Non-pharmacologic Treatment of Depression

Public Health Detailers Training NYC Department of Health and Mental Hygiene

Ann M. Sullivan, M.D. Regional Director of Psychiatry for the Queens Health Network New York City Health and Hospitals Corporation

Depression Treatment
Psychotherapy
Alone or as adjunctive therapy

Pharmacotherapy
Effective for major depression and dysthymia Questionable effectiveness in minor depression

Primary care
Education Supportive Counseling Care Management

Psychotherapy
Sometimes referred to as counseling or talk therapy As effective as medication for treating mild to moderate depression. In more severe cases, should be used in conjunction with medication A therapist listens, talks and helps you find new ways of thinking about yourself, the world, your relationships, and the future.

Therapist can be a trained psychologist, social worker, psychiatrist, nurse practitioner, or counselor

*Judy Stein

Psychotherapy
Psychotherapy for depression is not necessarily talking about your childhood More often focused on current concerns and ways to address them Modes of treatment
Individual, group, family or marriage therapy

Significant improvement can usually be made in 10-15 sessions.

*Judy Stein

Evidence-based Psychotherapies
Cognitive-behavioral Therapy (CBT)
Helps to change negative styles of thinking and behaving often associated with depression

Interpersonal Therapy
Clarifies and resolves interpersonal difficulties, ie. role disputes, social isolation, prolonged grief, role transition
*Judy Stein

Evidence-based Psychotherapies
Problem-solving therapy
Teaches patients to address current life difficulties by breaking larger problems into smaller pieces and identifying specific steps toward change

*Judy Stein

PCP Monitoring of Psychotherapy

A referral for psychotherapy does not relieve the referring physician of follow-up obligations
Premature discontinuation of psychotherapy is common Regardless of the type of psychotherapy selected, the patients response to treatment should be carefully monitored

*Judy Stein

PCP Monitoring of Psychotherapy

All treating clinicians must have sufficient ongoing contact with the patient and with each other to ensure that relevant information is available to guide treatment decisions

Some clinical benefits of psychotherapy should be evident in 6 to 8 weeks

*Judy Stein

Making Referrals for Psychotherapy

1-800 LifeNET
www.nmha.org (Therapist Locator) Utilize referral form; includes pcp contact information to maintain ongoing communication between pcp ad mental health specialist
* Judy Stein

Primary Care
Education Supportive Counseling Care Management:
Self-management Adherence Monitoring Progress Monitoring

Patient Education
Dispel negative perceptions/address stigma:
Explain the causes, mechanisms, and impact Compare to other treatable medical illnesses (ie. high blood pressure) Inform patients that antidepressant medication helps correct imbalances in brain chemicals
*Judy Stein

Patient Education
Educate about medical treatment options Effectiveness Onset of action of meds Potential adverse side effects

All patients should be cautioned not to expect immediate symptom relief

may need to take antidepressants for as long as 6 weeks before they experience benefits

If patients know what to expect will be less likely to discontinue meds prematurely

*Judy Stein

Patient Education
Inform patients about non-pharmacologic options

Psychotherapy Self management techniques, incl. physical activity nutrition/diet, social supports, etc.
Type of treatment recommended depends on the type of symptoms, the severity of symptoms and the patients personal preferences

*Judy Stein

Key Educational Messages

For patients starting psychotherapy:
Psychotherapy takes a little longer before you will feel any improvements If you have any problems or are not satisfied with your therapist, call your PCP for assistance

Tell all patients:

If you are feeling worse dont wait until your next appointment. Call pcp office right away!
*Judy Stein

Key Educational Messages

For patients starting antidepressant meds:
Antidepressants only work if taken every day Antidepressants are not addictive Benefits from meds appear slowly Continue meds even after you feel better

*Judy Stein

Key Educational Messages

For patients starting antidepressant meds, cont:
Mild side effects are common and usually improve with time If youre thinking about stopping meds, call clinician first. The goal of treatment is complete remission; sometimes it takes a few tries.

*Judy Stein

PCP Supportive Counseling

Patient Engagement
Educating patients about depression and treatment options facilitates patient-pcp partnership in the care process, enhances adherence to treatment plan

PCPs can further facilitate a relationship with the patient through use of supportive therapy techniques, ie. BATHE pneumonic
Techniques for gathering information and responding to patient emotions that make the patient feel validated and comfortable communicating openly about their condition

*Judy Stein

BATHE pneumonic
Used to elicit information from patients and address mental health concerns in a busy practice

Allows physician to reinforce effective coping strategies and provide general support
*Judy Stein

BATHE pneumonic
Background
Ask open-ended questions to encourage open dialogue

Affect
Ask questions such as How do you feel about that? to encourage patient to talk about his/her feelings
*Judy Stein

BATHE pneumonic
Trouble
Ask What about the situation troubles you most? helps the physician elicit the meaning to the patient of a specific situation Asking How are you handling that? will help the physician assess the patients coping skills and level of functioning
Legitimize a pts reaction to a situation by comments such as That must be very difficult for you.

