strategies that lack a foundation in following evidence-based treatment guidelines and using patient assessment tools. Without measurement-based care to guide decisions, clinicians may rely on global clinical judgments, which can be biased and less accurate than specific symptom assessments.1
In 1994, PCPs were found to recognize only about half of patients with a mental illness, and when psychiatric disorders were recognized, treatment was only minimally effective.2 The usual care of MDD in primary care settings was of questionable benefit. This finding led to the development of instruments and approaches that could help PCPs efficiently identify and manage MDD.
Many adults seek treatment for depression from their PCPs. To provide the best level of care and to optimize patients’ outcomes, clinicians should use guideline- and measurement-based care. The following sections outline instruments and approaches for assessing MDD, collaborating with other health care professionals and patients, and treating comorbid medical illnesses.
Effectively managing depression begins with establishing a good relationship with the patient and completing a thorough biopsychosocial assessment. The APA treatment guidelines3 for MDD recommend obtaining a medical, psychiatric, and family history along with evaluating the patient’s current symptoms and medications. Clinicians should also determine the patient’s level of social and occupational functioning, quality of life, and risk for suicide, recommending another treatment setting when appropriate. Patients at risk for suicide or without social support may require a referral to a specialist or hospitalization until their symptoms improve.3
In addition to implementing treatment guidelines, using measurement-based tools is crucial when diagnosing MDD and managing patients throughout the phases of the disorder. As one meta-analysis4 showed, screening for MDD in primary care could lead to improved outcomes, particularly when coupled with adequate treatment and follow up. Several trials, such as STAR*D, have tested and validated tools for routine clinical practice. (For more information on assessment tools, see “Evaluating and Monitoring Treatment Response in Depression Using Measurement-Based Assessment and Rating Scales” by Madhukar H. Trivedi, MD.)
Some common assessment tools include the PHQ-9, QIDS, and FIBSER. Of note, the PHQ-9 and QIDS focus only on depression and do not help with recognition of other psychiatric conditions, such as bipolar disorder or anxiety disorders. Thus, a confirmatory clinical interview remains critical to proper diagnosis.
Patient Health Questionnaire (PHQ-9). The self-administered PHQ-9 was developed to help PCPs diagnose patients with mental disorders. The PHQ-9 is comparable to the original clinician-administered PRIME-MD, but it takes only about 3 minutes for the clinician to review. A valid and efficient tool for identifying MDD, the PHQ-9 has 85% accuracy compared with the diagnoses of independent mental health professionals.5
Quick Inventory of Depressive Symptomatology (QIDS). The 16-item QIDS has both self-report (QIDS-SR) and clinician-rated (QIDS-C) versions. The QIDS-SR correlates well with the IDS-SR and HDRS and is equally sensitive to symptom change.6 For measuring depressive symptom severity in primary care, the QIDS remains a useful rating tool.
Frequency, Intensity, and Burden of Side Effects Ratings (FIBSER). The FIBSER was created as a self-report measure of side effects for patients treated in the STAR*D project. Rather than measuring the impact of specific side effects, the FIBSER measures the 3 domains of impact: frequency, intensity, and burden. Its reliability and brevity make it a practical tool for the primary care setting.7
Collaborating With Health Care Professionals and Patients
Along with conducting patient assessments that incorporate treatment guidelines and measurement-based care, clinicians should take an organized practice approach to treating MDD. Communication between the PCP and other health care professionals can improve patients’ overall treatment and ensure that issues are comprehensively addressed ().3
AV 1. Implementing Collaborative Care When Treating MDD (02:01)
Practical approaches involving a mental health specialist have evolved into collaborative care strategies in which the primary and specialty care resources are integrated to provide individualized, high-quality care. A review8 found extensive research supporting the effectiveness of collaborative care versus usual primary care in improving depressive outcomes, even up to 5 years. Collaborative care provides close patient follow up, facilitates timely treatment adjustment, and promotes patient self-monitoring and adherence.8 (See the depression management toolkit for additional resources, including patient handouts.)
