Providing Guideline-Concordant Assessment and Monitoring for Major Depression in Primary Care​

J. Sloan Manning, MD

Department of Family Medicine, University of North Carolina, Chapel Hill, and the Mood Disorders Clinic, Moses Cone Family Practice Center, Greensboro

W. Clay Jackson, MD, DipTh

Departments of Family Medicine and Psychiatry, University of Tennessee College of Medicine, Memphis

Providing mental health services to patients in primary care is not new, but the number of these cases that clinicians see is significant and may be increasing. About one-third of patients rely on PCPs to treat psychiatric conditions, including major depression.1 A shortage of psychiatrists means that PCPs must be prepared to diagnose and treat major depression. The American College of Preventive Medicine affirms the need for PCPs to identify depression and recommends depression screening for all adults.2 By following established diagnostic and treatment guidelines, such as those by the APA, PCPs can provide accurate diagnoses and regular monitoring of depression.

Diagnosing Depression

Assessing patients for depression should include the combination of a clinical interview and a validated assessment tool to compile an accurate patient history, confirm depressive symptoms, and provide a baseline for symptom tracking needed to define treatment response and remission.

Clinical interview. The clinical interview gives PCPs the opportunity to develop a therapeutic alliance with patients as they collect information on patients’ past and present illness, current symptoms, general medical history, family history, and functional impairment. Symptoms to watch for, besides depressed mood, include sleep problems, anhedonia, guilt, difficulty with thinking and concentration, and suicidality, and these symptoms may be easily remembered with the mnemonic SIGECAPS (AV 1).3 Assessment of past and recent suicidal behavior is necessary for all patients with MDD and will help triage to the appropriate treatment setting.4 PCPs must also assess substance use and rule out other psychiatric or medical conditions that could cause suicidality or other depressive symptoms.4,5

AV 1. Symptoms of Depression (00:37)

Based on Caplan and Stern3

Assessment tools. When the clinical interview indicates possible depression, PCPs may use one of several validated tools to confirm the presence and duration of depressive symptoms. The 2 questions from the PHQ-26 can be used to screen for depression because they address whether patients are experiencing depressed mood or anhedonia, at least 1 of which must be present for an MDD diagnosis per the DSM-5.7 For patients who answer “yes” to either question, the next step is to administer the full PHQ-9 or another validated instrument. The PHQ-9 takes about 3 minutes for patients to complete and can be scored quickly by the clinician. Other validated tools include the HDRS and the QIDS-SR.

Additional assessment tools include the patient-rated Sheehan Disability Scale (SDS), which assesses the degree of functional impairment in work, social life, and home life caused by depressive symptoms, and the WHO-5, a patient-rated instrument of 5 quality-of-life factors. In a study8 comparing the PHQ-9, the General Health Questionnaire, the WHO-5, and physicians’ clinical diagnosis, the WHO-5 performed the best as a depression screening tool in primary care. However, an assessment tool cannot take the place of the clinical interview.5

Treating Depression

Successful depression screening must be followed with care (preferably staff-assisted) that includes close monitoring of patients who begin depression treatment.9 Current guidelines recommend antidepressant medication, psychotherapy, or a combination of the 2 for patients in the acute phase of depression.4 Other treatment options include ECT, TMS, or light therapy.4 For more information about treatment, please see “Treating Depression in Primary Care: Initial and Follow-Up Treatment Strategies.” Treatment in the acute phase is targeted to end the depressive episode and return the patient to full functioning. Clinicians and patients must set treatment goals and routinely measure symptoms so that insufficient response can be appropriately managed to reach those goals, as is done with medical conditions such as hypertension and diabetes mellitus.

