The management of depression in both primary and specialty care was the topic of a recent presentation by Jeffrey Weilburg M.D. to the Drug Therapy Committee. Dr. Weilburg, Associate Medical Director for the MGPO and a member of the Psychiatry Department of the MGH, presented preliminary naturalistic data on antidepressant use in a sample of 16,911 patients who have a PCHI PCP and were enrolled in a commercial insurance plan from 7/1/99 - 12/31/01. The analysis was based on pharmacy claims data.

A complete description of the methods of data analysis used by Dr. Weilburg and his colleagues is beyond the scope of this discussion, but great care was taken to ensure the reliability of these administrative data. It is within that context that the data should be viewed. Although one may quibble with the design and methods, the results are sufficiently disturbing to question how we manage patients with depression.

• Most authorities, including local experts, agree that maintenance therapy should continue for 6-12 months after resolution or improvement in symptoms. Weilburg and colleagues required only that there be any period of 90 days of continuous therapy for patients to be rated as having had minimally adequate treatment. Most authorities also agree that use of at least a minimum effective dose of antidepressant is required during the full period of treatment. Weilburg and colleagues used fluoxetine 20mg or its equivalent (see table below) as the minimum likely effective dose in their definition of an adequate therapeutic trial. Minimum likely effective doses were determined for patients treated in primary care settings by literature review and discussion with local experts. The doses used correspond closely to those found in the pamphlet recently circulated by TAHP on depression and its treatment. Despite this minimal definition of adequacy, only 47% of all patients under the care of a PCHI physician received an adequate regimen of antidepressant. This rate of treatment adequacy is similar to that seen in other health care systems.
• Patients treated by psychiatrists were more likely to receive an adequate antidepressant treatment regimen (55%) than those treated solely by a primary care physician (29%). When patients were seen by both a psychiatrist and a primary care physician, the adequacy rate increased to 67%.
• Similar rates of adequacy, overall and by prescriber type, were found for patients with an MGH PCP.

Additional information is likely to be forthcoming from Dr. Weilburg and his colleagues, including data concerning potential differences in adequacy based on initial drug choice.

These data suggest that, despite the widespread use of antidepressants and the resultant costs, many patients are not receiving adequate treatment. The reasons for this failure are likely to be multifactorial and include, among others:

• Inadequacy in prescribing either in terms of dose and/or in duration.
• Failure on the part of the patient in terms of compliance and persistence.

Short duration of treatment appeared to be a main driver of inadequate treatment; the relative contribution of physician and patient factors in duration failure remains to be determined.

Prescribers should consider the following recommendations:

1. When a decision is made to treat depression in a primary care practice, remember that treatment consists of a titration period and a maintenance period. The maintenance period for treatment to reduce the rates of disease recurrence is 6-12 months in duration. Table 1 describes the minimum effective dose as defined by Weilburg et al.

 

Table 1: Minimum likely effective doses used by Weilburg et al:

2. Patients should be advised that they will likely need to be treated for up to one year after their symptoms improve. Specific instruction about continuation and follow-up visits to evaluate mood status and medication issues may be ways to ensure adequate treatment duration.

The PCOI website (http://oi.mgh.harvard.edu/pcoi/frontpage_frames.asp) contains many useful and brief documents to help patients understand their disease and their own role in treatment. Here is the patient information on depression from the site

Depression

What is depression?

Depression is the feeling of terrible sadness that affects mood, thoughts, behaviors and wellbeing. Most people (80% -90%) can be helped with treatment. However, many depressed people don't get the help they need - some think they have a sleep or eating problem. Others may be just too tired or ashamed to seek help. Depression is a serious medical condition and getting help early can make a big difference.

What are the symptoms?

There are many symptoms that vary from person to person. Not everyone gets every symptom and some can be mild. Common ones are:

• Constant sad, anxious or empty feeling
• Loss of interest or pleasure in almost all activities
• Changes in eating or weight
• Disturbed sleep
• Slowed or restless movements
• Tiredness or loss of energy
• Feeling of worthlessness or guilt
• Trouble in thinking, concentrating, or making decision
• Thoughts of death or suicide

Many people with depression also suffer anxiety and tend to worry more about their physical health. They may have problems in their relationships (including marriage) and may function less well at work. They are also more likely to abuse alcohol and drugs.

Are there different kinds of depression?

