Using Measurement-Based Care With Patient Involvement to Improve Outcomes in Depression

CME Background

Original material is selected for credit designation based on an assessment of the educational needs of CME participants, with the purpose of providing readers with a curriculum of CME activities on a variety of topics from volume to volume.

CME Objective

After studying this case, you should be able to:

• Understand and follow current guidelines when treating patients with depression
• Select and use appropriate assessment tools when managing patients with depression

Accreditation Statement

The CME Institute of Physicians Postgraduate Press, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Credit Designation

The CME Institute of Physicians Postgraduate Press, Inc., designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Note: The American Academy of Physician Assistants (AAPA) accepts certificates of participation for educational activities certified for AMA PRA Category 1 Credit™ from organizations accredited by ACCME or a recognized state medical society. Physician assistants may receive a maximum of 1.0 hour of Category I credit for completing this program.

Date of Original Release/Review

This educational activity is eligible for AMA PRA Category 1 Credit™ through November 30, 2016. The latest review of this material was October 2013.

Financial Disclosure

All individuals in a position to influence the content of this activity were asked to complete a statement regarding all relevant personal financial relationships between themselves or their spouse/partner and any commercial interest. The CME Institute has resolved any conflicts of interest that were identified. No member of the CME Institute staff reported any relevant personal financial relationships. Faculty financial disclosure appears later in the article.

Despite the available treatment options and measurement tools for depression, the remission rates for patients with major depressive disorder (MDD) remain low. Because the majority of patients seek depression treatment from their primary care providers (PCPs), these clinicians need to implement best practices on applying appropriate follow-up care and evaluating treatment response to help their patients with depression achieve remission. This commentary summarizes an online CME program (consisting of 2 activities) by Larry Culpepper, MD, MPH, and Madhukar H. Trivedi, MD, on the treatment of depression in primary care, assesses the outcomes of that program, and presents highlights from a discussion between Dr Culpepper and Dr Trivedi as they identified areas of continued need in treatment adherence and patient satisfaction.

Summary of CME Activities

In “Improving Patient Outcomes in Depression Through Guideline-Concordant, Measurement-Based Care,”1 Dr Culpepper explains how practice guidelines, such as those from the American Psychiatric Association2 (APA), and assessment tools can improve patient outcomes in depression. Using tools such as the Patient Health Questionnaire3 (PHQ) and the Quick Inventory of Depressive Symptomatology4 (QIDS) at baseline and follow-up visits will help clinicians track patients’ symptoms over the course of treatment, while other tools can assess medication side effects and comorbid conditions (Frequency, Intensity, and Burden of Side Effects Rating scale5 [FIBSER]; Generalized Anxiety Disorder6 [GAD-7]; My Mood Monitor7 [M-3] checklist). Tracking symptoms, side effects, and co-occurring disorders will enable clinicians to make better treatment decisions and adjust treatment as necessary. To help with decision making and patient follow up, case managers and specialists should collaborate with PCPs to provide support and advice. Patients with comorbid conditions such as anxiety, posttraumatic stress disorder (PTSD), or bipolar disorder will require extra monitoring because the additional symptoms and their treatment can interfere with depression management. Dr Culpepper concludes that treating patients with MDD requires strategies that incorporate guidelines, measurement-based tools, collaboration between providers, and treatment of comorbid conditions to improve outcomes.

Dr Trivedi, in “Evaluating and Monitoring Treatment Response in Depression Using Measurement-Based Assessment and Rating Scales,”8 affirms the importance of using standardized tools to assess depressive symptoms and recommends measurement-based care (MBC) to help clinicians tailor practice approaches to the individual patient with MDD. Patient-rated scales, such as the PHQ-9, QIDS-SR, and Beck Depression Inventory9 (BDI), are easily incorporated in clinical practice because they are relatively easy for patients to complete before face-to-face visits and are quickly reviewed by clinicians. When patients complete an assessment scale at each visit, clinicians can promptly recognize partial response or nonresponse. Clinicians should follow a set visit and medication dose titration schedule to ensure that patients do not remain symptomatic for too long between appointments. Along with assessing depressive symptoms, clinicians who take an MBC approach will also monitor suicidality, treatment adherence, and medication side effects. By consistently evaluating and measuring treatment response, clinicians can help patients with MDD achieve and maintain complete remission.

Summary of Outcomes

In this CME program, outcomes were measured by comparing answers to case-based questions from a control group versus program participants. Participants were also asked how often they currently used certain clinical strategies (based on the educational objectives; Table 1) and how often they planned to use those strategies after participating in the program. The activities succeeded in achieving the stated educational objectives, as evidenced by the percentage of participants who correctly answered the case-based questions after the activity compared with the number of control group respondents.

