Depression Follow-up in Primary Care: A State of the Science Review

Depression is a major and prevalent concern in primary care. Despite the many efforts over the past four decades to improve the quality of treatment and follow-up for depression, a gap remains between the current levels of follow-up care versus follow-up care that research suggests leads to optimal clinical outcomes. Because so many somatic complaints and medical comorbidities associated with depression are seen in primary care, the FNP is well positioned to recognize, manage, and provide appropriate follow-up care for depression. Specific guidelines are needed in order for FNPs to successfully monitor and provide follow-up treatment for depression in primary care. Research has shown that administering multiple repeated assessments to depression patients provides more accurate and useful information for management of the condition; it also improves outcomes by detecting patients who are not responding adequately to treatment. In order to achieve this goal, FNPs in the primary care setting must increase the frequency and quality of follow-up visits, consistently utilize patient self-assessment tools, maintain ongoing communication with patients, and follow a guideline to manage follow-up care.

DEPRESSION FOLLOW-UP IN PRIMARY CARE 1 Depression Follow-up in Primary Care: A State of the Science Review Heather Crockett, Jenn Pantelakis, Jennifer Rowley, and Nancy Shina Westminster College, Salt Lake City, Utah DEPRESSION FOLLOW-UP IN PRIMARY CARE 2 Copyright 2015 by Heather Crockett, Jenn Pantelakis, Jennifer Rowley, and Nancy Shina. All rights reserved DEPRESSION FOLLOW-UP IN PRIMARY CARE 3 DEPRESSION FOLLOW-UP IN PRIMARY CARE 4 DEPRESSION FOLLOW-UP IN PRIMARY CARE 5 DEPRESSION FOLLOW-UP IN PRIMARY CARE 6 Abstract Depression is a major and prevalent concern in primary care. Despite the many efforts over the past four decades to improve the quality of treatment and follow-up for depression, a gap remains between the current levels of follow-up care versus follow-up care that research suggests leads to optimal clinical outcomes. Because so many somatic complaints and medical comorbidities associated with depression are seen in primary care, the FNP is well positioned to recognize, manage, and provide appropriate follow-up care for depression. Specific guidelines are needed in order for FNPs to successfully monitor and provide follow-up treatment for depression in primary care. Research has shown that administering multiple repeated assessments to depression patients provides more accurate and useful information for management of the condition; it also improves outcomes by detecting patients who are not responding adequately to treatment. In order to achieve this goal, FNPs in the primary care setting must increase the frequency and quality of follow-up visits, consistently utilize patient self-assessment tools, maintain ongoing communication with patients, and follow a guideline to manage follow-up care. Keywords: depression, management, primary care, stepped care, screening, collaborative care DEPRESSION FOLLOW-UP IN PRIMARY CARE 7 Table of Contents Introduction ........................................................................................................... 11 Purpose of the Study .......................................................................................... 13 Background Information and Review of the Literature ........................................ 13 Statement of the Problem .................................................................................. 13 History of Screening for Depression ................................................................. 14 Benefits of Using a Screening Tool ....................................................................... 15 Screening Helps Control Costs .......................................................................... 15 Screening Improves Medication Compliance ................................................... 17 Screening Decreases Comorbidities Associated with Depression .................... 19 Current Screening Guidelines and Recommendations .......................................... 21 Screening Tools Are Not Currently Being Utilized by Health Care Providers . 24 Obstacles in the Utilization of Screening Tools ................................................ 25 Supporting Evidence ......................................................................................... 26 Methods ................................................................................................................. 27 Search Criteria ................................................................................................... 27 Exclusion Criteria .............................................................................................. 28 DEPRESSION FOLLOW-UP IN PRIMARY CARE 8 Inclusion Criteria ............................................................................................... 28 Procedure ........................................................................................................... 28 Theoretical Framework ......................................................................................... 29 Collaborative Care Framework ......................................................................... 29 The Stepped Care Model ................................................................................... 29 Management Strategies ......................................................................................... 31 Guidelines for Stepped Care Management of Depression ................................ 31 Screening ........................................................................................................... 31 Acute phase ....................................................................................................... 35 Follow-up .......................................................................................................... 36 Addressing Minimal or Non-Response at Follow-up ........................................ 37 Addressing Minimal or Non-Response after Altering Initial Treatment ........... 37 Continuation phase ............................................................................................ 38 Maintenance phase ............................................................................................ 38 Discontinuation Phase ....................................................................................... 39 Figure A ............................................................................................................. 40 Recommendations and Summary .......................................................................... 41 DEPRESSION FOLLOW-UP IN PRIMARY CARE 9 Limitations ......................................................................................................... 42 Conclusion ......................................................................................................... 43 References ............................................................................................................. 44 Appendix A ........................................................................................................... 50 Appendix B ............................................................................................................ 51 Appendix C ............................................................................................................ 52 Appendix D ........................................................................................................... 53 Appendix E ............................................................................................................ 55 Appendix F ............................................................................................................ 