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Diagnosing and Treating Depression – Adult/Pediatric – Ambulatory

Diagnosing and Treating Depression – Adult/Pediatric – Ambulatory - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Psychiatry


1
Diagnosing and Treating Depression
– Adult/Pediatric – Ambulatory
Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
Table of Contents
EXECUTIVE SUMMARY ........................................................................................................... 3
SCOPE ...................................................................................................................................... 5
METHODOLOGY ...................................................................................................................... 6
INTRODUCTION ....................................................................................................................... 6
RECOMMENDATIONS .............................................................................................................. 7
Screening and Assessment .................................................................................................... 7
Patient Presentation and Risk Factors ..................................................................................12
Establish a Diagnosis ............................................................................................................13
Involve Behavioral Health ......................................................................................................20
Provide Treatment .................................................................................................................20
Perform Follow-up Care ........................................................................................................28
UW HEALTH IMPLEMENTATION ............................................................................................32
REFERENCES .........................................................................................................................32
APPENDIX A. RATING SCHEMES FOR THE STRENGTH OF THE
EVIDENCE/RECOMMENDATIONS ..........................................................................................36
APPENDIX B. DEPRESSION SCREENING ALGORITHM.......................................................38
APPENDIX C. DEPRESSION TREATMENT IN ADOLESCENTS ALGORITHM ......................39
APPENDIX D. DEPRESSION TREATMENT IN ADULTS ALGORITHM ..................................40
APPENDIX E. DEPRESSION TREATMENT DURING PREGNANCY ALGORITHM ................41
APPENDIX F. CONSIDERATION OF CONCURRENT CONDITIONS ......................................42
APPENDIX G. DEPRESSION SIDE EFFECT PROFILES ........................................................43
APPENDIX H. PRODUCT AND DOSAGE CHART ..................................................................44
APPENDIX I. DEPRESSION HEDIS MEASURE ......................................................................45
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2
CPG Contact for Content:
Name: Jennifer Lochner, MD – Family Medicine
Phone Number: (608) 424-3384
Email Address: jennifer.lochner@fammed.wisc.edu
CPG Contact for Changes:
Name: Lindsey Spencer, MS- Center for Clinical Knowledge Management (CCKM)
Phone Number: (608) 890-6403
Email Address: lspencer2@uwhealth.org
Coordinating Team Members:
Heather Huang, MD – Internal Medicine/Psychiatry
Lisa Grant, MD – Internal Medicine
Julie Fagan, MD – Internal Medicine
Richard L. Brown, MD, MPH – Family Medicine
Jaime Marks, MD – Family Medicine
Nancy Pandhi, MD- Family Medicine
Erin Peck, MD – Family Medicine
Henny Regnier, NP – Family Medicine
Michael Peterson, MD, PhD - Psychiatry
Jake Behrens, MD - Psychiatry
Roseanne Clark, MD – Psychiatry
Charlotte Ladd, MD – Psychiatry
Shanda Wells, PsyD - Psychiatry
Stephanie Steinman, PhD, LPC – Psychiatry
Jason Horowitz, PhD – Psychology (Pediatric)
Lynnda Zibell-Milsap, CNS – Nursing Practice Innovation
Prasanna Raman, MD – Pediatrics
Robin Wright, MD – Pediatrics
Carey Gleason, PhD – Geriatrics
Ann Baggot, NP – OB/GYN
Sarah Shull, PharmD – Drug Policy Program
Lauren Fiedler- Administration Operation
Travis Dollak- Quality, Safety and Innovation (QSI)
William Caplan, MD- Quality, Safety and Innovation (QSI)
Ryley O’Brien – Center for Clinical Knowledge Management (CCKM)
Kim Hein-Beardsley – Unity Health Insurance
Nikki Nellen – Physicians Plus Insurance Corporation
Lindsey Duca, PsyD – Meriter-Unity Point
Heidi Vierstra – Meriter-Unity Point
Review Individuals/Bodies:
Jennifer Perfetti - Psychiatry
Kirsten Rindfleisch, MD – Family Medicine
Alexander Young, MD- Family Medicine
Peggy Scallon, MD- Psychiatry- General
Committee Approvals/Dates:
Clinical Knowledge Management (CKM) Council (04/23/2015)
ξ Interim revisions (12/17/2015)
Release Date: April 2015 | Next Review Date: April 2017
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2015CCKM@uwhealth.org

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Executive Summary
Key Revisions (Interim Update 12/2015)
1. Modified recommendations for adolescent medications (page 24)
Key Practice Recommendations
1. Suspect and screen for major depressive disorder
2. Diagnose depression and rule out other disorders
3. Involve Behavioral Health when indicated
4. Develop and implement a treatment plan
5. Evaluate and monitor effectiveness of treatment plan
Companion Documents
1. Screening Algorithm
2. Treatment Algorithm- Adolescents
3. Treatment Algorithm- Adults
4. Treatment Algorithm- Pregnant Women
5. Table of Considerations of Concurrent Conditions
6. Table of Depression Medication Side Effect Profiles
7. Depression Medication Products and Dosage Chart
Related UW Health Clinical Practice Guidelines:
1. Preventive Health Care – Pediatric/Adult – Ambulatory Guideline
2. Attention Deficit and Hyperactivity Disorder (ADHD) – Adult – Ambulatory Guideline
3. Attention Deficit and Hyperactivity Disorder (ADHD) – Pediatric – Ambulatory
Guideline
4. Diabetes – Adult/Pediatric – Inpatient/Ambulatory Guideline
5. Alcohol – Adult/Pediatric – Ambulatory Guideline
6. Tobacco Cessation – Adult/Pediatric – Inpatient/Ambulatory Guideline
7. Eating Disorders – Adult/Pediatric – Ambulatory Guideline
Related Patient Assessment Tools:
1. Patient Health Questionnaire-2 (PHQ-2)
2. Patient Health Questionnaire-9 (PHQ-9)
3. PHQ-9 Modified for Adolescents (PHQ-A)
4. Edinburgh Postnatal Depression Scale (EPDS)
External Resources:
1. State of Wisconsin Maternal & Child Health (MCH): provides information, resources,
and referrals for women, family members and professionals. Maintains an online
directory of mental health providers for perinatal mood disorders.
2. Postpartum Support International
3. Massachusetts General Hospital Center for Women’s Mental Health: provides a
range of current information including discussion of new research findings in
women’s mental health and how such investigations inform daily clinical practice.
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Pertinent UW Health Policies & Procedures
1. UWMF Policy 114.009 – Person at Risk for Suicide
2. UWHC Policy 8.14 – Suicide Assessment and Intervention in Clinic
3. UWHC Policy 10.10 – Suicide Assessment and Prevention
4. UWHC Policy 10.14 – Emergency Detention – State Mental Health Act
5. UWHC Policy 10.17 – Involuntary Commitment – State Mental Health Act
Patient Resources (by population)
General
1. HFFY #4525: Depression- A Guide to Recognition and Treatment
2. HFFY #5299: Mental Health in Times of Crisis
3. HFFY #4472: Common Questions about ECT
4. Healthwise: Depression: Chronic Disease
5. Healthwise: Depression: Stopping Antidepressant: Deciding About
6. Healthwise: Mood Disorders: General Info
7. Healthwise: Suicidal Thoughts: Family Member
8. Health Information: Depressed Feeling
9. Health Information: Depression
10. Health Information: Depression (PDQ): Supportive Care- Health Professional Information
11. Health Information: Depression (PDQ): Supportive Care- Patient Information
12. Health Information: Depression and Suicide
13. Health Information: Depression and the Holidays
14. Health Information: Depression Evaluation Calculator
15. Health Information: Depression Screening
16. Health Information: Electroconvulsive Therapy for Depression
17. Health Information: Depression: Dealing With Medicine Side Effects
18. Health Information: Depression: Helping Someone Get Treatment
19. Health Information: Depression: Should I Stop Taking My Antidepressant?
20. Health Information: Depression: Should I Take an Antidepressant?
21. Health Information: Depression: Stop Negative Thoughts
22. Health Information: Depression: Supporting Someone Who Is Depressed
23. Health Information: Depression: Taking Antidepressants Safely
Pediatrics
1. HFFY #6327: How to Recognize and Treat Childhood Depression
2. Healthwise: Depression: Pediatric
3. Healthwise: Depression: Relapse Prevention: Teen
4. Healthwise: Depression: Self Care: Teen
5. Healthwise: Depression: Treatment: Teen
6. Healthwise: Depression: Treatment: Your Teen
7. Healthwise: Suicidal Thoughts: Your Teen
8. Health Information: Depression in Children and Teens
9. Health Information: Should My Child Take Medicine to Treat Depression?
Pregnant Adults
1. HFFY #5112: Postpartum (After Birth) Depression
2. Healthwise: Depression: Postpartum
3. Healthwise: Pregnancy: Depression: General Info
4. Health Information: Depression After Pregnancy
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5. Health Information: Depression During Pregnancy
6. Health Information: Managing Postpartum Depression
7. Health Information: Depression: Should I Take an Antidepressant While I’m Pregnant?
Adults
1. HFFY #5267: Emotional Changes and Dementia
2. Healthwise: Depression: Relapse Prevention
3. Healthwise: Depression: Self Care
4. Healthwise: Depression: Treatment
5. Health Information: Depression in Older Adults
Scope
Disease/Condition(s): Major Depressive Disorder
Clinical Specialty: Internal Medicine, Family Medicine, Pediatrics, OB/GYN,
Pharmacy, Psychiatry, Health Psychology
Intended Users: Primary Care Physicians, Physicians Assistants (PA), Registered
Nurses, Licensed Practice Nurses (LPN), Psychiatrists, Health Psychologists, Licensed
Practice Counselors (LPC), Pharmacists
CPG objective(s): To provide a framework for the diagnosis and treatment of
depression in pediatric and adult primary care patients.
Target Population:
Pediatric (12-17 years) and adult (18 years+) primary care patients.
Interventions and Practices Considered:
1. Screening and assessment using validated assessment tools
2. Pharmacotherapy
3. Psychotherapy
4. Electroconvulsive therapy (ECT)
5. Light Therapy
6. Collaborative Care
Major Outcomes Considered:
1. Remission of depression
2. Reduction in depressive symptoms
Guideline Metrics:
ACO
1. GPRO PREV-12 (NQF 0418): Preventive Care and Screening: Screening for Clinical
Depression and Follow-up Plan
2. GPRO MH-1 (NQF 0710): Depression Remission at Twelve Months
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CPG-Derived
1. Percentage of patients who screen positive on the PHQ-2 and receive follow-up
assessment (using the PHQ-9 or PHQ-A)
2. Percentage of pregnant patients screened for depression at the first prenatal visit
and during the third trimester.
3. Percentage of postpartum patients screened for depression in the first year after
childbirth.
4. Percentage of patients who screen positive on the PHQ-9 or PHQ-A and receive
treatment (pharmacotherapy, psychotherapy, etc.).
5. Percentage of patients 12-18 years old with major depression and an initial PHQ-9
score ≥10 points who demonstrate remission at 12 months (defined as PHQ-9 score
≤ 4 points).
6. Rates of alcohol and drug use screening in patients who are depressed.
Methodology
Methods Used to Collect/Select the Evidence:
Electronic database searches were conducted by CCKM and workgroup members to
collect evidence for review. Expert opinion and clinical experience was also considered
during discussions of evidence.
Methods Used to Assess the Quality and Strength of the Evidence:
Recommendations developed by external organizations maintained the evidence grade
assigned within the original guideline document and were adopted for use at UW
Health. Recommendations developed internally during the workgroup meetings were
evaluated using the Grading of Recommendations Assessment, Development and
Evaluation (GRADE) algorithm (See Figure 1 within Appendix A).