Correct answers on these questions, given as a posttest after the activities, indicate both immediate learning and impact on clinician competence, as well as reinforcement of current practice. On the 2 questions in this program, 68% of participants (vs 39% of the control group) correctly answered question 1 regarding the best intervention to help a patient with medication adherence and 80% (vs 55% of the control group) correctly answered question 2 regarding the follow-up for a patient showing improvement on her PHQ-9 score after 6 weeks of treatment. These results demonstrated a significant improvement (P < .0001) between the control group and the participants (Figure 1).

In addition, participants were asked how often they currently used the clinical strategies recommended in the activities (see Table 1) and how often they planned to use those strategies after participating in the program. The planned future use of both strategies was slightly greater than the reported current use.

Based on participant feedback, some identified future needs included education on APA guidelines for other illnesses, updates to the Diagnostic and Statistical Manual for Mental Disorder, Fifth Edition (DSM-5), practical approaches to treating MDD, using scales for comorbid conditions, and approaches for collaborative care.

Discussion

After reviewing the outcomes of the program and considering future educational needs, Drs Culpepper and Trivedi discussed 2 questions related to monitoring and treating patients with MDD.

How Can Clinicians Improve Treatment Adherence?

Dr Culpepper: Clinicians should gain patients’ trust and encourage them to buy in to both the diagnosis and the treatment plan.

Dr Trivedi: That process includes having the clinician help patients become partners in their management. When patients are actively engaged, they recognize the need for treatment as well as monitoring outcomes.

• Use guideline-concordant, measurement-based care with assessment tools for treating patients with MDD.
• Encourage patients with depression to be active partners in their care.
• Refocus patients to continue treatment if they have not regained full remission and functioning.

Dr Culpepper: Clinicians should also educate patients about their diagnosis and integrate treatment goals into the discussion to establish a good therapeutic relationship.

Dr Trivedi: Incorporating new technology into the daily treatment planning can also help clinicians by saving time during the office visit. My goal is to get about 70% of patients completing assessments before they come in, and that requires technology.

Dr Culpepper: Integrating depression care management with care management of other chronic conditions has made treatment adjustment in primary care settings easier and more effective (Figure 2).10 There is a marked increase in the number of medications and management steps, so technology, integration, measurement, communication, and guidance should all work together to determine the best next step for patients.

Dr Trivedi: When a large portion of care management can be done by well-informed patients, they become really engaged in their overall care. These patients can complete rating scales on a regular basis to monitor themselves and then call for appointments when they need them.

Dr Culpepper: Yes, shifting treatment to include patients as an informed part of the care team can help long-term management. Patients can reactivate the care relationship or increase the intensity of the care relationship if and when they need it, such as during times of stress. A 12-month study11 that examined usual care of depression and chronic illnesses versus a team-based intervention with self-management support and collaborative care found that patients in the intervention group were able to follow through with their medical regimens better than the usual care group, even during times of stress.

Dr Trivedi: The question of treatment adherence is one component of MBC. The potential hurdles to adherence (such as comorbid conditions, lack of education, medication cost, side effects) are addressed right from the beginning. Another component of MBC is addressing procedural problems, such as adjusting medication doses, setting reminders, or allowing the patient to change the timing. When clinicians educate patients on possible scenarios at the beginning of treatment, it can alleviate patients’ anxiety and help them understand their responsibility.

Adherence is part of continued clinical care management, and incorporating the patient as a partner in that endeavor is very important. For example, a patient with hypertension who goes to the pharmacy and gets his blood pressure taken can call the doctor to follow up if anything seems out of the ordinary. The patient is taking an active role.

How Should Clinicians Encourage Patients Who Need to Continue Treatment?

Dr Culpepper: I recommend the QIDS as a very useful tool because it provides more information than the PHQ-9 about the problems the patient may be experiencing. Along with using a rating scale to assess current symptoms, I typically revisit the prior history of the patient. Is this the first episode? Is this a patient who has had multiple past episodes?

Using a motivational interviewing approach, I also assess the patient’s functioning. Are they doing things they used to do or not? If patients are satisfied with their symptom improvement, their functional improvement may still be significantly affected. If they have a chronic history of depression, they may not have been functioning for quite some time and may not recognize that limitation. Clinicians can refocus patients by reframing the treatment goals, which should include a return to full functioning.

