Phase 2 Measures of Depression Population Each Phase 2 depression team is required to track and report the core national measures (measures 1 through 4) along with the count of patients with depression tracked by the clinical information system. “Patients with depression” is defined as patients with the diagnosis of major depression (ICD-9 code 296.20-296.3), dysthymia (chronic depression) (ICD-9 code 300.4), depression NOS (ICD-9 code 311), and adjustment disorder with depression, or minor depression (ICD-9 code 309.0). ICD-9 codes are not always accurate, however; and organizations are reminded that clinical judgment should subsequently take precedence when selecting patients to include in a specific diagnostic category. The measures, as currently defined, apply to all adults; i.e., those greater than or equal to 16 years of age. Teams are welcome to track and report any of the additional measures (5-13) as useful to their work. Psychiatric co morbidity is to be expected in persons who have depression. Most studies evaluating the effectiveness of chronic disease models of depression care have excluded patients with bipolar disorder, schizophrenia, and severe alcohol and substance use disorders. The studies have usually included patients with co-occurring panic disorder and generalized anxiety disorder. Few have systematically measured post-traumatic stress disorder. Limited data indicate that the depression chronic care model is most likely to improve outcomes for patients with new episodes of depression and mild to moderate psychiatric co morbidity. Each center should decide which patients with clinical depression and other co-occurring mental disorders will be included in the registry. Clinical judgment, not empirical data, provides the best evidence for these decisions. Other important factors that impact the decision include: 1) the balance between demand for chronic care services and availability of depression care management services; 2) pattern of psychiatric co morbidity in your patient population; 3) availability of specialty mental health expertise on-site; 4) availability of specialized mental health services with easy referral (e.g. substance abuse); 5) interest, experience and competence of primary care providers in managing patients with more complex psychiatric co morbidity. Additional “key points to consider” are listed at the bottom of the depression measures document. REQUIRED MEASURES Definition Data Gathering Plan Notes/Comments
1.CSD* patients with 50% reduction in PHQ 2.CSD* patients with a 5
Percent of CSD* patients who attain On the last workday of the month,
point reduction in PHQ score within 6 months
This enables monitoring of changes in performance in the last 12 calendar months on a continuing basis.
3. Patients who have a diagnosis of depression and a documented PHQ score within the last 6
diagnosis of depression who have a PHQ can be either a New Episode
4. Depressed patients with documented self- management goal setting in the last 12 months
diagnosis of depression in the registry.
Additional Recommended Measures: These measures are not required; however, you will find that they can be used to enhance care and increase the ability to achieve the required measures above. Definition Data Gathering Plan Notes/Comments 5. CSD* patients with documented PHQ reassessment between 4- 8 weeks of last New Episode PHQ **
Numerator = all CSD* patients with PHQ**, and New Episode PHQ is
6. CSD* patients with documented early follow- up of last New Episode
Treatment: Early Follow-Up) follow-up 1 to 3 weeks (7-21 days)
after their last New Episode PHQ** Then, count the number of CSD*
7. CSD* patients who, 4 months or longer after last New Episode PHQ**, have 50% reduction in PHQ score
Episode PHQ is within the last 12 calendar months.
8. CSD* patients with PHQ Percent of CSD* patients with a score less than 5 at least 4 months after last New Episode PHQ**
outcomes (Refs 7, 11, 12 & 14).
9. Patients with a diagnosis of major depression or dysthymia on an antidepressant*** at visit, are taking an last visit (Recommended to be used in conjunction with measure #10)
antidepressant*** at the time of the patients with a diagnosis of major
Denominator = all patients with a diagnosis of major depression or dysthymia. .
10. Patients with diagnoses of minor depression, depression NOS, or adjustment disorder (PHQ <10) NOT
<10) NOT on an antidepressant*** depression NOS, or adjustment
on an antidepressant*** (recommended to be used Numerator = all patients with a in conjunction with measure #9)
<10) NOT on an antidepressant***. patients with a diagnosis of minor
is severe functional impairment. SSRIs have been shown to be helpful for premenstrual dysphoric disorder.