More

Set goals and measure progress. The main goal of treatment is remission, or having minimal to no symptoms. Progress toward remission can be monitored using rating scales. For example, remission has been defined as a score of ≤ 7 on the HDRS, ≤ 5 on the QIDS-SR, and < 5 on the PHQ-9.10,11 By administering the same assessment tool at baseline and follow-up visits, clinicians can easily track symptom worsening or improvement. Treatment response, defined as a 50% decrease in baseline depression scores, is an insufficient outcome.10 Patients who respond but do not remit experience continued symptoms and impaired functioning and are at risk for relapse.10 Patients who achieve complete remission are more likely to achieve normal functioning than those with only partial remission. In a 6-month study,12 47% of patients in partial remission achieved normal social and occupational functioning, compared with 77% of patients in complete remission (AV 2). Other potential benefits of full remission include increased brain volume,13 decreased risk for type 2 diabetes,14 and, as demonstrated by Weissman et al in the STAR*D trial,15 improved psychopathology in the children of depressed mothers.

AV 2. Patients Who Reached Normal Functional Level
(SOFAS ≥80) (00:40)

Data from Romera et al12
Partial remission = HDRS score of >7 and ≤15
Complete remission = HDRS ≤7

Assess adherence. When clinicians are monitoring symptoms, they should also discuss treatment adherence with patients and, if necessary, address any barriers. Patients may lack motivation or have unrealistic expectations about treatment, in which case the clinician can provide education to the patient and involve family members for added support.4 If patients have trouble remembering to take medication, using smartphone apps, such as Pillboxie, Dosecast, RxmindMe, or MedCoach, may help. Adverse effects, such as weight gain and difficulties with sexual function, may also influence nonadherence and require PCPs to make treatment adjustments.

Monitor comorbid conditions. Patients with depression often have comorbid medical and psychiatric conditions that affect depression management. For example, comorbid anxiety at baseline is associated with difficulty attaining remission,16 and residual anxiety upon remission is associated with depressive relapse (AV 3).17 High BMI has also been found to affect treatment response.18 In one study,18 response rates to antidepressant treatment after 5 weeks were 50% for participants with normal BMI (≤ 25), 47% for overweight (BMI ≤ 30) patients, and 17% for obese (BMI > 30) individuals. In addition to anxiety and weight, PCPs should regularly monitor for alcohol and other substance abuse because it increases patients’ risk of suicide, social impairment, and other psychiatric conditions.19

AV 3. Residual Anxiety Symptoms As Predictor of Recurrence During Maintenance Treatment (00:33)

Data from Dombrovski et al17
No anxiety symptoms = score of 0 on HDRS anxiety subscale
Anxiety symptoms = score of 3 on HDRS anxiety subscale

Conclusion

Many patients will go undiagnosed with depression unless their PCPs screen for it. Assessing patients for depression should include a thorough clinical interview enhanced with an assessment tool such as the PHQ-9, QIDS-SR, or HDRS. Once patients begin treatment, these tools can also be used to monitor response. While response is an initial goal of treatment, the main goal should be complete, sustained remission because it is associated with improved function. Functional status and well-being can be assessed with tools including the SDS and WHO-5. PCPs can effectively manage patients with depression by following established guidelines and monitoring symptoms, adherence, side effects, and comorbid conditions.

Clinical Points

  • Screen adult patients for depression during the clinical interview using a validated assessment tool, such as the PHQ-9
  • Make remission and return to full functioning the treatment goal for patients with depression
  • Monitor treatment response and functional improvement with rating scales
  • Monitor patients for adherence problems, side effects, and comorbid conditions

Abbreviations

APA = American Psychiatric Association, BMI = body mass index, DSM-5 = Diagnostic and Statistical Manual of Mental Disorders, fifth edition, ECT = electroconvulsive therapy, HDRS = Hamilton Depression Rating Scale, MDD = major depressive disorder, PCP = primary care provider, PHQ = Patient Health Questionnaire, QIDS-SR = Quick Inventory of Depressive Symptomatology-Self-Report, SDS = Sheehan Disability Scale, SOFAS = Social and Occupational Functioning Assessment Scale, SSRI = selective serotonin reuptake inhibitor, TMS = transcranial magnetic stimulation, WHO-5 = World Health Organization Well-Being Index

Take the online posttest.

References

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