Methods Used to Formulate the Recommendations:
The interdisciplinary workgroup members agreed to adopt recommendations developed
by external organizations and/or arrived at a consensus through discussion of the
literature evidence and expert experiences. Recommendations developed by the
workgroup were reviewed and approved by appropriate UW Health committees prior to
full endorsement and implementation of the recommendations.
Rating Scheme for the Strength of the Evidence/Recommendations:
See Appendix A for the various rating schemes used within this document.
Introduction
According to the World Health Organization (WHO) major depression is the leading
cause of disability worldwide, with more than 350 million people affected.1 The U.S.
Preventive Services Task Force (2009) recommends depression screening in
adolescents and adults when systems are in place to ensure accurate diagnosis,
psychotherapy, and follow-up.2-4 Therefore, primary care physicians are in a unique
position to provide initial assessment and diagnosis, as well as first line treatment to
patients.
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Recommendations
Emergency “Same Day” Behavioral Health Consultation/Evaluation
is necessary when patients exhibit one or more of the following5:
 suicidal thoughts and/or plans that make the patient’s safety uncertain
 assaultive and/or homicidal plans that make the safety of others uncertain
 loss of touch with reality (psychosis) in the context of depression
Reference:
ξ UWMF Policy 114.009 – Person at Risk for Suicide
ξ UWHC Policy 8.14 – Suicide Assessment and Intervention in Clinic
Screening and Assessment
An algorithm for screening is included within Appendix B.
Initial Screening in all Nonpregnant Patients (12 years or older)
Depression screening in adolescents and adults is recommended by the U.S.
Preventive Services Task Force when systems are in place to ensure accurate
diagnosis, psychotherapy, and follow-up.3,4 (USPSTF Grade B) Although an optimal
interval for screening is currently unknown, it is recommended (and required by an ACO
Quality measure) to perform annual universal depression screening in all nonpregnant
patients older than 12 years of age. (UW Health Very low quality evidence, strong
recommendation) Initial screening should be completed using the Patient Health
Questionnaire-2 (PHQ-2).6,7
A total score of 3 points or greater on the PHQ-2 constitutes a positive screen and need
for further age appropriate follow-up assessment using the PHQ-9 or PHQ-A.6-8
Patient Health Questionnaire-2 (PHQ-2)
Population All nonpregnant patients 12 years or older
Number of Questions 2
Administrator Self-administered by patient
Scoring:
Max Score
Positive Threshold (At-Risk)
6 points
3 points or greater
Assessment in Nonpregnant Adolescents (12-17 years)
If a nonpregnant adolescent patient scores positive on the PHQ-2 (score of 3 points or
greater), it is recommended to complete additional assessment using the Patient Health
Questionnaire-9 (PHQ-9) or Patient Health Questionnaire-A (PHQ-A).7,9,10 (UW Health
Low quality evidence, strong recommendation)
Assessment using the PHQ-9 or PHQ-A may also be completed at any time based upon
patient presentation or risk and symptomology (i.e., emotional problems as the chief
complaint) in adolescents.9,11 (AAP Grade B, very strong recommendation)
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A total score of 10 points or greater on the PHQ-9 or PHQ-A indicates the need for
clinical evaluation and documentation of a follow-up plan.7,9,10,12
Patient Health Questionnaire-A (PHQ-A)
Population All patients 12-17 years
Number of Questions 13 (9 scored)
Administrator Self-administered by patient
Scoring:
Max Score
Positive Threshold (Need for clinical evaluation)
27 points
10 points or greater
Scoring Interpretation:
None
Mild depressive symptoms; disorder is unlikely
Moderate depressive symptoms; disorder is possible
Moderately severe depressive symptoms; disorder is likely
Severe depressive symptoms; disorder is very likely
0-4 points
5-9 points
10-14 points
15-19 points
20-27 points
Patient Health Questionnaire-9 (PHQ-9)
Population All patients 18 years or older
Number of Questions 9
Administrator Self-administered by patient
Scoring:
Max Score
Positive Threshold (Need for clinical evaluation)
Positive Threshold (Suicide Risk)
27 points
10 points or greater
Affirmative response to
Question 9
Scoring Interpretation:
None
Mild depressive symptoms; disorder is unlikely
Moderate depressive symptoms; disorder is possible
Moderately severe depressive symptoms; disorder is likely
Severe depressive symptoms; disorder is very likely
0-4 points
5-9 points
10-14 points
15-19 points
20-27 points
Assessment in Nonpregnant Adults (18 years or older)
If a nonpregnant adult patient scores positive on the PHQ-2 (score of 3 points or
greater), it is recommended to complete additional assessment using the PHQ-9.7,12,13
(UW Health Low quality evidence, strong recommendation)
Assessment using the PHQ-9 may also be completed at any time based upon patient
presentation or risk and symptomology (i.e., emotional problems as the chief complaint)
in adults.14 (ICSI Low quality evidence, strong recommendation)
A score of 10 points or greater on the PHQ-9 indicates the need for clinical evaluation
and documentation of a follow-up plan.7,12,13
Patient Health Questionnaire-9 (PHQ-9)
Population All patients 18 years or older
Number of Questions 9
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Administrator Self-administered by patient
Scoring:
Max Score
Positive Threshold (Need for clinical evaluation)
Positive Threshold (Suicide Risk)
27 points
10 points or greater
Affirmative response to
Question 9
Scoring Interpretation:
None
Mild depressive symptoms; disorder is unlikely
Moderate depressive symptoms; disorder is possible
Moderately severe depressive symptoms; disorder is likely
Severe depressive symptoms; disorder is very likely
0-4 points
5-9 points
10-14 points
15-19 points
20-27 points
Patients who are Pregnant (12 years or older)
Diagnosing depression in pregnant women is difficult because many common ‘normal’
symptoms during pregnancy may be misconstrued as depressive symptomatology.
Depressive symptoms may also falsely be interpreted as pregnancy-related. Examples
may include changes in appetite, sleep, libido, and loss of energy.
Pregnant adolescents or adults should be screened at the first prenatal visit, during the
third trimester (24-32 weeks), and at six weeks postpartum.14-17(UW Health Low quality
evidence, strong recommendation) Screening may be completed using the Edinburgh
Postnatal Depression Scale (EPDS), Patient Health Questionnaire-9 (PHQ-9) or Patient
Health Questionnaire-A (PHQ-A) assessment tools.13,15
A total score of 10 points of greater on the EPDS constitutes the need for clinical
evaluation and documentation of a follow-up plan. An affirmative response to Question
10 (suicidality) constitutes the need to access crisis intervention services.18
Edinburgh Postnatal Depression Scale (EPDS)
Population Postpartum patients
Number of Questions 10
Administrator Self-administered by patient
Scoring:
Max Score
Positive Threshold (At-Risk)
Positive Threshold (Suicide Risk)
30 points
10 points or greater
Affirmative response to Question 10
A total score of 10 points or greater on the PHQ-9 or PHQ-A indicates the need for
clinical evaluation and documentation of a follow-up plan.7,12
Patient Health Questionnaire-A (PHQ-A)
Population All patients 12-17 years
Number of Questions 13 (9 scored)
Administrator Self-administered by patient
Scoring:
Max Score
Positive Threshold (Need for clinical evaluation)
27 points
10 points or greater
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Scoring Interpretation:
None
Mild depressive symptoms; disorder is unlikely
Moderate depressive symptoms; disorder is possible
Moderately severe depressive symptoms; disorder is likely
Severe depressive symptoms; disorder is very likely
0-4 points
5-9 points
10-14 points
15-19 points
20-27 points
Patient Health Questionnaire-9 (PHQ-9)
Population All patients 18 years or older
Number of Questions 9
Administrator Self-administered by patient
Scoring:
Max Score
Positive Threshold (Need for clinical evaluation)
Positive Threshold (Suicide Risk)
27 points
10 points or greater
Affirmative response to
Question 9
Scoring Interpretation:
None
Mild depressive symptoms; disorder is unlikely
Moderate depressive symptoms; disorder is possible
Moderately severe depressive symptoms; disorder is likely
Severe depressive symptoms; disorder is very likely
0-4 points
5-9 points
10-14 points
15-19 points
20-27 points
Patients in Postpartum (12 years or older)
Many medical professionals often rely on their clinical impressions alone to determine
whether a woman appears depressed, but several studies have shown that up to 50%
of mothers with major depression are missed by primary care practitioners when
screening instruments are not used.16 If left untreated, the disorder can have serious
adverse effects for the mother, her infant’s development, and her relationship with
others.
Postpartum Depression (PPD) may begin 24 hours to several months after delivery.19
When its onset is abrupt and symptoms are severe, women are more likely to seek help
early in the illness. In cases with an insidious onset, treatment is often delayed, if it is
ever sought. Untreated, PPD may resolve within several months but can linger into the
second year postpartum. After the initial episode, women who have had PPD are at risk
for both non-puerperal and puerperal relapses.
Postpartum depression assessment should be conducted at 4-10 weeks (i.e., 6 week
OB visit) and 3-6 months (i.e., during Well-Child visits).14,16,18 (UW Health Low quality
evidence, weak recommendation) The EPDS addresses depressive and anxiety
symptomology, and is therefore preferred as anxiety frequently co-occurs with
depression in the postpartum period.20 However, some clinicians may be prefer to use
the PHQ-9 or PHQ-A because of familiarity and continuity.21
A total score of 10 points or greater on the EPDS constitutes the need for clinical
evaluation and documentation of a follow-up plan.15,20 An affirmative response to
Question 10 (suicidality) constitutes the need to access crisis intervention services.18
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Edinburgh Postnatal Depression Scale (EPDS)
Population Postpartum patients
Number of Questions 10
Administrator Self-administered by patient
Scoring:
Max Score
Positive Threshold (At-Risk)
Positive Threshold (Suicide Risk)
30 points
10 points or greater
Affirmative response to Question 10
A total score of 10 points or greater on the PHQ-9 or PHQ-A indicates the need for
clinical evaluation and documentation of a follow-up plan.7,12
Patient Health Questionnaire-A (PHQ-A)
Population All patients 12-17 years
Number of Questions 13 (9 scored)
Administrator Self-administered by patient
Scoring:
Max Score
Positive Threshold (Need for clinical evaluation)
27 points
10 points or greater
Patient Health Questionnaire-9 (PHQ-9)
Population All patients 18 years or older
Number of Questions 9
Administrator Self-administered by patient
Scoring:
Max Score
Positive Threshold (Need for clinical evaluation)
Positive Threshold (Suicide Risk)
27 points
10 points or greater
Affirmative response to
Question 9
Scoring Interpretation:
None
Mild depressive symptoms; disorder is unlikely
Moderate depressive symptoms; disorder is possible
Moderately severe depressive symptoms; disorder is likely
Severe depressive symptoms; disorder is very likely
0-4 points
5-9 points
10-14 points
15-19 points
20-27 points
Follow-up Plan Documentation
According to the ACO Quality measure, all patients who screen positive on a validated
depression screening tool must have a documented follow-up plan on the date of the
positive screen. This plan must contain one or more of the following:
ξ Additional evaluation for depression
ξ Suicide Risk Assessment
ξ Referral to a practitioner who is qualified to diagnose and treat depression
ξ Pharmacological interventions
ξ Other interventions or follow-up for the diagnosis or treatment of depression.
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Patient Presentation and Risk Factors
Physical complaints are extremely common in depression and are often the primary
manifestation of the illness. Somatic manifestations of depression include fatigue,
insomnia, anorexia, weight loss, gastrointestinal disturbances, and a variety of pain
complaints. Anxiety and agitation are common as secondary symptoms. It is important
that clinicians keep in mind that patients who have depression or any mental illness are
often stigmatized and may be at risk of not having medical complaints adequately
addressed.