55 DEPRESSION FOLLOW-UP IN PRIMARY CARE 10 Acknowledgements The authors would like to thank our professors, mentors, educators, editors, peers, and most of all our family members for putting their lives on hold while we endured to the end. DEPRESSION FOLLOW-UP IN PRIMARY CARE 11 Introduction The high prevalence of depression in adults who are seen in primary care is a topic of great concern. Research shows that depression is often undetected and under diagnosed, especially in the primary care setting. A vast number of patients with depression first present in a primary care practice and are seen by family nurse practitioners (FNPs). According to Uphold and Graham (2013), approximately 25% of all primary care visits involve a patient with critically significant levels of depression. Additionally, national surveys have shown that more Americans receive mental health care in a primary care setting than from a mental health specialist (Unutzer & Park, 2012). Oftentimes, patients with depression in primary care settings go undiagnosed, and therefore go untreated (Berghöfer, Roll, Bauer, Willich, & Pfennig, 2014). In primary care, it has been shown that some providers fail to recognize depression in up to half of all patients, due to lack of standardized guidelines for screening and follow-up care (Gelenberg et al., 2010). Depression is a disabling and costly health condition in the United States (Gelenberg et al., 2010). It is currently regarded as one of the leading causes of disability and ranks third among the leading causes of disease burden worldwide; it ranks first for disease burden in middle income and high income countries (Berghöfer et al., 2014). According to clinical guidelines in family practice, depression in adults can be defined as mood disorders that collectively involve physical, behavioral, and cognitive symptoms. These symptoms can prompt and exhibit persistent feelings of sadness, impair functioning, and even the loss of interest in previously enjoyed activities (Uphold & Graham, 2013). DEPRESSION FOLLOW-UP IN PRIMARY CARE 12 Depression impacts several spheres of functioning, including health, work, social, and family life. Reduced cognitive function is very prominent with depression, which results in a decreased ability to perform activities of daily living. This equates to greater rates of unemployment and time off work. For families, this can negatively affect the development of patients' children and family dynamics. Depression can also reduce adherence to medical treatments for other conditions and alter physical health, leading to increased health risks, such as obesity, smoking, and sedentary lifestyle. Depression has been recognized as an independent risk factor for chronic medical conditions (Cameron, Habert, Anand, & Furtado, 2014). People with undiagnosed or undertreated depression also tend to utilize health resources at a considerably higher rate than those who do not have depression (Berghöfer et al., 2014). According to the Centers for Disease Control (CDC) (2015), from 2009 to 2010 there were eight million ambulatory care visits to hospitals, outpatient clinics, and emergency departments with depression being the primary diagnosis. Clearly, depression is a major and prevalent concern. Despite the many efforts over the past four decades to improve the quality of treatment and follow-up care for depression, a gap remains between the current levels of follow-up care versus follow-up care that research suggests leads to optimal clinical outcomes (Baik, Crabtree, & Gonzales, 2013). Because so many somatic complaints and medical comorbidities associated with depression are seen in primary care, the FNP is well positioned to recognize, manage, and provide appropriate follow-up care for depression. It is important that FNPs are consistent, not only with treatment, but also with managing follow-up. DEPRESSION FOLLOW-UP IN PRIMARY CARE 13 Purpose of the Study The purpose of this state-of-the-science review is to determine what guidelines are available to FNPs to assist in adequate treatment and follow-up care after a patient has been diagnosed with depression. For the FNP, being able to develop and utilize the appropriate resources to recognize and treat a person with depression is key to monitoring and follow-up of depression in primary care setting. Numerous screening tools and recommendations for the diagnosis of depression are available; however, there is not a universal tool or specific guideline for FNPs to use for monitoring and follow-up of depression. Follow-up care after a diagnosis of depression is still an ongoing and ever-changing subject. Because of the high number of patients seen in primary care who present with signs and symptoms of depression, it is imperative that FNPs have clear and easy-to-use tools to manage these patients, ensuring optimal treatment outcomes and quality of life. Background Information and Review of the Literature Statement of the Problem According to Flückiger, Del Re, Munder, Heer and Wampold (2014), over 150 million people worldwide have been diagnosed with depression in the past decade. In western countries especially, prevalence rates of a one-time lifespan diagnosis of depression are as high as 30%, and comorbidities are frequent. A 12-month prevalence of depression in the United States is approximately 7%, with marked differences by age group, such that the prevalence in 18- to 29- year-old individuals is threefold higher than the prevalence in individuals aged 60 years and older. Females experience 1.5- to 3-fold DEPRESSION FOLLOW-UP IN PRIMARY CARE 14 higher rates than males, beginning in early adolescence (American Psychiatric Association, 2013). Even with depression being so prevalent in the United States, the National Committee for Quality Assurance in the State of Healthcare Quality Report cites treatment as among the poorest scoring areas of basic health care (as cited in Simon et al., 2011). Simon et al.'s study also found that treatment is often complicated by the fragmentation of the United States healthcare system, the absence of appropriate management, and lack of referral services. History of Screening for Depression Culpepper (2012), reported that interest in screening for depression in primary care did not take place until the early 1990s, when selective serotonin reuptake inhibitors (SSRIs) came into common use. SSRIs, as opposed to previously-available heterocyclics, have fewer side effects, less potential for lethality in overdose, and greater patient acceptance. They also require less time to monitor and adjust dosing. The availability of a more favorable treatment instigated interest in identifying patients who might benefit from their use. This, in turn, prompted increased screening for depression and the creation of various screening tools. During the 1990s, while screening for depression in primary care increased, it did not correlate with improved outcomes (Culpepper, 2012). During this time, there was little evidence connecting screening results to treatment options except anecdotal evidence from clinicians' family members' experience with anti-depressant use (Unützer & Park, 2012). Because screening did not correlate with positive outcomes, the U.S. DEPRESSION FOLLOW-UP IN PRIMARY CARE 15 Preventive Service Task Force (USPSTF), a task force that systematically reviews evidence-based practices and develops recommendations for preventive care guidelines, did not recommend depression screening in the primary care setting. The negative view of screening was addressed in 1999 by Pfizer Inc. with the publication of the Patient Health Questionnaire (PHQ-9), which was designed to help standardize and improve the screening of depression in primary care. The PHQ-9 study demonstrated that regular screening with the PHQ-9 questions improved outcomes of depression treatment. Based