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High levels of depressive symptoms are common and contribute to poorer clinical outcomes even in geriatric patients who are already taking antidepressant medication.

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High levels of depressive symptoms that persist across time are clinically ificant whether or not a patient has received a formal depression diagnosis or is already taking antidepressant medication. Given the negative impact of depression on clinical care and outcomes in medical and surgical patients, these depressed patients require ongoing depression care management Suter et al. Training occupational therapists and other care providers to assist in the delivery further strengthens the intervention.

A key feature of the intervention is that rather than asing depression care management DCM to a specialist, all primary clinicians are expected to manage depression as part of the routine care provided to their patients. The DCM protocol guides clinicians in when and how to take advantage of specialists and other resources. Home care clinicians are expected to manage an array of patients problems in addition to the presenting, mostly acute, conditions and to consult experts as needed.

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Thus the management of depression is treated like the management of many other medical conditions. The purpose of this article is to describe the clinical protocols developed as part of the Depression CAREPATH intervention to guide home care clinicians in the management of depression in their medical and surgical patients.

The intervention also helps home health agencies HHA develop the infrastructure needed to implement and sustain depression care management DCM as part of routine care. Effective use of the DCM protocol by clinicians requires that each HHA tailor key procedures to fit its own resources and routines. For example, HHAs should specify their own guidelines for case coordination so that clinicians will know whom to contact e. Similarly, each HHA should tailor a suicide risk protocol that operationalizes both gradations of suicide risks and the specific steps that should be taken by clinicians at each stage.

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They should also develop a list the mental health resources available in the communities that serve their patients. Each is described, below. The recommended process for identifying patients who require depression care management is illustrated in Figure 1. Patient who screen positive for depressive symptoms on the PHQ-2 should then be assessed with the full PHQ-9 to determine depression severity.

Agencies may, however, decide to use a lower cut-off score on the PHQ-2 as criterion for further assessment or to have nurses conduct a full PHQ-9 later in the visit. More thorough discussion of how to use the PHQ-9 in home healthcare has been discussed elsewhere Ell et al. Home health patients require DCM when they experience clinically ificant depressive symptoms, regardless of whether or not they are currently taking antidepressant medication or have a formal depression diagnosis. The screening protocol identifies clinically ificant depression as a score of: a.

Patients who screen positive for depressive symptoms on the PHQ-2 but score less than 10 on the PHQ-9 may have mild levels of depression. These patients may be evaluated by their physician if judged to be clinically indicated, but, as standard practice, we recommend that such patients be monitored with weekly PHQ-9 scores for two weeks to identify patients whose depression is worsening or those who may have under-reported symptoms at the start of care. Such information on the course of depressive severity is useful for reevaluating the need for DCM.

While monitoring symptoms, it is also recommended that clinicians provide these patients and their families educational materials about depression and depression treatment. The protocol recommends weekly PHQ-2 screening for two weeks for patients who score 2 or less at the start of care. Clinicians have frequently commented that some patients may be more willing to acknowledge depressive symptoms after they have gotten to know the clinician better or when the immediate medical needs that led to home health care are under control.

The protocol should be followed weekly or, for patients seen less frequently, at each visit. For patients whose depression is identified at first visit, the initial DCM visit may be integrated into this visit or as part of a more extended start of care. Each DCM visits involves five basic and interrelated clinical functions: 1. Assessment, beginning with the full PHQ-9; 2. Case coordination; 3.

Medication management; 4. Education of patients and families; and 5. Patient goal setting. Each is described below. The purpose of depression assessment is not to make a formal diagnosis but to identify its presence and follow the course of clinically meaningful symptoms across time. The DCM protocol recommends using the PHQ-9 as an efficient, evidence-based approach to quantifying depression severity and changes in severity over time. Because it was originally developed for use in primary care, many physicians understand the clinical meaning of PHQ-9 scores, thus making communication with physicians easier.