Common presentations of patients with depression may include14,22,23:
ξ multiple patient-initiated office visits (more than five per year)
ξ numerous unexplained symptoms
ξ work or relationship dysfunction
ξ sleep disturbance
ξ multiple worries and distress (irritable mood in adolescents)
ξ fatigue
ξ irritable bowel syndrome
Risk Factors
Risk factors are often intertwined and related, and may vary based upon patient age
and experiences. Patients with chronic illnesses such as diabetes, cardiovascular
disease, and chronic pain are at a higher risk for depression.14,24 Risk factors
associated with patient age or postpartum status are listed below. Older adults,
especially white men over age 65 years, are at a higher risk of suicide.25
Table 1. Risk Factors in Adolescents11,23,24
Biological
ξ Personal history of depression
ξ Family history of depression
ξ Female gender
ξ Hormonal changes during
puberty
ξ Low birth weight
ξ Maternal age < 18 yrs.
ξ Medical illness (i.e., asthma, diabetes,
migraines)
ξ Obesity
ξ Other psychological disorders (i.e.,
anxiety, learning disorders)
ξ Sleep disruptions
Psychological
ξ Emotional dependence
ξ History of suicide attempts
ξ Ineffective coping skills
ξ Low self-esteem
ξ Negative body image
ξ Negative thinking styles (i.e., “nothing
will ever work out”)
ξ Self-consciousness
Environmental
ξ Antisocial peer group
ξ Decreased physical activity
ξ Increased parental conflict
ξ Loss of relationship (i.e., death
of family member, romantic
relationship, friendship)
ξ Low socioeconomic status
ξ Overeating
ξ Poor academic performance
ξ Poor peer relationships
ξ Substance use
ξ Traumatic event (i.e., accident, physical
or sexual abuse)
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Table 2. Risk Factors in Adults14,22,23,25
Biological
ξ Personal history of depression
ξ Family history of depression (first-
degree relative)
ξ Female gender
ξ Medical co-morbidity
ξ Postpartum period
ξ Peri/postmenopausal period
ξ Chronic medical condition
ξ Men over age 65 years are at a higher
risk of suicide
Psychological ξ Negative thinking styles (i.e., “nothing will ever work out”) ξ Feelings of hopelessness
Environmental
ξ Lack of social support
ξ Loss of relationship (i.e., being
widowed, death of family
member, romantic relationship,
friendship)
ξ Substance use
ξ Major life change (i.e., job change,
financial difficulties)
ξ Traumatic event (i.e., accident,
physical or sexual abuse)
Table 3. Risk Factors for Postpartum Depression14,26
Biological
ξ Personal history of depressive
episode or psychiatric illness
ξ Depression or anxiety during
pregnancy
ξ Family history of mood or anxiety
disorders
ξ Fragmented or poor sleep
ξ Premorbid or gestational diabetes
ξ Difficulty breastfeeding in the first two
months postpartum
Psychological
ξ Dissatisfaction with the amount of social support from a spouse or significant
other
ξ Low self-esteem
Environmental
ξ Lack of psychosocial support
ξ Recent stressful life event
ξ Child care stress
ξ Low socioeconomic status
ξ Past or current abuse
Establish a Diagnosis
To diagnose a depressive disorder, the clinician should determine that criteria outlined
within the Diagnostic and Statistical Manual of Mood Disorders, Fifth Edition (DSM-5)
have been met using a detailed clinical interview.14,22,23 (ICSI Low quality evidence, strong
recommendation) It is recommended to conduct direct interviews with adolescent patients
and their families or caregivers.11 (AAP Grade B, very strong recommendation)
The diagnostic DSM-5 criteria for major depressive disorder are listed below.
DSM-5 Diagnostic Criteria:23
------------------------------------------------------------------------------------------------------------------
A. Five (or more) of the following symptoms have been present during the same 2-
week period and represent a change 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.
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1. Depressed mood most of the day, nearly every day, as indicated by either
subjective report (e.g., feels sad, empty, and hopeless) or observation made
by others (e.g., appears tearful). (Note: In children and adolescents, can be
irritable mood).
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
observation).
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. (Note: In children, consider failure to make expected weight
gain).
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 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 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 episode is not attributable to the physiological effects of a substance or to
another medical condition.
Note: Criteria A–C represent a major depressive episode.
Note: Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a
serious medical illness or disability) may include the feelings of intense sadness, rumination about the
loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive
episode. Although such symptoms may be understandable or considered appropriate to the loss, the
presence of a major depressive episode in addition to the normal response to a significant loss should
also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on
the individual’s history and the cultural norms for the expression of distress in the context of loss.
In distinguishing grief from a major depressive episode (MDE), it is useful to consider that in grief the
predominant affect is feelings of emptiness and loss, while in MDE it is persistent depressed mood and
the inability to anticipate happiness or pleasure. The dysphoria in grief is likely to decrease in intensity
over days to weeks and occurs in waves, the so-called pangs of grief. These waves tend to be associated
with thoughts or reminders of the deceased. The depressed mood of MDE is more persistent and not tied
to specific thoughts or preoccupations. The pain of grief may be accompanied by positive emotions and
humor that are uncharacteristic of the pervasive unhappiness and misery characteristic of MDE. The
thought content associated with grief generally features a preoccupation with thoughts and memories of
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the deceased, rather than the self-critical or pessimistic ruminations seen in MDE. In grief, self-esteem is
generally preserved, whereas in MDE feelings of worthlessness and self-loathing are common. If self-
derogatory ideation is present in grief, it typically involves perceived failings vis-à-vis the deceased (e.g.,
not visiting frequently enough, not telling the deceased how much he or she was loved). If a bereaved
individual thinks about death and dying, such thoughts are generally focused on the deceased and
possibly about “joining” the deceased, whereas in MDE such thoughts are focused on ending one’s own
life because of feeling worthless, undeserving of life, or unable to cope with the pain of depression.
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.
Note: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are substance-
induced or are attributable to the physiological effects of another medical condition.
--------------------------------------------------------------------------------------------------------------------------------------------
Interview for Key Symptoms
Patients should receive a thorough evaluation in order to establish a diagnosis of major
depressive disorder, identify other psychiatric or medical conditions that may require
attention, and develop a treatment plan. (UW Health High quality evidence, strong
recommendation) In adolescent patients, the clinician should also assess the functional
impairment across different domains.11 (AAP Grade B, very strong recommendation)
This evaluation may include:5,14
ξHistory of present illness and current symptoms
ξPsychiatric history including past symptoms of mania, hypomania, or mixed
episodes and responses to previous treatments
ξGeneral medical history
ξPersonal history including information about psychological development and
responses to life transitions and major life events
ξSocial, occupational, and family history including mood disorder and suicide
ξReview of prescribed and over-the-counter medications
It should be noted that older adults may be less likely to endorse low mood and
worthlessness; rather loss of interest and pleasure may be core symptoms of
depression.
Questions which are asked during the clinical interview should elaborate on answers
provided on the initial assessment(s) (i.e., PHQ-9, PHQ-A, or EPDS), and assess for
suicidal or homicidal intent, plan, and access to means.
Detecting Postpartum Depression (PPD)
The detection of PPD is often complicated by several factors, including:
ξMost women expect a period of adjustment after having a baby
ξStigma and societal pressures to be a “good mother”
ξConcern that sharing depressive thoughts might mean that their child could be
taken from them
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ξDelayed detection of PPD by providers’ minimizing a woman’s distress in an
effort to be reassuring.
Symptoms of PPD include:
ξDepressed mood
ξLack of pleasure or interest including in her baby
ξAgitation or motor retardation
ξFrequent thoughts of death or suicide
ξSleep disturbance (insomnia or hypersomnia)
ξAppetite disturbance (weight loss or gain)
ξLoss of energy
ξFeelings of worthlessness, inappropriate guilt, or being overwhelmed
ξDiminished concentration or indecisiveness
ξSymptoms that may be confused with normal sequelae of childbirth
Anxiety may be a prominent feature and more readily apparent than traditional
depressive symptoms. Co-morbid anxiety has been found to be present in 60% of
women with major depression in the postpartum period. Other co-morbid disorders
often present may include: social phobia, agoraphobia, obsessive compulsive and
avoidant personality disorders, all of which may contribute to social isolation. One of
the most concerning features of postpartum mood or anxiety disorders is
intrusive thoughts of harming the infant. These thoughts are most commonly
associated with postpartum depression but are also prominent in postpartum psychosis
and OCD, which are less common but important to recognize. These thoughts are
usually distressing to the mother and she may worry that discussing them might call into
questions her ability to parent. It is imperative to ask all postpartum women with any
mood or anxiety symptoms if they have experienced any intrusive thoughts of harming
their child. This is best accomplished by acknowledging that such thoughts are common
and usually transient in the postpartum period. In the absence of psychosis, the
likelihood of a woman acting on these thoughts is low; however, formal psychiatric
assessment is essential to clarify the diagnosis and initiate treatment. Any woman
endorsing thoughts of harming her infant should be referred immediately for psychiatric
care.
Consider a Differential Diagnosis
Many other psychiatric disorders, physical conditions or medications can cause
depressive symptoms. In evaluating adolescent (AAP Grade B, very strong recommendation)
and adult (UW Health High quality evidence, strong recommendation) patients with symptoms of
depression, the primary care practitioner should determine if the depression is a primary
process or whether it is a symptom of other medical conditions.11
Medical Conditions: Screening for other medical conditions should be based on
clinical judgment. Many medical conditions (i.e. hypothyroidism, hyperthyroidism,
cancer, coronary artery disease, diabetes mellitus, cerebral vascular accident, chronic
pain, HIV, Parkinson’s disease, multiple sclerosis) are risk factors for depression.14 If a
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patient presents with prominent symptoms of low energy or hypersomnia, consider an
evaluation for sleep apnea.27
In patients who are at risk for low levels of B12 (i.e., vegetarians, poor diet, drink
heavily, or are elderly), obtaining a baseline value may be considered. Repletion of B12
can improve mood and increase the efficacy of antidepressant medications.
In older adults, it is important to consider obtaining a baseline TSH value given the
higher rates of hypothyroidism in this population.5 Older patients may also be screened
for cognitive impairment through clinical assessment or use of a validated tool(s) such
as the 6-item screener with the St. Louis University Mental Status Examination
(SLUMS) or Montreal Cognitive Assessment (MoCA) as follow-up.
Depressive disorder, when present, should be considered an independent condition and
specifically treated. Treatment may include optimizing treatment for the medical
condition and/or providing specific treatment for the depression. When depression and
a medical condition co-exist, there are several plausible explanations:5
ξ The medical disorder biologically causes the depression (i.e., hypothyroidism).
ξ The medical disorder triggers the onset of depression in those who are
genetically predisposed to depression.
ξ The perceived severity of the illness causes depression (i.e., a patient with
cancer becomes depressed as a psychological reaction to prognosis and pain).
ξ The medical disorder and the depression are not causally linked.
It is important for the practitioner to differentiate among these several explanations in
patients with concomitant medical disorder(s) and depression.
Medications: Some medications may cause depressive symptoms:
Drug Causing Depression Potential Alternatives
Clonidine, Methyldopa, Reserpine Other antihypertensive agent (diuretics, ACE-I, CCB, ARB, etc)
Lipophilic beta blockers (propranolol)
Use lowest effective dose (atenolol or
metoprolol). For heart rate control consider
non-dyhydropyridine calcium channel blocker
Corticosteroids Minimize dose as allowed
Sedatives/Hypnotics Consider taper off
Benzodiazepines Minimize use
Estrogens/Progesterones Addition of Vitamin B6, use lower progestin
Anti-Parkinson Medications No alternatives
Anti-convulsants
(Especially levetiracetam, phenytoin)
Consider lamotrigine and other alternative
anti-epileptic drugs
Indomethacin Other NSAIDS
Interferons (Hep C, MS) No alternatives
Isotretinoin No alternatives
Opioids Minimize/taper off opioids or use NSAIDS
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Bipolar disorder: Use of antidepressants can precipitate mania or hypomania.
