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Guideline Summary
Guideline Title
Primary care diagnosis and management of adults with depression.
Bibliographic Source(s)
Michigan Quality Improvement Consortium. Primary care diagnosis and management of adults with depression. Southfield (MI): Michigan Quality Improvement Consortium; 2012 Jan. 1 p.
Guideline Status

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

Scope

Disease/Condition(s)

Major depression

Guideline Category
Diagnosis
Management
Risk Assessment
Screening
Treatment
Clinical Specialty
Family Practice
Internal Medicine
Obstetrics and Gynecology
Psychiatry
Psychology
Intended Users
Advanced Practice Nurses
Health Plans
Physician Assistants
Physicians
Guideline Objective(s)
  • To achieve significant, measurable improvements in the management of depression through the development and implementation of common evidence-based clinical practice guidelines
  • To design concise guidelines that are focused on key management components of depression to improve outcomes
Target Population
  • Adults 18 years or older with high risk for depressive disorder, including prenatal and postpartum populations
  • Individuals diagnosed with significant mood symptoms, particularly those meeting criteria for major depression
Interventions and Practices Considered

Diagnosis/Screening

  1. Assessment of symptoms of major depression using:
    • Patient health questionnaire (PHQ)-2 and PHQ-9
    • Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)
    • Edinburgh Postnatal Depression Scale (EPDS)
  2. Assessment of drug and alcohol use
  3. Assessment of symptoms suggesting bipolar disorder or psychosis
  4. Assessment of suicide risk

Management/Treatment

  1. Antidepressant medication
  2. Referral to a behavioral health specialist
  3. Frequent monitoring of medication
  4. Adjustment of medication dosage
  5. Continuing medication for 9-12 months after acute symptoms resolve in patients with recurrent major depression
Major Outcomes Considered

Not stated

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

The Michigan Quality Improvement Consortium (MQIC) health care analyst conducts a search of current literature in support of the guideline topic. Computer database searches are used to identify published studies, existing protocols, and/or national guidelines on the selected topic developed by organizations such as the American Diabetes Association, American Heart Association, American Academy of Pediatrics, etc. If available, clinical practice guidelines from participating MQIC health plans and Michigan health systems are also used to develop a framework for the new guideline.

For the current update of the guideline Google and MacArthur Initiative on Depression and Primary Care databases were searched in November 2011. Specific search terms used were PHQ-9 and PHQ-2.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Levels of Evidence for the Most Significant Recommendations

  1. Randomized controlled trials
  2. Controlled trials, no randomization
  3. Observational studies
  4. Opinion of expert panel
Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Using information obtained from literature searches and available health plan guidelines on the designated topic, the Michigan Quality Improvement Consortium (MQIC) health care analyst prepares a draft guideline to be reviewed by the medical directors' committee at one of their scheduled meetings. Priority is given to recommendations with [A] and [B] levels of evidence (see the "Rating Scheme for the Strength of the Evidence" field).

The initial draft guideline is reviewed, evaluated, and revised by the committee, resulting in draft two of the guideline. Additionally, the Michigan Academy of Family Physicians participates in guideline development at the onset of the process and throughout the guideline development procedure. The MQIC guideline feedback form and draft two of the guideline are distributed to the medical directors, as well as the MQIC measurement and implementation group members, for review and comments. Feedback from members is collected by the MQIC health care analyst and prepared for review by the medical directors' committee at their next scheduled meeting. The review, evaluation, and revision process with several iterations of the guideline may be repeated over several meetings before consensus is reached on a final draft guideline.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

When consensus is reached on the final draft guideline, the medical directors approve the guideline for external distribution to practitioners with review and comments requested via the Michigan Quality Improvement Consortium (MQIC) health plans (health care analyst distributes final draft to medical directors' committee, measurement and implementation groups to solicit feedback).

The MQIC health care analyst also forwards the approved guideline draft to appropriate state medical specialty societies and physicians with expertise in the related field for their input. After all feedback is received from external reviews, it is presented for discussion at the next scheduled committee meeting. Based on feedback, subsequent guideline review, evaluation, and revision may be required prior to final guideline approval.