on the findings of PHQ-9 study, the USPSTF changed their views on screening and currently recommends that physicians screen routinely for depression and comorbidities, and that they provide treatment in primary care settings (Culpepper, 2012). Benefits of Using a Screening Tool Since the FNP has limited time to spend with each patient, he or she must utilize screening time efficiently. Screening tools are a quick and objective way for the FNP to measure a patient's depression at the time of the visit as well as monitor his or her progress and the effectiveness of existing treatment. The benefits of screening in depression include helping to control costs, improving patient outcomes by improving medication compliance, addressing non-responders, decreasing comorbidities of depression, and preventing suicide. Screening Helps Control Costs Currently, the majority of patients with depression receive treatment in a primary care setting (Fuchs et al., 2015). In the United States' current healthcare environment, cost-containment, treatment efficiency, and improved outcomes must all be considered DEPRESSION FOLLOW-UP IN PRIMARY CARE 16 when treating depression. The relationship between cost and results is a relevant issue in the United States health care market, where treatment outcomes are often reviewed and graded by third-party payers. In order to determine the impact of treatment for depression, it is necessary to evaluate the outcomes. Doing so requires precise, reliable, valid, informative, and user-friendly measurement to evaluate the quality and efficacy of care in a clinical practice (Zimmerman, 2015). Using self-reported screening tools is a cost-effective way to screen for depression and to inform follow-up care and treatment once a diagnosis has been made. By using a self-reported screening tool at each subsequent visit, the FNP is able to monitor a patient's progress and response to treatment, while allowing for adjustments to be made. Many studies conducted in the mid 2000s found that unmanaged depression can lead to worsening outcomes of medical comorbidities such as heart disease, infections, diabetes, and suicide. This cause of increased health care utilization associated in treating these conditions poses a significant cost to the patient, insurance, and other payers. In addition, it poses increased costs to employers in lost time at work (Culpepper, 2012). According to Berghöfer et al. (2014), patients with depression are more likely to have an increased number of hospitalizations and emergency department visits, as well as more days spent in the hospital. This leads to greater utilization of health resources and costs, compared to patients without a depression diagnosis. According to the CDC (2015), from 2009 to 2010 there were 8 million ambulatory care visits to hospitals, outpatient clinics, and emergency departments, with depression being the primary diagnosis. According to Meunier et al. (2014), decreasing the total cost of care is an important component of overall healthcare reform. Since depression currently serves as the primary diagnosis for DEPRESSION FOLLOW-UP IN PRIMARY CARE 17 8 million ambulatory medical visits annually, improving depression outcomes in patient care would help to decrease overall healthcare utilization and help better control nationwide healthcare costs. This large cost associated with depression could be decreased with improvements in the follow-up care of depression by the FNP. Screening Improves Medication Compliance While the use of antidepressant medication has grown dramatically over the last 15 years in patients being treated for depression in primary care, the overall treatment of depression has failed to improve. In Fuchs et al.'s 2015 study, the majority of providers reported prescribing medication to treat patients with depression 81% of the time. The study also reports that many patients who initiated medication treatment or received medication adjustments for depression were not seen within the next month, as is recommended by the American Psychiatric Association (2010). It is important that FNPs ensure adequate medication compliance by following up with clients at regular intervals. Because the treatment for depression is primarily pharmacotherapy, this rate of medication adherence and follow-up contact are especially low. This lack of contact with the provider during the initial follow-up period after being prescribed a medication has been attributed to decreased rates of medication adherence. Cameron et al. (2014) found that patients who experience a greater number of side effects from their anti-depressant medications are more likely to discontinue antidepressant treatment earlier. Therefore, FNPs should ensure frequent follow-up visits after prescribing treatment in order to monitor for undesirable side effects or non-response to medications. This helps the FNP to identify the potential for suboptimal outcomes and to revise treatment plans for better results. DEPRESSION FOLLOW-UP IN PRIMARY CARE 18 Zimmerman (2015) reports that patients who have increased contact with providers are more active in treatment, have better trust in their providers, and are more likely to continue treatment. Benefits of having increased contact with providers include more opportunities to measure a patient's progress with treatment of depression. Additional benefits from monitoring depression according to Zimmerman include the following: • Identifying non-responders: By using a scale to monitor a patient's progress, the provider can assess if the current treatment is appropriate based on the patient's responses; the provider can then change treatment if the patient is not responding, or if their response is inadequate. • Detecting residual symptoms: Ongoing screening helps the clinician to determine whether treatment has been successful or if further intervention is required. • Increasing treatment compliance: Many patients undergoing treatment for depression drop out of treatment within six months of initiating care. Patients who more actively participate in their treatment were less likely to do so. Increasing communication with patients and using self-reported scales to measure depression helps patients increase their active participation in their care, thus reducing drop-out rates. • Identifying Seasonal Variation: Consistent screening helps the provider detect seasonal variations that may be attributed to seasonal affective disorder. Yeung et al. (2012) established that having more contact with a care provider to assist in the management of depression symptoms is correlated with better compliance DEPRESSION FOLLOW-UP IN PRIMARY CARE 19 and long-term improvement. Patients who received regular updates about their treatment and progress were twice as likely to respond positively to treatment and were more likely to experience remission of symptoms within six months. Additionally, providers who received regular feedback from patients were more likely to adjust therapy to accommodate the patient than those who did not receive feedback regularly. Multiple repeated assessments have been shown to provide more accurate and more useful information for the treatment and management of depression. Screening Decreases Comorbidities Associated with Depression Suicide. Depression is associated with high mortality, much of which is accounted for by suicide (American Psychiatric Association, 2013). Because depression and suicide have a high correlation, primary care practice has the potential to play an important role in identifying and managing patients with suicidal thoughts. According to the CDC (2015), a suicide happens once every 13 minutes in the United States, which equates to an average of 113 suicides per day. In 2013, there were 41,149 suicides, making suicide the tenth leading cause of death for all ages. However, the exact