BRIEF REVIEW OF THE VHA/DoD CLINICAL PRACTICE GUIDELINE FOR THE .

Review of the VHA/DoD Clinical PracticeGuideline for the Management of MAJORDEPRESSIVE DISORDER IN ADULTSCharles C. Engel, Jr., MD, MPHAssociate Professor of PsychiatryUniformed Services University of the Health Sciences, Bethesda, MarylandDirector, Deployment Health Clinical Center, Walter Reed Medical Center,Washington, DC

Overview Why a guideline for depression? Main guideline elements Guideline tools Guideline piloting Questions

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Major Depressive DisorderAn Important Public Health Problem Common Detectable Reduces functioning & quality of life Associated with behavioral health risk(e.g., substance use disorders, STDs) Treatable Under-recognized & under-treated

Depression as a Coexisting Condition50%32.5%25%32% ost MI* Massie & Holland, 1995; Lustman et al, 1998;Dobie & Walker, 1992; Morris et al, 1990

ICD-9 Diagnoses – DoD CCEP Report10,020 with Gulf War InfectiousAny Dx45%41%37%22%20%19%18%18%11%9%Primary Dx17%17%19%6%6%11%7%6%2%3%

Work Days Lost – DoD Days of Lost Work % ofTotalMean All 015.2%8718.12.8%8660.72.8%43,7712.4100.0%

Depression & Physical SymptomsNumber of Number of Psychiatric DisorderSymptomsPatientsAnxietyMoodPhysical (N 1000)0-12-34-56-89 215225191230130Somatoform (N 900)01-23-56 6541438749N (%)Any2 ( 1)17 ( 7)25 (13)68 (30)68 (48)5 ( 2)27 (12)44 (23)100 (44)84 (80)16 ( 7)50 (22)67 (35)140 (61)113 (81)68 (10)42 (29)35 (40)40 (55)107 (16)60 (42)40 (46)34 (68)102 (25)74 (52)77 (89)45 (94)Kroenke et al. Arch Fam Med 1994; 3:774

MDD GuidelinePurpose To increase primary care awareness,diagnosis and treatment of MDD Part of the Army Surgeon General’s goalto provide consistent and high qualityhealth care

Guideline Development Representatives of VHA, Army, Navy, Air Force,and academia Primary care, psychiatrists, psychologists,social workers, administrators, and a chaplain Review evidence & develop guideline document Develop guideline implementation tools Pilot the guideline Adopt the guideline Intensify implementation efforts Reinitiate the process

Depression GuidelineStructureThree Clinical Modules Primary Care Outpatient Mental Health Care Inpatient Mental Health Care

Main Guideline Points Screening Emergencies/Red Flags Depression Assessment Alternative Causes – Medical & Psychiatric Triage Review & Initiate Therapy Follow-up/Reassessment

Primary CareInitial ScreeningEvery patient screened once annually – prior to seeing provider, unless diagnosispreviously recorded two question screen (from Prime-MD)Do you have little interest or pleasurein doing things?Do you feel down, depressed orhopeless?

Tools for GuidelineImplementation

Tools:Primary Care Provider Info Algorithms Depression Red Flags (urgent risk factors) Cage-Aid (comorbid alcohol assessment) SIG-E-CAPS (depression symptom assessment) Suicide & violence assessment Diagnostic criteria (MDD & Dysthymia) Patient education guidance Admission & referral criteria Antidepressant table

PrimaryPrimary CareCare ModuleModuleBoxes1.2 - 4.5.6.StrategyScreeningEmergenciesGeneral assessmentDepression symptoms?

PrimaryPrimary CareCare ModuleModuleBoxesStrategy12.13.14, 17.DangerPsychosisAlternative causes-substances, physical illness, meds21 – 24.Psychiatric causesmania, MDD, comorbidities–

PrimaryPrimary CareCare ModuleModuleBoxesStrategy21 – 24.Psychiatric causes–mania, MDD, comorbidities25-29.30.Review options, triageInitiate pharmacotherapy

PrimaryPrimary CareCare ModuleModuleBoxesStrategy36.37-40.41-44.Follow -up Q 1-2 weeksReassess at 4 -6 weeksAdjust, 12 week reassess

Tools:Primary Care Provider Info Algorithms Depression Red Flags (urgent risk factors) Cage-Aid (comorbid alcohol assessment) SIG-E-CAPS (depression symptom assessment) Suicide & violence assessment Diagnostic criteria (MDD & Dysthymia) Patient education guidance Admission & referral criteria Antidepressant table

Red Flags Does patient need emergency treatment?Suicidal or violent thoughtsInability to care for selfPsychosis or maniaUnstable medical illnessDelirium Is active chemical abuse or dependencypresent? Is there a history of noncompliance or abuse ofmedications? Is there a strong suggestion of a personalitydisorder?

