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Psychotherapy for Major Depressive Disorder

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					      Major
Depressive Disorder


  Major Depressive Disorder (MDD) Guideline
  Diagnostic Nomenclature for Clinical Depressive Conditions
   Conditions            Diagnostic Criteria                                               Duration

                         ≥ 5 of the following symptoms (must include either depressed
                         mood or anhedonia):
                         • Depressed mood
                         • Loss of interest in most activities (anhedonia)
                         • Significant change in weight or appetite
   Major Depression      • Insomnia or hypersomnia                                         ≥ 2 weeks
                         • Decreased concentration
                         • Decreased energy
                         • Inappropriate guilt or feelings of worthlessness
                         • Psychomotor agitation or retardation
                         • Suicidal ideation

                         3 or 4 of the symptoms listed above with the addition of feelings
   Dysthymia             of hopelessness and the omission of suicidal ideation (must       ≥ 2 years
                         include depressed mood)

                         Variables: all included disorders must cause clinically significant
   Depression NOS
                         impairment in daily functioning but fail to meet classification
   (Not Otherwise                                                                            ≥ 2 weeks
                         for MDD or dysthymia (e.g., minor depression with 2 to 4
   Specified)
                         depressive symptoms)

   Reference: VA/DoD Clinical Practice Guideline for Management of Major Depressive Disorder (MDD), May 09
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MDD Guideline Algorithm Page 1
Primary Care - Initial Assessment and Diagnosis
1      Patient age > 18 with suspected
    depression presenting to primary care?
                      [A]
                                                                                                                      Screening for MDD

2                                                                                                          Over the past two weeks, how often
    Brief assessment of initial presentation
                                                                                                           have you been bothered by any of the
         to assess for dangerousness                                                                       following problems?
                      [B]
                                                   4                                                       1. Little interest or pleasure in doing
3                                                          Provide appropriate care or refer to               things
          Unstable urgent condition?           Y
                                                           stabilize and follow legal mandates             2. Feeling down, depressed, or
                     [C]
                                                                             [D]                              hopeless.
                  N                                                                                                              [A]
5      Obtain relevant history, physical
         examination and lab tests                                                                                  Sidebar 1: Assessment
                     [E]
                                                                                                           - Medical history
                                                                                                           - Physical examination
6    Obtain symptom score using PHQ-9                                                                      - Mental Status Exam
      Determine and document DSM IV                                                                        - Relevant lab tests
                                                                                                           - Drug inventory (including over the
              criteria for MDD
                                                                                                             counter and herbals)
                      [E]
                                                                                                           - Psychosocial history

7           Do medication(s) or                    8
        comorbid medical condition(s)          Y             Provide medical treatment and
          contribute to symptoms?                                follow-up as indicated
                     [F]
                                                   9                Did depression                Y   10
                                                                                                                   Continue medical follow-up
                                                                  symptoms resolve?                                       as indicated
                                                       N


                    DHCC Clinicians Helpline: 1 (866) 559-1627 DSN: 662-6563 www.PDHealth.mil
                          PDH-CPG Tool Kit Pocket Cards Version 1.0 December 2003
MDD Guideline Algorithm Page 1 (Continued)
Primary Care - Initial Assessment and Diagnosis
          Presumptive diagnosis of          Y
11
                  MDD?
                 N

              History of MDD?               Y
12
               N
        Are there symptoms of
       depression or functional                                                 13        Assess for manic or hypomanic
                                            Y
18   impairment that do not meet                                                           symptoms or family history of
      DSM IV criteria for MDD?                                                          bipollar disorder or other psychiatric
                  [H]                                                                               comorbidities
                                                                                                          [G]
                 N
                                                                                                                                 15
                                                                                       14                                   Y
                                                                                                Suspected bipolar                 Consider management of
                                19                                                                 disorder?                         Bipolar Disorder
                                       Are there concerns              Y
                                     aboiut funtional ability or                                      N                          17
                                     patient’s mental health?                          16
                                                                                               Occurrence of other          Y    Referral/consult to specialty
                                           N
                                21 Provide psychoeducation                                    major mental illnesses                         care
                                     for self management
                                               [I]
                                                                                                     N
     23                              22                      20     Follow-up and                  Continue on
            Repeat screening              Follow up within
               annually                      4-6 weeks             consider referral                   Page 2
                                                                   to mental health              Initial Treatment
                                                                       specialty




                  DHCC Clinicians Helpline: 1 (866) 559-1627 DSN: 662-6563 www.PDHealth.mil
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     MDD Guideline Algorithm Page 2
     Primary Care - Initial Treatment

24         Patient with presumptive
         diagnosis or history of MDD,
          meets DSM-IV diagnostic                                 Sidebar 2: DSM-IV Diagnostic Criteria for MDD
              criteria for MDD?                  MDD diagnosis requires the presence of symptom 1, 2, or both; and at least 5
                                                 of 9 symptoms that persist for at least 2 weeks:

                                                 1. Depressed mood nearly every day for most of the day, based on self-report or
25                                                  observation of others
       Determine level of severity of MDD
                                                 2. Marked reduction or loss of interest or pleasure in all or nearly all, activities for
      symptoms and functional impairment
                                                    most of the day, nearly every day.
                       [J]
                                                 3. Significant non-dieting weight loss or weight gain (>5% change in body weight)
                                                 4. Insomnia or hypersomnia nearly every day
                                                 5. Psychomotor agitation or retardation (should be observable by others)
                                                 6. Fatigue/loss of energy nearly every day
26                                               7. Feelings of worthlessness or excessive/inappropriate guilt nearly every day
         Discuss treatment options and           8. Diminished cognitive function (reduced ability to think or concentrate) nearly
         patient’s preferences. Arrive at           every day
           shared decision regarding             9. Recurrent thoughts of death and/or suicide, suicide planning, or a suicide attempt
            treatment goals and plan
                        [K]