number that were directly correlated with depression is unknown. This cost the United States an estimated 51 billion dollars in combined medical and work loss in 2013. In a study by Roca et al. (2015), it was found that many patients who commit suicide had contact with their primary care provider in the year prior to committing suicide. Suicidal ideation is associated with severe depression, which in turn is associated with poor response to treatment. Suicide risks should always be assessed as a routine component of depression evaluation. However, patients do not always disclose their suicidal thoughts to providers, and evidence suggests that primary care providers infrequently ask about suicidality DEPRESSION FOLLOW-UP IN PRIMARY CARE 20 when evaluating for depression (Bauer, Chan, Huang, Vannoy, & Unützer, 2013). If the FNP is using the PHQ-9 tool, Question 9 specifically asks about suicidal ideation, thus giving the FNP a way to initiate conversation about suicide (Bauer et al., 2013). If suicidal ideations are triaged and managed with earlier follow-up, treatment can be intensified quickly, with the hope of preventing suicide. Therefore, the FNP's role in detection and treatment of depression are important parts in helping to prevent suicide. Medical Comorbidities. Depression-related mortality is not only associated with poor adherence to treatment, but also with poor self-care for patients with comorbid conditions (Gallo et al., 2013). Comorbidities can be, but are not limited to, cardiovascular disease, musculoskeletal degeneration, diabetes, cancer, infectious disease, and other psychiatric conditions (Culpepper, 2012). Meunier et al. (2014) reported that patients with depression show an increased utilization of healthcare with presenting comorbidities. A seven-year follow-up study by Culpepper (2012) found that patients with depression and comorbidities had more emergency department visits, more hospitalization admits, and longer inpatient stays when compared to patients with these same conditions but without depression. Culpepper found that improvement of depression was strongly and independently associated with improved long-term mortality. Additionally, Culpepper noted that depression that is well managed will have positive outcomes for other chronic diseases such as diabetes and cardiac disease. By addressing depression management and follow-up in primary care, the FNP has the opportunity to incorporate a strategy of integrated comorbidity management to improve outcomes instead of a single-disease approach, which has proven to be disappointing. DEPRESSION FOLLOW-UP IN PRIMARY CARE 21 Current Screening Guidelines and Recommendations In 2002, the USPSTF developed recommendations for the screening of depression in primary care. They also added the requirement that the screening be completed in clinical practices that have systems in place to provide accurate diagnosis, treatment, and follow-up care (USPSTF, 2009). The USPSTF recommends that all patients who score positive for depression need to be further evaluated. The FNP can do so objectively and routinely with a standardized scale (Zimmerman, 2015). Despite the USPTSF's recommendation for further evaluation, they currently do not recommend that providers use any particular screening tool to guide follow-up management of depression (Fuchs et al., 2015). Therefore, many FNPs assess the progress of their depressed patients through unstructured interactions that may yield un-quantified judgments. These include broad questions such as How are you feeling? or How are you doing? The patient's replies are usually also broad generalized responses such as, okay or fine (Zimmerman, 2015). Because these responses are not accurate in reflecting the actual status of the patient, the FNP is not always able to make the best decision. There are various screening tools to assist in the detection of depression in primary care that can be utilized for follow-up treatment. These self-administered screening tools can be effective and time efficient. The most common screening tools are simple questionnaires through which the patient is asked to self-report whether they are experiencing any of the symptoms most commonly associated with depression. These are often used because they are simple and straightforward to implement (Berghöfer et al., 2014). The most commonly used screening tools used in practice are: the Clinically DEPRESSION FOLLOW-UP IN PRIMARY CARE 22 Useful Depression Outcome Scale (CUDOS), the Patient Health Questionnaire 2 (PHQ- 2), the PHQ-9, and the Quick Inventory. • CUDOS: Designed to be a brief survey (completed in less than 3 minutes), it is quickly scored, and clinically useful (see Appendix C). It contains 18 items that assess all of the DSM-5 diagnostic criteria for major depression (Zimmerman, 2015). • PHQ-2: Includes two questions from the PHQ-9 (see Appendix A). It is designed to be used as a first-line depression screening measure, followed by the full PHQ- 9 when a patient screens positive (Fuchs et al., 2015). • PHQ-9: Assesses the nine DSM-5 diagnostic criteria for diagnosing major depressive disorder (see Appendix B) (Zimmerman, 20015). It was developed as a depression screening measure for use in primary care (Fuchs et al., 2015). • Quick inventory of depressive symptomatology: A multiple-choice questionnaire that covers the symptoms of the DSM-5 diagnosis for depression (see Appendix D) (American Psychiatric Association, 2013). It takes 5 to 10 minutes to complete. For patients suspected of having depression, screening with the PHQ-2 and the PHQ-9 has proven to be effective (Katzman, Anand, Furtado & Chokka, 2014). These self-report questionnaires are highly utilized because they closely align with the DSM-5 criteria (see Appendix F) for depression and are easily administered to patients in a timely manner (Cameron et al., 2014). The PHQ-2 is a 2-question screening tool screen for depression. If the outcome is positive; providers can then administer the PHQ-9, a DEPRESSION FOLLOW-UP IN PRIMARY CARE 23 more thorough questionnaire. The PHQ-9 is a 9-item standardized questionnaire that corresponds with the nine current DSM-5 criteria for depression. The PHQ-9 has good test-retest reliability, internal consistency, and sensitivity to change over time (see Appendix E). It has been extensively studied as a screening measure in primary care settings and has proven to be a useful tool for diagnosing and managing depression (Zimmerman, 2015). While there are many self-administered measurement tools for screening for depression, the PHQ-9 is one of the most commonly used in screening, diagnosing, and managing depression. Yeung et al. (2012) conducted a study using the PHQ-9 to assess follow-up after a diagnosis of depression has been made in primary care. The participants in the study were of diverse socioeconomic backgrounds and employment with recent diagnoses of depression, and all had started on antidepressants. The study included 3- and 6-month check-ins with the patient using an emailed PHQ-9 form and a follow-up telephone call. Among the patients with a baseline PHQ-9 score greater than or equal to five, there was a 46.7% remission rate (versus 42.8% control) and a 67% response rate (versus 59.7% control). By providing follow-up at regular intervals, patients who received regular check-ins were more likely than those in the control group to achieve the goal of remission (Yeung et al., 2012). In a study done by Fuchs et al. (2015), when the PHQ-9 was delivered routinely as a part of standard care, there were reported benefits that included improved communication with patients and greater involvement in monitoring symptoms from the provider. According to Gelenberg et al. (2010), the PHQ-9 is one of the most feasible self-questionnaires, because it takes only minutes for patients to DEPRESSION