Although the DSM-5 diagnostic criteria for an episode of major depression in bipolar
disorder are the same as the criteria for unipolar major depression, the treatment for
both disorders is different.23 Therefore, screening for bipolar disorder and any previous
episodes of hypomania and mania should always be done before initiating treatment for
depression.14,22
The following symptoms of mania (lasting at least a week) or hypomania (lasting at least
4 days) may be used to differentiate bipolar disorder from depression:23
ξ Inflated self-esteem or grandiosity
ξ Decreased need for sleep (i.e., feels rested after only 3 hours of sleep)
ξ More talkative than usual or pressure to keep talking
ξ Flight of ideas or subjective experience that thoughts are racing
ξ Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external
stimuli), as reported or observed
ξ Increase in goal-directed activity (either socially, at work or school, or sexually) or
psychomotor agitation (i.e., purposeless non-goal-directed activity)
ξ Excessive involvement in activities that have a high potential for painful
consequences (i.e., engaging in unrestrained buying sprees, sexual
indiscretions, or foolish business investments)
Anxiety, panic, obsessive-compulsive or phobic disorders: More often than not
depression is accompanied by a co-morbid anxiety disorder which can impact the
treatment approach. Depression can also mask underlying psychiatric disorders.
Anxiety symptoms are frequent in depressive episodes. The depression may precede
the panic or anxiety disorder, or the anxiety disorder may be part of the longitudinal
course of the mood disorder. When a patient has anxiety symptoms, the existence of
depressive symptoms should be evaluated. For those patients whose disorder has
some obsessive features, the mood disorder is the initial focus of treatment.
Bereavement: is considered a normal state that most often resolves without treatment.
In those bereaved patients who meet the diagnostic criteria for a depression following
the loss, the diagnosis of a depressive disorder may be made.23
Substance abuse: Major depressive disorder frequently occurs with alcohol or other
substance use disorders. A patient with major depressive disorder who has a co-
occurring substance use disorder is more likely to require hospitalization, more likely to
attempt suicide, and less likely to adhere to treatment than a patient with major
depressive disorder of similar severity uncomplicated by substance use. Therefore, a
history of the patient's substance use, including current use, should be obtained. For
recommendations related to alcohol or tobacco screening and treatment, refer to the
UW Health Alcohol Assessment and Intervention – Adult/Pediatric – Ambulatory or
UW Health Tobacco Cessation – Adult/Pediatric – Inpatient/Ambulatory Clinical
Practice Gidelines.
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Patients should be advised to stop substance use. Patients with significant alcohol,
sedative or opioid use should be monitored for withdrawal and managed accordingly.
Referral to AODA services should be considered for patients who have difficulty
stopping on their own or who are facing significant interpersonal, occupational, medical,
financial or legal consequences from substance use.5
Eating disorders: It is recommended that young adults who present with any mood
disorder be interviewed for symptoms of anorexia nervosa and/or bulimia at some point
during treatment. One-third to one-half of patients with eating disorders has a
concurrent depressive syndrome. If both depression and an eating disorder are
present, the eating disorder, generally, should be the principal therapeutic target.5 For
recommendations related to screening and assessment, refer to the UW Health Eating
Disorders – Adult/Pediatric – Ambulatory Clinical Practice Guideline.
Attention Deficit and Hyperactivity Disorder (ADHD): It is recommended that
adolescents and adults who present with inattention be interviewed for symptoms of
ADHD as par of the evaluation. For recommendations related to ADHD diagnosis, refer
to the UW Health ADHD – Pediatric – Ambulatory and UW Health ADHD – Adult –
Ambulatory Clinical Practice Guidelines.
Other Postpartum Conditions: The criteria for diagnosing postpartum depression
(PPD) apply to the diagnosis of PPD as well, with symptoms occurring nearly every day,
most of the day, for at least two weeks. PPD often begins later than baby blues and
postpartum psychosis, which often occur right away.
Postpartum Blues:
The "baby blues" are subclinical mood fluctuations characterized by mild depressive
symptoms that typically peak 3 to 5 days after delivery and resolve by the 10th postnatal
day. These symptoms include tearfulness, irritability, fatigue, anger, insomnia, anxiety,
mood liability, and sensitivity. All women with postpartum baby blues should be
monitored for the onset of continuing or worsening symptoms.26
Postpartum Psychosis:
Postpartum depression must be distinguished from postpartum psychosis, which occurs
in 0.1% of childbearing women. The most significant risk factors for postpartum
psychosis are a personal or family history of bipolar disorder or a previous psychotic
episode. Most puerperal psychoses have their onset within the first month of delivery
and are manic in nature. Warning signs heralding the onset of puerperal psychosis
include:
ξ An inability to sleep for several nights
ξ Irritable mood
ξ Agitation
ξ Avoidance of the infant
ξ Delusion or hallucinations often involve the infant
ξ Racing thoughts
ξ Rapid speech
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ξ Perplexed affect
Of women who develop a postpartum psychosis, there is a 5% infanticide or suicide
rate; thus postpartum psychosis is a medical emergency and requires immediate
psychiatric evaluation and usually requires psychiatric admission for medication
management and safety.26
Involve Behavioral Health
Referral to a Behavioral Health Specialist is recommended when there is:14
ξ possibility of bipolar disorder
ξ psychiatric co-morbidity (for example, substance abuse, anxiety, obsessive
compulsive disorder, or eating disorders)
ξ concern regarding the possibility of suicide and/or homicide
ξ substance abuse
ξ psychosis with the depression
ξ no improvement with medications prescribed by the primary prescriber despite
multiple dose adjustments and trials of different medication classes
ξ significant or prolonged inability to work and care for self and/or family
ξ diagnostic uncertainty
Provide Treatment
The objectives of treatment are:
ξ Reduction and ultimately resolution (remission) of all signs and symptoms of the
depressive syndrome. This may be assessed objectively through administration
of an assessment tool such as the PHQ-9. The ACO Quality measure defines
remission in adults 18 years or older as a PHQ-9 score < 5 within one year of
positive screening (PHQ-9 score > 9 points).
ξ Restoration of psychosocial and occupational function to that of the baseline
asymptomatic state.
ξ Reduction of the likelihood of relapse or recurrence.
Primary care clinicians should develop a treatment plan with patients and their families
in adolescence (AAP Grade C, very strong recommendation) or adulthood (ICSI Low quality
evidence, strong recommendation), and set specific treatment goals in key functional areas
such as home, peer and school settings.14,28 (AAP Grade D, very strong recommendation)
It is recommended to use evidence-based treatments, such as psychotherapy,
pharmacotherapy, electroconvulsive therapy, or light therapy, whenever possible and
appropriate to achieve the goals of the treatment plan.28 (AAP Grade A, very strong
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recommendation) The Collaborative Care model is recommended for all patients with
depression in primary care.14,29-31 (ICSI High quality evidence, strong recommendation)
The Collaborative Care model expands the primary care team to include a consulting
psychiatrist and care manager. Key principles of this model include:32
ξ Measurement-based treatment to target (or stepped care) where each patient’s
treatment goals and outcomes are clearly identified and routinely measured by
validated tools, such as the PHQ-9. If no improvement is seen, treatments are
actively modified until the expected result or outcome is achieved.
ξ Population-based care requires care teams to share a defined group of patients
tracked in a registry. Care managers track patient symptoms and promote
adherence to the treatment plan, while others provide pharmacotherapy and
psychotherapy.
ξ Patient-centered team care involves collaboration between the patient, primary
care provider, behavioral health provider and other team members to develop
treatment goals and plans. Immersion of behavioral health providers into primary
care clinics reduces the need for duplicate assessments and enhances the
effectiveness of referrals
Factors to consider in making treatment recommendations (Table 4) are the severity of
symptoms, presence of psychosocial stressors, presence of co-morbid conditions,
insurance coverage, pregnancy status, and patient preferences or prior treatment
experiences.5,12
Table 4. Suggested Treatment Modalities Based on Depression Severity or Other Factors
Factors Treatment Options
Adolescents Adults
Symptom
Severity
(based on
total PHQ-9
or PHQ-A
scores)
Mild (5-9 pts.) Psychotherapy
(IPT, CBT)
ξ Psychotherapy alone and/or
Behavioral Activation
ξ Pharmacotherapy alone
Moderate (10-14 pts.)
Pharmacotherapy
(SSRIs) in
combination with
psychotherapy
(IPT, CBT)
ξ Psychotherapy alone (CBT, IPT)
ξ Pharmacotherapy alone
ξ Combination therapy (medications
and psychotherapy)
Moderately severe
(15-19 pts.)
Severe (20-27 pts.)
ξ Pharmacotherapy alone
ξ Pharmacotherapy in combination
with psychotherapy (CBT, IPT)
ξ Electroconvulsive Therapy
Psychosocial Stressors ξ Psychotherapy
Patient is Pregnant ξ Psychotherapy
ξ Discuss risks and benefits of pharmacotherapy
Seasonal episodes ξ Light therapy
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Treatment Modalities
Psychotherapy: Cognitive-behavioral therapy, interpersonal psychotherapy (IPT) and
behavioral psychotherapies (i.e., behavioral activation) have demonstrated acute
efficacy in treating major depressive disorder.5
ξ Behavioral Activation: A therapy that encourages behavioral changes using
motivational interviewing. Recommend increase in activities such as adding 20
minutes of exercise 3-4 times per week, improving diet, increase social activities,
engage in enjoyable activities, stress reduction (mindfulness practice, relaxation)
and sleep hygiene.5,22
ξ Cognitive-behavioral Therapy (CBT): A therapy founded on the perspective that
irrational beliefs and distorted attitudes towards the self, environment, and future
perpetuate depressive affects and compromise functioning. The goal of CBT is to
reduce depressive symptoms by challenging and reversing these beliefs and
attitudes and encourage patients to change their maladaptive preconceptions
and behaviors.5
ξ Interpersonal Psychotherapy (IPT): A therapy which focuses on current life
changes including loss, role disputes and role transition (i.e., becoming a new
mother, divorce, primary caretaker for an elderly family member), social isolation,
deficits in social skills, and other interpersonal factors that may interact with the
development of depression. The goal of IPT is to intervene by identifying the
current trigger for the depressive episode, facilitating mourning in the case of
bereavement, promoting recognition of related affects, resolving role disputes,
and transitions, and building social skills.5
Pharmacotherapy: For essentially all patients, the clinician who provides the
medication also provides support, advice, reassurance, instills optimism as well as
medication monitoring. This “clinical management” is critical with depressed patients
whose pessimism, low motivation, low energy, and sense of social isolation or guilt lead
them to give up, not comply with treatment, or to drop out of treatment.
Many drug interactions occur with antidepressant therapy; many of these occur
with medications commonly prescribed in primary care.
Selection of a particular medication should take into consideration the following:5,14
ξ Prior positive/negative response to medication (personal or family history)
ξ Clinician experience with specific antidepressants
ξ Patient preference
ξ Other health conditions (i.e., ADHD, smoking cessation) (see Appendix F)
ξ Side effect profiles (see Appendix G)
ξ Safety in overdose (i.e., 10 days of a TCA can be a lethal overdose)
ξ Concurrent medications that make selected medications more or less risky
ξ History of first degree relatives’ responses to medication
ξ Cost and insurance coverage
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Drug information on antidepressant therapies is included in Appendix H.
Pediatric and adult patients with a major depressive disorder may experience worsening
of their depression, emergence of suicidal ideation and suicidality, whether or not they
are taking antidepressants and this may persist until significant remission occurs.
Patient education on depression is important for patient adherence with therapy. For
antidepressant medications, compliance with a therapeutic dose is more important than
the specific drug selected.