The MQIC Medical Directors approved this updated guideline in January 2012.

Recommendations

Major Recommendations

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.

The level of evidence grades (A–D) are provided for the most significant recommendations and are defined at the end of the "Major Recommendations" field.

Detection and Diagnosis

  • Assess for major depression using a validated screening tool (e.g. Patient Health Questionnaire [PHQ]-2) and diagnostic tool (e.g. PHQ-9), or
  • Assess if criteria for major depression are met using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (DSM-IV) [A].
    Must have a total of five symptoms for at least two weeks. One of the symptoms must be depressed mood or loss of interest. Relevant symptoms include:
    • Little interest or pleasure in doing things
    • Feeling down, depressed, or hopeless
    • Insomnia/hypersomnia
    • Feeling tired or having little energy
    • Poor appetite or overeating
    • Feeling bad about one's self (failure, let yourself or family down)
    • Trouble concentrating
    • Moving/speaking so slowly that others could have noticed, or fidgety/restless
    • Thoughts of being better off dead, or of hurting one's self
  • Assess for drug and alcohol use.
  • Assess by six weeks post-partum using the Edinburgh Postnatal Depression Scale.
  • Assess whether patients have symptoms suggesting bipolar disorder [C], or psychosis.

Eligible Population

Adults 18 years or older with high risk for major depressive disorder, including prenatal and post-partum populations

Frequency

  • At each evaluation where the patient's high-risk status, symptoms, or signs raise suspicion of current or uncontrolled depression
  • At the first prenatal care visit; on post-partum visits (within six weeks of discharge) and if symptoms or signs raise suspicion

Screening for Suicide Risk

Assess risk of suicide by direct questioning about suicidal ideation and, if present, suicidal planning, potential means, and personal/family history of suicidal attempts [D].

  • If patient at risk for suicide, refer to emergency department or crisis intervention center.

Eligible Population

Individuals diagnosed with significant mood symptoms, particularly those meeting criteria for major depression

Frequency

At each encounter addressing depression until patient is treated to remission and has not expressed suicidal thinking in previous visits

Management of Patients Who Are Prescribed Antidepressant Medication

  • Initiate antidepressant medication following manufacturer's recommended doses [A].
  • Consider referral to Behavioral Health Specialist when [D]:
    • Additional counseling as desired
    • Primary physician not comfortable managing patient's depression
    • Diagnosis is uncertain or complicated by other psychiatric factors (e.g., bipolar disorder, psychosis)
    • Complex social situation
    • Management is complex, response to medication at therapeutic dosage is not optimal, or considering prescribing multiple agents
    • Psychotherapy and/or hospitalization required
  • Monitor medication frequently (e.g., every two weeks) and adjust to a therapeutic level as assessed by clinical data not to exceed the highest recommended dose. [D] Medication should not be abruptly discontinued.
  • If no response after 2 to 3 weeks on therapeutic dosage, increase dosage as tolerated and begin new observation period. If no response after 2 to 3 weeks on maximal dosage, then switch antidepressant. If partial response after 2 to 3 weeks on maximal dosage, then switch antidepressant or augment with additional agent.
  • Patients with recurrent major depression usually require lifelong treatment. Continue medication for at least 9 to 12 months after acute symptoms resolve. [A]

Eligible Population

Individuals diagnosed with significant mood symptoms, particularly those meeting criteria for major depression

Frequency

Schedule sufficient follow-up visits to assess response to treatment and titrate dose (typically every two weeks, monthly at a minimum) [D].

Definitions:

Levels of Evidence for the Most Significant Recommendations

  1. Randomized controlled trials
  2. Controlled trials, no randomization
  3. Observational studies
  4. Opinion of expert panel
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of evidence is provided for the most significant recommendations (see the "Major Recommendations" field).

This guideline is based on several sources, including the Major Depression in Adults in Primary Care guideline. Institute for Clinical Systems Improvement, 2011 (www.icsi.org External Web Site Policy).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Through a collaborative approach to developing and implementing common clinical practice guidelines and performance measures for diagnosis and management of depression, Michigan health plans will achieve consistent delivery of evidence-based services and better health outcomes. This approach also will augment the practice environment for physicians by reducing the administrative burdens imposed by compliance with diverse health plan guidelines and associated requirements.