FOLLOW-UP IN PRIMARY CARE 24 complete and can be administered by telephone, mail, or in the clinic by any medical personnel. Screening Tools Are Not Currently Being Utilized by Health Care Providers While there are many benefits to using a screening tool, current research shows that they are not currently being utilized routinely in practice. When providers have a positive screen using the PHQ-2, they often fail to follow it up with the PHQ-9 to further assess the severity of the patient's depression. The PHQ-9 has been studied extensively and found to be effective and one of the most commonly used tools, but it is still not highly-utilized in primary care. Fuchs et al. (2015) did a study of 200 family medicine patients and found that only about 5% of patients who screened positive on the PHQ-2 were followed up with a PHQ-9. Of those patients who screened positive, only 16.5% attended a follow-up visit within one month. Fuchs et al. further point out that the patients who screened positive for depression and returned to see their providers for follow-up appointments were often not rescreened using the PHQ-9. Instead of utilizing the PHQ-2 or PHQ-9 screening tool, providers often relied on their clinical judgment to make treatment decisions. There are many other reasons that providers failed to administer the PHQ-9. Some feel that re-screening is inadequate once a patient is diagnosed with depression. It competes for clinicians' time with other concurrent healthcare issues. Other reasons included forgetting to rescreen, and doubting the utility of the screening tool (Fuchs et al., 2015). Not systematically following up with a patient's outcomes, FNPs may risk having sub-optimal outcomes for their patients. DEPRESSION FOLLOW-UP IN PRIMARY CARE 25 Obstacles in the Utilization of Screening Tools Obstacles that inhibit the utilization of screening tools include patient willingness, clinician acceptability, and cost. Patients may find longer self-assessment tools to be burdensome and may prefer using shorter questionnaires. Clinicians also report lengthier questionnaires to be a time burden and are reluctant to administer them. Some assessment tools need to be purchased; however, there are self-report scales such as the PHQ-2 and PHQ-9 that are available at no cost, are easily acquired, and are quickly administered (Zimmerman, 2015). Thota et al. (2012), presented several obstacles to utilizing adequate follow-up treatment tools for depression, including: • Some patients may not follow prescribed treatment recommended by their provider. They may have low appointment attendance, or may not fully understand the importance of treatment compliance. • Limited or absent insurance coverage for mental health services may prevent patients from being able to afford and continue treatment for their depression. • Financial costs of appointments and medications limit patients' ability to receive the most appropriate treatment available. • Lack of time available with the provider due to large volumes of patients seen in clinic may prevent optimal communication and exploration of depression and its accompanying symptoms. • Limited availability of mental health services in a patient's community may inhibit access to treatment and beneficial support systems. DEPRESSION FOLLOW-UP IN PRIMARY CARE 26 Because depression can be a reaction to life events, including physical illness, bereavement, relationship issues, and financial problems, understanding the primary cause of a patient's depression can assist the FNP in dealing with patient compliance (National Institute for Health and Clinical Excellence, 2009a). When planning depression follow-up visits, the FNP must take into consideration the patient's personal life, personality, and social context. These factors have a bearing on the patient's compliance and outcome of treatment (Hardy, 2013). Supporting Evidence Although screening may improve the recognition and diagnosis of depression, it does not guarantee that providers will act to initiate treatment or provide adequate follow-up care. Zimmerman (2015) found that remission of depression is more likely to occur with treatment that includes monthly assessment of symptoms and feedback to the clinicians. Yeung et al. (2012) state that having more contact with the provider is correlated with better medication compliance and long-term improvement. Their study showed that patients who received regular updates about their treatment and progress were twice as likely to respond positively to treatment and were more likely to experience remission of symptoms within six months when compared to those who did not have regular follow-up. Additionally, providers who received regular feedback from patients were more likely to adjust therapy to accommodate the patient than those who did not get feedback regularly. Feedback to providers is important in order to determine if patients are responding adequately to current treatment. In order to determine the effectiveness of treatment, it is DEPRESSION FOLLOW-UP IN PRIMARY CARE 27 necessary to evaluate outcomes. For example, when an FNP is treating hypertension, blood pressure is measured to determine if a current treatment plan is effective or if the approach needs to be altered (Zimmerman, 2015). In caring for patients with depression, follow-up and continual screening can help to assess the effectiveness of treatment, including medication compliance and side-effect tolerability (Yeung et al., 2012). Integration of self-assessment tools to help monitor depression and the effects of treatment is intended to help patients reach remission goals. By measuring outcomes on a consistent basis, FNPs are able to monitor the patient's progress, which may prompt the need for change in treatment if the patient does not improve. Consistent follow-up care to get adequate support for patients is important in maintaining positive long-term outcomes (Kivelitz, Schilz, Melchior, & Watzke, 2015). Methods Search Criteria The methods for our state of the science review included a search of literature ranging from 2010 to 2015 using EBSCO Host, PubMed, CINAHL, Medline, PsycINFO, and the database at Westminster College's Giovale Library. References to landmark studies previous to 2010 were also included. We searched for relevant articles using the following search terms: depression, follow-up depression, depression treatment, stepped care model for depression, monitoring of depression, care management for depression, treatment of depression in primary care, depression screening, depression remission, and depression treatment guidelines. DEPRESSION FOLLOW-UP IN PRIMARY CARE 28 Exclusion Criteria Excluded from this study were unpublished articles, dissertations, position papers, and abstracts, as well as articles focusing on pediatrics or anyone under the age of 18. Additionally, we excluded articles on postpartum depression and the treatment of depression during pregnancy. Inclusion Criteria We included articles appearing in peer-reviewed journals, as well as evidenced-based treatment guidelines in this study. These articles and guidelines contained qualitative and quantitative studies, literature reviews, and randomized controlled trials. We included articles concerning people over the age of 18 diagnosed with depression, depression management in primary care, and articles on current guidelines associated with depression follow-up. We also included screening guidelines and protocols currently in place in family practice and psychiatry, and articles related to the definition and understanding of depression. The articles were available in English and full text. We found 28 articles that met the above criteria. Procedure We reviewed 28 articles that met our inclusion and exclusion criteria. We read each for content and use of prominent research for treatment and follow-up of depression