ξ Take medication daily as prescribed.
ξ Antidepressants must be taken daily for 2-4 weeks for a noticeable effect.
ξ Be educated on potential side effects. Many side effects resolve after 1-2 weeks.
ξ Continue to take medication even if you are feeling better, increased risk of
relapse if stopped before 6 months.
ξ Do not stop taking antidepressant without checking with your provider. Some
antidepressants may have uncomfortable withdrawal symptoms.
ξ Contact your provider if you have questions about your medication.
ξ Be sure to make and keep follow-up appointments. This is important to ensure
full response to your medication.
ξ The medication is not addictive and will not change your personality. Depression
alters brain functioning and the medication helps restore normal patterns, so you
eat and sleep more normally, think more clearly and have more energy.
ξ The medication should help you benefit from the psychotherapy you are
receiving.
ξ Do not drink alcohol with medication.
Patients with Substance Abuse and Use of Antidepressants
Detoxifying patients before initiating antidepressant medication therapy is advisable
when possible.33 Antidepressants may be used to treat depressive symptoms following
initiation of abstinence if symptoms do not improve over time. It is difficult to identify
patients who should begin a regimen of antidepressant medication therapy soon after
initiation of abstinence, because depressive symptoms may have been induced
by intoxication and/or withdrawal of the substance. A family history of major depressive
disorder, a history of major depressive disorder preceding alcohol or other substance
abuse, or a history of major depressive disorder during periods of sobriety raises the
likelihood that the patient might benefit from antidepressant medication, which may then
be started early in treatment. Comparing the temporal pattern of symptoms with
the periods of use and abstinence of the substance may help to clarify the patient's
diagnosis. Repeated, longitudinal assessments may be necessary to distinguish
substance-induced depressive disorder from co-occurring major depressive disorder,
particularly because some individuals with substance use disorders reduce their
substance consumption once they achieve remission of a co-occurring major
depressive disorder.
Benzodiazepines and other sedative-hypnotics carry the potential for abuse or
dependence and should rarely be prescribed to patients with co-occurring substance
use disorders, except as part of a brief detoxification regimen. Hepatic dysfunction and
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24
hepatic enzyme induction frequently complicate pharmacotherapy of patients with
alcoholism and other drug abuse. These conditions may require careful monitoring of
blood levels (as appropriate for the medication), therapeutic effects, and side effects to
avoid the opposing risks of either psychotropic medication intoxication or under dosing.
Electroconvulsive Therapy (ECT): ECT may be administered unilaterally or bilaterally
(using a bitemporal or bifrontal electrode placement). This therapy is typically
administered 2-3 times per week for 6-12 treatments or until symptoms have remitted.5
Light Therapy: Light therapy is an FDA approved treatment for seasonal depression
and is covered by most insurance companies.22 Use of a light box (10,000 lux for 30
minutes every morning) in the dark months of the year (September – March) can be
considered as a treatment option.5
Treatment in Nonpregnant Adolescents (12-17 years)
An algorithm for treatment in adolescents is included within Appendix C.
Interpersonal or cognitive behavioral psychotherapy (individual or group) should be
considered a first-line treatment option for mild depression in adolescent patients.24,28,34
(AAP Grade A, very strong recommendation) Psychotherapy alone is not recommended for the
acute treatment of patients with severe and/or psychotic depressive disorders and has
not been shown to reduce the risk for suicide attempts in adolescent patients.35
Psychotherapy in combination with antidepressant medication may be needed for
moderate to severe depression in adolescents24(AAFP Grade A) or if any of the following
symptoms are present: severe insomnia, severe anxiety, marked anhedonia, or
thoughts of suicide. Medication may also be the preferred method of treatment in
individuals who decline psychotherapy or who have required medication to treat
depression in the past.
Selective serotonin reuptake inhibitors (SSRIs) have demonstrated efficacy in
adolescent patients and may be considered as the first-line pharmacotherapy treatment
option.3,24,28,34 Preference should be given to the two FDA-approved agents (fluoxetine
and escitalopram); however off-label use of citalopram or sertraline may be
considered.36,37 (UW Health Moderate quality evidence, weak recommendation) While patients
are more likely to benefit from antidepressant treatment than commit suicide, the
risks and benefits of SSRI use should be weighed due to risk of suicidal thoughts
(suicide ideation).3,28,34 Side effects of SSRIs may include: irritability, insomnia,
appetite change, gastrointestinal symptoms, headaches, diaphoresis, restlessness, or
sexual dysfunction.38
Atypical antidepressants (bupropion, venlafaxine, mirtazapine, duloxetine) may be
considered as a second-line pharmacotherapy option only after at least two SSRIs have
proven to be ineffective.34,39 (UW Health Very low quality evidence, weak recommendation) Side
effects to these medications may include: irritability, nausea, anorexia, headaches, or
insomnia. Blood pressure changes may also occur with venlafaxine.38
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Treatment in Nonpregnant Adults (18 years or older)
An algorithm for treatment in adults is included within Appendix D.
Clinicians should provide antidepressant medications and/or referral to psychotherapy
as treatment for major depression.14 (ICSI Low quality evidence, strong recommendation)
Treatment decisions may be completed through a shared-decision making process
which considers the patient’s willingness to invest time in psychotherapy, the presence
of psychosocial stressors, disease severity, and patient preference.
Mild to moderate levels of depression in adults have been treated as effectively with
psychotherapy as with pharmacotherapy. Therefore, cognitive-behavioral therapy or
interpersonal therapy may be recommended as a treatment option in adults.14 (UW Health
Low quality evidence, weak recommendation) Psychotherapy in combination with
antidepressant medication may be needed for moderate to severe depression in
adults14 (UW Health High quality evidence, weak recommendation) or if any of the following
symptoms are present: severe insomnia, severe anxiety, marked anhedonia, or
thoughts of suicide.
Medication may also be the preferred method of treatment in individuals who decline
psychotherapy, or who have required medication to treat depression in the past.
Medication class may be determined through a discussion with the patient using the
concurrent condition and product list information outlined in Appendix F and Appendix
H, respectively.
When prescribing medications in older adults age 65 years or older, careful
consideration should be taken of how the drug metabolism may be affected by
physiologic changes, comorbid illnesses, and/or concomitant medications.14 (ICSI Low
quality evidence, strong recommendation) Antidepressants should be initiated in older adults at
½ (or even ¼) of the usual starting doses.5 Note: Some tablets are not scored and
pharmacies (including UW Health) may not split the tablet. Thus, they will not fill some
prescriptions. It is important to keep in mind renal and hepatic status of a patient when
choosing antidepressant doses, as well as to consider drug-drug interactions (including
the risk of serotonin syndrome).5
NOTE: Adult patients with a diagnosis of major depression on an antidepressant
medication are subject to follow requirements established by the Healthcare
Effectiveness Data and Information Set (HEDIS). For more information, see Appendix I.
ECT is most commonly recommended for adults with severe depression accompanied
by psychosis, suicidal intent, or refusal to eat.5 (APA Grade I) It may be tried when
medications are not tolerated or other forms of therapy haven’t proved effective (APA
Grade I), by patient preference, or in patients who have had a previously positive
response to ECT.5 (APA Grade II) A full psychiatric assessment is recommended before
considering this treatment method.5,22
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Use of a light box (10,000 lux for 30 minutes every morning) in the dark months of the
year (September – March) can be considered as a treatment option, especially in
patients who suffer from seasonal depressive episodes.5 (APA Grade III)
Treatment in Patients who are Pregnant (12 years or older)
Algorithms for treatment in patients who are pregnant are included within Appendix E.
The treatment of depression during pregnancy should be completed using a shared-
decision making process which weighs the potential risk of fetal exposure to
psychotropic medication against the potential adverse effects of an untreated
disorder.14,17,40 (UW Health Low quality evidence, weak recommendation) It is important to
engage the patient and significant others in this discussion about what is best for their
situation (patient preference), the different treatment options available, and that the
ultimate goal is for the patient and baby to be as safe as possible.41 The treatment
decision may also depend on the patient's history of depression before the pregnancy,
their previous experience with medications, the severity of the depression, support
available, response to alternative treatment modalities, etc.
Psychotherapy (IPT or CBT) is recommended whenever possible for mild to moderate
depression, in patients who have exhibited a positive response in the past, or by patient
preference.5,40 (APA Grade I) Interpersonal therapy is considered to be particularly useful
during pregnancy as it directly addresses issues associated with role transitions and
relationships with the partner.
Patients, who have become significantly depressed while off antidepressant medication
in the past, will likely need to continue taking antidepressant medication in pregnancy to
prevent recurrence of symptoms. Pregnant patients with new onset of moderate to
severe depression in pregnancy may also need psychiatric medication in addition to
psychotherapy to ensure the best treatment response.5,14 (APA Grade II) The goal of
pharmacotherapy is to treat to remission to avoid exposing the infant to both the
antidepressant medication and maternal depression.
Current evidence is insufficient to establish a direct relationship between antidepressant
use during pregnancy and risks or adverse birth outcomes.40,42 SSRIs (except for
paroxetine) and TCAs may be used if preferred by the patient. (UW Health Low quality
evidence, weak recommendation) Paroxetine (FDA category D) is not recommended in
women who are planning to become pregnant or those who are pregnant and in their
first trimester, as some studies have found increased risk of cardiac defects with more
than 25 mg/day of paroxetine use in the first trimester.40,43,44 (UW Health Low quality
evidence, weak recommendation)
ECT is an additional treatment option for patients who are pregnant with depression and
psychotic or catatonic feature, moderate to severe depression unresponsive to
pharmacotherapy or psychotherapy, or by patient preference.5 (APA Grade II)
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Treatment in Patients in Postpartum (12 years or older)
Interpersonal psychotherapy (individual or group) or cognitive behavioral therapy should
be considered a first-line treatment option for mild-moderate postpartum depression, by
patient preference, or in patients who have exhibited a positive response in the past.5,45
(UW Health Moderate quality evidence, weak recommendation) Women with severe depression,
suicidal ideation, or psychosis should be referred for psychiatric care. Such women
require a comprehensive, multifaceted approach to treatment, including crisis
intervention, pharmacotherapy, psychotherapy, and strengthening of social support
networks.
Psychotherapy in combination with antidepressant medication may be needed if any of
the following symptoms are present: severe insomnia, severe anxiety, marked
anhedonia, thoughts of suicide, or intrusive thoughts of harm to the infant.5 Medication
may also be the preferred method of treatment in women who decline psychotherapy, or
who have required medication to treat depression in the past.
Postpartum Medications and Lactation
While there are not absolute contraindications to using a particular antidepressant
medication while breastfeeding, there are no specific FDA-approved antidepressants
labeled for peripartum use.46 If pharmacotherapy is preferred during the postpartum
period, it is recommended to use SSRIs as the first line of therapy.47 (UW Health Low
quality evidence, weak recommendation) Therefore, initiation or continuation of medication
should not interfere with the decision to begin or continue breastfeeding.
If the woman is breastfeeding, some agents may be preferred over others. Despite
differences in relative infant exposure between individual SSRIs, the probability of an
adverse event with SSRIs is remote. 42,47-51 Mothers should be maintained on SSRIs
that work best for them. If a medication is effective for the management of depression, it
is not advisable to change breastfeeding mothers to another SSRI.47
Sertraline and paroxetine may be preferred SSRIs, based on the relatively low
exposure through breast milk.47 Exposure is determined by evaluating the concentration
of the medication in the mother’s milk factored by the amount of milk the infant usually
receives. The remaining SSRIs, as well as bupropion and venlafaxine, are not known
to be contraindicated in nursing women, but less information is known about these
medications during lactation. A decision to use these medications should be based on
a patient-specific risk-benefit evaluation, and the infant should be observed closely for
side effects.52
Fluoxetine is not considered a first-line agent for women who are breastfeeding. The
relative exposure of the infant through breast milk is higher than other SSRIs (9%)
probably due to the long half-life and active metabolite.47 Fluoxetine has had several
case reports of adverse effects in the infant, including colic, delayed weight gain,
irritability, and disturbed sleep.43,53 For this reason, fluoxetine should generally not be
considered first line treatment with a new diagnosis of depression.