                          DHCC Clinicians Helpline: 1 (866) 559-1627 DSN: 662-6563 www.PDHealth.mil
                                PDH-CPG Tool Kit Pocket Cards Version 1.0 November 2009
 MDD Guideline Algorithm Page 2 (Continued)
 Primary Care - Initial Treatment


27    Is there indication for referral       28                                            Sidebar 3: Indications for Referral to Mental Health
       to mental health specialty?       Y          Refer to Mental Health
                    [L]                                Specialty Care                   - Unclear diagnosis
                                                                                        - Evidence of psychotic features, past-mania or hypomania
                N                                                                       - Signs of comorbid psychiatric conditions
29                                                                                      - Unable to treat patient in primary care
       Initiate treatment strategies                                                    - Need for psychosocial interventions
         effective for depression                                                       - Patient preference
              [See sidebar 4]
                     [M]
                                                                          Sidebar 4: Initial Treatment Strategies for MDD
                                                                        PHQ-9       FUNCTIONAL
30                                                SEVERITY                                           INITIAL STRATEGY
      Address psychosocial needs                                        SCORE       IMPAIRMENT
                 [N]                              Mild                  10-14       Mild             Monotherapy-antidepressants or
                                                                                                     psychotherapy or, possibly combination

31                                                Moderate              15-19       Moderate         Antidepressants or psychotherapy or,
     Schedule follow-up in 4-6 weeks                                                                 combination

                                                  Severe                ≥ 20        Severe           May start with antidepressants or
                                                                                                     psychotherapy but should prefer combination
          Continue on Page 3                                                                         or multiple antidepressants
      Treatment Management and
               Follow-up                          Psychoeducation and self-management should be provided for all severity levels




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                              PDH-CPG Tool Kit Pocket Cards Version 1.0 November 2009
      Major
Depressive Disorder


  MDD Guideline Algorithm Page 3
  Primary Care - Treatment Management and Follow-up
                                                                                                  Sidebar 5: Assessment of Treatment Response
32
       Patient with a diagnosis of MDD                                                          - Symptoms severity (PHQ9) and risk for suicide
                 on treatment                                                                   - Tolerability to treatment (Adverse effects)
                                                                                                - Adherence to treatment
                                                                                                - Medical problems influencing recovery
33                                                                                              - Psychosocial barriers to therapy
     Complete assessment (see sidebar 5)
                                                                                                - Revaluate diagnosis and appropriate treatment
         Review current medication
         Assess for dangerousness
                     [O]
                                                                                                          Sidebar 6: Treatment Strategies
                                                    35
34              Unstable or                                                                     Monotherapy (Psych. or Drugs)
                                           Y         Provide appropriate care or refer to
            dangerous condition?                                                                Combine psych and pharmacotherapy
                                                     stabilize and follow legal mandates
                    [C]                                                                         Complex psychopharmacology
                                                                       [D]
                                                                                                Somatic interventions
                 N                                                                              Inpatient/residential
36             Is patient condition                 37
             improving and current             Y         Continue current treatment
         treatment strategy tolerable?                     strategy. Reassess by                 Sidebar 7: Indication for Consultation or Referral
                        [P]                                      4-6 weeks                               to Mental Health Specialty Care
                                                                     [Q]                        - Primary care out of comfort zone
                 N                                                                              - Complicated depression with comorbidity
                                               38                                               - Lack of resources
                                                              Full remission?               Y   - Treatment resistance
                                                                     [R]                        - Patient request

                                                                N




                         DHCC Clinicians Helpline: 1 (866) 559-1627 DSN: 662-6563 www.PDHealth.mil
                               PDH-CPG Tool Kit Pocket Cards Version 1.0 November 2009
  MDD Guideline Algorithm Page 3 (Continued)
  Primary Care - Treatment Management and Follow-up

44 Adjust/modify treatment:                 39
   - Consider longer duration                      Continue treatment to
   - Consider increasing dose                        prevent relapse
   - Consider augmentation                                  [S]
   - Consider switching to another agent
   - Consider modifying treatment
     strategy
                                           40
              (See sidebar 6,7)
                                                        Sustained                Y
                     [U]
                                                        remission?

45                                                                          41
                                                    N                                 Continue maintenance
             Schedule follow-up                                                      therapy in Primary Care
                                                         Relapse                                [T]


                                                                           42
                                                                                           Sustained                 Y
                                                                                           remission?

                                                                                            N


                                                                                          Recurrence


                                                                                                        43

              Return to Box 32                                                                                 Screen annually



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                              PDH-CPG Tool Kit Pocket Cards Version 1.0 November 2009
MDD Guideline Algorithm ICD-9 and DSM-IV Codes

ICD-9 Code               Diagnosis                     DSM-IV Code            Diagnosis

                         Major Depressive Disorder,                           Major Depressive
296.2x                                                 296.2x
                         Single Episode                                       Disorder, Single Episode

                         Major Depressive Disorder,                           Major Depressive
296.3x                                                 296.3x
                         Recurrent Episode                                    Disorder, Recurrent

300.4                    Dysthymic Disorder            300.4                  Dysthymic Disorder

                         Depressive Disorder, Not
311                                                    311                    Depressive Disorder NOS
                         elsewhere classified

ICD-9 and DSM-IV 5th Digit Subclassification Codes: “x” in 296.0-6x

                                                                              3 Severe, No Psychotic
0 Unspecified            1 Mild                        2 Moderate
                                                                                Behavior

4 Severe, with
                         5 In Partial or Unspecified Remission                6 Full Remission
  Psychotic Behavior




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                      PDH-CPG Tool Kit Pocket Cards Version 1.0 November 2009

				
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