in primary care settings. DEPRESSION FOLLOW-UP IN PRIMARY CARE 29 Theoretical Framework Collaborative Care Framework A beneficial option for treatment is a collaborative care model. More than 40 randomized controlled trials done over the past two decades have provided an evidence base for this approach, commonly called collaborative care for depression. Collaborative care is an intervention model that utilizes case managers to connect patients, primary care providers, and mental health specialists (Thota et al., 2012). The model employs case managers that play a supportive role to primary care providers, managing patient education, depression follow-up, and adherence to treatment (Thota et al., 2012). The Stepped Care Model Unützer & Park (2012) found that effective collaborative care adheres to management that is based on stepped care. Stepped care focuses on identifying depressive symptoms and providing treatment options appropriate for the different needs of people with a particular diagnosis (Haddad & Tylee, 2011). When utilizing stepped care, the treatment can be systematically altered, intensified, or stepped up when a patient is not improving as expected. This method of organizing care involves creating a standardized guideline for treating illnesses based on symptoms and has been used for the management of diverse conditions from diabetes and hypertension to addiction and back pain (Haddad & Tylee, 2011). In treatment based on the stepped care model, patients are educated on the systematic approach and on the treatment tools such as the PHQ-9 that will be used help track symptoms of depression. Patients are encouraged to request DEPRESSION FOLLOW-UP IN PRIMARY CARE 30 changes in the treatment plan if it is not effective or if the side effect burden is too much (Unützer & Park, 2012). Unützer & Park (2012) describe key processes involved in utilizing the stepped care model of collaborative care in the treatment of depression. The first process is the systematic diagnosis and tracking of patient outcomes. Once diagnosed, the care manager coaches the patient on self-care, medication compliance, and expectations. The care manager educates the patient on the systematic approach of scheduled visits and possible plan of care changes if desired outcomes are not met. Self-assessment tools, such as the PHQ-9, are utilized to track symptoms of depression over time. Close follow-up is maintained to ensure patients do not fall through the cracks. Once treatment is initiated, the second process of stepped care begins. Stepped care is managed according to evidence-based algorithms that guide the FNP in changing the treatment strategy if the patient is not improving during subsequent follow-up visits. When a patient continues to have symptoms of depression after the initial treatment, changes can be made if needed. Additional treatments, such as medication increases, medication changes, or augmentation, are examples. Once the patient has responded to treatment and report remission from depressive symptoms, the FNP will collaborate with the patient to create a relapse prevention plan. The relapse prevention plan should include advising the patient on medication continuation as clinically indicated, as well as educating the patient about personal warning signs of depression recurrence. DEPRESSION FOLLOW-UP IN PRIMARY CARE 31 Management Strategies Guidelines for Stepped Care Management of Depression By utilizing the American Psychiatric Association (2010) practice guideline for the treatment of depression, we have created a systematic and simplified algorithm specifically for FNPs to treat patients with depression (Figure A). The guideline helps to direct the FNP through screening, treatment in the acute phase, follow-up, addressing non-response, continuation therapy, maintenance therapy, and discontinuation of treatment (Gelenberg et al., 2010). Screening The first level of assessment is screening. The FNP should review risk factors and patient history of all patients to determine if depression screening is warranted. There are two categories of risk factors-high-risk clinical groups and high-risk symptom presentations-that should alert the FNP to inquire further, as indicated in Table 1 (Cameron et al., 2014; Katzman et al., 2014). Patients currently being treated for depression or with risk factors should be screened at each subsequent visit to monitor for changes. DEPRESSION FOLLOW-UP IN PRIMARY CARE 32 Table 1 For those patients with any of the above risk factors for depression, the FNP should administer the PHQ-2. It consists of asking two questions: 1. In the last month, have you been bothered by little interest or pleasure in doing things? 2. In the last month, have you been bothered by feeling down, depressed, or hopeless? The patient should be instructed to answer these questions based on symptoms experienced over the past two weeks on a rating scale of 0-3 (0 meaning not at all, 1 meaning several days, 2 meaning more than half the days, 3 meaning nearly every day) DEPRESSION FOLLOW-UP IN PRIMARY CARE 33 (Zimmerman, 2015). A combined score of 3 or above on these two questions should prompt the FNP to administer the full PHQ-9 questionnaire (Table 2) (Gelenberg et al., 2010). While screening is a process in the treatment of patients with depression, it is also an important part of a larger guideline that leads to further evaluation and treatment (Fuchs et al., 2015). Table 2 DEPRESSION FOLLOW-UP IN PRIMARY CARE 34 Different treatment approaches should be used according to the severity of depression. The level of severity should be categorized using the PHQ-9 score (Table 3), which can range from 0 to 27. A total score of 4 or less indicates none to minimal symptoms and does not warrant treatment. A score of 5 to 9 is suggestive of mild depression and cues the FNP to watch the patient closely and repeat the PHQ-9 at follow-up visits. A score of 10 to 14 is indicative of moderate depression, which should be addressed with a treatment plan including a consideration of counseling or pharmacotherapy as well as follow-up contact in two weeks. A score of 15 to 19 indicates moderately severe depression and warrants active treatment with pharmacotherapy and/or counseling. If a patient scores above 20, immediate initiation of pharmacotherapy is recommended and possible referral to a mental health specialist (PHQ Screeners, n.d.; Zimmerman, 2015). Table 3 DEPRESSION FOLLOW-UP IN PRIMARY CARE 35 Acute phase Once diagnosed with depression, the patient enters the acute phase of treatment. According to the American Psychiatric Association, the treatment of depression in the acute phase should include three steps. The first step is choosing the initial modality of treatment (pharmacology, psychotherapy, or a combination of both); the second step is assessing the treatment response; and the third step is addressing nonresponse to treatment (Cameron, Habert, Anand, & Furtado, 2014). There are both advantages and disadvantages to each single-modality treatment. While psychotherapy may be a safer option, the efficacy will depend on the individual patient's learning curve. Pharmacotherapy may offer a quicker fix of symptoms, but it comes with side effects and a higher incidence of relapse. Combination therapy can be very effective when a single-modality treatment fails, especially in severe, recurrent, and chronic depression (Katzman et al., 2014). SSRIs and serotonin-norepinephrine reuptake inhibitors (SNRIs) are generally the first-line pharmacotherapy treatment, because they offer superior safety and tolerability (Cameron et al., 2014). The goal in treating depression is to decrease the patient's report of signs and symptoms of depression, restore occupational functioning, and restore psychosocial functioning. The long-term goal of treatment is to help reduce the likelihood of