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The relative infant exposure to tri-cyclic antidepressants is low and they are well
tolerated by the infant. TCAs are seldom used due to maternal adverse effects, but may
present a safe option when SSRIs are not effective or tolerated.47
Perform Follow-up Care
Acute phase of treatment (first 6-12 weeks) aims to resolve all signs and symptoms
of the current episode of depression and to restore psychological and occupational
functioning (a remission).5
Patient non-compliance is high in those with depression, and the practitioner must
assertively engage the patient in follow-up care and assessments. Proactive follow-up
contacts (by telephone or in person clinic visits) based on the Collaborative Care model
can significantly decrease depression severity.14,29-31
Recommended contacts for adult patients based upon depression severity are outlined
below (Table 5)14 (UW Health Low quality evidence, weak recommendation), however certain
patient populations (i.e., new onset, unstable) may require more frequent contacts and
closer observation. Similar contact frequencies for adolescents are appropriate, with the
addition of monthly contacts to parents to discuss treatment adherence and response.54
(UW Health Moderate quality evidence, weak recommendation)
All patients being treated with antidepressants for any indication should be monitored
appropriately and observed closely for clinical worsening, suicidality, and unusual
changes in behavior, especially during the initial few months of a course of drug therapy
or at times of dose changes, either increases or decreases.
Table 5. Suggested Follow-up Contacts Based on Depression Severity14,54
Symptom
Severity
(based on
total PHQ-9
or PHQ-A
scores)
Mild (5-9 pts.)
If no improvement after one month,
consider referral to Behavioral Health for
evaluation
Moderate (10-14 pts.)
Initially consider weekly contacts to
ensure adequate engagement, then
repeat monthly
Moderately severe (15-19 pts.)
Initially consider weekly contacts to
ensure adequate engagement, then
repeat a minimum of every 2-4 weeks
Severe (20-27 pts.) Weekly contacts until less severe
Note: Parents of adolescent patients may be contacted monthly to discuss
treatment adherence and response.
Assessment of Treatment Response
No psychotherapy should be continued unmodified if there is no symptomatic
improvement after one month.5 (APA Grade I)
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Treatment response should be assessed using the PHQ-9 or PHQ-A within 4-6 weeks
of initiation in patients on drug therapy (alone or in combination with psychotherapy).5,34
(APA Grade II) Most patients respond partially to medication within 2-3 weeks and full
symptom remission is typically seen in 6-8 weeks.5 Patients receiving psychotherapy
alone should be assessed using the PHQ-9 or PHQ-A within 6-12 weeks of initiation,
depending on the expectation of the given type of therapy.5 Patients who demonstrate
remission or a response (defined as a 50% or greater reduction in symptoms as
measured by the PHQ-9 or PHQ-A) should move into the continuation phase.14,34
Treatment response should be assessed using the PHQ-9 or PHQ-A within 4-8 weeks
for adults or 8-10 weeks for adolescents, following any change in treatment particularly
if the change was due to a lack of response to previous therapy.5,34 (APA Grade I)
Adjusting Treatment if No Response- Stepped Care Approach
Treatment in the acute phase should not be discontinued prematurely in patients who
do not fully respond at the initial assessment. (APA Grade I) If the patient does not
demonstrate a response to pharmacotherapy (alone or in combination with
psychotherapy) within 6 weeks (4 weeks in severely ill) of initiation, or responds only
partially by 12 weeks, other treatment options should be considered (APA Grade I)
including:5
ξ Assess medication adherence
ξ Continue medication at a corrected dose
ξ Change medication (APA Grade II)
ξ Augment with a second medication (not advised until initial trial adequate in time
and dosage)
ξ Refer for professional psychotherapy. Most patients receiving time-limited
psychotherapy respond partially by 5-6 weeks and fully by 10-12 weeks.
ξ Obtain a Behavioral Health consultation
Patients receiving psychotherapy alone who do not respond initially to treatment should
consider augmentation with pharmacotherapy, assessing the frequency of sessions and
whether the type of therapy or therapeutic alliance is addressing the patient’s needs.5
(APA Grade I)
Continuation phase (4 - 9 months beyond acute treatment) is intended to prevent
relapse by continuing the treatment of antidepressants, psychotherapy, or other
therapies (i.e., ECT). Given the significant risk of relapse during the continuation phase,
it is essential to assess depressive symptoms, functional status, and quality of life using
the PHQ-9 or PHQ-A.5 (APA Grade II) Following remission or a response, patients should
be contacted monthly during the continuation phase to monitor for relapse.30,54 (UW
Health Moderate quality evidence, weak recommendation)
It is strongly recommended that adult patients on pharmacotherapy continue therapy for
4-9 months following successful acute phase treatment.5 (APA Grade I) Adolescent
patients should continue medication for 6-12 months.34 Continuation of psychotherapy
such as CBT is also recommended.5 (APA Grade I) Patients who continue psychotherapy
should be reassessed every 3-4 months to ensure adequate improvement.5
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Once the patient has been asymptomatic for at least 4 to 9 months following a
depressive episode, recovery from the episode is declared. At recovery, treatment may
be stopped unless the patient is considered at high risk for recurrence. Maintenance
therapy should be considered in high risk patients experiencing three or more prior
major depressive episodes (APA Grade I), or two prior episodes and any of the following
risk factors(APA Grade II):5
ξ Chronic major depressive disorder (severe prior episodes)
ξ Presence of residual symptoms
ξ Ongoing psychosocial stressors
ξ Early age at onset
ξ Family history of mood disorders
Prior to discontinuation of treatment, patients should be informed of the potential for
relapse and a plan should be established to seek treatment if symptoms reoccur.5 (APA
Grade I) The discontinuation of antidepressant therapy should be tapered over at least
several weeks in adults5 (APA Grade I) and over 2-3 months in adolescents.34 It is
important to notify patients receiving psychotherapy of discontinuation, well in advance
of the last session.5 (APA Grade I)
Maintenance phase (1 year to lifetime beyond continuation therapy) is aimed at
preventing new or future depressive episodes. Adult (APA Grade I) or adolescent (UW
Health Very low quality evidence, weak recommendation) patients who have had three or more
episodes of depression or at high risk for recurrence should be considered for long-term
maintenance medication therapy (antidepressant).5,34 Patients should be contacted
throughout the maintenance phase every 3-12 months if stable.14
Recurrent depression is common in elderly patients. Therefore, maintenance therapy
with an SSRI is recommended. Interpersonal psychotherapy alone is not effective in this
population.14,55 (UW Health High quality evidence, strong recommendation)
Management of Medication Side Effects
Side effects are common with SSRIs, SNRIs, mirtazapine, and bupropion but can be
managed for most patients. See Appendix G for a list of common side effects and
alternative options.
To minimize GI distress, headache, and agitation associated with starting an SSRI or
SNRI, start at half of the target dose for 1 week then increase to the full amount. If the
patient complains of side effects, you can recommend cutting the dose in half and
titrating even more slowly (e.g., starting with 5 mg of citalopram, increasing to 10, then
15, then 20 mg). Taking at bedtime with a little food will also minimize nausea. If slow
titration is not effective in minimizing these side effects, (GI distress, agitation, or
headache), you may need to consider using another SSRI, SNRI, bupropion,
mirtazapine, duloxetine, or a TCA instead. Mirtazapine is particularly helpful for patients
who experience akathisia, or intense restlessness that causes them to pace.56
While the above side effects usually go away with time, sedation and sexual side effects
of SSRIs and SNRIs persist and are dose dependent. For sedation, switching to
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31
escitalopram, venlafaxine, or bupropion is often helpful, as these are the least sedating
antidepressants. An initial strategy for reducing sexual side effects can be lowering the
dose by 25-50% if the patient is stable and willing. Alternatively, bupropion can be
added to an SSRI to minimize sexual side effects by as much as 80%. A dose of 300
mg a day is recommended6 – lower doses are not as effective. Bupropion may also be
helpful for patients who complain of lethargy, amotivation, tobacco dependence, or poor
concentration. A final option is to add buspirone to the SSRI/SNRI. This is the best
choice when the patient has comorbid anxiety that might worsen with bupropion. Start
with 5 mg BID for 1 week then increase by 10 mg a week to a target dose of 30-60 mg a
day. The dose-limiting side effect for most people is dizziness, which can be managed
by giving a higher dose at night than in the morning.57,58
The chronic side effects of bupropion are similar to the effects of caffeine: jitteriness,
anxiety, sleeplessness, and tremor. Short term side effects include decreased appetite,
and nausea. If a person becomes too stimulated with bupropion, you will have to either
lower the dose or change to another medication.5
Mirtazapine’s two persistent side effects are sedation and weight gain. There is little that
can be done to minimize these, although the daytime sedation does improve with time;
therefore, switching to another medication is warranted if these side effects are
problematic.5
Venlafaxine should always be started at 37.5 mg and titrated by this amount every 4-5
days to a target dose of 75-150 mg. A more abrupt titration will almost always cause
agitation. It does not become an “SNRI” until at least 112.5 mg – so if it is being used for
this purpose, it is best to increase to a target dose of 150 mg at the start of treatment.5
In patients who are sensitive to most medication, duloxetine or escitalopram are often
well tolerated when started at the lowest possible dose (2.5 mg for escitalopram and 20
mg for duloxetine) and titrated very slowly.
Special Considerations for Older Adult Patients (65 years or older)
Older adults are also more likely to experience the side effects such as falls, sedation or
cognitive impairment.59
In adults age 65 and older SSRI’s and SNRI’s may cause hyponatremia. A plasma
sodium should be checked at baseline 2-3 weeks after initiation and 2-3 weeks after
each titration. Patients should be educated about the symptoms of hyponatremia.60
Citalopram should not be prescribed at doses higher than 40 mg per day due to a risk of
QT prolongation. In patients 60 years and older the maximum dose is 20 mg per day.
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32
UW Health Implementation
Potential Benefits:
ξ Appropriate screening, diagnosis and treatment of depression
ξ Improved patient outcomes in terms of symptoms, quality of life, functioning, and
medical utilization
Potential Harms:
ξ Side effects and adverse effects associated with various treatments (i.e., increased
risk for suicidal ideation in adolescents taking SSRIs)
Implementation Plan/Tools
1. Guideline will be housed on U-Connect on the UW Health CPG webpage.
2. Release of the guideline will be advertised in the Clinical Knowledge Management
Corner within the Best Practice newsletter.
3. Links to this guideline will be updated and/or added in appropriate Health Link or
equivalent tools, including:
Smart Sets
Depression [77]
Disclaimer
CPGs are described to assist clinicians by providing a framework for the evaluation and
treatment of patients. This Clinical Practice Guideline outlines the preferred approach
for most patients. It is not intended to replace a clinician’s judgment or to establish a
protocol for all patients. It is understood that some patients will not fit the clinical
condition contemplated by a guideline and that a guideline will rarely establish the only
appropriate approach to a problem.
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33
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27. Epstein LJ, Kristo D, Strollo PJ, et al. Clinical guideline for the evaluation, management
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44. Källén BA, Otterblad Olausson P. Maternal use of selective serotonin re-uptake
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55. Reynolds CF, Dew MA, Pollock BG, et al. Maintenance treatment of major depression in
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Antipsychotic-induced Akathisia. Annals of Pharmacotherapy. 2008;42(6):841-846.
57. Norden M. Buspirone treatment of sexual dysfunction associated with selective serotonin
re-uptake inhibitors. Depression. 1994;2(2):109-112.