Handling

Empathy

*Judy Stein

Self Management

The individuals ability to manage the symptoms, treatment, physical and social consequences, and lifestyle changes inherent in living with a chronic condition.

*Judy Stein

Self Management
Empower and prepare patients to manage their health and health care Self management support (SMS): emphasize the patients central role in managing their illness use of effective SMS strategies, ie. assessment, goal setting, action planning, problem-solving, and follow-up organize internal and community resources to provide ongoing self management support to patients
*Judy Stein

Self Management
Self management support goal-setting:
Encourage patient to select one or two small, achievable goals to work on each week for the next several weeks to alleviate some symptoms Goals can include physical activity, pleasurable activities, spending time with supportive people, or relaxing activities Ask how confident patient is on a scale of 1 to 10 that they can accomplish selected goal and address barriers

*Judy Stein

Care Management Definitions

A.

Basic Care Management:

The care manager supports the PCC (Primary Care Clinician by (1) delivering patient education (2) eliciting patient preferences (3) monitoring patient adherence to treatment and response (4) provides feedback to the PCC about patient progress so that any needed changes in management are made in a timely manner. B.

Care Management Plus:

(1) Develop Self-Management Plans (2) Uses problem solving techniques (3) Uses motivational interviewing

Care Management Definitions cont.

C. Care Management as part of primary clinician (PCP, social

worker, Nurse, etc.) responsibilities

Care Management Process

BASICS: 1. Initial follow up call/visit (1-3 weeks) to monitor patient adherence and progress 2. Ensure educational materials are given or can be sent in mail and reinforce if needed 3. During follow up call:
Assess progress with PHQ-9 Assess medication adherence, side effects, questions Assess self-management goal progress Assess compliance with psychotherapy visits if provided

Care Management Process

4. Communicate results to Primary Care clinician and coordinate before next visit or if more urgent intervention is needed Chronic Care Follow up 3 to 6 months follow up calls when patient is in remission and on maintenance therapy Yearly screening calls for patients with prior episodes

5.

Figure II-C TYPICAL CARE MANAGER ACTIVITIES ACROSS THE INTERVENTION*

BASICS:
Office Visit #1: Establishing the Relationship with the Patient PCC introduces concept and purpose of care management and sets first call time. Some practices will provide patient education materials. Others will ask the care manager to mail subsequently. NOTE: Every contact should end with a confirmation of timing of the next call and reminder that PCC will get progress note. Every routine contact has a Care Manager Report completed and sent to PCC (use discretion following PRN calls)
* The MacArthur Initiative on Depression & Primary Care: Care Manager Training Manual

Figure II-C TYPICAL CARE MANAGER ACTIVITIES ACROSS THE INTERVENTION*

Telephone Contact at 1 week: Initial Adherence Contact(s)

If medication prescribed: Verify meds prescribed. Prescription filled? Taking meds? Adverse side effects?
If referred to psychological counseling: Appointment made? First visit kept? Adverse feelings about referral?

If self-management were set: Practicing? If not, need new goals? If no goals set with PCC, assist in setting goals
If patient education materials provided: Reviewed? Any questions? If not provided, get mailing address and send Facilitate next action steps: If does is being titrated upward or mental health appointment not completed, schedule additional adherence contact(s)

* The MacArthur Initiative on Depression & Primary Care: Care Manager Training Manual

Figure II-C TYPICAL CARE MANAGER ACTIVITIES ACROSS THE INTERVENTION*

Optional Telephone Contact(s) between 1 and 4 weeks: Additional Adherence Contact(s) If medication is being titrated: Has increased dose been started? Adverse effects? If mental health referral: Has first visit been completed? If call due to barriers: Any resolution? Next steps including office visit if needed

Telephone Contact at 4 weeks: Assessment of Initial Treatment Response Administer and score PHQ-9. Report results of PHQ-9 to patient, PCC and psychiatrist (before next PCC visit) PCC may request additional care manager contacts if treatment modified. Supervising psychiatrist may also suggest additional visits or make informal consultation contact with PCC. (This holds true for all subsequent calls)

* The MacArthur Initiative on Depression & Primary Care: Care Manager Training Manual

