Depression Toolkit

8/9/2019 Depression Toolkit

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CCNC DepressionToolkit


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Table of ContentsPrimary Care Toolkit : Overview ......................................................................................................... 1

CCNC Depression Work Group Implementation Recommendations ....................................................... 2

Adult (>18 years) Depression Flow Chart ................................................................................................. 3

Critical Decision Points (CDPs) for Acute Phase Treatment of Major Depression ................................... 4

Overview of Care Process in the Treatment of Depression ...................................................................... 6

Primary Care Toolkit : Screening/Evaluation ..................................................................................... 7

PATIENT HEALTH QUESTIONNAIRE (PHQ-9) + 3 ................................................................................ 8

PHQ-9 Screening and Diagnosis .............................................................................................................. 9

Differential Diagnosis Screening ............................................................................................................. 10

Suicidal Thoughts/Behaviors: Clinical Considerations ............................................................................ 11

Primary Care Toolkit: Medication Information................................................................................ 12

Guide to Antidepressants (Long List) ..................................................................................................... 13

Guide to Antidepressants (Short List) .................................................................................................... 15

Antidepressants Side Effects Evaluation ................................................................................................ 16

Primary Care Toolki t: Patien t Educat ion ......................................................................................... 17

Depression and You ................................................................................................................................ 18

Important Information About Your Depression Medication ..................................................................... 20

Depression Self-Care Action Plan ........................................................................................................... 21

Primary Care Toolkit: Documentation, QI, Billing .......................................................................... 24

Red Flags for Depression ....................................................................................................................... 24

DSM-IV Criteria for Major Depressive Episode ....................................................................................... 25

ICD-9 CODING ........................................................................................................................................ 26

Medicaid Billing and Coding .................................................................................................................... 27

Depression Flowsheet ............................................................................................................................. 29

Chart Review Tool for Depression .......................................................................................................... 30

Primary Care Toolkit: Spanish Language Resources .................................................................... 31

2 PREGUNTAS PARA LA EVALUACIÓN DE LA DEPRESIÓN ............................................................ 32

LA DEPRESIÓN Y USTED ................................................................................................................... 33

INFORMACIÓN IMPORTANTE ACERCA DE SU MEDICAMENTO ANTIDEPRESIVO ....................... 35

CUESTIONARIO DE SALUD DEL PACIENTE (PHQ-9) + 3 .................................................................. 36

Telephonic Depression Care Management ..................................................................................... 35

Role of the Phone Clinician in the Treatment of a Depressed Patient .................................................... 38

Phone Call Follow-Up Protocol in the Treatment of Depression ............................................................ 39

Suicide Assessment Form ...................................................................................................................... 40


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Phone Call Follow-Up Interventions for Clinicians .................................................................................. 41

Sample Scripts for Phone Call Interventions in the Treatment of Depression ........................................ 42

Depression Management Follow-Up Guidelines and Tip Sheet ............................................................. 46

Depression: Phone Call Follow-Up ......................................................................................................... 48

Phone Clinician’s Phone Call Tracking Log ............................................................................................ 49


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Primary Care Toolki t: Overview

Primary Care Toolkit:Overview


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CCNC Depression Work Group ImplementationRecommendations

To meet the requirements for evidence based depression treatment in the primary care settingcertain levels of “support” need be in place at a practice. Screening with a PHQ-9 for depressionis not by itself sufficient to be considered evidence based care. However, in appreciation of thescarcity of resources at most practices the depression work group had as a goal to come upwith the minimum requirements that a practice would need to have in place to meet thatstandard. These are:

• A practice based “champion” who would be responsible for organizing an“implementation team” that would include buy in from physicians, nursing, andadministration.

• A community based psychiatrist who would be an identified provider and who wouldserve primarily as a resource to the practice assuring enhanced community psychiatricaccess (referrals would be seen quickly by this provider). This would likely NOT includephone consultation since there is no billing mechanism. It is possible the networkpsychiatrist could fill that role but this would need to be worked out by each network.

• Someone in the practice who could make follow-up phone calls and then track whenpatients are due for follow-ups as they go through the depression algorithm.

• A commitment to monitor how the program is working (primarily fidelity measures ratherthan patient outcomes at first; see Audit Tool for suggestions). The initial suggestedfidelity measure would be the presence of a PHQ-9 having been completed at baselinefor anyone who has had an anti-depressant initiated (1st anti-depressant or change to a

new anti-depressant).

We would suggest that each practice choose which specific patients to target for screeningbased on what would best fit their needs, and give the best chance for implementation success.Some possible choices are patients with diabetes, cardiovascular disease, patients alreadyreceiving anti-depressants, chronic pain patients, or high users of resources. The expectation isthat the network psychiatrists and behavioral health coordinators could serve as a support to thepractice in getting the program up and running, and to help trouble shoot over time.

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Adult (>18 years) Depression Flow Chart

Two Question Screen: PHQ-2 Annually, new adult patients, and when suspect

POSITIVE response on either 2 Question Screen or

Clinical Concern

Follow up within one month. If no improvement,begin antidepressant and treat as Acute Phasemajor depression or brief counseling

Continuation / Maintenance Phase GOAL: prevent relapse/ recurrence Office vis its q 8 - 12 weeks or as needed

Ant idepressant Therapy:

1st

Episode: 7-12 months of continuouspharmacotherapy

2nd

Episode: 1-2 years OR lifetime withcomplicating factors

3rd

Episode: lifetime therapy if all 3episodes occur within one 5 year period

Also consider adjunctive psychologicalcounseling - see above for details.

Consider referral,psychiatric consultation,or hospitalization if thePatient: ▪ Is a risk to self or others▪ Has had two failedmedication trials, bothtrials with an adequatedose and duration of atleast 6 weeks, iftolerated ▪ Exhibits psychotic symptoms or hx ofbipolar disorder ▪ Has comorbidsubstance abuse ▪ Has severe

psychosocial problems

Determine PHQ-9total score. If >5continue, if < 5 top

Acute Phase: (See CDP chart for Acute Phase Care)GOAL: achieve remission ▪ PHQ-9 < 5 & no significant functional impairment▪ 2 follow-up contacts, at least one of which is with theprescribing provider within 4-6 weeks

Also consider adjunctive psychological counseling - seeabove for details.

Start Antidepressant

Physician Validation o f Major DepressiveD/O (MDD). R/O of medical and psychiatri ccondi tions, i.e., Bipolar, substance abuse, normal

grieving process, severe psychosocial problems SCORE NOT DUE TO OTHER CONDITIONS

Minimal to milddepressive

symptoms PHQ-9 score 5 - 9

MDD-Moderate PHQ-9 Score 10 - 14

MDD- Moderately Severe (PHQ-9) Score 15-19

MDD- Severe (PHQ-9 Score > 20)

• Watchful Waiting***• Supportive Counseling• Educate patient to call if

condition deteriorates• Repeat PHQ-9 at follow-

up• Consider referral if

PHQ-9 scores fall inhigh risk areas

Recommendantidepressant

and/orpsychological

counseling

Antidepressant stronglyrecommended; consider

the addition ofpsychological counseling

MAJOR DEPRESSIVE DISORDER

▪ ecommen ounse ng ▪ Educate Patient to call if condition deteriorates ▪ Repeat PHQ-9 at one month follow -up

No

Yes

Adult (>18 years)Depression Flow Char

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Critical Decision Points (CDPs) for Acute Phase Treatment ofMajor Depression

CDP

PHQ-9BaselineSeverity

Parameters

TreatmentModification

Treatment OptionsDesigned for medication treatment only. Psychotherapy for mild to

moderate depression is also considered evidenced based.

WEEK0

CDP#1

Severity ≥ 10

Initiate antidepressant medication at lower end of the dose range.

WEEK 1

PhoneCall

If severity >20 orclinical concern

Evaluate patient status, initial response to therapy, medicationtolerance; if PHQ-9 question #9 (suicide) was +, conduct SuicideScreening and assessment; May be from trained physician, therapist,nurse, or care manager (If indicated return appointment scheduled

prior to week 4.)

WEEK 2

PhoneCall

Recommendedfor all patients(Do PHQ-9)

Evaluate patient status, initial response to therapy, medicationtolerance. May be from trained physician, therapist, nurse, or caremanager (If indicated return appointment scheduled prior to week 4.)

WEEK 4

CDP #2

PHQ-9 ≤ 5 None

PHQ-9, >5 and5 and


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PHQ-9 ≥10 Modify treatmentIncrease antidepressant dose to higher range if there has been apartial response. Consider switching antidepressant.

