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Depressive Disorders Clinical Guidelines* Developed in Collaboration with FBHPartners’ Providers, Mental Health Partners, Jefferson Center for Mental Health, and Arapahoe House DSM 5 Diagnostic Codes: 296.99; 296.2x; 300.4; 625.4; 311 Diagnostic Considerations: 1. Review diagnostic criteria in DSM 5 to ensure the accuracy of the specific depressive disorder to be diagnosed. All depressive disorders feature the presence of mood symptoms (sad or irritable), along with cognitive and somatic symptoms which interfere with ability to function effectively. They differ in terms of etiology, duration and timing, and the differentiation between depressive disorders can affect decisions as to the optimal treatment approach. 2. Complete assessment using a variety of sources including standardized rating scales to assist in diagnosis and as a baseline for treatment outcomes. See References and Resources for a list of public domain instruments. Obtain a history of symptoms, including observations by family and teacher informants when assessing children and adolescents. Assess family history of depressive disorders, as well as other psychotic or mood disorders. 3. Differential diagnosis • Depressive Disorders o The key depressive disorders treated by behavioral health providers are: disruptive mood dysregulation disorder, major depressive disorder, persistent depressive disorder (dysthymia), premenstrual dysphoric disorder, substance/medication-induced depressive disorder, other specified or unspecified depressive disorder. o Assessment of the etiology, course, duration, and age of onset help differentiate between depressive disorders. Assessment of substance use and medications that may contribute to symptom presentation is critical in determining appropriate treatment. o Specifiers further illustrate the etiology, symptomology, and likely prognosis. Thorough assessment of symptoms and associated features, onset or pattern of onset, and recent pregnancy will further clarify making appropriate specifications. If peripartum onset is present, ensure that mother and child (if applicable) are receiving appropriate medical care. • Bipolar disorder and ADHD, include symptoms, such as irritability and psychomotor agitation that may overlap with those of depressive disorders. Ensure assessment of history of manic symptoms and symptoms of inattention and hyperactivity in childhood. • Adjustment disorders, sadness and grief may contribute to depressive-like symptoms. Assessment of precipitating events may lead to ruling out a depressive disorder as significant psychosocial events may suggest a normal response of sadness or grief or the severity or duration of symptoms may suggest the presence of an adjustment disorder. Be sure to reassess symptoms after 6 months to update the diagnosis if appropriate. • Medical conditions should be assessed to rule out physical conditions that may mimic or cause depression, e.g., hypothyroidism, sleep disorders, chronic fatigue syndrome, stroke, dementia, Parkinson’s Disease, as well as medications with side effects similar to symptoms of depression, e.g., heart and blood pressure medications, steroids, and narcotics. 4. Presentation of symptoms may differ depending on age. In children, somatic symptoms (headaches, stomach aches, etc.), social withdrawal and decline in school performance are common. Among adolescents, depression is often associated with substance abuse, impulsive or reckless behavior, hypersomnia and increased irritability. In older adults, depression may manifest as cognitive impairment and increased somatic complaints. Revised December 2014 5. Consider co-occurring conditions, such as substance abuse or trauma, as these can greatly complicate treatment. Evaluate for the presence of other psychiatric conditions that frequently co-occur with depression, including anxiety (panic disorder and OCD), eating disorders, and borderline personality disorder. 