Practical Aspects of the HEDIS Antidepressant Medication Measure
A Case Study and Literature Review
Clinical Presentation
Marie F. is a 42-year-old social worker with a medical history significant for hypertension and gastroesophageal reflux disease. She presents to her primary care physician’s office feeling tired and “down”. She reports a lack of interest in activities she previously enjoyed. She does not report any life events which might have precipitated these feelings. She reports having seen advertisements on television for antidepressant drugs and believes she is suffering from “clinical depression”
Clinical Presentation
In addition to a physical exam and laboratory studies, her primary care physician performs a depression screen and includes a PHQ-9 (a nine-item Patient Health Questionnaire) to ensure a diagnosis.
After discussion of the risks and benefits of therapy, Marie is started on an antidepressant by her primary care physician and is instructed to follow-up in 4 weeks.
Clinical Presentation
She receives a notice that she is eligible for enrollment in her health plan’s depression disease management program. She sends in the response card, requesting a telephone contact to discuss the program. Approximately 2 weeks later, she receives a telephone call from Lorri F., a case manager from her health plan. Lorri describes the goals of the depression disease management program, which includes patient education, assistance in locating a psychologist or reinforcing the need for follow-up visits with the PCP, and close telephone follow-up to assess Marie’s progress
Clinical Presentation
As requested, Marie returns for a follow-up visit with her primary care physician in 4 weeks. She is feeling somewhat better. Her primary care physician believes she requires more time on the antidepressant to reach maximum improvement. He asks her to return to the office in 4 weeks. Marie is confused as to why she requires another follow-up visit since she is improved. Lorri calls Marie to discuss how she is doing on treatment. She explains that she is better, but doesn’t understand why she needs to keep going back to her doctor. She is so busy that she doesn’t really have the time. Lorri explains the rationale behind frequent and close follow-up visits and suggests that Marie finds out whether her primary care physician would be open to a phone discussion.
How often should patients with depression be seen?
Several major organizations recommend close follow-up, the frequency of which depends upon the severity of symptoms NCQA recommends at least 3 follow-up visits within the first 3 months of treatment Better physician communication skills, a stronger patient-physician relationship, and frequent follow-up are associated with better adherence and outcomes in patients being treated for depression
APA Web Site. Available at: http://www.psych.org/psych_pract/treatg/pg/Depression2e.book.cfm. Accessed 6/8/06. NCQA Web Site. Available at: http://www.ncqa.org/sohc2002/SOHC_2002_AMM.html#Definition. Accessed 6/8/06. Ruoff G. J Fam Pract. 2005;54(10). Available at: www.jfponline.com. Accessed 6/8/06.
“It Won’t Work Unless You Take It…”
Study of 401 depressed patients receiving SSRIs in a managed care organization in Northern California Telephone surveys to assess treatment adherence and measures which affected that adherence Discussion about adverse effects with the physician led to a higher rate of compliance Patients who had more than 3 depressionrelated office visits within the first 6 months had a higher rate of compliance
Bull SA, Hu XH, Hunkeler EM, et al. JAMA. 2002;288(11):1403-1409.
The Take Home Point
Frequent and close followup with a patient being treated for depression can result in improved rates of compliance and better treatment efficacy Other potential positive outcomes include decreased morbidity, decreased absenteeism, and improved quality of life
Clinical Presentation
Lorri is able to show Marie the value of close follow-up with her primary care physician. Marie makes a followup appointment in 4 weeks as instructed. Marie notices that she is continuing to feel better, and is nearly back to what she considers “normal”. Her physician feels she has entered remission and suggests that she continue taking her antidepressant for a total of 6-12 months. Marie does not understand why she needs to keep taking the antidepressant since she is feeling better.
Clinical Presentation
Lorri calls Marie to see how the visit with her primary care physician went. Marie explains that she is feeling better and wants to stop her medication. She doesn’t understand why her physician wants her to stay on the medication for up to a full year. Lorri asks if Marie is having any side effects from the medication. Marie replies ‘no’. Lorri then asks why Marie wants to stop taking the antidepressant. Marie replies that since she is feeling better, she doesn’t think she needs it anymore. Marie also tells Lorri that she doesn’t want to become dependent upon the antidepressant. Lorri explains the rationale behind continuing antidepressant therapy for 6-12 months.
How long do patients need to take antidepressants?
Generally, most authorities agree that a longer duration of therapy results in improved clinical outcomes The exact duration of therapy recommended varies depending upon the source referenced
Does continued antidepressant therapy work?
Patients at risk for recurrent depression should be continued on therapy after the initial acute phase of treatment Consideration to long term therapy should be given to those at the highest risk for relapse Patients treated with antidepressants whose symptoms remit after 12 weeks should continue treatment for at least an additional 6 months
Geddes JR, Carney SM, Davies C, et al. Lancet. 2003;361:653-661. Reimherr FW, Amsterdam JD, Quitkin FM, et al. Am J Psychiatry. 1998;155:1247-1253. Donoghue J, Hylan TR. Br J Psychiatry. 2001;179(suppl 42):s9-s17.
What do the experts say?
If patients respond to acute phase medication, it is generally continued at the same dosage for 4 to 9 months after return to the clinically well state After acute phase treatment, patients with one or more lifetime episodes of major depressive disorder should continue to receive therapy for an additional 4 months to 5 years depending upon clinical circumstances
NLM Web site. Available at: http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat6.section.15982. Accessed 6/8/06. NIHM Web Site. Available at: http://www.nimh.nih.gov/publicat/depression.cfm. Accessed 6/8/06. Care Management Institute, Kaiser Per.manente. Adult primary care depression guidelines. Oakland (CA): Kaiser Permanente; April 2004: 132. Available at: http://www.guideline.gov/summary/summary.aspx?doc_id=6007.
What do the experts say?
American Psychiatric Association
During the 16-20 weeks following remission, patients who have been treated with antidepressant medications in the acute phase should be maintained on these agents to prevent relapse
American College of Physicians
Antidepressant medication should be continued at the same dose for at least 4 months beyond initial recovery or improvement to decrease the probability of short-term relapse
APA Web Site. Available at: http://www.psych.org/psych_pract/treatg/pg/Depression2e.book-7.cfm#c. Accessed 6/8/06. Snow V, et al, for the ACP-ASIM. Ann Intern Med. 2000;132:738-742.
The Take Home Point
Longer therapy with antidepressants results in decreased rates of relapse, increased rates of remission, and overall better patient outcomes Some patients may require extended duration therapy with antidepressants based upon disease severity, prior history of depression, or risk of relapse
Clinical Presentation
Lorri is successful in making Marie understand the need for medication compliance. Marie stays on her antidepressant medication for a total of 13 months and then visits her primary care physician to discuss discontinuation. Her physician tapers her off the medication and she has no ill effects as a result of the discontinuation. At 6 months after discontinuation, Marie has no signs or symptoms of depression.