SECTION VII: PLANNING CARE MANAGEMENT CONTACTS AND CONDUCTING CALLS*

BASICS: There are a number of useful principles for care managers who are engaged in telephonic management of chronically ill patients. The principles listed here will help with efficiency and workload over time. Training sessions and supervision calls are used to assist with the implementation of these principles.
Maintain a balance between efficiency (staying on task with completion of the Care Manager Log) and attending to the needs of the patient Acknowledge the patients issues and concerns, yet focus on solutions rather than extensive discussion of the details Identify a clear and attainable plan the patient can follow Offer appropriate assistance with scheduling appointments; locating a mental health specialist; setting self-management goals; and problem solving to overcome barriers to treatment
The MacArthur Initiative on Depression & Primary Care: Care Manager Training Manual

SECTION VII: PLANNING CARE MANAGEMENT CONTACTS AND CONDUCTING CALLS*

Care managers must remember they are not the patients mental health specialist and must be on guard not to slip into such a role in the course of the calls with the patient. Care managers should have an understanding with the organization/practice regarding number of failed call attempts they will make before referring the patient back to the PCC for follow-up. In order to be effective, a range of early morning, mid-day and early evening hours should be available through out the week to initiate calls. This range of hours is not needed on a daily basis but in blocks of time on pre-determined days in order to accommodate patients with work, child care or other responsibilities. Initial calls generally require 15-20 minutes, while calls at any of the 4 week intervals will require approximately 30 minutes. The longer calls at the 4 week intervals are due to a re-administration of the PHQ-9 over the phone with the patient.

* The MacArthur Initiative on Depression & Primary Care: Care Manager Training Manual

CARE MANAGEMENT PLUS

I. MOTIVATIONAL INTERVIEWING

Five Stages of Change: 1. 2. 3. 4. 5. Precontemplation (unaware, not interested in change) Contemplation (thinking about change in the near future) Preparation (making plans to change) Action (actively modifying behavior) Maintenance (Continuation of new healthier behavior)

CARE MANAGEMENT PLUS PROBLEM SOLVING TECHNIQUES BREAK DOWN BARRIERS*

Patient Has Not Begun Taking Medication for the Following Reason(s) Not comfortable with depression diagnosis

PATIENT MIGHT SAY:

I dont really feel depressed. I dont think that I am that depressed. I am really just stressed out.

EXPLORE BY ASKING:
What do you think is going on?
* The MacArthur Initiative on Depression & Primary Care: Care Manager Training Manual

CARE MANAGEMENT PLUS PROBLEM SOLVING TECHNIQUES BREAK DOWN BARRIERS*

INTERVENE BY:

Explaining to the patient that their primary care clinician believed they are depressed and that treatment would be helpful.
Explore what is uncomfortable about the diagnosis (do they know someone who is depressed or seriously mentally ill and perhaps this is frightening to them).

Explore what they believe having depression means and dispel some of the myths.
If a patient continues to be adamant that they do not have depression, acknowledge their stance and focus more on what symptoms they have.

* The MacArthur Initiative on Depression & Primary Care: Care Manager Training Manual

CARE MANAGEMENT PLUS PROBLEM SOLVING TECHNIQUES BREAK DOWN BARRIERS*

For example, suggest that the medication they have been prescribed will help relieve their difficulty sleeping. If after talking further with the patient, you think that he or she is relaxing more about the diagnosis you might mention that depression is a combination of the various symptoms that they are experiencing difficulty sleeping, feeling hopeless, etc. (areas they checked off on the PHQ-9).

* The MacArthur Initiative on Depression & Primary Care: Care Manager Training Manual

CARE MANAGEMENT PLUS PROBLEM SOLVING TECHNIQUES BREAK DOWN BARRIERS* (Continued)
Concerned about addiction PATIENT MIGHT SAY: I dont want to be on the medicine forever. I dont want to become addicted to it. EXPLORE BY ASKING: Have you heard or known about someone who had trouble with the medication being addictive? INTERVENE BY: Informing the patient that the depression medication is not addictive. Explain that it is common for people to be on the medication for six months to a year and in some cases longer. Be sure to say that the decision about how long to stay on the medication should be made with their primary care clinician.
* The MacArthur Initiative on Depression & Primary Care: Care Manager Training Manual

CARE MANAGEMENT PLUS PROBLEM SOLVING TECHNIQUES BREAK DOWN BARRIERS* (Continued)
Emphasize that they should not stop or change their medication dose without talking to their primary care clinician first. Mention that often people go off of their medication too soon because they are feeling better. By stopping medication too soon, they are running the risk of a relapse.

* The MacArthur Initiative on Depression & Primary Care: Care Manager Training Manual