Von Korff and Goldberg9 discovered that the management strategies that reliably improved patient outcomes included case management with some level of specialist support. The reviewers concluded that approaches to improve the primary care treatment of MDD should include low-cost case management and collaboration among the PCP, the case manager, and a mental health specialist.9
AV 2. Noncompliance in Patients With Depression (00:32)
Case management, which can be provided via in-office visits or structured telephone calls, is designed to assess symptomatic improvement and side effect burden, to educate patients and their families about the disease and its treatment, and to ensure that patients follow their treatment plan.10 Patients with depression are more likely than nondepressed patients to be nonadherent to their treatment regimen ().11 In conjunction with PCPs, case managers can help address and resolve issues that contribute to treatment nonadherence and cause patients to discontinue treatment or miss appointments.
The mental health specialist, such as a psychiatrist or psychologist, may remotely supervise the case manager, consult with the PCP, and provide referral advice. By reviewing cases with the clinician on a weekly basis, the specialist can answer questions about individual patients. The collaboration of the PCP with a case manager and a supervising specialist enables the clinician to be more confident in making depression diagnoses and managing patients with MDD.10
Treating Comorbid Medical Illnesses
An effective MDD management plan in primary care should include not only guideline-concordant and measurement-based care and collaboration but also care of patients’ comorbid medical illnesses. More than half of patients with depression have significant medical comorbidity, which can contribute to somatic symptoms, complicate diagnosis and treatment, worsen patients’ prognoses, and hinder recovery.12
A primary care study13 examined patients with depression and poorly controlled diabetes and coronary heart disease who received guideline-based, collaborative care management with a nurse case manager collaborating with PCPs, patients, and consultants. Compared with the usual care group, the intervention group had significantly greater improvements in blood pressure, cholesterol, and depression scores (P < .001); had a better quality of life (P < .001); and had a greater satisfaction with both medical and mental health care (P < .001).13 A subsequent study14 of the same groups examined the impact of medication adherence, self-monitoring, and treatment adjustment on patient outcomes. Although medication adherence did not differ between groups, the collaborative care group had higher initiation and adjustment rates for antidepressants, insulin, and antihypertensive medications. By improving physicians’ performance in regularly assessing and adjusting treatment and patients’ behaviors in monitoring their conditions, the collaborative care program improved the outcomes and quality of life in patients with depression and chronic medical conditions.14
AV 3. An Integrated Treatment Approach for Patients With Depression and Diabetes (00:47)
A 12-week study15 examined integrated care for primary care patients with depression and type 2 diabetes (). The integrated treatment group had significantly improved medication adherence (≥ 80%; P < .001) and glucose control (P < .001) and were more likely to achieve depression remission (P < .001) compared with the usual care group.15
Besides medical illnesses, MDD can also be comorbid with substance use problems and other psychiatric conditions, such as anxiety disorder, bipolar disorder, or PTSD. Screening and severity measures for use in primary care include the GAD-7, a brief self-report scale for generalized anxiety disorder,16 and the PC-PTSD, a 4-item tool used to detect new cases of PTSD.17
The problem for some clinicians is that too many instruments can lead to an unrealistic workload. One tool designed to screen for multiple psychiatric illnesses in primary care is the My Mood Monitor (M-3) checklist, a self-rated, 1-page, 27-item tool for depressive, bipolar, anxiety, and posttraumatic stress disorders.18 The M-3 has equivalent diagnostic accuracy compared with single-disorder screens, and tools like the M-3 can help streamline the assessment process.
Using practice guidelines and measurement tools and collaborating and integrating treatment approaches in primary care can improve MDD outcomes. Practice guidelines and assessment tools help clinicians create effective management plans and review symptom severity throughout treatment. Collaborative care provides better patient assessment and monitoring to improve outcomes not only for depressive symptoms but also for comorbid medical and psychiatric conditions that frequently occur in primary care patients. Further, case managers and mental health specialists can assist clinicians by providing follow up after appointments. Clinicians can also improve patient outcomes by treating comorbid conditions along with depression. PCPs can effectively manage patients with MDD using practice approaches that incorporate guidelines, measurement tools, collaboration, and multiple-condition treatment.