WEEK10

PhoneCall

For patients whoremain in theacute phase (Do

PHQ-9)

Evaluate patient status, response to therapy, medication tolerance. IfPHQ-9 question #9 (suicide) was +, conduct Suicide Screening andassessment. May be from trained physician, therapist, nurse, or care

manager (If indicated return appointment scheduled prior to week 12.)

WEEK12

(q 4wks)

CDP #4

PHQ-9≤ 5 None Enter Continuation Phase

PHQ-9, >5 and


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Overview of Care Process in the Treatment of Depression

STEP 1: SCREENING AND DIAGNOSIS• Display of Red Flags for possible Depressive Diagnosis• Completion of 2 QUESTION screening for all patients• Completion of PHQ-9 for patients with positive screening• Scoring PHQ-9 for diagnosis and severity• Addi tional Screening for Suicide Risk, Substance Abuse, Bipolar Disorder, Psychosis, or

comorbidity as indicated with referral to a mental health provider for urgent/emergent cases

STEP 2: TREATMENT SELECTION • Clinical Interview to identify previous history/treatment of depression or other mental health

disorder• Utilize PHQ-9 Score and patient preference to drive selection of treatment plan:

1. Referral to Mental Health provider for Urgent/Emergent Care 2. Wait and Observe 3. Medication alone4. Medication plus Counseling 5. Counseling alone

• Referral to Clinical phone follow up for Education and Follow---Up Plan

STEP 3: INITIATION OF TREATMENT PLAN• CM to provide the following:

1. Educational Materials with Verbal Instruction during office visit or by Phone Call andMailing within

2. Provide assistance with obtaining medication (samples, sliding scale) to include writtenmedication

3. Establish Treatment Care Plan with patient engagement4. Schedule time for first clinical phone follow---up contact

STEP 4: ACUTE PHASE FOLLOW-UP• Clinical phone call follow-up at set intervals per protocol, to include:

1. Documentation of repeat PHQ-9 to determine treatment response 2. Use of Medication Effectiveness/Side Effect Evaluation tool to determine patient's

medication compliance and effectiveness of therapy if patient experiences sub-optimalresponse

3. Reminders to foster patient adherence to follow-up appointment schedule with PrimaryCare Provider schedule with Primary Care Provider (Initial Visit + 3 PCP/MHP Visit s over the first 12 weeks of treatment is recommended by HEDIS)

• Continued assistance with obtaining medication at no charge / reduced charge• Ongoing communication with PCP regarding patient's progress

STEP 5: CONTINUATION AND MAINTENANCE CARE• Continue pharmacologic and/or counseling treatment for 4-9 MONTHS to prevent relapse• Provide patient education related to symptoms of relapse• Continue schedule of repeat PHQ-9 per phone call to monitor patient adherence to treatment

plan and to provide support/re-teaching as needed• Ensure that patient is scheduled for further PCP visit s if PHQ-9 scoring indicates

recurrence/worsening of symptoms• PCP to determine patients at highest risk for need of Long Term Prophylactic Treatment • Follow patients requiring treatment > 6 months per protocol

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Primary Care Toolkit: Screening/Evaluation

The Spirit of MI

“ People may not remember what you say, butthey remember how you made them feel.”Primary Care Toolkit:Screening/Evaluation


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Complete Questions 1 - 9 Initially then at all Critical DecisionPoints (CDPs)

Not at allSeveral

Days

More thanhalf the

days

Nearlyevery da

1. Little interest or pleasure in doing things 0 0 0 0

2. Feeling down, depressed, or hopeless0 0 0 0

3. Trouble falling/staying asleep, sleeping too much0 0 0 0

4. Feeling tired or having little energy 0

0

0

0

5. Poor appetite or overeating0 0 0 0

6. Feeling bad about yourself-or that you are a failure or have letyourself or your family down

0 0 0 0

7. Trouble concentrating on things, such as reading the newspaper orwatching television

0 0 0 0

8. Moving or speaking so slowly that other people could have noticed.Or the opposite-being so fidgety or restless that you have beenmoving around a lot more than usual

0 0 0 0

9. Thoughts that you would be better off dead or hurting yourself insome way. (if positive, complete the Suicide Risk Assessment)

0 0 0 0

PHQ-9 Scor ing Formula

# Symptoms ___ X 0 = ___ X 1 = ___ X 2 = ___ X 3

Per Category ______ + _______ + _______ + _______ =

PHQ-9 Total Score: _______Q#1 was developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, & Colleagues. For research information contact Dr. Spitzer at [email protected].

10. If you checked off any problem on this questionnaire so far how difficult have these problems made it for you to do your work,take care of things at home, or get along with other people?

Not at All Somewhat Somewhat Difficult Very Difficult Extremely Difficult

Complete Questions 11-12 at INITIAL VISIT ONLY

11. In the past two years, have you felt depressed or sad most days, even if you felt okay sometimes? Yes No12. Has there ever been a period of at least four days when you were so happy, over energetic or irritable that you got into troubleor your family or friends worried about it or a doctor said you were manic? Yes No

Best Phone #: ________________ Ok to leave message? YES or NO Note: ______________________

Medication: __________________ Dose: ______________________ Frequency: _________________

1st copy to Medical Record 2nd copy to Initiate Phone Protocol

PATIENT HEALTH QUESTIONNAIRE (PHQ-9) + 3Nine Symptom Checklis t for Depression Screening

Name: ___________________________________________ DOB: _____________ Medicaid #: __________________

Practi ce #: ________________ Provider : ___________________________________ Diagnosis /ICD-9 Code: ________

Date of Init ial Diagnosis : ___________________ Screening Date: __________________

Over the last 2 weeks how often have you been bothered by any of the following problems?

___ CA Medicaid ___ Referred for Phone Protocol

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PHQ-9 Screening and Diagnosis

PHQ 9 Quick Depression Assessment for Initial Diagnosis:

• If there are at least 4 positive responses in the “ More than half the days” or “ Nearly every day” columns (including Questions #1 and #2), consider a depressive disorder. Add scores to

determine severity. • Consider Major Depressive Disorder if there are at least 5 positive responses in the “ More than

half the days” or “ Nearly every day” columns (one of which is Question #1 or #2).• Consider Other Depressive Disorder If there are 2-4 positive responses in the “ More than half the

days” or “ Nearly every day” columns (one of which is Question #1 or #2).• Functional Assessment: Question #10

NOTE: Diagnoses of Major Depressive Disorder or Other Depressive Disorder also require impairment ofsocial, occupational, or other important areas of functioning and ruling out normal bereavement, a historyof Manic Episode (Bipolar Disorder), and a physical disorder, medication or other drug as the biologicalcause of the symptoms.

Patient Health Questionnaire (PHQ-9) Form

Symptoms & Impairment PHQ-9SeverityProvisional Diagnosis

1-4 symptoms (not including questions 1 or 2),+ functional impairment

5 symptoms includ ing question 1 or 2, +functional impairment

15-19 Moderate Severe Major Depression

> 5 symptoms includ ing question 1 or 2, +

functional impairment≥ 20 Sever Major Depression

* If symptoms present for > 2 years, chronic depression, or functional impairment is severe, remissionwith watchful waiting is unlikely. IMMEDIATE active treatment is indicated for Major Depression.

Three (3) Phases of Depression Treatment** Acute Phase Aims at minimizing depressive symptoms – typically first 3- 4

months of therapyContinuation Phase Tries to prevent return of symptoms in the current episode – 4-12

months (Repeat PHQ-9 Q 4-6 months).

Maintenance Phase Tries to prevent return of symptoms within 2 years – 12-24

monthsMedication Therapy is recommended for at least 9 months after return to well state.

** REFERRAL or co-management with mental health specialty clinician if the patient is:High Suicide RiskBipolar DisorderInadequate Treatment ResponseComplex Psychosocial NeedsOther Active Mental Disorder

Adopted from The MacArthur Initiative on Depression and Primary Care at Dartmouth & Duke, Version 9.0 -January 2004.

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Differential Diagnosis Screening

Patient Name: _________________________ DOB: _________________________ Date: _____________

GRIEF REACTION SCREENING YES NO 1. Did your most recent period of feeling depressed or sad begin after someone close to you died?

2. If so, did the death occur more than 2 months ago?

If “NO” to first question, or if “ YES” to both questions, treat the patient for depression.

MANIA SCREENING rule out Bi Polar Disorder YES NO

1. Has there ever been a period of at least four days when you were so happy or excited that you got intotrouble, or your family or friends worried about it or a doctor said you were manic?

A “ yes” response ind icates potential bipolar disorder. Assess further for mania.

