Health Care Guideline Depression in Primary Care How to cite this document: Trangle M, Gursky J, Haight R, Hardwig J, Hinnenkamp T, Kessler D, Mack N, Myszkowski M. Institute for Clinical Systems Improvement. Adult Depression in Primary Care. Updated March 2016. Copies of this ICSI Health Care Guideline may be distributed by any organization to the organization’s employees but, except as provided below, may not be distributed outside of the organization without the prior written consent of the Institute for Clinical Systems Improvement, Inc. If the organization is a legally constituted medical group, the ICSI Health Care Guideline may be used by the medical group in any of the following ways: • copies may be provided to anyone involved in the medical group’s process for developing and implementing clinical guidelines; • the ICSI Health Care Guideline may be adopted or adapted for use within the medical group only, provided that ICSI receives appropriate attribution on all written or electronic documents and • copies may be provided to patients and the clinicians who manage their care, if the ICSI Health Care Guideline is incorporated into the medical group’s clinical guideline program. All other copyright rights in this ICSI Health Care Guideline are reserved by the Institute for Clinical Systems Improvement. The Institute for Clinical Systems Improvement assumes no liability for any adap- tations or revisions or modifications made to this ICSI Health Care Guideline. www.icsi.org Copyright © 2016 by Institute for Clinical Systems Improvement Health Care Guideline: Adult Depression in Primary Care 1 Depression suspected • Universally screen Seventeenth Edition • Presentation • Risk factors March 2016 • Special population (pregnant/post-partum; cognitive impairment) 2 Text in blue in this document Diagnose and characterize major depression/persistent depressive disorder indicates a link to another part of with clinical interview to include: • DSM-5 criteria the document or website. • Alternate diagnoses • Patient history 3b 3a Use organization’s protocol if available no Is patient safe to self to assess and minimize suicide risk/ and/or others? involve mental health specialists yes 4a 4b Is the presence of substance yes Refer to substance use disorder and/or use disorder orno psychiatric mental health providers/programs for comorbidity suspected? assessment and treatment 5 Discuss treatment recommendations while factoring in cultural considerations and if patient fits into special population (medical comorbidity, pregnant/post-partum, cognitive impairment) 6 Comprehensive treatment plan with shared decision-making • Collaborative care model • Educate and engage patient 7a Establish follow-up plan 7b 7c Has patient yes • Continuation and maintenance reached treatment duration based on episode remission? • Relapse prevention no 7d If patient is not improving on initial treatment, utilize stepped care approach that includes: • Evaluate dose, duration, type and adherence to treatment • Reconsider treatment modality • Reconsider diagnosis • Reconsider impact of comorbidities • Consider other strategies Return to Table of Contents www.icsi.org Copyright © 2016 by Institute for Clinical Systems Improvement 1 Adult Depression in Primary Care Seventeenth Edition/March 2016 Table of Contents Work Group Leader Algorithms and Annotations ........................................................................................ 1-57 Michael Trangle, MD Algorithm .............................................................................................................................1 Psychiatry, HealthPartners Evidence Grading ............................................................................................................. 3-4 Medical Group and Foreword Regions Hospital Introduction ................................................................................................................. 5-6 Work Group Members Scope and Target Population ...........................................................................................7 Allina Medical Clinic Aims ................................................................................................................................7 Daniel Kessler, LP Recommendations Table ........................................................................................... 8-10 Psychology Summary Table of Recommendations for Major Depressive Disorder and Essentia Health Persistent Depressive Disorder .................................................................................11 Jeffrey Hardwig, MD Implementation Recommendation Highlights ........................................................ 12-13 Psychiatry Related ICSI Scientific Documents ..............................................................................13 Todd Hinnenkamp, RN Annotations .................................................................................................................. 14-57 Internal Medicine Fairview Health Services Quality Improvement Support .................................................................................. 58-83 Robert Haight, PharmD, Aims and Measures ...................................................................................................... 59-60 BCPP Measurement Specifications ................................................................................... 61-76 Pharmacy Implementation Recommendations .............................................................................. 77-78 Mayo Clinic Implementation Tools and Resources .................................................................................79 Mioki Myszkowski, MD Implementation Tools and Resources Table ................................................................. 80-83 Family Medicine Supporting Evidence................................................................................................... 84-125 North Memorial Health References .................................................................................................................. 85-105 Care Appendices ............................................................................................................... 106-125 Nicky Mack, RN Family Medicine Appendix A – Patient Health Questionnaire (PHQ-9) .........................................106-107 Appendix B – ICSI Shared Decision-Making Model ..........................................108-114 Olmsted Medical Center Appendix C – Specialized Therapies ...................................................................115-117 Jeffrey Gursky, MD Appendix D – Special Populations ......................................................................118-125 Psychiatry ICSI Disclosure of Potential Conflicts of Interest ...................................................... 126-128 Jodie Dvorkin External Review and Acknowledgements ..................................................................129 Project Manager/Health Care Consultant Document History and Development .................................................................. 130-131 Senka Hadzic Document History ............................................................................................................130 Clinical Systems ICSI Document Development and Revision Process .......................................................131 Improvement Facilitator www.icsi.org Institute for Clinical Systems Improvement 2 Adult Depression in Primary Care Seventeenth Edition/March 2016 Evidence Grading Literature Search A consistent and defined literature search process is used in the development and revision of ICSI guidelines. Two literature searches were conducted for this guideline. The searches were conducted in PubMed, Ovid and PsychInfo. The first search included systematic reviews, meta-analyses, randomized controlled trials and observational studies from January 2013 – February 2015. The search was limited to adults over 18 years of age. The search excluded animal studies and non-English language studies. The terms included screening; patient health questionnaire-9 (PHQ-9); insomnia; therapeutic alliance in depressed patients; psychotherapies; antidepressants; implementation and best practices; special populations and disparities; telepsychiatry and outcomes; complementary medicine; integrated care, coordinated care, collaborative care; continuity of patient care, follow-up, office visits and frequency; effective treatments for adults with major depression who also have diabetes; prevalence and treatment of depression in patients who had stroke; after care; follow- up; remission; remission induction; functional impairment; cognitive impairment; genomics, genetics and pharmacogenetics; shared decision-making; and TMS (transcranial magnetic stimulation). The second literature search was specific to treatment recommendations for major depressive disorder and persistent depressive disorder and included systematic reviews, meta-analyses and randomized controlled trials. It covered the period between January 2005 and September 2015 and was limited to adults over 18 years of age. The search excluded animal studies and non-English language studies. The terms included treatment, treatment outcomes and multiple treatment comparison; psychological treatment and supportive therapy, cognitive behavioral therapy; antidepressant agents, pharmacotherapy and drug therapy; combined treatment; duration of treatment, acute phase, continuation phase, maintenance phase; depression and major depression;