6. Carefully evaluate suicidal risk. Static factors that increase risk for self-harm include age, race, family history of mood disorders, past attempts to harm self, and multiple episodes of depression. Dynamic factors include psychosocial stress and support, substance abuse, and recent suicidal ideation and/or attempts. See related guideline “Suicidal Behavior Clinical Guideline” on Assessing Suicidal Behaviors. Treatment Guidelines: 1. Goals of treatment are to ensure the client’s safety and achieve symptom relief, as early relief of symptoms is associated with continued engagement in treatment and superior long-term outcomes. Additionally, the client should be encouraged to resume and maintain normal daily activities with adequate symptom relief. 2. Initiate a safety plan and assess suicide risk regularly, particularly with a history of selfinjury or suicide attempt, verbal statements regarding suicide or not wanting to live, or other risk factors (e.g., substance abuse, chronic pain, or recent loss). Suicide risk may increase as the client begins feeling better and experiences more energy. See related guideline “Suicidal Behavior Clinical Guideline” on Treating Suicidal Behaviors. 3. Include family members or other key supports (i.e. friends, clergy, peers) in the treatment process. Encourage the client and his/her key supports to participate in safety planning and provide education about the disorder and treatment process. See “Depression Tips” for education materials to use with families and clients. 4. Consider a referral for medication evaluation, especially if the client is experiencing psychotic symptoms, suicidal ideation or behavior, or severe vegetative symptoms or when there is family history of mood disorders, recurrent episodes of depression, or past response to medications. If the client is prescribed medication for depression, support medication adherence and coordinate care with the prescriber. Providers can reference the attached Appendix B for antidepressant dosing tables and the Texas Medication Algorithm for complete Major Depressive Disorder medication algorithms at http://www.jpshealthnet.org/sites/default/files/tmap_depression_2010.pdf 5. Initiate evidence-based psychological treatment for depression, e.g. Cognitive-Behavioral Treatment (CBT), Acceptance and Commitment Therapy (ACT), Inter-personal Therapy (IPT), Problem-Solving therapy (PST). Psychotherapy is most productive with symptom relief and establishing sufficient emotional stability to address underlying issues, e.g. past trauma, marital conflict. See Resources for treatment manuals. 6. Treatment of co-occurring substance use disorders should be thoughtfully coordinated. If different providers are involved in the care team, ensure active care coordination. Clients may be at differing stages of readiness to address SUD. Readiness is important to assess and treat accordingly. If the client chooses not to address the SUD at this time, be alert to changes in readiness and motivation over time. Referral to self-help groups may be an option. Revised December 2014 7. Coordinate care with medical providers, including PCPs who may have made the initial referral for behavioral health treatment, as there is a significant body of research indicating that the relationship between depression and other health conditions is bidirectional. See Appendix A “Medical Illness and Major Depressive Disorder.” 8. Evaluate the effectiveness of treatment at regular intervals using a self-report depression assessment instrument and/or the ORS-SRS to assess the therapeutic alliance and client functioning. If the client is not on medication and is not improving, consider referral for medication evaluation. In addition, reassess diagnosis to ensure the correct treatment is in place and co-occurring conditions are addressed. Adjust treatment intensity as symptom severity improves or worsens. 9. Consider cultural differences in treatment planning. Be comfortable asking about cultural differences. Consider how the client’s cultural identity and cultural explanation of illness affect the presentation of symptoms and the treatment approach. Awareness of cultural factors influencing depression can provide context. For example, the higher prevalence rates of depression for lesbian and gay youths and gay men can increase understanding of societal triggers. 