2. Diagnostic criteria include the concurrent presence of at least 4 of the following symptoms (one of whichmust be the first symptom listed):

a. A Dist inct Period of Abnormal, Persistently Elevated, Expansive, or Irr itable Mood b. Less Need for Sleepc. Inflated Self-Esteem/Grandiosityd. More Talkative than usual (pressured speech)e. Distractibilityf. Increased Goal-Directed Activity or Psychomotor Agitationg. Excessive involvement in pleasurable activities without regard for negative consequences ( e.g.,

buying sprees, sexual promiscuity)

ALCOHOL USE / ABUSE SCREENING (CAGE): YES NO

1. Have you ever felt you ought to CUT DOWN on your drinking?

2. Have people ANNOYED you by criticizing your drinking?

3. Have you ever felt bad or GUILTY about your drinking?• Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover

(EYE-OPENER)?

Two or more “ yes” responses are positive for possible alcohol abuse.

Action Taken: • Screening negative; no further action required • Positive Screening; medication prescribed • Positive Screening; medication prescribed and referral to staff for Phone Protocol • Positive Screening; patient referred to Mental Health Provi der

Name of MH Provider :

Comments:

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Suicidal Thoughts/Behaviors: Clinical Considerations

1. First, clarify whether the ideation is active or passivea. Current vs. not:

Are you having these thoughts right now? When did you last have them?b. Active vs. Passive:Do you have thoughts you’d be better off dead, or are you having thoughts of harming orkilling yourself?

IF active suicidal ideation currently, you need to further assess plans and intent

2. Next, assess intent and plana. Do you have any plans on how you would harm yourself?

IF yes, what have you thought about? Have you actually done anything to hurtyourself?

3. Key demographic risk factors for completed suicidesa. Age, noteworthy in two groups

Individuals aged 65 and older, especially white males over 85 years (59/100,000)Adolescents and young adults aged 15---24 years, for whom it is the third leadingcause of death (10.3/100,000)

b. Single or living alonec. Male sex

4. Other key variables to considera. Past psychiatric hospitalizationsb. Family history of suicide attemptsc. Any other history of impulsivityd. Access to means to harm selfe. Hopelessnessf. Comments that others will soon not have to worry about the patient's problemsg. Past suicide attemptsh. History of substance use (impulsivity)i. Availability of social support

j. Why now? Is there a crisis?k. Recent actions of giving away possessions

Risk Description Action

Low No Current Thoughts NoMajor Risk Factors

None

Intermediate Current thoughts, but noplans, with or without riskfactors

Assess suicide risk and contract with patient to call ifsuicide thoughts become more prominent. Considermental health referral.

High Current thoughts with plans Emergency management by qualified expert; referral tomobile crisis, crisis walk---in clinic, ER or psychiatrichospital. Maintain 1:1 observation. Involuntarycommitment if clear and immediate danger to self andrefuses referral.

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Primary Care Toolkit: Medication Information

Primary Care Toolkit:Medication Information


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Guide to Antidepressants (Long List)

MedicationTherapeuticDose Range

(mg/day)

InitialSuggested

DoseTitration Schedule Advantages Disadvantages

Serotonin Reuptake Inhibitors (SSRIs)

FLUOXETINE HCLProzac

10-80

20mg AC breakfast(10mg in elderly &those withcomorbid panicdisorder)

If no response after 4weeks, increase by10mg every 7 days astolerated.

Helpful for anxietydisorders.

Long half-life good forpoor compliance.

Generic available.

Less frequentdiscontinuationsymptoms.

Slower to reachsteady state.

Sometimes toostimulating.

Possibly morecytochromeP450interactions.

CITALOPRAM HBrCelexa

20-4020mg. ACbreakfast (10mg inelderly & thosewith panicdisorder)

20 mg daily for 4

weeks.If no response,increase by 10mgevery 7 days astolerated.

Probably helpful foranxiety disorders.

Possibly fewercytochrom P450interactions.

Generic soon.

ESCITALOPRAMOXALATELexapro

10-20 10mg.Increase to 20mg ifonly partial responseafter 4 weeks.

10mg. dose usuallyeffective for most

PAROXETINEPaxil

10-50

(40 in elderly)

20mg AC breakfast(10mg in elderly &those with

comorbid panicdisorder)

If no response after 4weeks, increase by

10mg every 7 days astolerated.

FDA approved formost disorders.

Generic soon.

Sometimessedating.

PAROXETINE CRPaxil CR

25-62.5

(50 in elderly)

25mg qd

(12.5mg in elderly& those with panicdisorder)

If no response after 4weeks, increase by

12.5mg every 7 daysas tolerated.

May cause lessnausea and GIdistress.

Occasionallymoreanticholinergiclike effects.

SERTRALINEZoloft 25-200

50mg ACbreakfast (25 mgfor elderly)

If no response after4 weeks, increase by25-50mg every 7days as tolerated.

Maintain 100mg.

Dose for 4 weeksbefore next increase.

FDA approved foranxiety disorders.Safety shown post

MI.

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Serotonin and Norepinephrine Antagonist

MIRTAZAPINERemeron

15-45

15mg qHS

(7.5mg for those inneed of sedation /hypnotic)

Increase in 15mgincrements astolerated (7.5mg inelderly)

Maintain 30mg for 4wks. before furtherincrease.

Few druginteractions.Little sexualdysfunction.

May stimulateappetite.

Sedation at lowdose only.

May initiallystimulate appetite

Norepinephrine- and Dopamine-Reuptake Inhibitors

BUPROPION(Wellbutrin SR)

300-400 150mg qAM

Increase to 150mg bidafter 7 days.

Increase to 200mg bidif poor response.

Allow 8 hrs betweendoses & initially not atHS.

No more than100mg/day withhepatic disease.

Stimulating. Littleor no sexualdysfunction.

At higher doses,may induceseizures inpersons withseizure disorder.Stimulating. BIDdosing.

Serotonin and Norepinephrine Reuptake Inhibitor

VENLAFAXINEVENLAFAXINE ER(Effexor, EffexorXR) 75 -375

75mg qd with food(37.5mg if anxiousor debilitated)

Bid or tid dosing(except ER/XR).ER/XR – 37.5 qAMfor 1 wk., then 75mg.qAM for 2wks., then150mg. If partialresponse after 4 wks.increase to 225mgqAM.

Norepinephrine effectonly in doses

>150mg.

XR version qd dosing.

Helpful for anxietydisorders.

Possibly fewercytochrome P450interactions.

May increaseblood pressure athigher doses.

BID dosing unlessusing XR.

EXPENSIVE.

Primarily Norepinephrine Reuptake Inhibi tor

DESIPRAMINE(Norpramin,Pertofrane)

100-30050mg qAM (25-100 in elderly)

Increase 25-50mg q3-7 days to initial targetof 150mg. in 4 wks.

More effect onNorepinephrine thanserotonin.

Anticholinergic.

NORTRIPTYLINE(Aventyl, Pamelor)

25-150

25mg qPM

(10mg. in frailelderly)

Increase 10-25mgevery 5 days to 75mg.

Dosing too high maybe ineffective.

Obtain serum levelsafter 5 wks. if noteffective.

Availability ofreliable, valid bloodlevels. Lowerorthostatichypotension than

other tricyclics.Generic available

Caution with BPHCan exacerbatecardiacconduction

problems or CHF

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Guide to Basic Antidepressants (Short List)

Medication TherapeuticDose Range

(mg/day)

Initial SuggestedDose

Titration Schedule Advantages Disadvantages

erotonin Reuptake Inhibitor s (SSRIs)

luoxetineHCL (Prozac) 10 - 80

20mg AC breakfast (10mg in elderly & those withcomorbid panicdisorder)

If no response after 4 weeks,increase by 10mg every 7 days astolerated.

Helpful for anxiety disorders. Long half-life good for poor compliance.Less frequentdiscontinuation symptoms.

Slower to reach steady state. Sometimes too stimulating.More cytochrome P450 interac

Citalopram HBr Celexa)

20 - 40 20mg. ACbreakfast (10mg inelderly & those withpanic disorder)

20 mg daily for 4 weeks. If no response, increase by 10mgevery 7 days as tolerated.

Probably helpful for anxiety disorders.Possibly fewer cytochromeP450 interactions.

SertralineZoloft)

25 - 200 50mg ACbreakfast. (25 mgfor elderly)

If no response after 4 weeks, increase by 25-50mg every 7 days as tolerated. Maintain 100mg dose for 4 weeksbefore next increase.

FDA approved for anxiety disorders. Safety shown post MI andin CHF.

erotonin and Norepinephrine Antagonist

MirtazapineRemeron)

15 - 45 15mg qHS (7.5 mgfor those in need ofsedation/hypnotic)

Increase in 15mg increments as tolerated (7.5mg in elderly.Maintain 30mg for 4 wks. beforefurther increase.

Few drug interactions. Little sexual dysfunction. May stimulate appetite.

Sedation at low dose only. May initially stimulate appetite.