relapse and recurrence. Up to two-thirds of patients will not achieve remission with the first antidepressant dose. If a patient shows more than minimal improvement (greater than 20% on a rating scale) after four to six weeks, they should be continued at the same dose for an additional 2 to 4 weeks before considering a change in treatment. If after 4 to 8 weeks a patient shows minimal or no response (<20% reduction on a rating scale), the DEPRESSION FOLLOW-UP IN PRIMARY CARE 36 FNP should consider increasing the dose or adding an adjunct medication (Cameron et al., 2014). Follow-up Once an initial treatment plan has been implemented, the next step should be to follow up on a regular basis. It is important for FNPs to follow up with patients every 1 to 2 weeks when initially prescribing pharmacotherapy. During the first 2 weeks, patients have the greatest risk for adverse outcomes. Once the initial response to treatment has been evaluated, the visits can be decreased to every 2 to 4 weeks or longer if they respond well to treatment (Cameron et al., 2014). At follow-up appointments the PHQ-9 screening tool should be administered again to evaluate the patient's response to treatment (Table 4). Adherence should be increased by educating patients on expected lag time until full effect (e.g. 3 to 4 weeks), the expected length of treatment, common side effects, and the necessity of continuing the medications even when they are feeling better (Cameron et al., 2014). Table 4 DEPRESSION FOLLOW-UP IN PRIMARY CARE 37 Addressing Minimal or Non-Response at Follow-up At least moderate improvement of symptoms should be seen at 4 to 8 weeks of treatment initiation. If minimal or no response is seen, the diagnosis should be re-evaluated and the treatment plan adjusted (Gelenberg et al., 2010). While remission is a major goal in recovery from depression, up to two-thirds of patients do not achieve remission with the first antidepressant treatment (Cameron et al., 2014). If an antidepressant is being utilized, optimizing the dosage is a reasonable first step as long as the side-effects are tolerable and the upper dose limit has not been reached (Gelenberg et al., 2010). If a patient is being treated with psychotherapy alone, the FNP should consider increasing the intensity or type of therapy, or assess the need to augment with a medication (Gelenberg et al., 2010). Addressing Minimal or Non-Response after Altering Initial Treatment If minimal or no response is seen within 4 to 8 weeks after altering the initial modality or dose, it may be necessary to change to a different medication. Although choice of pharmacotherapy is beyond the scope of this paper, the FNP may change medication to a different medication in the same class (e.g. SSRI to SSRI) or to a different class of medication (e.g. SSRI to SNRI). Another option is augmenting the current medication with an additional antidepressant or non-antidepressant such as a second-generation antipsychotic or mood stabilizer (Gelenberg et al., 2010). The FNP will need to review current recommendations to guide prescribing. DEPRESSION FOLLOW-UP IN PRIMARY CARE 38 Continuation phase A patient can be considered to have achieved remission if he or she has had 3 weeks with the absence of sadness and reduced interest in activities, as well as no more than three remaining symptoms of depression, as defined in the DSM-5 (American Psychiatric Association, 2013). Once a patient has achieved remission of symptoms of depression, he or she can be considered to be in remission and enter the continuation phase. This phase is focused on continued treatment to reduce the risk of relapse. During the continuation phase, the FNP should continue to evaluate symptoms, side-effects, adherence, and functional status. Most important, the patient should be monitored for signs of possible relapse (Gelenberg et al., 2010). Because relapse is most common in the first six months following recovery (Cameron et al., 2014), continuation of treatment in the same dose, intensity, and frequency of medication or psychotherapy as in the acute phase is recommended (Cameron et al., 2014). It is recommended that the treatment continue at the same dose and/or frequency for at least four to nine months. In the continuation phase, depression-focused psychotherapy is also highly recommended to prevent relapse (Gelenberg et al., 2010). If a relapse occurs, the initial treatment used in the acute phase should be restarted, and a thorough search for other potential stressors such as substance abuse, general medical conditions, or psychosocial stressors should be conducted (Cameron et al., 2014). Maintenance phase After 4 to 9 months of continuation therapy, it is important to determine if the patient should continue maintenance treatment. Patients with a history of three or more DEPRESSION FOLLOW-UP IN PRIMARY CARE 39 depressive episodes should proceed to the maintenance phase once remission is achieved. Other patients who should be considered for maintenance therapy include patients with risk factors such as family history of mood disorders, patients still experiencing residual symptoms, and patients with ongoing psychosocial stressors. These patients are at higher risk for relapse. Patients with chronic or recurring medical or psychological comorbidities may require indefinite treatment (Gelenberg et al., 2010). Discontinuation Phase When considering discontinuation of pharmacotherapy or psychotherapy, the FNP should educate patients on the risk of depressive symptom relapse and work with the patient to establish a plan for seeking treatment if this occurs (Gelenberg et al., 2010). Patients should be advised to not stop medication abruptly and to taper dosage over several weeks to minimize the risk of symptom recurrence (Gelenberg et al., 2010). Patients should be monitored over several months following discontinuation and should return to the acute phase treatment if symptoms do recur (Gelenberg et al., 2010). DEPRESSION FOLLOW-UP IN PRIMARY CARE 40 Figure A Adapted from the American Psychiatric Association, 2010 Initial Visit/Screening Mild Mild to Moderate Administer PHQ-2 If PHQ-2 Score is greater than 3 then administer PHQ-9 PHQ-9 = 5-9 Watchful Waiting Follow-up PHQ-9 at next visit PHQ-9 = 10-14 Create treatment plan Pharmacotherapy (SSRI, SNRI) OR Psychotherapy Moderate to Severe PHQ-9 = 14-27 Pharmacotherapy AND Psychotherapy Possible Referral Assess side-effects Monitor for suicidality Continue education on expected lag time for full effect Initial Follow-up 2-4 weeks 4-8 week follow-up Minimal or No Response Moderate Response Administer PHQ-9 (<20% reduction in PHQ-9 score on rating scale) Adjust dose up Change treatment plan Augment with Psychotherapy (>20% reduction in PHQ-9 score on rating scale) Continue current treament Consider augmenting with second medication based on current PHQ-9 Acute Phase 4-8 week follow-up Minimal or No Response Moderate Response Depression Guideline for Family Nurse Practitioners Continuation Phase Maintenance Phase Discontinuation Phase Screening Administer PHQ-9 (<20% reduction in PHQ-9 score on rating scale) Change to new med in same or different class Change treatment plan Augment with Psychotherapy (>20% reduction in PHQ-9 score on rating scale) Continue current treatment Consider augmenting with second medication based on current PHQ-9 If remission of symptoms of depression on current treatment Monitor every 3 to 6 months depending on response Monitor for side-effects Continue at same dose as found effective in the acute phase for at least 4-9 months Continuation Maintenance Discontinuation Continue treatment indefinitely if history of 3 or more depressive episodes Continue treatment if family history of mood disorders, presence of residual symptoms and ongoing psychosocial stressors Taper over several weeks and monitor for recurrence of