10. Encourage healthy behaviors such as regular exercise, diet, sleep hygiene, social support, and discourage substance use. Refer to wellness programs such as stress management and/or support groups. 11. Facilitate relapse prevention by helping the client/family develop an action plan to identify how the client will address early symptoms of depression. *The Clinical Guidelines are meant to assist providers in making the best decisions about appropriate treatment in specific clinical circumstances. You are not required to follow them nor are you expected to be proficient in all of the therapeutic models described below. However, following the guidelines is one way to help ensure that your care is consistent with the most current research and best practices and that it is medically necessary. References and Resources Adapted from Gelenberg, A.J., Freeman, M.P., Markowitz, J.C., Rosenbaum, J.F., Thase, M.E., Trivedi, M.H., et al. Practice guideline for the treatment of patients with major depressive disorder [Internet]. 3rd ed. Arlington (VA): American Psychiatric Association; 2010 Oct [cited 2014, September 29]. Available from: http://psychiatryonline.org/data/Books/prac/PG_Depression3rdEd.pdf Public Domain Depression Rating Scales: http://www.phqscreeners.com/pdfs/02_PHQ-9/English.pdf (PHQ-9) http://www.brightfutures.org/mentalhealth/pdf/professionals/bridges/ces_dc.pdf (CES-DC; children) http://www.chcr.brown.edu/pcoc/cesdscale.pdf (Center for Epidemiological Studies-Depression Scale) http://healthnet.umassmed.edu/mhealth/ZungSelfRatedDepressionScale.pdf (Zung Self-Rating Depression Scale) http://healthnet.umassmed.edu/mhealth/HAMD.pdf (Hamilton Rating Scale for Depression) http://www.psy-world.com/madrs_print1.htm (Montgomery and Asburg Depression Rating Scale) http://www.stanford.edu/~yesavage/GDS.html (Geriatric Depression Scale) Cognitive-Behavioral Treatment Manuals: Revised December 2014 CBT manual for treating adolescents with depression: https://trialweb.dcri.duke.edu/tads/tad/manuals/TADS_CBT.pdf A Brief Behavioral Activation Treatment for Depression: http://web.utk.edu/~dhopko/BATDmanual.pdf Group Therapy manual for CBT Treatment of Depression: http://www.hsrcenter.ucla.edu/research/wecare/doc/cbt_manuals/PDF_EMANUAL_1.pdf Treatment manuals for depressed youth by Clarke and Lewinsohn; includes group and individual treatment manuals: http://www.kpchr.org/public/acwd/acwd.html Klerman, G., Wisssman, M. & Rounsaville, B. (1984). Interpersonal Psychotherapy of Depression. New York: Basic Books. Websites with Helpful Tips for Clients: DBSA - Depression and Bipolar Support Alliance: http://www.dbsalliance.org Mental Health America: http://www.nmha.org/ ValueOptions® Achieve Solutions: https://www.achievesolutions.net/achievesolutions Books/Workbooks: Mind Over Mood by Dennis Greenberger and Christine Padesky Skills Training Manual for Diagnosing and Treating Chronic Depression by James McCullough. Interactive Online Community Support and Resources: MyStrength Now https://www.mystrength.com/ PatientsLikeMe http://www.patientslikeme.com/ Daily Strength http://www.dailystrength.org/ Mental Health America (MHA) Inspire https://www.inspire.com/groups/mental-health-america/ Mobile Apps: Depression Check Optimism MyStrength Now Revised December 2014 Appendix A Issue of Medical Illness and Major Depressive Disorder (MDD) A growing body of evidence describes the relationship between medical illness and Major Depressive Disorder (MDD) as bidirectional. This phenomenon has been most extensively studied in cardiovascular disease, and recent evidence points to a bidirectional relationship between MDD and diabetes and obesity. • MDD increases an individual’s risk for developing a medical illness and worsens the prognosis of co-occurring medical illnesses. Individuals, with MDD, are 2 to 3 times more likely to develop type 2 diabetes, congestive heart failure, and hypertension as well as 2-3 times more likely to have a heart attack (myocardial infarction) or stroke (cerebral vascular accident), leading to increased risk of mortality. • Having a medical illness puts individuals at increased risk for developing MDD or worsening depression outcomes, including developing chronic depression, incomplete recovery of