Norepinephrine- and Dopamine-Reuptake Inhibi tors

Bupropion Wellbutrin SR) 300 - 400 150mg qAM

Increase to 150mg bid after 7 days. Increase to 200mg bid if poor response.

Allow 8 hrs. between doses & initiallynot at HS. No more than 100mg/day with hepatic disease.

Stimulating. Little or no sexual dysfunction.

At higher doses, may induceseizures in persons w/seizure disorder.Stimulating.BID dosing.

erotonin and Norepinephrine Reuptake Inhibitor

VenlafaxineEffexor & Effexor

XR) 75 - 375

75mg qd with food (37.5mg if anxiousor debilitated)

Bid or tid dosing (except XR). XR –37.5 qAM for 1 wk., then 75mg. qAMfor 2wks., then 150mg. If partialresponse after 4 wks. increase to225mg qAM. Norepinephrine effectonly in doses >150mg.

XR version qd dosing. Helpful for anxiety disorders.

Possibly fewer cytochromeP450 interactions.

May increase blood pressure ahigher doses. BID dosing unless using XR.


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Antidepressants Side Effects Evaluation

Patient Name: __________________________________ Date of Evaluation: ______________________

1. In the last week, how many days did you miss taking your antidepressant medication? ___________

2. How well are you tolerating the antidepressant?a. No problems; will continue antidepressantb. Minor problems; will continue antidepressant

(If responds A or B, not necessary to con tinue)

c. Moderate intolerance; may need does adjustment or further discussion with providerd. Significant problems; considering stopping antidepressant without provider intervention

1=minimal 2=mild 3=moderate 4=severe

Evaluator: _______________________________________________________________

ParameterNew Onset(yes/no)

Severity

Jittery, activation, restlessness Yes No 1 2 3 4 Not Present

Insomnia Yes No 1 2 3 4 Not Present

Nausea, vomiting, diahrrea,abdominal cramps, anorexia

Yes No 1 2 3 4 Not Present

Headache Yes No 1 2 3 4 Not Present

Sexual dysfunction Yes No 1 2 3 4 Not Present

Daytime sleepiness or feeling tired Yes No 1 2 3 4 Not Present

Confusion, disorientation,memory impairment

Yes No 1 2 3 4 Not Present

Other State: 1 2 3 4 Not Present

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Primary Care Toolkit: Patient Education

Primary Care Toolkit:

Patient Education


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Depression and You

Who gets depressed?Depression is a very common but highly treatable condition that affects about 1 in every 20 Americanseach year. Depression is not a character flaw, a sign of personal weakness or a condition that can be

willed or wished away. Depression is a medical il lness that can affect anyone. Over 11 million peopleevery year have this illness, with twice as many women as men. Many women are particularly vulnerableafter the birth of a baby. Men are less likely to suffer from depression but are also less likely to admit thatthey have the illness.

Unfortunately, many people with depression do not tell their primary care doctor how they are feeling.Talking to their doctor about how they feel is the depressed person's first important step toward gettingbetter.

What is depression?Since depression is a medical condition, like diabetesor heart disease, it is more than just of feeling ofsadness or being "down in the dumps". It affects yourday to day life and your thoughts, ideas, actions andphysical well being.

Some common causes may include: certain medicalconditions, some medications, drugs or alcohol, familyhistory or other mental illness conditions. It may resultfrom certain life events, such as the loss of a loved one,or by stress. An imbalance in the chemicals in the brainthat control mood can also cause depression.

REMEMBER: Depression is NOT the result of a weakness or a fault, it is a medical illness that canbe effectively treated.

How will I know if I am depressed?

People who are depressed generally experience one or more of the following symptoms ALL DAY,NEARLY EVERY DAY, FOR AT LEAST 2 WEEKS.

• Loss of interest in things previously enjoyed• Feeling sad, blue, or down in the dumps.• You may also have at least three (3) of the following symptoms:

o Feeling restless, slowed down or unable to sit stillo An increase or decrease in appetite or weighto Thoughts of death or suicideo Difficulty thinking, concentrating, remembering or making decisionso Sleeping too much or too littleo Feeling tired all the time, or loss of energy.

• Other symptoms you may experience include:o Headacheso Aches and painso Being anxious or worriedo Digestive problemso Feeling hopelesso Nausea and/or vomiting

What should I do if I have these symptoms?TALK TO YOUR DOCTOR: Many people suspect that something is wrong but hesitate to find help or feelguilty or responsible for their symptoms. Sometimes they are not aware that help and treatment is

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available. If you think you may have a problem there are health care providers that can help you. Theycan help you find out if there is a physical cause for your symptoms, treat the symptoms or refer you to amental health specialist for evaluation.

How will treatment help me?Treatment will help to lessen or remove your symptoms and return you to your normal life. Treatment isaimed at complete remission of symptoms and staying well afterward. You can also help your primarycare doctor treat you more effectively by participating in your treatment through ASKING QUESTIONSand FOLLOWING THROUGH WITH TREATMENT that both you and your doctor decide is best for you.

What type of treatment wi ll I get?As with any illness, sometimes more than one type of treatment may be tried to find what works best foryou. It is important not to get discouraged since many options exist and many people can expectimprovement and recovery.

The primary treatments for depression include medication,talking with a therapist or medication combined with talkingto a therapist.

Who may prov ide mental health treatment?

Depression, depending upon the symptoms, may betreated by primary care providers as well as specializedmental health providers. The primary care provider you seemay refer you to a mental health specialist such as: apsychiatrist, a psychologist, a social worker, or a casemanager.

Who should see a mental health specialist?Although many people are successfully treated for depression by their primary care provider, there aretimes when it may be necessary for referral to a specialized mental health provider. Some commonreasons for a referral may include the need for a combination of treatments, or for very severe orpersistent symptoms that do not improve with treatment. If you think you need to see a specialty provider,talk to the doctor, nurse, or case manager.

How will doc tor or nurse know if I have depression?Your health care provider will assess your physical and mental condition during your visit in order todecide if you are depressed. The following activities may occur:

• Answering Depression Screening Questions of filling out a Health Questionnaire.• Discussion of your symptoms• Perform a physical exam to determine your general health status• Perform some basic laboratory tests.• Inquire about your family’s medical and mental history

THERE IS HOPE. THERE IS HELP. TALK TO YOUR DOCTOR TODAY.

The common types of TREATMENT for depression include:• Antidepressant medicine• Therapy with a mental health specialist• A combination of mental health therapy and medication

Your provider will discuss your treatment with you and you may want to explore risks and benefits ofeach. A treatment plan will be recommended by your provider based upon your specific needs andcondition. If you are using DRUGS or ALCOHOL, please discuss this with your provider.

Your antidepressant medication is not addictive or habit forming. It is not an upper; it is not a downer.

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Important Information About Your Depression Medication

IMPORTANT THINGS TO REMEMBER WHILE TAKING ANTIDEPRESSANTS:• It takes time for your medication to work.• Antidepressants only work if they are taken EVERY DAY!• Most people start to feel better in 1-4 WEEKS.• DON'T GIVE UP if you don't feel better right away.• The first week is the hardest. Some people have mild side effects and don't feel that the medicine is

working. The side effects usually go away in a few days.• After you begin to feel better, continue to take the medicine exactly as your provider ordered it, even

if you feel better.

If you are thinking about stopping your medication, CALL YOUR DOCTOR FIRST.

Common side effects include the following:• Sleepiness or difficulty sleeping• Dry mouth• Constipation•

Nausea and/or Vomiting• Skin rash• Restlessness• Weight gain or loss• Dizziness• Headache• Sexual dysfunction

It is important for you to report any side effects from your medicine and to keep all follow-upappointments. Depending on your symptoms you may need to continue to take medication for anextended period of time even after you are feeling better. For some people, continuation of medicationover a long time period is very successful in preventing a relapse. STOP taking the medicine and call theclinic if you develop a rash or if side eff ects are severe.

Provider: _____________________________________Phone: _______________________________________

References: 1) Rost K. Depression Tool Kit for Primary Care NIMH grant NH54444. 2) 2003 CIGNA Behavioral Health. 3) AHCPR,Management of Major Depressive Disorder in Adults, Instructions for Patient Education, Patient's Guide, 1993. 4 Strock, Margaret(2004). Depression. NIH Publication No. 04-3561, National Institute of mental Health, National Institutes of health, U.S. Departmentof Health and Human Services, Bethesda, MD, 20 pp.http://www.nimh.nih.gov/publicat/depression.cfm

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Depression Self-Care Action Plan

Patient: ______________________________ DOB: __________________________

Practice: _____________________________ Phone No: ______________________

Depression is TREATABLE and RECOVERY is the RULE and not the EXCEPTION!