11. Depressed patients who improve in function
question (#10). (Note that only patients
score of >0 on their last New Episode Function, which must be within the last 12 calendar months.
12. Patients with diagnosis of major depression or dysthymia remaining on antidepressant*** for at least 6 months (Depression Guideline Treatment: Duration of
diagnosis of major depression or dysthymia for at least 6 months (180 days).
13. Percent of CSD* patients on an antidepressant*** &/or in psychotherapy within one month of last New Episode PHQ**
be better than usual care (Refs. 2 and
psychotherapy before or any time within 30 days after the last New Episode PHQ** (or even before). Denominator=all CSD* patients having a New Episode PHQ** in the last 12 months.
* CSD: A patient with CSD (clinically significant depression) is defined as a patient with a diagnosis of depression and a new episode PHQ of 10 or greater. CSD is not a DSM-4 or ICD diagnosis, but rather a name (created by the Collaborative faculty) for a clinical syndrome that functions as a close proxy for the diagnosis of major depression. In most cases of CSD, the technical depression “diagnosis” will generally be major depression. ** New Episode PHQ: “New Episode PHQ” is defined as the PHQ baseline score, which (along with a diagnosis of depression) begins a new clinical episode of depression “New episode” of depression refers to the clinical determination that a patient is suffering from depression (major, minor, or dysthymia) AND that outcome of the “new episode” will be monitored starting from the date of entry of the “new episode PHQ.” Because depression is a chronic, recurrent illness, some patients may recover from a “new episode” and then experience a relapse or recurrence (that is, a repeat “new episode”). For operational purposes of the Collaborative, a patient should be in remission for at least three months before a clinical determination is made that the patient is experiencing a “new episode”. ***Antidepressants include the following: TRICYCLICS SSR ANTIDEPRESSANTS Key points to consider:
• The start of a new episode of depression is a clinical decision. Operationally, for purposes of measurement of process and outcome, a new episode of
depression begins with the recording of a numerical value for a “new episode PHQ” and the recording of a diagnosis of depression. A new episode of depression could be CSD (definition above) or not CSD, with any diagnosis of depression (major, minor, dysthymia, etc.).
• Treatment and measurement for a new episode of depression starts with a clinical decision, not just the PHQ score alone. Upon reaching a clinical decision
that a patient suffers from a depression that should be treated or followed (partly based on a PHQ score of 5 or greater), the patient should be entered into the registry. The PHQ score obtained at the time that this clinical decision is made should be recorded as the “new episode PHQ” score in the registry.
• “Remission” ends an episode of depression. For operational purposes of the Collaborative, remission is defined at the attainment of at least one PHQ <5,
along with a clinical determination that the patient has probably sustained this degree of recovery for a minimum of three consecutive months.
• Each center should develop a written policy that describes which patients should be included or excluded in the Population of Focus - based on clinical
judgment. If you do not clarify whether and how patients with psychiatric co morbidity are included in the POF, there may be confusion and variation from clinician to clinician. This will make it more difficult to interpret clinical measures in the collaborative work.
• Patients with bipolar disorder and schizophrenia should not be included in the POF. They are not included in the collaborative depression measures and will
not appear in PECS key measurement tracking and reporting. However, separate “clinics” can be created in PECS to track these patients with psychiatric co morbidities. In other words, you can treat these patients, but they should not be included in the POF.
• Patients with depression and alcohol/substance abuse problems can be included in the POF, unless the alcohol/substance disorder predominates the
clinical picture, making a clear diagnosis or effective treatment of depression too complicated. This could be evident initially or after some period of treatment. If the latter is the case, then remove the patient from the POF.
• Patients with co-occurring anxiety disorders remain in the POF.
• Patients who have depressive disorders for whom it is necessary to refer them to outside mental health specialists should remain in the POF as long as they
remain active patients in the primary care clinic. These patients probably need continued care management and coordination.
Important References Related to Chronic Disease Model and Outcomes for Patients with Depression in Primary Care
Most of the studies documenting the success of the chronic care model for improving outcomes in patients with depression have had multiple components of the model within each intervention. It is difficult to isolate the impact of one component of the chronic care model. Below are a series of articles from the United States that form the foundation for the measures outlined above.