The three most common kinds are major depression, dysthymia and bipolar depression. Major depression is a more severe type and affects the ability to do everyday tasks. Dysthymia is usually milder, occurs over a longer period of time and doesn't affect everyday tasks. However, it does interfere with feeling good and functioning well. Bipolar depression (manic-depressive) causes mood swings that change between severe highs (mania) and lows (depression). In manic phases, the person may be overactive, over-talkative, have less need for sleep and show poor judgment. Other kinds of depression include post-partum depression, which affects new mothers, and seasonal affective disorder (SAD), which occurs during the winter months.

Who does it affect?

Depression is one of the most common medical problems in the United States. It affects adults and children. Women are twice as likely as men to be affected. Depression also runs in families. You are more likely to suffer a bout of major depression if you have one or more close relatives who have been depressed.

What causes depression?

No one knows exactly what causes depression, but researchers are learning more about its biological and environmental roots. Major depression seems to involve changes in the transmission of chemical messengers (neurotransmitters) in certain parts of the brain. Environmental causes, such as trauma or early losses, also play a role. An episode of depression may be triggered by a stressful life event but, in many cases, the change in mood can't be traced to anything in particular.

What can I expect the doctor to do?

There are no specific lab tests for depression. In some cases, the doctor may order a test to make sure that your low mood isn't caused by a physical problem. He or she will ask questions about your symptoms and about your life history. Depending on how severe your depression is, your primary care doctor will help you monitor your condition, prescribe medications, or refer you to a therapist (nurse, social worker, psychiatrist, psychologist).

What is the treatment for depression?

For more serious bouts of depression, a combination of psychotherapy and medication is usually most helpful. The most commonly prescribed medications are selective serotonin reuptake inhibitors (SSRIs). They are easy and safe to take, but you do need to take these medications as directed. It usually takes some time - between two and six weeks - before you feel the full effects. Sometimes you may need to try several different medications before you find the one that works best for you. Most people need to continue medications, even if they are feeling better, for six to nine months. In some cases, people need to take the medication for a long time. Many of these medications require you to stop taking them gradually.

Can depression be prevented?

Depressive episodes may be precipitated by problems encountered in life, but may also arise spontaneously, without apparent precipitant. Stress management and maintenance of a healthy life style by proper diet, sleep and exercise, may be useful in maintaining a healthy mood state. If depression appears getting help early can diminish symptoms and prevent your depression from getting worse. Since episodes of depression sometimes increase in frequency and become more severe over time, early treatment can be very important. Maintenance of medication treatment for patients with several prior depressive episodes lowers the chance of recurrence of depression.

What can I do to help myself?

• Set realistic goals for yourself - you may need to break large tasks into smaller ones.
• Try to be with other people. Let your family and friends help you.
• Involve yourself in activities that you enjoy.
• Get regular exercise. It helps many people feel better emotionally.
• Take it easy on yourself. Lower your expectations and postpone important decisions until the depression has lifted.
• Remember that the negative thoughts you may be having are part of the depression, not always a reflection of what is actually happening.
• If you feel desperate and are worried that you may do harm to yourself, or if you just need to talk, you can call the Samaritans (Boston # 617/247-0220) or 1-800 SUICIDE (1-800-784-2433). You can also go to the Emergency Department at MGH or another hospital.

When can I expect to feel better?

Treatment of depression has become quite sophisticated and effective. The prognosis today is excellent. Treatment can make your low moods milder and less frequent. Many people are able to stop their depression completely. When treatment is successful, it's important to stay in close touch with your doctor or therapist, since ongoing treatment is often required to prevent relapses.

Where can I get more information?

• The National Institute of Mental Health (NIMH), part of the National Institutes of Health, has many booklets, fact sheets, and brochures on depression. You can get this information by calling NIMH at (301) 443-4513, or by visiting the web site at http://www.nimh.nih.gov/publicat/depressionmenu.cfm.
• The Depression and Related Affective Disorders Association web site offers patient information on the various kinds of depression. The material on the DRADA Web Site is reviewed for medical accuracy by a psychiatrist on the faculty of the Johns Hopkins School of Medicine. Visit the web site at www.hopkinsmedicine.org/drada.
• The Blum Patient and Family Learning Center is located on the first floor of the main building (White) at MGH. Librarians there can help you find out more about depression. Call (617) 724-7352 or drop in. If you don't have access to the internet, you are welcome to use computers at the Blum Center to look for medical information.

This document is intended to provide health related information so that you may be better informed.
It is not a substitute for your doctor's medical advice and should not be relied upon for treatment for specific medical conditions.

© 2001 The General Hospital Corporation.
Primary Care Operations Improvement Site prepared by the MGH Laboratory of Computer Science

http://www.ahrq.gov/clinic/3rduspstf/depression/