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Depression - Treatment in Adults Algorithm

Depression - Treatment in Adults Algorithm - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Psychiatry, Related


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- Adult/Pediatric –
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.
CONTINUATION 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 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2015CCKM@uwhealth.org