The symptoms assessed by the PHQ-9 parallel those of DSM-IV criteria for major depressive episode, so that physicians and specialists may use the in diagnostic decision making as well as determining severity. The ongoing record or chart of weekly scores is useful in clinical decision making, case coordination, discussions with physicians, and patient education. Evidence of clinically ificant depressive symptoms indicates that some form of treatment may be needed or, for patients already taking an antidepressant, a review and possible change in treatment is required. The steps for case coordination will depend upon the agency and its resources, and should be developed into formal guidelines for clinicians.

It is important, however, that case coordination at some point involve someone with the professional knowledge and authority to make changes in medications, especially for symptomatic patients who are already taking an antidepressant or patients with very high PHQ-9 scores. As discussed above, providing a record or chart of the weekly PHQ-9 scores will be important to clinical decision making in these consultations. Case coordination is most effective when clinicians present information to physicians that is clear, concise, and contains the information needed by physicians for their own decision making.

A Case Presentation Template, shown in Figure 3was developed to facilitate such as a discussion Brown et al. Clinicians who are unable to reach the physician can fax or the pertinent information using this same tool. This information includes clear and unembellished statements regarding the: 1.

Reason for the call; 2. The symptoms of depression, their duration and severity PHQ-9 scoresuicidal ideation, psychiatric history if any ; 4. Key psychosocial factors e. Medical illnesses, medications, and 6. Recommendation for further evaluation by MD or psychiatric nurse. It was found that, with training, case presentations following this template usually take less than two minutes. The Case Presentation Template Figure 3 can be modified for this purpose.

The summary is important to a successful transition of care for patients with short, as well as long, lengths of stay. Antidepressant medication and psychotherapy are the most effective treatments for depression in late life.

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The persistence of symptoms despite antidepressant medication is an indicator that a review of, and possible change in, treatment is indicated. While managing antidepressant medication is similar to general medication management, there are several additional considerations.

In the general population, older patients taking antidepressants are over 2. More generally, finding an effective antidepressant regimen for a specific patient can take time. The therapeutic dose for most antidepressants is not a single value but falls within a range of values. Treating depression often involves changing doses, changing to a different antidepressant or different class of antidepressant or augmenting one medication with another. Therefore, basic knowledge of antidepressant classes and access to information on dosing for specific antidepressants is useful to clinicians in discussions with physicians.

A list of commonly used antidepressants Figure 4 can be useful to clinicians while conducting home visits, although they will want additional information for more complex circumstances. As with other medications, managing antidepressants involves understanding possible side-effects.

An advantage of SSRIs and SNRIs is that serious side effects are rare, although knowledge about how to identify them and when to contact a physician is important. Most side effects are not serious, however, and appear within days after the patient first begins taking the medication or after an increase in dosage. Most are also transient and normally resolve within a few weeks.

Clinicians can help patients with interventions to help them cope with side effects until they resolve. Sometimes patients misinterpret symptoms of depression such as fatigue or lack of appetite as side effects of medication. It is useful to determine whether the symptoms preceded the antidepressant, and if so, reassure patients that the depression, not the antidepressant, is causing the problem.

Like other medications, adherence to antidepressants increases the likelihood of their being effective. A challenge in promoting adherence to antidepressants, however, is that most patients do not respond to antidepressant medication for several weeks. Full remission may take much longer.

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Patients who do not get better quickly may want to stop their medication because they feel discouraged. Similarly, it is usually recommended that antidepressant treatment last a year or more after the acute phase i. Patients who begin to feel better may want to stop taking their medication. Clinicians can intervene by reminding patients that they should never make changes to antidepressant treatment without supervision by their physician or other treating clinician. As discussed below, helping patients understand the purpose of antidepressant medication and dispel myths about depression can also promote adherence Feldman et al.

The more patients and families know what depression is, what causes it and how to treat it, the more likely they will follow the prescribed medication or psychotherapy plan, monitor symptoms and communicate their progress to clinicians. What are the s of serious depression? What causes depression?

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