depressive symptoms, and more depressive relapses. One major study suggested that obesity increased the risk of onset of depression by 55%. These studies suggest that interventions aimed at modifying factors associated with one illness will positively affect co-occurring illnesses as well. This information supports the following for behavioral health staff treating an individual with MDD: • The importance of ensuring coordination of care with the medical provider so that the medical provider knows that the individual is being treated for MDD • Referral to psychiatry when there is a history of major medical problems, even if self-reported, in particular a heart attack (MI), congestive heart failure, hypertension, diabetes, or stroke, so that the psychiatrist can confirm and help monitor their medical history References Druss, B.G. & Walker, E.R. (2011). Mental disorders and medical comorbidity. The Synthesis Project: Robert Wood Johnson Foundation. Katon, W.J. (2003). Clinical and health services relationship between major depression, depressive symptoms and general medical illness. Biological Psychiatry, 54 (8), 216-226. Golden, S.H., Lazo, M., & Carnethon, M. (2008). Examining a bidirectional association between depressive symptoms and diabetes. JAMA, 299 (23), 2751-2759. Luppino, F.S. , de Wit, I.M., & Bouvey, P.E. (2010). Overall weight, obesity, and depression: A systematic review and meta-analysis of longitudinal studies. Archives General Psychiatry, 67, (3), 220-229. Golden, S.H., Williams, J.E., & Ford, D.E. (2004). Depressive symptoms and the risk of type 2 diabetes: ; The Atherosclerosis Risk in Communities study. Diabetes Care, 27, 429-435. Hays, J.C., Krishnan, K.R., & George, L.K. (1997). Psychosocial and physical correlates of chronic depression. Psychiatry Res., 72, (3),149-159. Koike, A.K., Unutzer, J., & Wells, K.b. (2002). Improving the care for depression in patients with comorbid medical illness. American Journal Psychiatry, 159, (10), 1738-1745. Revised December 2014 Appendix B Antidepressant Dosing Tables Table 1: Antidepressant Dosing used for Acute Phase Treatment of Depression Type/Class Medication Initial Target Usual Dose Recommended Dose (Level) (Level) Administration Schedule SSRI Fluexetine (Prozac) 20 mg 20-60 mg QAM Paroxetine (Paxil) 20mg 20-60 mg QAM Paroxetine, extended 12.5 mg 25-75 mg release Sertaline (Zoloft) 50mg 50-200 mg QAM Citalopram (Celexa) 20 mg 20-60 mg QAM Escitalopram (Lexapro) 10 mg 10-20 mg TCA Amitriptyline Desipramine 25-50 mg 25-50 mg (>125 ng/ml) 25-50 mg (IMI+DMI > 200 ng/ml) 25 mg (50-150 ng/ml) 100-300 mg 100-300 mg 50-200 mg (50150 ng/ml) QHS Bupropion SR (Wellbutrin SR) Bupropion (Wellbutrin) Mirtazapine (Remeron) Nefazodone (Serzone) Venlafaxine (Effexor) Venlafaxine XR (Effexor XR) 150 mg 300-400 mg bid < 200 mg/dose 150 mg 15 mg 50 mg 37.5 mg 37.5 mg 300-450 mg 15-45 mg 150-300 mg 75-375 mg 75-375 mg tid < 150 mg/dose QHS bid bid QD Phenelzine Tranylcypromine 15 mg 10 mg 45-90 mg 30-60 mg QD-tid QD-tid Imipramine Nortriptyline Others MAOIs QHS QHS 100-300 mg (200- QHS 400 ng/ml) Revised December 2014 Table 2: Augmentation Dosing for Inadequate Response Type/Class Medication Target Dose Maximum (Blood Level) Dose (Blood Level) Recommended Lithium 600-1200 mg 1200-1800 Augmentation (0.4-0.6 mg (.8-1.0 Agents mEq/L) mEq/L) T3-Cytomel 25-50 50 micrograms micrograms Buspirone 25-50 mg 45-60 mg Other Dextroamphetamine 5-30 mg 60 mg Augmenting Agents Methylphenidate 5-30 mg 40-60 mg Recommended Administration Schedule BID QAM BID-TD QAM BID References: Suehs, B., Argo, T.R., Bendele, S.D., Crismon, M.L., Trivedi, M.H., & Kurian, B. (2010). Texas Medication Algorithm Project Procedural Manual: Major Depressive Disorder Algorithms. Found at: http://www.jpshealthnet.org/sites/default/files/tmap_depression_2010.pdf Gelenberg, A.J., Freeman, M.P., Markowitz, J.C., Rosenbaum, J.F., Thase, M.E., Trivedi, M.H., et al. Practice guideline for the treatment of patients with major depressive disorder [Internet]. 3rd ed. Arlington (VA): American Psychiatric Association; 2010 Oct [cited 2014, September 29]. Available from: http://psychiatryonline.org/data/Books/prac/PG_Depression3rdEd.pdf Revised December 2014