Tools:Depression Care Forms Patient Self-Assessment (Prime-MD PHQ) Primary Care Provider Assessment Primary Care Referral Mental Health Feedback

Form 717-RPage 1 of 2DepressionSelf-Assessment1. Meds & OTC2. Alcohol3. Prime-MD PHQ

Form 717-RPage 2 of 2DepressionClinicianAssessment1. Medical Hx2. Structured MS & E3. Diagnosis4. Red Flag Risk Factors5. InterdisciplinaryTreatment Plan6. Patient & FamilyEducation/Instructions

FormForm 723723 -R-RPagePage 11 ofof 22Primary Care Referralto Mental Health1. Referral Reason2. Med Problems3. Depressionassessment4. Structured MSE5. Current therapies

FormForm 723723 -R-RPagePage 22 ofof 22Mental HealthProvider Response1. Diagnostic impression2. Recommended meds3. Recommendedtherapies4. Patient education5. Primary carerecommendations

Tools:Patient Education Materials Clinic posters Depression videotapes Self-management brochure Patient & family information brochure

Patient Posters

Patient Posters

Patient Posters

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Patient & FamilyEducation BrochurehsinapSinelbaliaAv

Patient Self-Management Folder

Tools:Primary Care Provider Info Algorithms Depression Red Flags (urgent risk factors) Cage-Aid (comorbid alcohol assessment) SIG-E-CAPS (depression symptom assessment) Suicide & violence assessment Diagnostic criteria (MDD & Dysthymia) Patient education guidance Admission & referral criteria Antidepressant Medication Table

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VHA/DoD Key Points CardsPrimary Care, Specialty & Inpatient

Pilot SitesDepression Guideline Ireland Army Community HospitalFort Knox Walter Reed Army Medical Center DeWitt Army Community HospitalFort Belvoir Tripler Army Medical Center Madigan Army Medical Center (informal)

Piloting Process Local administrative and clinical“champions” Local implementation plan Coordination calls Site assessments at approximately 3 and6 months Tools are improved based on experience Lessons learned are collated for generaldissemination

Lessons LearnedDepression Piloting Champion ‘transitions’ and institutionalknowledge Assessment form only necessary if patientsscreen positive Forms under-utilized – automation will help Referral form viewed as unnecessary Need to bundle ‘like’ guidelines forimplementation planning Behavioral health satellite broadcast inSep 02

Concluding Review Why a guideline for depression? Main guideline elements Guideline tools Guideline piloting

Performance Measures DetectionPercent of patients seen in a generalmedicine, or primary care clinic whowere screened for depression during theprevious twelve (12) months. AssessmentPercent of patients diagnosed with adepressive disorder during the previous12 months.

Performance Measures TreatmentPercent of patients newly diagnosed withand treated for major depressive disorderpast twelve (12) months who continueon prescribed medication for at least 90days in the next 120 days or at had leasteight (8) psychotherapy sessions in thenext 180 days.

Performance Measures EffectivenessPercent of patients who were seenduring the past 12 months with adiagnosis of major depression who havea systematic symptom assessment at 12weeks following diagnosis or if inremission by week 12, a systematicsymptom assessment at the time of thedocumented remission.

For More Information:VHA and MEDCOM Website URLs: MEDCOM Depression Guidelines Main Page:www.qmo.amedd.army.mil/depress/depress.htm Toolkit and Supply Ordering Information:www.qmo.amedd.army.mil VHA Guidelines Home Page:www.oqp.med.va.gov/cpg/cpg.htm

Review of the VHA/DoD Clinical Practice Guideline for the Management of MAJOR DEPRESSIVE DISORDER IN ADULTS Charles C. Engel, Jr., MD, MPH Associate Professor of Psychiatry Uniformed Services University of the Health Sciences, Bethesda, Maryland Director, Deployment Health Clinical Center, Walter Reed Medical Center, Washington, DC