Dr Trivedi: That’s right. When patients have discussed their desired treatment goals with the clinician, the clinician can remind them of functional outcomes, such as work productivity, that may require continued treatment. Patients who show treatment resistance are more likely than first-step treatment responders to experience decreased work productivity, and even patients who achieve remission in second-step treatment may continue to have impairments at work.12

Dr Culpepper: Clinicians should also explore if patients are really satisfied with their current status or if they are worried about side effects like weight gain or other problems if their medication is adjusted. If patients have made their own assessment of side effects versus improvement, clinicians may need to help them see the benefits of continuing to work toward complete remission and functional recovery.

Conclusion

The CME program by Drs Culpepper and Trivedi emphasizes how guideline-concordant, MBC with regular assessment can improve patient outcomes in depression. When PCPs use a rating scale at baseline and follow-up visits, they will recognize a lack of response and make well-informed treatment decisions. By collaborating with specialists and care managers, PCPs can receive advice and support for monitoring patients’ adherence and side effects and making treatment adjustment as necessary.

This CME program met its educational objectives (see Table 1), as indicated by responses to case-based questions (control group vs participants) and current versus planned use of recommended clinical strategies.

To promote treatment adherence, clinicians should encourage patients with depression to become partners in their care management. By setting and tracking treatment goals, clinicians and patients will be able work together to see patients return to full functioning. For patients who are satisfied with some symptom improvement but are still experiencing residual symptoms, clinicians should revisit their original goals and refocus patients to continue treatment until they reach precondition levels of functioning, including work productivity.

To continue to help clinicians, future CME activities could focus on education regarding guidelines for other illnesses, DSM-5 updates, practical approaches to treating MDD, use of scales for comorbid conditions, and approaches for collaborative care.

Disclosure of off-label usage: Dr Culpepper has determined that, to the best of his knowledge, no investigational information about pharmaceutical agents that is outside US Food and Drug Administration-approved labeling has been presented in this activity.

References

1. Culpepper L. Improving patient outcomes in depression through guideline-concordant, measurement-based care. J Clin Psychiatry. 2013;74(4):e07. PubMed doi:10.4088/JCP.12075tx1c

2. American Psychiatric Association. Practice Guideline for the Treatment of Patients With Major Depressive Disorder, Third Edition. Washington, DC: American Psychiatric Association; 2010. http://psychiatryonline.org/content.aspx?bookid=28&sectionid=1667485. Accessed August 27, 2013.

3. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-613. PubMed doi:10.1046/j.1525-1497.2001.016009606.x

4. Rush AJ, Trivedi MH, Ibrahim HM, et al. The 16-Item Quick Inventory of Depressive Symptomatology (QIDS), clinician rating (QIDS-C), and self-report (QIDS-SR): a psychometric evaluation in patients with chronic major depression. Biol Psychiatry. 2003;54(5):573-583. PubMed doi:10.1016/S0006-3223(02)01866-8

5. Wisniewski SR, Rush AJ, Balasubramani GK, et al, for the STARD Investigators. Self-rated global measure of the frequency, intensity, and burden of side effects. J Psychiatr Pract. 2006;12(2):71-79. PubMed doi:10.1097/00131746-200603000-00002

6. Spitzer RL, Kroenke K, Williams JB, et al. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092-1097. PubMed doi:10.1001/archinte.166.10.1092

7. Gaynes BN, DeVeaugh-Geiss J, Weir S, et al. Feasibility and diagnostic validity of the M-3 checklist: a brief, self-rated screen for depressive, bipolar, anxiety, and post-traumatic stress disorders in primary care. Ann Fam Med. 2010;8(2):160-169. PubMed doi:10.1370/afm.1092

8. Trivedi MH. Evaluating and monitoring treatment response in depression using measurement-based assessment and rating scales. J Clin Psychiatry. 2013;74(7):e14. PubMed doi:10.4088/JCP.12075tx2c

9. Beck AT, Ward CH, Mendelson M, et al. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4(6):561-571. PubMed doi:10.1001/archpsyc.1961.01710120031004

10. Katon WJ, Lin EH, Von Korff M, et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med. 2010;363(27):2611-2620. PubMed doi:10.1056/NEJMoa1003955

11. Ludman EJ, Peterson D, Katon WJ, et al. Improving confidence for self care in patients with depression and chronic illnesses. Behav Med. 2013;39(1):1-6. PubMed doi:10.1080/08964289.2012.708682

12. Trivedi MH, Morris DW, Wisniewski SR, et al. Increase in work productivity of depressed individuals with improvement in depressive symptom severity. Am J Psychiatry. 2013;170(6):633-641. PubMed doi:10.1176/appi.ajp.2012.12020250