1. Stay Physically Active. Make sure you make time to address your basic physicalneeds. Try taking a walk for a certain amount of time each day.

2. Make Time for Pleasurable Acti vities. Even though you may not feel as motivated,or get the same amount of pleasure as you used to, commit to scheduling someFUN activity each day – like doing a hobby, listening to your favorite music, orwatching a video.

GOAL: Every day during the next week, I will spend at least _______ minutesdoing _______________________________________________________________

_____________________________________________________________________.

3. Spend Time with People who can Support you. It's easy to avoid contact withpeople when you are depressed, but you need the support of friends and lovedones. Explain to them how you feel, if you can. If you can't talk about it, THAT'S OK

– just ask them to be with you, maybe accompanying you on one of your activities.

GOAL: During the next week, I wil l make contact for at least _______ minutes with ____________________ (name), doing/talking about _________________________. ____________________ (name), doing/talking about _________________________. ____________________ (name), doing/talking about _________________________.

4. Practice Relaxing. For many people, the changes that come with depression – nolonger keeping up with our usual activities and responsibilities, feeling increasinglysad and hopeless – lead to anxiety. Since physical relaxation can lead to mentalrelaxation, practicing relaxing is another way to help yourself. Try deep breathing,taking a warm bath, or just finding a quiet, comfortable, peaceful place and repeatcomforting things to yourself like "IT'S OK."

GOAL: Every day during the next week, I will practice physical relaxation at least _______ times, for at least _______ minutes each t ime.

Simple Goals and Small Steps.It is easy to feel overwhelmed when you're depressed. Some problems and decisionscan be delayed, but others cannot. It can be hard to deal with them when you're feeling

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sad, have little energy, and aren't thinking clearly. Try breaking things down into SMALLSTEPS. Give yourself credit for each step that you accomplish.

THE PROBLEM IS: ______________________________________________________________________

MY GOAL IS: ______________________________________________________________________

STEP 1: ______________________________________________________________________

STEP 2: ______________________________________________________________________

STEP 3:

______________________________________________________________________How likely are you to follow through with these activities prior to your next visit?

Not likely 1 2 3 4 5 6 Very Likely

Developed by Ted Amann, RN (inspired by Group Health Cooperative of Puget Sound) Property of CareOregon, Inc.

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Primary Care Toolkit: Documentation, QI, Billing


Documentation, QI,Billing


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Red Flags for Depression

• History of Depression• Multiple Unexplained Somatic Symptoms• Recent Major Stressor or Loss• High Healthcare Utilizer• Chronic Pain or Chronic Illnesses

• Chief Complaint of Sleep Disturbance, Fatigue, Appetite orWeight Change

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DSM-IV Criteria for Major Depressive Episode

A. Five (or more) of the following symptoms have been present during the same 2 week period andrepresent a change from previous functioning: at least one of the symptoms is either (1) or (2):

1. Depressed mood most of the day, nearly every day2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly

every day3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of

body weight in a month), or decrease or increase in appetite nearly every day4. Insomnia or hypersomnia nearly every day5. Psychomotor agitation or retardation nearly every day6. Fatigue or loss of energy nearly every day7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional)

nearly every day8. Diminished ability to think or concentrate, or indecisiveness, nearly every day9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a

specific plan, or a suicide attempt or a specific plan for committing suicide B. The Symptoms cause clinically significant distress or impairment in social, occupational, or other

important areas of functioning.C. The symptoms are not due to the direct physiological eff ects of a substance (e.g., a drug of abuse or

a medication) or a general medical condition (e.g., hypothyroidism).D. The symptoms are not better accounted for by bereavement.

Adapted from the Diagnostic and Statistical Manual of Mental Disorders, 4th ed.

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ICD-9 CODING

• Is the depressed mood better accounted for by a general medical condition , substance use, oranother mental disorder ?

293.83 Mood Disorder Due to General Medical Condition291.8 Alcohol-Induced Mood Disorder292.89 Substance-Induced Mood Disorder (incl meds)

• Has the depressed mood or loss of interest or pleasure persisted over a 2-week period?296.20 Major depressive disorder, single episode296.30 Major depressive disorder, recurrent episode311 Depression NOS

• Has the depressed mood been present for most of the past 2 years (1 yr. in children)?300.4 Dysthymic Disorder (Depression with anxiety)

• Is the depressed mood associated with the death of a loved one & has it persisted for less than 2months?

V62.82 Bereavement

• Has the mood occurred in response to an identifiable psychological stressor & does not meet criteriafor any of the preceding disorders?

309.0 Adjustment Disorder with Depressed Mood309.28 Adjustment Disorder with Mixed Anxiety and Depressed Mood

• Is the mood clinically significant, & are the criteria not met for any of the above describeddisorders?

311 Depressive Disorder NOS

• If the clinical has determined that a disorder is not present but wishes to note the presence ofsymptoms.

780.79 Malaise and Fatigue (Decreased Energy) Insomnia NOS780.52 Codes updated per ICD---9 CM 2005 classifications.

Stein DJ, Gorman JM: Pharmacotherapy Algorithms for Primary Care, MBL Publishing, New York, 2001.Codes updated per ICD-9 CM 2005 classifications.

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Medicaid Bil ling and Coding

For the past two years CCNC Networks, together with interested primary care providers, have pilotedintegrating behavioral health providers into the medical home. Division of Medical Assistance made thecommitment to address issues of sustainability. As outlined in the January2009 Medicaid Bulletin the

Division of Medical Assistance has authorized the following codes in support of this model.

The provider must meet the following conditions: “In addition to physicians, nurse practitioners, and healthdepartments, these codes can be billed “incident to” the physician by the following professionalspecialties: licensed psychologists, licensed psychological associates, licensed clinical social workers,licensed professional counselors, licensed marriage and family counselors, certified nurse practitioners,certified clinical nurse specialists, licensed clinical addictions specialists or certified clinical supervisors.

Practitioners must continue to follow the guidelines for services provided “incident to” the physician. Referto the article tiled Modification in Supervision When Practicing “Incident To” a Physician in the October2008 general Medicaid bulletin for additional information.” .Extra resources and rates here.

These codes can be billed same day as E/M or Health Check visi ts. They will not deduct from

medical or mental health lim its.

99406 Smoking and tobacco use cessation counseling visit 3-10 min99407 Smoking and tobacco use cessation counseling visit (intensive) > 10 min99408 Alcohol and/or substance (other than tobacco) abuse structured screening (AUDIT, DAST) 15-30min99409 Alcohol and/or substance (other than tobacco) abuse structured screening (AUDIT, DAST) > 30min99420 Admin and interpretation of health risk assessment instrument (i.e. PHQ9) per unit; CPT code99420 is limited to 2 units per day.

It cannot be used to bill for smoking and tobacco use cessation counseling visit or alcohol and/orsubstance abuse structured screening and brief intervention since the codes listed above can be bil led

instead.The 96110 remains the appropriate code for a validated development screen (i.e. ASQ)This code cannot be used for services when they are a required component of a Health Check visit suchas the developmental screen (ASQ) but can be used for secondary screens (i.e. ASQ SE, MCHAT) thatoccur at that visit. Screening of the parent (i.e. Edinburgh) may be reimbursed by Medicaid if the parent isenrolled in a Medicaid program that covers screening. The screening should be billed under the parent’sMedicaid number.

96150 Health and Behavior Assessment - 15 minutes units96151 Health and Behavior Re-Assessment Face to Face Individual - 15 minutes units

Must provide medical (not behavioral health) ICD-9 code. If provided by physician the E/M code shouldincorporate these services. If provided by a behavioral health provider “incident to” this code can be billed

same day in addition to the physician’s E/M. Behavioral health providers should not bill this service"incident to" on the same date a therapy code is billed.

To insure that North Carolina’s medical services remain of the highest quality, the NC Center forExcellence in Integrated Care updates their web site to include evidenced based practices for all of thecodes listed above. All tools including the health risk assessments have been vetted by the NCPS,NCAFP and NCPA. Please take a moment to review at www.icarenc.org

27

http://www.ncdhhs.gov/dma/bulletin/%201008bulletin.htmhttp://www.ncdhhs.gov/dma/bulletin/%201008bulletin.htmhttp://www.ncdhhs.gov/dma/bulletin/%201008bulletin.htmhttp://www.ncdhhs.gov/dma/bulletin/%201008bulletin.htmhttp://www.icarenc.org/index.php?option=com_content&view=category&layout=blog&id=50&Itemid=114http://www.icarenc.org/index.php?option=com_content&view=category&layout=blog&id=50&Itemid=114http://www.icarenc.org/index.php?option=com_content&view=category&layout=blog&id=50&Itemid=114http://www.icarenc.org/index.php?option=com_content&view=category&layout=blog&id=50&Itemid=114http://www.ncdhhs.gov/dma/bulletin/%201008bulletin.htmhttp://www.ncdhhs.gov/dma/bulletin/%201008bulletin.htm


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A note of gratitude to our innovative pilot Community Care practices and Division of Medical Assistance for their contribution thathelped to made this possible. Currently DMA does not have published guidelines with regards to these codes. Please continue toreview the Medicaid bulletins as policy guidelines could potentially alter the information provided above.