1. Katon W, Von Korff M, Lin E, Walker E, Simon GE, Bush T, Robinson P, Russo J. Collaborative management to achieve treatment guidelines. Impact
on depression in primary care. JAMA 1995; 273:1026-31.
2. Schulberg HC, Katon W, Simon GE, Rush AJ. Treating major depression in primary care practice: an update of the Agency for Health Care Policy and
Research Practice Guidelines Arch Gen Psychiatry 1998; 55: 1121-7.
3. Katon W, Robinson P, Von Korff M, Lin E, Bush T, Ludman E, Simon G, Walker E. A multifaceted intervention to improve treatment of depression in
primary care. Arch Gen Psychiatry 1996;53:924-32.
4. Schulberg HC, Block MR, Madonia MJ, Scott CP, Rodriguez E, Imber SD, Perel J, Lave J, Houck PR, Coulehan JL. Treating major depression in
primary care practice. Eight month clinical outcomes. Arch Gen Psychiatry 1996; 53:913-9.
5. Katon W, Von Korff M, Lin E, Simon G, Walker E, Unutzer J, Bush T, Russo J, Ludman E. Stepped collaborative care for primary care patients with
persistent symptoms of depression: a randomized trial Arch Gen Psychiatry 1999; 56: 1109-15.
6. Williams JW Jr, Barrett J, Oxman T, Frank E, Katon W, Sullivan M, Cornell J, Sengupta A. Treatment of dysthymia and minor depression in primary
care: a randomized controlled trial in older adults JAMA 2000; 284:1519-26.
7. Wells KB, Sherbourne C, Schoenbaum M, Duan N, Meredith L, Unutzer J, Miranda J, Carney MF, Rubenstein LV. Impact of disseminating quality
improvement programs for depression in managed primary care: a randomized controlled trial JAMA 2000; 283: 212-220.
8. Lin EH, Von Korff M, Russo J, Katon W, Simon GE, Unutzer J, Bush T, Walker E, Ludman E. Can depression treatment in primary care reduce
disability? A stepped care approach Arch Fam Med 2000; 10:1052-8.
9. Katon W, Rutter C, Ludman EJ, Von Korff M, Lin E, Simon G, Bush T, Walker E, Unutzer J. A randomized trial of relapse prevention of depression in
primary care. Arch Gen Psychiatry 2001; 58:241-7.
10. Sherbourne CD, Wells KB, Duan N, Miranda J, Unutzer J, Jaycox L, Schoenbaum M, Meredith LS, Rubenstein LV. Long-term effectiveness of
disseminating quality improvement for depression in primary care. Arch Gen Psychiatry 2001; 58:696-703.
11. Katon W, Russo J, Von Korff M. Lin E, Simon G, Bush T, Ludman E, Walker E. Long-term effects of a collaborative care intervention in persistently
depressed primary care patients. J Gen Intern Med 2002; 17:741-8.
12. Unutzer J, Katon W, Callahan CM, Williams JW Jr, Hunkeler E, Harpole L, Hoffing M, Della Penna RD, Noel PH, Lin EH, Arean PA, Hegel MT, Tang L,
Belin TR, Oishi S, Langston C; IMPACT investigators. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA 2002; 288:2836-45.
13. Schulberg HC, Raue PJ, Rollman BL. The effectiveness of psychotherapy in treating depressive disorders in primary care practice: clinical and cost
perspectives. Gen Hosp Psychiatry 2002; 24:203-12.
14. Rost K, Nutting P, Smith JL, Elliott CE, Dickinson M. Managing depression as a chronic disease: a randomized trial of treatment in primary care. BMJ
15. Ford DE, Incus HA, Unutzer J, Buaer MS, Gonzalez JJ, Wells KB; NIMH Affective Disorders Workgroup Practice-based interventions Ment Health Serv
16. Ackermann RT, Williams JW Jr. Rational treatment choices for non-major depressions in primary care: an evidence-based review J Gen Intern Med
17. Miranda J, Duan N, