Clinical Practice Guidelines for Detection and Treatment of Depression
Horizon Blue Cross Blue Shield of New Jersey has adopted the Detection and Treatment of Depression guidelines published by the American Psychiatric Association (APA) and the HEDIS 2005 technical specifications for antidepressant medication management and the ambulatory follow-up after hospitalization for mental health illness. This guideline is not intended to direct the course of clinical care you provide to an individual Horizon BCBSNJ member. Neither do these guidelines replace your independent professional clinical judgment nor your professional duty to exercise your special knowledge and skill in the treatment of your patients. You remain responsible for the quality and type of health care services provided to Horizon BCBSNJ members. I. Detecting and Diagnosing Depression: In patients at risk for depression (i.e. those suffering from a loss, substance abuse, chronic medical illness, unemployment, divorce etc.) and others who you may wish to screen for depression, consider administering the two questions called the Whooley Depression Screen. These can efficiently detect depression with 96% sensitivity and 57% specificity (if either or both questions are answered yes). The two questions are: a. During the past month, have you often been bothered by feeling down, depressed, or hopeless? b. During the past month, have you often been bothered by little interest or pleasure in doing things? 1. If you suspect a patient is depressed, with or without a positive “WhooleyScreen”; the following actions are suggested: • Assess the patient’s current medical and behavioral symptoms, including potential medical conditions that may mimic depression such as thyroid conditions, Alzheimer’s, etc., and medications that cause depressive symptoms such as steroids, oral contraceptives and diuretics. • Discuss with the patient their medical history, family history and allergies. • Perform a complete physical examination. • Choose a suitable antidepressant as warranted. • Consider the option of referring the patient for psychotherapy while ensuring adequate follow-up in the primary care setting. • Consider referral to a behavioral health professional for diagnosis and/or management of depression at any time if this is your preference. 2. A referral to a behavioral health professional is recommended in the following circumstances, as suggested by the American Psychiatric Association: • The patient fails to fully respond to one or two medication trials. • The presence of suicidal or homicidal ideation, intent or plans. • The patient is suffering severe psychotic or bipolar depression. • The presence of psychotic features makes hospitalization a consideration. • The patient’s symptoms show persistent psychosocial problems. • Formal psychotherapy is a consideration. • Specialized treatments, such as electroconvulsive treatment or light therapy, are a consideration. • The patient or clinician wishes a second opinion. I. Monitoring the Treatment Plan: The APA and National Committee for Quality Assurance (NCQA) have developed treatment standards for depression management. Management includes patient education, a treatment plan, effective medication compliance and understanding the delayed effectiveness of antidepressant medications.
1 Horizon NJ Health Clinical Practice Guideline for the Detection and Treatment of Depression, July 2006
A. Standard Treatment Parameters: • Optimal Contacts for Medication Management: A minimum of three visits during the twelve-week period after an initial antidepressant medication prescription, at least one visit with the medication prescriber. The patient may require a behavioral health referral for psychotherapy. If a patient was recently hospitalized for a mental health illness, a follow-up visit should occur within seven days of discharge. • Acute Phase: The first twelve weeks of depression treatment. The focus in the first four to eight weeks is on finding a suitable medication that is well tolerated at a dose showing some initial effectiveness for the individual patient. If there is no effectiveness at eight weeks, an alternate medication should be tried. APA also recommends a psychiatric consultation. • Continuation Phase: The continuation phase is defined as the 16 to 20 week period after sustained and complete remission from the acute phase. To prevent relapse, continue antidepressant medication at the same dose used during the acute phase. Consider the use of psychotherapy to help prevent relapse. B. Other issues: A complete explanation of the selection and management of antidepressant medication and management of depression is beyond the scope of this guideline. We recommend incorporating the following information into each patient treatment plan: • Other medical and physical issues, such as a risk for falls and cardiac disease, which may exacerbate certain antidepressant side effects. • Other medications in the patient’s regimen, including over-the-counter drugs, herbal remedies, natural products and complementary therapies. • The patient’s past medical history and medication preferences (i.e. prior medication history, history of bipolar diathesis, females of childbearing age). Explore the family history of depression. • Side effects, which may be more or less tolerable given the individual’s depressive symptoms, and medication preferences. (i.e. sexual side effects, drowsiness) • Generally, it is preferable to gradually discontinue antidepressants. Patients with refractory and/or recurrent depression may continue on a maintenance dose of antidepressants. Sources: 1. American Psychiatric Association 2. HEDIS 2005 Technical Specifications 3. U.S. Preventive Services Task Force
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Horizon NJ Health Clinical Practice Guideline for the Detection and Treatment of Depression, July 2006