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Intervention: Watch/Wait: Medication Psychotherapy (circle all that apply)

Depression Flow Sheet Patient Name:______________ DOB: _______________

Severity: Mild Moderate Severe ID#: _______________________ Gender: M F

DateProvider InitialsType of Visit

PHQ Scores & Txphase repeat PHQq 4-6 wks and prn

* Medication Flow(see indicators formed ∆ below)

* PsychotherapyFlow (seeindicators for Txchange below)

Next scheduledFollow-Up vis itType of Visit

Date: _______________Provider: ____________• Office Visit

o Depressiono Other Reason

• Phone Call

Score: __________• Watch/Wait• Acute phase Tx• Cont. Phase Tx• Maint. Phase Tx

• New Rx: __________________• Dosage changed to:

__________________• Dced: ____________• No Change

• Community MentalHealth Center

• PCP BehavioralHealth

• Private Counselingo New Referralo Current Patient

Next scheduled visit due: ____________________

Type of visit:• Office Visit• Phone Contact

Date: _______________

Provider: ____________• Office Visit


• Phone Call

Score: __________• Watch/Wait• Acute phase Tx• Cont. Phase TxMaint. Phase Tx

• New Rx:

__________________• Dosage changed to:

__________________• Dced: ____________No Change




Next scheduled visit due:

____________________




• Phone Call



__________________• Dced: ____________No Change








• Phone Call

Score: __________•

Watch/Wait• Acute phase Tx• Cont. Phase TxMaint. Phase Tx


__________________• Dced: ____________No Change


•

PCP BehavioralHealth• Private Counselingo New Referralo Current Patient





• Phone Call



__________________• Dced: ____________No Change








• Phone Call

Score: __________• Watch/Wait•

Acute phase Tx• Cont. Phase TxMaint. Phase Tx


__________________• Dced: ____________No Change


• PCP Behavioral

Health• Private Counselingo New Referralo Current Patient



Three (3) Phases of Depression Treatment* Consider change intherapy, medication ofaddition of medications if noresponse at 6 weeks orpartial response at 12weeks.

ACUTEAims at minimizing depressive symptoms – typically first 3- 4 months oftherapy

CONTINUATIONTries to prevent return of symptoms in the current episode – 4-12 months(repeat PHQ-9 Q 4-6 months).

MAINTENANCE Tries to prevent return of symptoms within 2 years – 12-24 months

Medication Therapy is recommended for at l east 9 months after return to well state.

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Chart Review Tool for Depression

Patient Name: DOB: Program: CHN/HCAPCCNC

Medicaid ID Number:

Primary Care Physician: Date Last OV:

OUTCOME MEASURE AUDIT RESULT

Yes No N/A Adult Primary Care patient with evidence of annual 2 question sc reening for depression or

an initial screening for a new patient

Evidence of completion of PHQ-9 +3 Question Diagnosti c Screening Tool f or Depression

secondary to a positive response to one of 2 Question Screening items

Evidence of appropriate Follow-Up Contacts: at least 3 follow-up contacts with a PCP or mental health

practitioner during the 12 week Acute Treatment Phase, at least one with the prescribing practitioner

for patient with a new episode of depression and treated with antidepressant medication (if less than 3

visits, indicate # of visits : 0; 1; 2)

Yes No

Effective Acute Phase Treatment: For patientsdiagnosed with a new episode of depression:

treated with antidepressant medication

remained on antidepressant during the entire 12

week Acute Treatment Phase

Effective Continuation Phase Treatment: Forpatients diagnosed with a new episode ofdepression:

treated with antidepressant medication

patient remained on an antidepressant for atleast 6 months.

Effectiveness of Treatment: patient showsimprovement using repeat PHQ-9 at least a 50% reduction in symptoms by week 12

Percentage of average improvement of patients us ing PHQ-9 at week 12 %

OPTIONAL DATA: Circle appropriate response

Has this patient been referred to a Specialist for Mental Health Therapy? Yes Past Yr Never

Did the patient receive a MH visit? Yes No UK

Documentation of a Depression Action Plan? Yes Past Yr No

Ant idepressant : Drug Name Drug Dose/Frequency Date of Rx Date D/Ced

Comments:

Date of PHQ-9 Initial Screen: 2 3 4

Score of PHQ-9 Initial Screen: 2 3 4

Aud itor : Date of Audit:

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Primary Care Toolkit: Spanish Language Resources


Spanish LanguageResources


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2 PREGUNTAS PARA LA EVALUACIÓN DE LA DEPRESIÓN

En el transcurso de las últimas dossemanas, ¿le han molestado alguno de lossiguientes síntomas?

Si No

1. ¿Poco interés o placer en hacer las cosas?

2. ¿Sintiéndose desanimado, deprimido o sinesperanza?



Si No




En el transcurso de las últimas dos

semanas, ¿le han molestado alguno de lossiguientes síntomas?

Si No





Si No





Si No





Si No





Si No





Si No




En el transcurso de las últimas dos

semanas, ¿le han molestado alguno de lossiguientes síntomas?

Si No





Si No





Si No





Si No



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LA DEPRESIÓN Y USTED

¿Quién se deprime?La depresión es una condición muy común pero altamente tratable, la cual afecta a 1 de cada 20Americanos cada año. La depresión no es una falla o defecto del carácter, una señal de debilidadpersonal o una condición que puede ser traspasada. La Depresión es una enfermedad médica quepuede afectar a cualquiera. Más de 11 millones de personas contraen esta enfermedad cada año. Deestos la mitad son mujeres. Muchas mujeres son especialmente vulnerables después de haber dado aluz. Los hombres tienen menos probabilidades de sufrir esta enfermedad, pero de igual manera esmenos probable que lo admitan.

Desafortunadamente, muchas de las personas quepadecen depresión no le hablan a su médico de sussíntomas. El primer paso hacía el mejoramiento de lapersona con depresión es hablar con su médicoacerca de sus síntomas.

¿Qué es depresión?Debido a que la depresión es una condición médica, al

igual que la diabetes o enfermedades del corazón,está es más que un sentimiento de tristeza. Afecta suvida cotidiana y sus pensamientos, ideas, acciones ybienestar físico.

Algunas causas comunes pueden incluir: ciertas condiciones médicas, algunos medicamentos, drogas oalcohol, historial familiar u otras condiciones de enfermedades mentales. Pueden ser el resultado deciertos eventos de la vida, como la pérdida de un ser querido, o por causas de estrés. Un desequilibriode los químicos en el cerebro que controlan el humor también puede causar depresión.

RECUERDE: LA DEPRESIÓN NO ES EL RESULTADO DE DEBILIDAD O CULPA, ES UNAENFERMEDAD MÉDICA LA CUAL PUEDE SER TRATADA EFICAZMENTE.

¿Cómo sabré si estoy deprimido?

Las personas deprimidas por lo general experimentan uno o más de los siguientes síntomas:

TODO EL DÍA, CASI TODOS LOS DÍAS, DURANTE POR LO MENOS 2 SEMANAS:• Pérdida de interés en cosas que disfrutaba anteriormente.• Sentimiento de tristeza o melancolía.

TAMBIÉN PUEDE EXPERIMENTAR POR LO MENOS 3 DE LOS SIGUIENTES SÍNTOMAS:• Sentirse inquieto, lento e incapaz de estar sentado. I Incremento o reducción en apetito o peso.• Pensamientosdemuerteosuicidio.• Dificultad para pensar, concentrarse, recordar o tomar decisiones.• Durmiendo demasiado o muy poco.

• Sentimiento de cansancio todo el tiempo, o pérdida de energía.• Otros síntomas que puede experimentar incluyen:

o Dolor de cabezao Dolor y malestaro Ansiedad o preocupacióno Problemas Digestivoso Sentimiento de desesperación

¿Qué debo hacer si tengo estos síntomas?

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Hable con su médico. Muchas personas sospechan que algo anda mal pero dudan en buscar ayuda o sesienten culpables o responsables por sus síntomas. En ocasiones no se dan cuenta que existe ayuda ytratamiento. Si piensa que puede tener un problema, existen proveedores de salud que le puedenayudar. Le pueden ayudar a encontrar si existe alguna causa física, la cual pueda estar afectando sussíntomas, tratarlos o referirlo a un especialista en salud mental para su evaluación.