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adults: a 12-week prospective study. Arch Intern Med. Feb 2004;164(3):327-332.
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Appendix A. Rating Schemes for the Strength of the
Evidence/Recommendations
Grading of Recommendations Assessment, Development, and Evaluation (GRADE)
Figure 1: GRADE Algorithm
GRADE Ranking of Evidence
High We are confident that the effect in the study reflects the actual effect.
Moderate We are quite confident that the effect in the study is close to the true effect, but it is also
possible it is substantially different.
Low The true effect may differ significantly from the estimate.
Very Low The true effect is likely to be substantially different from the estimated effect.
GRADE Ratings for Recommendations
Strong for using/
Strong against using
The net benefit of the treatment is clear, patient values and circumstances are
unlikely to affect the decision.
Weak for using/
Weak against using The evidence is weak or the balance of positive and negative effects is vague.
American Academy of Family Physicians
SORT Evidence Rating System
A Consistent, good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, disease-oriented evidence, usual practice, expert opinion or case
series
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2015CCKM@uwhealth.org

37
American Academy of Pediatrics11,28
Level of Supporting Evidence- Oxford Centre for Evidence-based Medicine
A Consistent, good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, disease-oriented evidence, usual practice, expert opinion or case
series
AAP Recommendation Strength
Very strong > 90% agreement
Strong > 70% agreement
Fair > 50% agreement
Weak < 50% agreement
American Psychiatric Association5
APA Grading Scheme
I Recommended with substantial clinical confidence
II Recommended with moderate clinical confidence
III May be recommended on the basis of individual circumstances
United States Preventive Services Task Force (USPSTF)
USPSTF Grade Definitions
A The USPSTF recommends this service. There is high certainty that the
net benefit is substantial.
B
The USPSTF recommends this service. There is high certainty that the
net benefit is moderate or there is moderate certainty that the net benefit
is moderate to substantial.
C
The USPSTF recommends selectively offering or providing this service to
individual patients based on professional judgment and patient
preferences. There is at least moderate certainty that the net benefit is
small.
D
The USPSTF recommends against the service. There is moderate or high
certainty that the service has no net benefit or that the harms outweigh the
benefits.
I
Statement
The USPSTF concludes that the current evidence is insufficient to assess
the balance of benefits and harms of the service. Evidence is lacking, of
poor quality, or conflicting, and the balance of benefit and harms cannot
be determined.
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2015CCKM@uwhealth.org

Appendix B. Depression Screening Algorithm
Adults (18 years or older)Adolescents (12-17 years) Pregnant Women (12 years or older)
Perform universal annual
screening or assessment based
on symptoms/patient
presentation using the PHQ-2
Screen at the
first prenatal visit, during the 3
rd

trimester (24-32 weeks), and 6
weeks postpartum using the EPDS,
PHQ-9 or PHQ-A.
PHQ-2 score
3 or greater?
Perform follow-
up assessment
using the PHQ-9
or PHQ-A
Yes
Complete
documentation.
Repeat screening in
one year or next
visit.
No
PHQ-9 or PHQ-
A score > 10?
Document follow-up plan (which must contain one or more of the following):
- additional evaluation for depression
- suicide risk assessment
- referral to a practitioner who is qualified to diagnose and treat depression
- pharmacological interventions
- other interventions or follow-up for the diagnosis and treatment of depression
Yes
No
Perform universal annual
screening or assessment based
on symptoms/patient
presentation using the PHQ-2
PHQ-2 score
3 or greater?
Perform follow-
up assessment
using the PHQ-9
Yes
PHQ-9 score
> 10?
Complete
documentation.
Repeat screening
in one year or
next visit.
No
No
EPDS score
> 10?
PHQ-9 or PHQ-A
score > 10?
Complete
documentation.
Repeat screening if
necessary.
No
Affirmative
response to
Question 10?
Perform suicide assessment.
Consider accessing crisis
intervention services.
Yes
No
Yes
Yes
Establish a diagnosis using DSM-5 Criteria
Provide treatment
Refer to Treatment Algorithm for Depression in Adults Refer to Treatment Algorithm for Depression in Pregnant Women
Refer to Treatment Algorithm for Depression in Adolescents
Last reviewed: 04/2015
Last revised: 04/2015
Contact CCKM for questions.
Depression – Pediatric/Adult –
Ambulatory Clinical Practice Guideline
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2015CCKM@uwhealth.org

Appendix C. Depression Treatment in Adolescents Algorithm
Diagnosis of Depression
Mild Severity
(PHQ-9 or PHQ-A
score 5-9 points)
Moderate Severity
(PHQ-9 or PHQ- A score 10-19
points)
Severe Severity
(PHQ-9 or PHQ-A score
20-27 points)
Initiate
psychotherapy
alone
(i.e., CBT or IPT)
Initiate psychotherapy alone
(i.e., CBT or IPT),
pharmacotherapy alone, or
combination therapy
(psychotherapy and
medications)
Initiate
pharmacotherapy
or ECT
Assess Initial Response using PHQ-9 or PHQ-A
At 4-6 weeks if pharmacotherapy (alone or in
combination) or 6-12 weeks if psychotherapy alone
Response?*
Prevent Relapse
If on mediations , continue for
6-12 months.
If receiving psychotherapy alone,
continue for 3-4 months.
Yes
Consider referral to Behavioral
Health at any time, especially if:
ξ Possibility of bipolar disorder
ξ Psychiatric co-morbidity (i.e.,
substance abuse, anxiety, OCD,
eating disorder)
ξ Concern regarding the
possibility of suicide and/or
homicide
ξ Psychosis with depression
ξ No improvement with
medications despite multiple
dose adjustments and trials of
different medication classes
ξ Significant or prolonged
inability to work and care for
self and/or family
ξ Diagnostic uncertainty
Last revised: 04/2015
Last reviewed: 04/2015
Contact CCKM with questions.
Adjust or Change Therapy
Stepped Care Approach
Consider:
- Assessing therapy adherence
- Adju sting medication dose or class
- In creasing number of therapy sessions
- Augmenting or changing therapy type
- Referral to Behavioral Health
No
ACUTE PHASE
(6-12 weeks)
Contact patient every 1-2
weeks to assess
treatment adherence and
response. Check in with
parents monthly.
C ONT INUATION PHASE
(4-9 months)
Contact patient monthly for
up to 12 months.
MAINTENANCE
PHASE
(1 year to lifetime)
Assess Response using PHQ-9 or PHQ-A
Full symptom
remission?**
Assess Response using PHQ-9
or PHQ-A
8-10 weeks following change
in treatment
Adjust Treatment
and return to Acute
Phase
No
High risk for
recurrence?
Yes
Discontinue Treatment
- Tap er antidepressants over 2-3 months
- Notify patient prior to final psychotherapy session
No
Continue
pharmacotherapy and
contact patient every 3-
12 months if stable.
Yes
Risk factors for recurrence:
3 or more major depressive episodes OR 2 prior
episodes and any of the following factors:
- Chronic major depressive disorder
- Presence or residual symptoms
- Ongoing psychosocial stressors
- Early age at onset
- Family history of mood disorders
*Response : a 50% or greater reduction in symptoms (as measure by the PHQ-9).
**Remission : the absence of depressive symptoms, or the presence of minimal
depressive symptoms (PHQ-9 score < 5 points)
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2015CCKM@uwhealth.org
Depression- Pediatric/Adult –
Ambulatory Clinical Practice Guideline

Appendix D. Depression Treatment in Adults Algorithm
Diagnosis of Depression
Mild Severity
(PHQ-9 score 5-9
points)
Moderate Severity
(PHQ-9 score 10-19 points)
Severe Severity
(PHQ-9 score 20-27
points)
Initiate
psychotherapy
alone and/or
behavioral
activation
Response
after
4 weeks?
Consider
referral to
Behavioral
Health
No Yes
Initiate psychotherapy alone
(i.e., CBT or IPT),
pharmacotherapy alone, or
combination therapy
(psychotherapy and
medications)
Initiate
pharmacotherapy
or ECT
Assess Initial Response using PHQ-9
At 4-6 weeks if pharmacotherapy (alone or in
combination) or 6-12 weeks if psychotherapy
alone
Response?*
*Response : a 50% or greater reduction in symptoms (as measure by the PHQ-9).
**Remission : the absence of depressive symptoms, or the presence of minimal
depressive symptoms (PHQ-9 score < 5 points)
Prevent Relapse
If on mediations , continue for 4-9
months.
If receiving psychotherapy alone,
continue for 3-4 months.
Yes
Consider referral to Behavioral
Health at any time, especially if:
ξ Possibility of bipolar disorder
ξ Psychiatric co-morbidity (i.e.,
substance abuse, anxiety, OCD,
eating disorder)
ξ Concern regarding the
possibility of suicide and/or
homicide
ξ Psychosis with depression
ξ No improvement with
medications despite multiple
dose adjustments and trials of
different medication classes
ξ Significant or prolonged
inability to work and care for
self and/or family
ξ Diagnostic uncertainty
Last revised: 04/2015
Last reviewed: 04/2015
Contact CCKM with questions.
Depression- Pediatric/Adult –
Ambulatory Clinical Practice Guideline
Adjust or Change Therapy
Stepped Care Approach
Consider:
- Assessing therapy adherence
- Adjusting medication dose
- Increasing number of therapy sessions
- Augmenting or changing therapy type
- Referral to Behavioral Health
No
ACUTE PHASE
(6-12 weeks)
Contact patient
weekly, then monthly
(moderate severity), or
every 2-4 weeks
(moderately severe).
Patients with severe
depression should be
contacted weekly until
symptoms less severe.
C ONT INUATION PHASE
(4-9 months)
Contact patient monthly for
up to 12 months.
MAINTENANCE
PHASE
(1 year to lifetime)
Assess Response Monthly
using PHQ -9
Full symptom
remission?**
Assess Response using PHQ-9
4-8 weeks following change in
treatment
Adjust Treatment
and return to Acute
Phase
No
High risk for
recurrence?
Yes
Discontinue Treatment
- Taper antidepressants over several weeks
- Notify patient prior to final psychotherapy session
No
Continue
pharmacotherapy and
contact patient every 3-
12 months if stable.
Yes
Risk factors for recurrence:
3 or more major depressive episodes OR 2 prior
episodes and any of the following factors:
- Chronic major depressive disorder
- Presence or residual symptoms
- Ongoing psychosocial stressors
- Early age at onset
- Family history of mood disorders
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2015CCKM@uwhealth.org

Pregnant Patient Diagnosed with Depression
Appendix E. Depression Treatment during Pregnancy Algorithm
Currently taking
antidepressant?
Mild/Moderate
Severity
Moderate/
Severe Severity
New
diagnosis?
YesNo
Willing to
discontinue?
Continue
pharmacotherapy
after discussion of
risks and benefits;
monitor symptoms
No Yes
Psychotherapy
(IPT or CBT)
Positive
response?
Continue
psychotherapy;
monitor symptoms
Yes
Willing to
consider
medication?
No
Consider medication in
addition to
psychotherapy; monitor
symptoms
Yes
Past relapse
after stopping
medication?
Yes
Consider tapering
antidepressant,
monitor for relapse
and refer to
psychotherapy
No
Severity
moderate to
severe?
No
Consider
referral to
Psychiatry
Yes
No
Last reviewed: 04/2015 | Last revised: 04/2015
Contact CCKM for questions.