symptoms Counsel on risk of relapse Plan for seeking treatment if relapse occurs 4-8 week follow-up Administer PHQ-9 Referral to mental health specialist if continued minimal response DEPRESSION FOLLOW-UP IN PRIMARY CARE 41 Recommendations and Summary Discussion Our goal was to create a simplified patient self- assessment tool and FNP guideline for the screening, treatment, and follow-up after an initial diagnosis of depression that could be used in the primary care setting. Managing depression is challenging compared with other chronic diseases, because depression severity is rated by the patient and not by physical assessment, lab results, or other types of objective evidence. The FNP must consider patient perception, which is completely subjective, and try to quantify it using an objective tool to measure depression severity. Using self-report questionnaires such as the PHQ-2 and the PHQ-9 helps the FNP to accurately evaluate the patient's current status (Zimmerman, 2015). These questionnaires are a cost-effective option, because they require little professional time. Then, based on results, treatment may consist of any combination of antidepressant medication, follow-up appointments, and supportive counseling (Hansson, Chatai, & Bodlund, 2012). Evidence-based literature has proven that patients who receive follow-up care after an initial diagnosis of depression have early remission (e.g. during the first 6 months) and have less chance of relapse (Fuchs et al., 2015). The 2015 USPSTF's recommendations found that collaborative care interventions improved remission and recovery, response to treatments, and adherence to prescribed treatment (U.S. Preventive Services Task Force, 2015). The common theme of the literature reviewed for this discussion was the need for ongoing contact between patient and provider. In one study, the most frequently mentioned factors for remission of depression in a sample of 117 patients were: ongoing contact between patient and DEPRESSION FOLLOW-UP IN PRIMARY CARE 42 provider (53.0%), antidepressants (40.2%), and personal development (27.2%) either through a counselor or spontaneous self-improvement (Hansson et al., 2012). If there is no ongoing contact, the effectiveness of medication or other treatments is more challenging to evaluate (Zimmerman, 2015). The need for ongoing contact between the FNP and the patient is an area of further research that needs to be explored. The FNP could manage depression via phone call, email, text, or apps. This type of alternative communication, as opposed to an office visit, may bring more compliance and therefore better outcomes and higher incidence of remission. Because cost and time are barriers for patients, these alternative methods of communication between FNP and patient may allow for better management and better outcomes. Limitations Our research had several limitations. We focused on adults ages 18 to 65, and we did not include children under the age of 17, elderly persons older than 65 years of age, or patients with postpartum depression diagnoses. Our research discusses generalized comorbidities associated with depression, but it does not go in depth on all that may be correlated. This paper does not focus on specific treatments for depression. It is left up to the providers to determine what treatment is best. This paper focuses on the importance of FNPs following a guideline for continual follow-up of depression after the initial diagnosis is made. DEPRESSION FOLLOW-UP IN PRIMARY CARE 43 Conclusion It has been well established that depression has become a national epidemic that remains undertreated. The FNP working in primary care is responsible for the monitoring and progress of follow-up for depression treatment. With no universal guidelines, the FNP may rely on clinical judgments and prior knowledge about the patient's depression status to guide his or her decision-making regarding monitoring and working towards remission. This lack of consistency has led to undertreated depression, which can have great negative consequences. Consistent follow-up will improve patient outcomes by detecting patients who are not responding adequately to prescribed treatment. Improving the frequency and quality of follow-up visits is an important and achievable step. This can be accomplished by consistently using measurement tools and communication. Administering multiple repeated patient self-assessments has been shown to provide more accurate and useful information for the management of depression. Working towards symptom reduction and early remission, patients have a better chance of avoiding relapse and achieving remission. By consistently using a guideline as part of daily practice, the FNP can ensure quality follow-up and monitoring of depression. 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Retrieved from http://www.uspreventiveservicestaskforce.org/Page/Document/draft-recommendation- statement115/depression-in-adults-screening1 Yeung, A.S., Jing, Y., Brenneman, S.K., Chang, T.E., Baer, L., Hebden, T., Kalsekar, I., McQuade, R.D., Kurlander, J., Siebenaler, J., Fava, M. (2012). Clinical Outcomes and MEasurement-based Treatment (COMET): A trial of depression monitoring and feedback to primary care physicians. Depression and Anxiety (29): 865-873. Zimmerman, M., Roy-Byrne, P., Solomon, D., (2015) Using scales to monitor symptoms and treat depression (measurement based care). Retrieved from http://www.uptodate.com.ezproxy.lib.utah.edu/contents/using-scales-to-monitor-symptoms- and-treat-depression-measurement-based-care? source=search_result&search=using+scales+to+monitor+syptoms+and+trea DEPRESSION FOLLOW-UP IN PRIMARY CARE 49 t+depression&selectedTitle=2~150 DEPRESSION FOLLOW-UP IN PRIMARY CARE 50 Appendix A DEPRESSION FOLLOW-UP IN PRIMARY CARE 51 Appendix B PHQ-9 Depression Questionnaire DEPRESSION FOLLOW-UP IN PRIMARY CARE 52 Appendix C CUDOS DEPRESSION FOLLOW-UP IN PRIMARY CARE 53 Appendix D Quick Inventory of Depressive Symptomatology DEPRESSION FOLLOW-UP IN PRIMARY CARE 54 DEPRESSION FOLLOW-UP IN PRIMARY CARE 55 Appendix E PHQ-2, PHQ-9 Comparisons DEPRESSION FOLLOW-UP IN PRIMARY CARE 56 Appendix F Current Diagnostic Criteria for Major Depressive Disorder According to the DSM-5 Major depressive disorder is characterized by episodes of depression lasting at least two weeks (although most episodes last considerably longer) involving clear cut changes in affect, cognition, and neurovegetative functions and inter-episode remissions. The diagnosing criteria are as follows: Diagnostic Criteria A 5 or more of the following symptoms must be present during the same 2-week period and represent changes from previous functioning. At least one of the symptoms is either: (1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms that are clearly attributable to another medical condition. 1. Depressed mood most of the day, nearly every day, as indicated by either subjective report or observation made by others. 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observations). 3. 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 day. 4. Insomnia or hypersomnia nearly every day. 5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down). 6. Fatigue or loss of energy nearly every day. 7. Feelings of worthlessness or excessive or inappropriate guilt (which DEPRESSION FOLLOW-UP IN PRIMARY CARE 57 may be delusional) nearly every day (not merely self-reproach or guilt about being sick). 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others). 9. Recurrent thoughts of death (not 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 episode is not attributable to the physiological effects of a substance or to another medical condition. A-C represents a major depressive episode. D. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders. E. There has never been a manic episode or a hypomanic episode.