¿Cómo me puede ayudar el tratamiento?El tratamiento le ayudará a disminuir o alejar sus síntomas y regresarlo a su vida normal. El tratamientopropone una remisión completa de síntomas y a estar bien después de este. Usted también puedeayudar a su médico a tratarlo más eficazmente a través de su participación en el tratamiento, haciendopreguntas y llevando un seguimiento de su tratamiento, el cual entre usted y su médico decidirán cual esel mejor.

¿Qué clase de t ratamiento recibiré?Al igual que con cualquier otra enfermedad, en ocasiones más de un tipo de tratamiento será necesariopara saber cual funciona mejor para usted. Es muy importante no desanimarse ya que existen muchasopciones y existe recuperación y mejoramiento.

LOS TRATAMIENTOS PRINCIPALES PARA DEPRESIÓN INCLUYEN MEDICAMENTOS, HABLARCON UN TERAPEUTA, O LA COMBINACIÓN DE MEDICAMENTO Y HABLAR CON UN TERAPEUTA.

¿Quién puede proveer tratamiento de salud mental?Dependiendo de los síntomas, la depresión puede ser tratadapor médicos generales al igual que por especialistas en saludmental.

Su médico puede referirlo a un especialista en salud mentalcomo lo son: siquiatra, psicólogo, trabajador social o unadministrador de casos.

¿Quién debe ver a un especialista en salud mental?Aunque muchas personas son tratadas exitosamente por su médico de cabecera, existen ocasiones enlas cuales será necesario ser referido a un especialista en salud mental. Algunas razones comunes para

ser referido pueden incluir la necesidad de una combinación de tratamiento o síntomas severos ypersistentes. Si considera la necesidad de acudir a un especialista, hable con su médico, enfermera oadministrador de casos.

¿Cómo sabrá mi médico o enfermera si tengo depresión?Su médico evaluará su condición física y mental durante su visita al consultorio para decidir si estádeprimido. Pueden ocurrir las siguientes actividades en su consulta:• Contestar preguntas para revisión de depresión o llenar cuestionarios de salud.• Discusión de sus síntomas.• Llevar a cabo de un examen físico para determinar su estado de salud en general.• Realizar exámenes básicos de laboratorio.• Preguntas acerca de su historial familiar médico y mental.

EXISTE ESPERANZA, EXISTE AYUDA, HABLE CON SU MÉDICO HOY MISMO.

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INFORMACIÓN IMPORTANTE ACERCA DE SUMEDICAMENTO ANTIDEPRESIVO

Los tipos de TRATAMIENTO para la depresión más comunes incluyen:• Medicamentos anti-depresivos• Terapia con un especialista en salud mental•

Una combinación de terapia de salud mental y medicamento

Su proveedor de salud discutirá su tratamiento con usted y quizá usted quiera conocer los riesgos ybeneficios de cada uno. Un plan de tratamiento será recomendado por su médico basándose en susnecesidades específicas y condición. Si está usando DROGAS O ALCOHOL, por favor discuta esto consu proveedor de salud.

SU MEDICAMENTO ANTIDEPRESIVO NO ES ADICTIVO. NO HARÁ QUE SE SIENTA ELEVADO, NIDESGANADO

COSAS IMPORTANTES PARA RECORDAR MIENTRAS ESTÁ TOMANDO ANTIDEPRESIVOS:• Toma algún tiempo para que su medicamento funcione• Antidepresivos solamente funcionan si se toman DIARIO!•

La mayoría de las personas comienzan a sentirse mejor en un lapso de 1 a 4 semanas • NO SE DÉ POR VENCIDO si no se siente bien inmediatamente.• La primera semana es la más difícil. Algunas personas tienen efectos secundarios leves y piensan

que elmedicamento no está funcionando. Los efectos secundarios por lo general se quitan a los pocosdías.

• Después de comenzar a sentirse mejor continué tomando su medicamento exactamente como se loordeno el médico, a pesar de que ya se sienta mejor.

Si está pensando en dejar de tomar su medicamento. LLAME A SU MÉDICO PRIMERO. Los efectossecundarios comunes incluyen lo siguiente:• Boca seca• Estreñimiento•

Aumento o pérdida de peso• Salpullido en la piel• Nerviosismo• Dolor de Cabeza• Mareo• Dificultad para dormir o para mantenerse dormido• Náusea y/o vómito• Trastorno sexual

ES MUY IMPORTANTE QUE REPORTE CUALQUIER EFECTO SECUNDARIO QUE TENGA QUE VERCON SU MEDICAMENTO Y CONTINUAR CON SUS CITAS MÉDICAS

Dependiendo de sus síntomas quizá necesite continuar tomando su medicamento por un período de

tiempo largo a pesar de continuar sintiéndose mejor. Para algunas personas, continuar tomando elmedicamento por un periodo de tiempo largo resulta muy exitoso para prevenir una recaída.

Si desarrolla un salpullido, o si los efectos secundarios son severos no continué tomando sumedicamento yllame a la clínica.

Provider :________________________________

Número de Teléfono: __________________________________

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CUESTIONARIO DE SALUD DEL PACIENTE (PHQ-9) + 3

Lista de los Nueve Síntomas para Revisión de la DepresiónNombre del Paciente: _________________________ Fecha De Nacimiento: ______________ Fecha:

______________¿En las últimas dos semanas, con qué frecuencia ha experimentado los siguientes síntomas?

PREGUNTAS Nunca

Varios

dias

Más de la

mitad de losdías

Casi todo

los días

Conteste las preguntas 1-9 inicialmente y después todos losPuntos de Decisión Crítica (PDC)

0 1 2 3

1. Poco interés o placer en hacer cosas 0 0 0 0

2. Sentirse desanimado, deprimido o sin esperanza0 0 0 0

3. Tener problemas para dormir, mantenerse dormido o dormirdemasiado

0 0 0 0

4. Sentirse cansado o tener poca energía0 0 0 0

5. Poco apetito o comiendo demasiado0 0 0 0

6. Sentir falta de amor propio o pensar que es un fracaso o fallarlea usted mismo o a su familia

0 0 0 0

7. Tener dificultad en concentrarse en cosas tales como leer elperiódico o ver televisión

0 0 0 0

8. El moverse o hablar tan despacio que otras personas a sualrededor se dan cuenta; o todo lo contrario, que cuando estánervioso/a o inquieto/a usted se mueva muchísimo más de lonormal.

0 0 0 0

9. Pensamientos de que pudiera estar mejor muerto o hacersedaño a si mismo. (Si contestó afirmativamente, complete laEvaluación de Riesgo de Suicidio)

0

0

0

0

PHQ-9 Scori ng Formula

# Symptoms ___ X 0 = ___ X 1 = ___ X 2 = ___ X 3

Per Category ______ + _______ + _______ + _______ =

PHQ-9 Total Score: _______

10. Si contestó afirmativamente a cualquiera de los problemas en el cuestionario, ¿cuánta dificultad le han causado estosproblemas en el trabajo, al atender su hogar o llevarse bien con otras personas?

Ninguna Dificultad Alguna Dificultad Mucha Dificultad Muchísima Dificultad

COMPLETE LAS PREGUNTAS 11 Y 12 SOLAMENTE EN LA VISITA INICIAL11. ¿En los últimos dos años, se ha sentido deprimido/a o triste la mayoría de los días, a pesar de sentirse bien en otras

ocasiones? Si No12. ¿Ha habido un periodo, de al menos cuatro días, en los que se sentía tan feliz, con demasiada energía o tan irritable que se

metió en problemas, o su familia o amigos se preocuparon o el médico le dijo que se encontraba en un estado maniaco? Si No

Número de Teléfono: ________________ ¿Se puede dejar mensaje? SI or NO Nota: ______________________

Medication: __________________ Dose: ______________________ Frequency: _________________

1st copy to Medical Record 2nd copy to Initiate Phone Protocol

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Telephonic Depression Care Management

Telephonic DepressionCare Management


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Phone Call Follow-Up Protocol in the Treatment of Depression

20 24 32 401 2 4 6 8 12 1610

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Suicide Assessment Form

THIS FORM IS FOR REFERENCE PURPOSES ONLY. THE ITEMS BELOW SHOULD BE ENTERED DIRECTLY INTOCMIS, THEN PRINTED AND PLACED ON THE CHART.

Screening Date (MM/DD/YYY): Insurance:

Patient Name: (last) (first) (MI)

DOB (MM/DD/YYYY): ID Number

Practice: Completed By:

Question YES NO Recommended Action/Intervention

Have you ever attempted to harm yourself? If YES, MODERATE to HIGH RISK.

In the past month, have you made any plans orconsidered a method that you might use to harmyourself?

If YES, MODERATE to HIGH RISK.