Depression – Pediatric/Adult – Ambulatory Clinical Practice Guideline
Reference: Yonkers KA, Wisner KL, Stewart DE, et al. The management of depression during pregnancy: a report from the American
Copyright © 201 5University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2015CCKM@uwhealth.org

42
Appendix F. Consideration of Concurrent Conditions
Depression With First-Line Therapeutic Options* May be Problematic
No Additional Comorbid
Conditions
Fluoxetine, Citalopram, Escitalopram,
Paroxetine, Sertraline, Trazodone, Mirtazapine,
Venlafaxine, Desvenlafaxine, Bupropion
TCA-side effect profile less desirable
Nefazodone-hepatotoxicity
Pregnancy Sertraline, Citalopram, Fluoxetine, TCA Paroxetine, Venlafaxine, Duloxetine
Elderly patients Fluoxetine, Paroxetine
Alcohol Use
Duloxetine=Liver injury, as manifested by ALT
and total Bilirubin elevations, with evidence of
obstruction have occurred with coadministra-
tion of alcohol and Duloxetine.
Anxiety or Panic
Disorder
Paroxetine, Fluoxetine, Mirtazapine, Sertraline,
Citalopram, Escitalopram
Venlafaxine, Desvenlafaxine
Bupropion-may increase anxiety
Cardiac Condition Sertraline
TCA Venlafaxine Desvenlafaxine, Bupropion
(increases blood pressure). Mirtazapine
(increases cholesterol), Citalopram
Chronic Pain TCA, SNRI such as Duloxetine
Decreased Appetite TCA, Mirtazapine Venlafaxine Desvenlafaxine SSRI
Dementia Bupropion, Mirtazapine, Citalopram
Dementia, Head Injury,
Post-Stroke Patients Citalopram, Escitalopram, Sertraline TCAs, Paroxetine, Mirtazapine, Bupropion
Diabetes Fluoxetine, Citalopram, Escitalopram, Paroxetine, Sertraline
TCAs, Mirtazapine (may increase
carbohydrate cravings), Duloxetine (causes
slowed gastric emptying), Paroxetine
Eating Disorders
(anorexia, bulimia) Fluoxetine, Paroxetine, Sertraline Bupropion, Mirtazapine
Fibromyalgia Duloxetine, Venlafaxine
Glaucoma Fluoxetine, Citalopram, Escitalopram, Sertraline, Bupropion
TCA, Paroxetine, Duloxetine, Venlafaxine,
Desvenlafaxine
Lactation Sertraline, Paroxetine Fluoxetine
Liver Disease Sertraline, Venlafaxine (use at low dose) , Desvenlafaxine (use at low dose)
TCAs, Fluoxetine, Paroxetine, Citalopram,
Escitalopram, Trazodone, Mirtazapine,
Nefazodone, Duloxetine
Obsessive Compulsive
Disorder
Fluoxetine, Citalopram, Escitalopram,
Sertraline, Paroxetine
Parkinson’s Disease Bupropion, Trazodone, Desipramine, Amoxapine, Nortriptyline, Protryptyline
SSRIs, Venlafaxine, Desvenlafaxine,
Nefazodone, Mirtazapine
Pheochromocytoma Selegiline patch
Renal Disease Fluoxetine, Citalopram, Escitalopram,
Sertraline
Mirtazapine, Paroxetine, Venlafaxine,
Desvenlafaxine, TCA-levels not predictive
Seizures/Seizure
Disorder
Fluoxetine, Citalopram, Escitalopram,
Sertraline, Paroxetine
Bupropion, Maprotiline, TCA (in overdose),
Duloxetine, Venlafaxine Desvenlafaxine
Symptoms of:
insomnia, weight loss,
or overstimulation
Mirtazapine, Trazodone, TCAs, Paroxetine
Venlafaxine, Desvenlafaxine, SSRI,
Bupropion
Symptoms of:
oversedation, weight
gain, or lethargy
Bupropion, Venlafaxine, Desvenlafaxine
Mirtazapine, TCA, Trazodone, Fluoxetine,
Sertraline, Citalopram, Escitalopram,
Paroxetine
*Prior to selecting an individual agent for therapy, prescribers should screen for other medications and
supplements that may cause problematic effects for the patient.
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2015CCKM@uwhealth.org

43
Appendix G. Depression Side Effect Profiles
Side effects may be observed early in pharmacotherapy treatment and improve over
time. If side effects persist, alternatives may be considered.5
Presenting Symptom First Line Therapeutic Options May Be Problematic
Agitation/Insomnia Mirtazapine, TCA
Selegiline Patch, Fluoxetine,
Sertraline, Paroxetine,
Citalopram, Escitalopram,
Bupropion, Venlafaxine,
Desvenlafaxine
Anticholinergic Side Effects
(dry mouth, blurred vision,
constipation, urinary
retention)
Citalopram, Escitalopram,
Fluoxetine, Sertraline, Venlafaxine,
Desvenlafaxine, Bupropion
TCA, Mirtazapine, Paroxetine,
Duloxetine, Selegiline Patch
GI Sensitivity Bupropion, TCA, Mirtazapine
Fluoxetine, Sertraline, Paroxetine,
Citalopram, Escitalopram,
Nefazodone, Venlafaxine,
Desvenlafaxine, Duloxetine (20%
pts nausea)
Headache TCA, Mirtazapine
Fluoxetine, Sertraline, Paroxetine,
Citalopram, Escitalopram,
Nefazodone, Venlafaxine,
Desvenlafaxine, Bupropion,
Selegiline Patch
Orthostatic Hypotension
Fluoxetine, Sertraline, Paroxetine
Citalopram, Escitalopram,
Venlafaxine, Desvenlafaxine,
Bupropion
TCA, Mirtazapine, Trazodone,
Selegiline Patch
Sedation
Fluoxetine, Sertraline, Paroxetine,
Citalopram, Escitalopram, Venlafax-
ine, Desvenlafaxine, Bupropion
TCA, Nefazodone, Trazodone,
Mirtazapine, Selegiline Patch,
Paroxetine
Sexual Dysfunction Bupropion, Mirtazapine
Fluoxetine, Sertraline, Paroxetine,
Citalopram, Escitalopram,
Venlafaxine, Desvenlafaxine,
Bupropion, Trazodone
Weight Gain
Fluoxetine, Sertraline, Citalopram,
Escitalopram, Venlafaxine,
Desvenlafaxine, Bupropion
TCA, Paroxetine, Mirtazapine,
Trazodone
Special Considerations for Older Adults (age 65 years or older) 5,59,61
Poor sleep/Insomnia Mirtazapine Benzodiazepines, Paroxetine
Weight loss Mirtazapine
Anxiety SSRIs, SNRIs
Hypersomnia and low energy Bupropion
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2015CCKM@uwhealth.org

44
Appendix H. Product and Dosage Chart
Product How Supplied Dosage Ranges Generic?**
SELECTIVE SEROTONIN REUPTAKE INHIBITORS
Citalopram
(Celexa)
10, 20, 40mg scored tab
10mg/4mL soln 20-40mg daily Yes
Escitalopram
(Lexapro)
5mg unscored, 10 and 20mg scored
tab 5mg/ 5mL 10-20mg daily Yes
Fluoxetine
(Prozac)
10, 20, 40 cap
90mg delayed release cap
10 mg, 20mg tab
20mg/5mL soln
10-80mg daily or
90mg weekly Yes
Paroxetine
(Paxil, Paxil CR)
10, 20mg scored tab
30, 40mg tab
10mg/5mLsusp
12.5, 25 mg, 37.5mg CR
10-60mg IR daily or
25-62.5mg CR daily
Yes
(includes CR)
Sertraline
(Zoloft)
25, 50, 100mg scored tab
20mg/mL concentrate 50-200mg daily Yes
Trazodone*
(Oleptro) 50, 100, 150, 300mg IR tab ER 150, 300mg
150-600mg IR daily in divided
doses
150 mg ER daily
Yes
Vilazodone (Viibryd) 10, 20, 40mg tablets 20 – 40mg once daily No
Vortioxetine (Brintellix) 5, 10, 15, 20 mg tablets 5 – 20mg once daily No
NOREPINEPHERINE SEROTONIN REUPTAKE INHIBITORS
Desvenlafaxine (Pristiq) 50, 100mg tab 50 daily Yes
Duloxetine (Cymbalta) 20, 30, 60mg cap 40-60mg daily Yes
Levomilnacipran (Fetzima) 20, 40, 80, 120mg ER capsules 40 – 120mg daily following
20mg X2day titration No
Mirtazapine
(Remeron)
7.5, 15, 30, 45 mg tab
15, 30, 45mg ODT 15-45mg daily
Yes
(includes ODT)
Venlafaxine
(Effexor, Effexor XR)
25, 37.5, 50, 75, 100mg IR tab
37.5, 75, 150, 225mg ER tab
37.5, 75, 150mg ER cap
75-225mg IR daily in divided
doses
37.5-75mg ER daily
Yes
(includes ER)
DOPAMINE REUPTAKE INHIBITOR
Bupropion
(Wellbutrin, Aplenzin)
75, 100mg IR tab
100, 150, 200mg SR tab
150, 300mg XL tab
174, 348, 522mg ER tab
100-150 mg IR TID
150-200mg SR BID
150-450 mg XL daily
(hydrochloride salt)
174-522 mg ER daily
(hydrobromide salt)
Yes
(includes ER &
XL but not
Aplenzin
products)
TRI-CYCLIC ANTIDEPRESSANTS*
amitriptyline 10, 25, 50, 75, 100, 150 mg tab 50-150mg daily at bedtime or
in divided doses
Yes
amoxapine 25, 50, 100, 150mg tab 50mg BID-TID Yes
desipramine 10, 25, 50, 75, 100, 150mg tab 100-300mg daily in
divided or single doses
Yes
doxepin
10, 25, 50, 75, 100, 150mg cap
10mg/mL conc
25-300mg daily in
divided or single doses
Yes
imipramine 10, 25, 50mg tab
75, 100, 125, 150mg cap 75-200mg daily Yes
maprotiline 25, 50, 75mg tab 75-150 mg daily in divided or
single dose
Yes
nortriptyline
10, 25, 50, 75mg cap
10mg/5mL soln
75-150mg daily in
divided or single doses
Yes
MONOAMINE OXIDASE INHIBITORS
phenelzine (Nardil) 15mg tab 15mg TID Yes
selegiline transdermal
(Emsam) 6, 9, 12mg/25 hr patch
6mg/24hr patch every 24
hours
No
Tranylcypromine (parnate) 10mg tab 30mg daily in divided doses Yes
*For TCA’s and trazodone, there are therapeutic blood levels that should be done if patient does not respond to
therapeutic dose. **Insurance coverage varies. Patients are less likely to take their medication if they cannot afford it.
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2015CCKM@uwhealth.org

45
Appendix I. Depression HEDIS Measure
Antidepressant Medication Management (AMM)
The percentage of members 18 years of age and older with a diagnosis of major
depression and prescription for an antidepressant medication, who remained on
antidepressant medication treatment. Two rates are reported:
Effective Acute Phase Treatment – percentage of members who remained on
an antidepressant medication for at least 84 days (12 weeks.) Members are
allowed 30 gap days in treatment, so actually looking for 84 days of medication
treatment over the course of 114 days from the Index Prescription Start Date
(IPSD.)
Effective Continuation Phase Treatment – percentage of members who
remained on an antidepressant medication for at least 180 days (6 months.)
Members are allowed 51 gap days in treatment, so actually looking for 180 days
of medication treatment over the course of 231 days from IPSD.
Intake period – The 12-month window starting on May 1 of the year prior to the
measurement year and ending on April 30 of the measurement year.
Index Prescription Start Date (IPSD) – Earliest Rx for an antidepressant during the
Intake Period (for example, for HEDIS™ 2015, we are looking for the 1st Rx filled
between May 1, 2013 and April 30, 2014.)
Member must not have filled an Rx for an antidepressant within 105 days prior to the
IPSD.
Ok to switch between antidepressants as long as you meet the rules of continuous use,
as described above.
Product line – Commercial, Medicaid, Medicare
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2015CCKM@uwhealth.org