Potential Harms

Not stated

Qualifying Statements

Qualifying Statements

Individual patient considerations and advances in medical science may supersede or modify these recommendations.

Implementation of the Guideline

Description of Implementation Strategy

Approved Michigan Quality Improvement Consortium (MQIC) guidelines are disseminated through email, U.S. mail, and websites.

The MQIC health care analyst prepares approved guidelines for distribution. Portable Document Format (PDF) versions of the guidelines are used for distribution.

The MQIC health care analyst distributes approved guidelines to the MQIC membership via email.

The MQIC health care analyst submits request to website vendor to post approved guidelines to the MQIC website (www.mqic.org External Web Site Policy).

The MQIC health care analyst completes an annual statewide postcard mailing to physicians in all areas of medicine including primary care and specialties. The postcard provides the complete list of MQIC guidelines and includes which have been recently revised, which are coming up for revision, and any new published guidelines.

The statewide mailing list is derived from the Blue Cross Blue Shield of Michigan (BCBSM) provider database. Approximately 95% of the state's MDs and 96% of the state's DOs are included in the database.

The MQIC health care analyst submits request to the National Guideline Clearinghouse (NGC) to post approved guidelines to the NGC website (www.guideline.gov External Web Site Policy).

Implementation Tools
Chart Documentation/Checklists/Forms
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Michigan Quality Improvement Consortium. Primary care diagnosis and management of adults with depression. Southfield (MI): Michigan Quality Improvement Consortium; 2012 Jan. 1 p.
Adaptation

This guideline is based on several sources, including the Major Depression in Adults in Primary Care guideline. Institute for Clinical Systems Improvement, 2011 (www.icsi.org External Web Site Policy).

Date Released
2004 Jan (revised 2012 Jan)
Guideline Developer(s)
Michigan Quality Improvement Consortium - Professional Association
Source(s) of Funding

Michigan Quality Improvement Consortium

Guideline Committee

Michigan Quality Improvement Consortium Medical Directors' Committee

Composition of Group That Authored the Guideline

Physician representatives from the 13 participating Michigan Quality Improvement Consortium health plans, Michigan State Medical Society, Michigan Osteopathic Association, Michigan Association of Health Plans, Michigan Department of Community Health, Michigan Peer Review Organization, and the University of Michigan Health System

Financial Disclosures/Conflicts of Interest

Standard disclosure is requested from all individuals participating in the Michigan Quality Improvement Consortium (MQIC) guideline development process, including those parties who are solicited for guideline feedback (e.g., health plans, medical specialty societies). Additionally, members of the MQIC Medical Directors' Committee are asked to disclose all commercial relationships as well.

Guideline Status

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

Guideline Availability

Electronic copies of the updated guideline: Available in Portable Document Format (PDF) from the Michigan Quality Improvement Consortium Web site External Web Site Policy.

Availability of Companion Documents

The following are available:

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI on December 10, 2004. The information was verified by the guideline developer on January 21, 2005. This summary was updated by ECRI on August 15, 2005, following the U.S. Food and Drug Administration advisory on antidepressant medications. This NGC summary was updated by ECRI on October 12, 2006. The updated information was verified by the guideline developer on November 3, 2006. This summary was updated by ECRI Institute on November 9, 2007, following the U.S. Food and Drug Administration advisory on Antidepressant drugs. This summary was updated by ECRI Institute on April 14, 2008. The updated information was verified by the guideline developer on April 18, 2008. This summary was updated by ECRI Institute on July 28, 2008. The updated information was verified by the guideline developer on July 29, 2008. This summary was updated by ECRI Institute on June 2, 2010. The updated information was verified by the guideline developer on June 28, 2010. This NGC summary was updated by ECRI Institute on May 29, 2012. The updated information was verified by the guideline developer on June 25, 2012.

Copyright Statement

This NGC summary is based on the original guideline, which may be reproduced with the citation developed by the Michigan Quality Improvement Consortium.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouseâ„¢ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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