- Consult the APA practice guidelines when devising your patients’ treatment plan
- Use a measurement-based assessment tool to record your patients’ depressive symptoms at baseline and at follow-up visits
- Use a collaborative approach to patient care by incorporating case managers and specialists to help track patients’ progress, monitor treatment adherence, and facilitate clinical decisions
- Treat medical and psychiatric conditions that are comorbid with MDD
APA = American Psychiatric Association, FIBSER = Frequency, Intensity, and Burden of Side Effects Rating scale, GAD = generalized anxiety disorder, HDRS = Hamilton Depression Rating Scale, IDS-SR = Inventory of Depressive Symptomatology–Self-Report, MDD = major depressive disorder, PCP = primary care physician, PC-PTSD = Primary Care-Posttraumatic Stress Disorder screen, PHQ-9 = 9-item Patient Health Questionnaire, PRIME-MD = Primary Care Evaluation of Mental Disorders, PTSD = posttraumatic stress disorder, QIDS = Quick Inventory of Depressive Symptomatology, STAR*D = Sequenced Treatment Alternatives to Relieve Depression
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- Trivedi MH, Rush AJ, Gaynes BN, et al. Maximizing the adequacy of medication treatment in controlled trials and clinical practice: STAR*D measurement-based care. Neuropsychopharmacology. 2007;32(12):2479–2489. PubMed
- Higgins ES. A review of unrecognized mental illness in primary care: prevalence, natural history, and efforts to change the course. Arch Fam Med. 1994;3(10):908–917. PubMed
- 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§ionid=1667485 . Accessed December 14, 2012
- Pignone MP, Gaynes BN, Rushton JL, et al. Screening for depression in adults: a summary of the evidence for the US Preventive Services Task Force. Ann Intern Med. 2002;136(10):765–776. PubMed
- Spitzer RL, Kroenke K, Williams JB, for the Patient Health Questionnaire Primary Care Study Group. Validation and utility of a self-report version of PRIME-MD: the PHQ Primary Care Study. JAMA. 1999;282(18):1737–1744. PubMed
- 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. PubMed
- 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. PubMed
- Katon W, Unützer J, Wells K, et al. Collaborative depression care: history, evolution and ways to enhance dissemination and sustainability. Gen Hosp Psychiatry. 2010;32(5):456–464. PubMed
- Von Korff M, Goldberg D. Improving outcomes in depression. BMJ. 2001;323(7319):948–949. PubMed
- Oxman TE, Dietrich AJ, Williams JW Jr, et al. A three-component model for reengineering systems for the treatment of depression in primary care. Psychosomatics. 2002;43(6):441–450. PubMed
- DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med. 2000;160(14):2101–2107. PubMed
- Yates WR, Mitchell J, Rush AJ, et al. Clinical features of depressed outpatients with and without co-occurring general medical conditions in STAR*D. Gen Hosp Psychiatry. 2004;26:421–429. PubMed
- Katon WJ, Lin EH, Von Korff M, et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med. 2010;363(27):2611–2620. PubMed
- Lin EH, Von Korff M, Ciechanowski P, et al. Treatment adjustment and medication adherence for complex patients with diabetes, heart disease, and depression: a randomized controlled trial. Ann Fam Med. 2012;10(1):6–14. PubMed
- Bogner HR, Morales KH, de Vries HF, et al. Integrated management of type 2 diabetes mellitus and depression treatment to improve medication adherence: a randomized controlled trial. Ann Fam Med. 2012;10(1):15–22. PubMed
- Spitzer RL, Kroenke K, Williams JB, et al. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092–1097. PubMed
- Ouimette P, Wade M, Prins A, et al. Identifying PTSD in primary care: comparison of the Primary Care-PTSD screen (PC-PTSD) and the General Health Questionnaire-12 (GHQ). J Anxiety Disord. 2008;22(2):337–343. PubMed
- Gaynes BN, DeVeaugh-Geiss J, Weir S, et al. Feasibility and diagnostic validity of the M-3 checklist: a brief, self-rated screen for depressive, bipolar, anxiety, and post-traumatic stress disorders in primary care. Ann Fam Med. 2010;8(2):160–169. PubMed