There’s a big difference between having a thoughand acting on a thought. Do you think you mightactually hurt yourself in the near future?


In the past four weeks, did you tell anyone that youwere going to commit suicide, or threatened that youmight do it?


Do you think there is any risk that you might hurt

yourself before you see your doctor/me the nexttime?

If YES, ACUTE RISK. If risk appears immediate,stay on phone with patient and call 911. Try to

identify if there is someone else around who canprovide safety for the patient. Do your best to makesure the patient goes to the ER immediately.

If yes to any of these questions, there is moderate to high risk, recommendation is:

1. If patient has ACTT, IIH, or CST services in place, call that agency’s crisis number which should be available inpatient’s home. Report findings to a live person, not over voicemail, and confirm they will respond in person. Afterensuring a first responder is in place, contact outpatient psychiatrist and /or other active provider to inform them ofacute safety concerns and that first responders were dispatched.

2. If crisis number is not known, OR if patient is not currently receiving services, call the MCO AccessLine for screening,triage, and referral. Report findings to screener. After the screening, the MCO may choose to dispatch mobile crisisservices. Contact outpatient psychiatrist and /or other active provider to inform them of acute safety concerns and thatAccessLine was contacted.

3. Call 911 if patient is unable or unwilling to make the call for help OR danger is imminent(i.e. answered YES to E)

Your follow up should include:

1. Notify all providers of patient’s condition2. Refer patient to MCO for care coordination services

***If responses to all items (A through E) are NO, patient is considered at “Low Risk” for suicide. Information should becommunicated to all providers via usual reporting channel(s).

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Phone Call Follow-Up Interventions for Clinicians

Administer ReportResults of

Screening Tools

EncourageAdherence to

Treatment Plan

Monitor Remission – Notify of

Exacerbation

MeasureTreatmentResponse

Identify Barriersand Problem Solve

Solutions

Provide OngoingPatient Education

Communicatewith Medical

Clinician

Clinical PhoneCall


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Sample Scripts for Phone Call Interventions in the Treatmentof Depression

Possible Barriers To Treatment With Recommended Interventions

1. Patient has not begun taking Medication for the Following Reasons:1. Patient is not comfortable with the "DEPRESSION" diagnosis.

Possible patient responses:• "I don't really feel depressed."• "I don't really think that I am that depressed."• "I'm just stressed out, not depressed."

Interventions:• Explain to the patient that their primary care clinician feels that they are depressed

and that the treatment would help.• Explore why the patient is uncomfortable about the diagnosis - equate with severe

mental illness or is frightened of the "label."• Explore what they think having depression means and dispel some of the myths.• If patient insists that they are not depressed, focus more on their symptoms.• For example, if their main symptom is insomnia, suggest that the medication they

have been prescribed will help to relieve that symptom.

2. Patient is not comfortable taking medication in general.Possible patient responses

• "I'm just not a medication type of person."• "I just don't like taking drugs."

Interventions:• Help the patient think about times when medications have been necessary and

useful.• Talk about depression medication as no different from taking medication for high

blood pressure or diabetes. Involve them in naming other diseases where medicationis both necessary and helpful.

• Try using the "BUS ANALOGY." Someone with a broken leg can get from point A topoint B by different means. He can walk, but with a great deal of difficulty, or he cantake the bus, which is a lot easier and faster. Then, once the leg is healed, he will notneed the bus. He only took advantage of its service for the short term when it wasneeded. The same is true for taking medication for depression. It can be a temporaryhelp during difficult times. When the depression is considered in remission, theperson will be able to decide, with his clinician, when he does not need to take itanymore.

• Point out that some people feel so much better on the medication that they decide tocontinue taking it indefinitely, especially if they have a history of multiple episodes.

• Remind the patient that their symptoms have not gone away over a period of time,and that for most people, the symptoms will not resolve on their own.

3. Patient is worried about being labeled as "mentally ill" if medication is taken.Possible patient responses:

• "I don't want to be on a medicine for a mental condition."• "I wouldn't want anyone to know that I was on this kind of medicine."• "People will think of me differently if they find out I'm on this kind of drug."

Interventions:• Frame taking medication with taking care of yourself. How would others judge you if

they felt that you were not taking care of yourself?• How would you feel about someone you knew not taking a medicine that could help

them feel better?

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• Explain that depression is a medical condition that occurs when a chemical in thebrain is not produced in sufficient amounts, just like diabetics do not produce insulinneeded by the body.

• Ask the patient, have you ever known someone with high blood pressure ordiabetes?

• Would you expect them to "buck up" and handle it themselves or take medicationnecessary to treat their medical condition?

• Rehearse what the patient can tell friends and family about the medication they aretaking. Refer to the Patient Education Instructions related to Anti-Depressantmedications.

4. Patient is unclear about what the medication does.Possible patient responses:• "I don't understand why the doctor prescribed this medicine."• "I don't even know what the medicine does or how it will help me."

Interventions:• Educate the patient on how their medication works and review medication instruction

sheet. If patient did not receive the Instructions, go over them and mail out to patient.• Recommend that the patient talk to the clinician during the next office visit.

5. Patient is concerned about becoming addicted to the medication.Possible patient responses:

• "I don't want to take this medicine forever."• "I don't want to get addicted to this medicine."

Interventions:• Inform the patient that depression medication is NOT addictive.• Explain that it takes time for the medication to start working, and that once in

remission, it is not unusual for patients to stay on the medicine for 6 months to ayear. Also emphasize that the decision for length of anti-depressant therapy is to bemade with the clinician.

• Emphasize the importance of staying on the medication and not to discontinue thedrug without discussing it with the clinician.

• Mention the tendency of some people to go off the medication as soon as they startfeeling better and that stopping too soon may put them at risk for a relapse.

6. Patient is concerned about their ability to pay for the medicine.

Possible patient responses:• "I don't have insurance, so I can't possibly pay for this medicine."

Interventions:• If patient is an HCAP recipient, they can utilize HCAP Medication Assistance

Program• Suggest that they discuss with their PCP if any less expensive generic drugs are

available to treat them, if samples are available, or refer them to a communityMedication Assistance Program, especially if long term therapy is anticipated.

2. Patient is considering or has stopped taking medicine for the following reason(s)1. Patient is experiencing distressing side effects.

Possible patient responses:• "I feel like my mouth is full of cotton."• "My husband/wife says I'm not interested in sex anymore."• "I feel like throwing up after I take the medicine."

Interventions:• Explain that most side effects are temporary and usually resolve in a few weeks.• Give the patient tips on how to handle the side effect i.e., put ice in their mouth or

suck on hard candy for dry mouth.• For more complex side effects such as loss of interest in sex, explore whether this

symptom is medication induced or whether it may be a part of their depression.• If the patient cannot tolerate the side effect, offer to speak with the clinician and call

them back if a different prescription is ordered.

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• Acknowledge that it can be frustrating finding the right medication or combination ofmedications, but it will be worth the effort to resolve their depression.

2. Patient is feeling better.Possible patient responses:

• "I feel better now so I think I can stop taking the medicine."

Interventions:•

Acknowledge that it is great that the medication is working, but explain that it is bestto remain on the drug until they and the clinician talk about it. Even then, themedication may be discontinued slowly and the patient will need to be monitored forpossible relapse.

3. Patient referred to a Mental Health Specialist but has not made/kept an appointment1. Patient has had a negative experience

Possible patient responses:• "I have been before but it didn't help me."

Interventions:• Discuss the reasons why the counseling was not effective.• Help the patient to understand more about what they didn't like the experience.•

Help the patient determine what they would like to happen if they wished for thesession to be helpful.

2. Patient is uneasy about what the visit will be like and the perceived stigma of needing toreceive assistance from a mental health specialist.Possible patient responses:

• "I'm not sure if I want to go right now."• "I don't really need to see somebody like that." "I'm not that bad off yet."• "I'm not totally crazy you know."

Interventions:

Mini Medication Side Effects Survey Tool

1. FREQUENCY of anti-depressant side effect over the past week: (do not rate if patient believes sideeffect is due to another medication)

• Present 10% of the time• Present 25% of the time•

Present 50% of the time• Present 75% of the time• Present 90% of the time• Present all of the time

2. INTENSITY (SEVERITY) of anti-depressant side effect over the past week:

• Trivial

• Mild

• Moderate

• Marked

• Severe1. ABILITY TO TOLERATE anti-depressant side effect over the past week:

• Minimal day to day impairment

• Mild day to day impairment• Moderate day to day impairment

• Marked day to day impairment

• Severe day to day impairment

• Unable to tolerate

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• Educate the patient about what they can expect to happen during counseling.• Determine what they "think" will happen during a visit and dispel any

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Depression Toolkit

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