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Maximize depression treatment efforts with measurement-based care

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Team-based approach works best

Ten years ago, the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study highlighted the importance of close monitoring of patients with depression. This is best done with a team-based approach; it’s best suited to handle issues of compliance, side effects, efficacy, and close follow-up. The team may consist of a psychotherapist, nurse, and, possibly, a pharmacist – in addition to the internist, Nitin S. Damle, MD, said in an interview.

Courtesy American College of Physicians

Dr. Nitin S. Damle

Integrating behavioral health into primary care practices involves structure, which includes office visits – even every 2 weeks until stable – follow-up phone calls by the nurse to assess adherence and problems with medication, and a pharmacist to track refill rates and side effects, and to recommend changes to medication due to lack of efficacy or side effects, he said.

Treatment algorithms are an effective means to find the most effective and safest medication, and screening with PHQ-9 and even QIDS has become more common in the primary care office. Still, the adaption of measurement-based care has been slow, partly because of the absence of adequate funding for an integrated primary care team-based approach to mental illness. Now there is no mechanism to cover the costs of personnel and infrastructure to provide for the level of monitoring and treatment that measurement-based care requires, according to Dr. Damle.

Health plans need to review the evidence, such as that from the STAR*D and other studies, and create funding mechanisms so that their members stay healthy and avoid complications of mental illness.

Dr. Damle is president of the American College of Physicians and clinical associate professor of medicine at Brown University, Providence, R.I. He has no relevant disclosures.


 

EXPERT ANALYSIS FROM SUMMIT OF NEUROLOGY & PSYCHIATRY

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WASHINGTON – Challenging patients with depression to stay engaged in their recovery while rigorously monitoring and measuring their treatment response can mean the difference between remission or resistance, according to an expert.

“We all wish for better treatments, but we really don’t have any coming available to us in the near future, so our task is to do as well as we can with what we have,” Michael E. Thase, MD, professor of psychiatry at the University of Pennsylvania, Philadelphia, said at Summit in Neurology & Psychiatry.

Whitney McKnight/Frontline Medical NewsDr. Michael E. Thase

“We know far too well that there is a large gap between what we might be able to accomplish and what actually happens in clinical practice,” Dr. Thase said.

To close that gap, start with evaluating what can be done to combat patient nonadherence. A 2007 study indicated that just under 20% of patients adhere to antidepressant medication guidelines (Prim Care Companion J Clin Psychiatry. 2007;9[2]:91-9.), and according to Dr. Thase, less than 10% of patients being seen for depression in primary care actually fill their prescriptions.

“Don’t delude yourself that these patients drop out of treatment because they no longer need it. They drop out mostly because they have gotten disgusted, disappointed, or discouraged,” said Dr. Thase, attributing the high rate of nonadherence to the nature of depression itself.

“Depression is a state of pessimism, low confidence, and of not really feeling capable.”

Helping patients overcome their reluctance to follow treatment guidelines begins with accurately assessing their symptom severity. Patients who rate 4 or less on the Patient Health Questionnaire–9 (PHQ-9), which is based on the DSM-IV, are considered in remission or not to have severe depression. Similarly, patients who score 5 or less on the Quick Inventory of Depressive Symptomatology (QIDS) are not considered in the danger zone.

The severity ratings included in the DSM-5 can help clinicians pinpoint the level of depression a patient is experiencing, as can a therapeutic relationship with the patient and the family, Dr. Thase said at the summit, held by Global Academy for Medical Education.

He urged clinicians to monitor adherence routinely by asking patients whether or not they have filled or refilled their prescriptions. It is helpful to ask patients about missing doses and whether they are feeling any improvement, he said.

“It’s a very simple process: You keep track of the patients. Chase after them if they don’t follow through. If you’re not keeping track, the patients think [what they do] doesn’t matter,” Dr. Thase said.

A 2010 study of chronic depression treatment in primary care practices showed that compared with regular care, aggressive monitoring of patient adherence and outcomes in 728 adults with depression resulted in better remission rates across 18 months of treatment. At 6 months 43.4% of patients who had been contacted regularly by nursing and social worker staff were in remission, compared with 33.3% of the 78 who had received regular care (P = .11). At 12 months, the results were 52% vs. 33.9% (P = .012), and at 18 months remission was reported in 49.2% vs. 27.3% (P = .004) (Ann Fam Med. 2010 Sep;8[5]:387-96).

By being alert to side effects, using a rating scale to measure symptom reduction, and not staying “locked” into the idea that all treatments require 6-8 weeks before patients see any improvement, clinicians can boost chances for adherence – and thus for remission – since patients who don’t improve in the first 2 weeks have just a 15% chance for improvement, Dr. Thase said. “You need 6-8 weeks to get to the maximum titration. That old 8-week rule applies mostly to patients who are showing improvement by week 2.”

If by week 2, the patient is not tolerating the medication’s side effects and has no symptom reduction, then move on to the next medication, Dr. Thase said, emphasizing the importance of seeing patients at least twice monthly. “If we’re only seeing a patient once a month, we’ve already fallen behind in the up-titration part, and we’ve missed the opportunity for early intervention if the patient is having side effects.”

Algorithms for choosing depression treatments should be a “fact of life,” he said. Start with the safest, easiest to tolerate, and least expensive of the available antidepressants, such as escitalopram and fluoxetine before working through the second- and third-line therapies and adjunctive therapies, all of which have greater risk profiles as you move through them. This algorithmic approach has been shown to result in patients scoring at least 10 points higher on a depression rating scale (JAMA Psychiatry. 2004;61:[7]669-80), which Dr. Thase said is equivalent to about a 30% higher chance of remission. “Don’t go over and over with the simple treatments that aren’t [evoking] a response. Move briskly on to the more complex treatments until patients respond.”

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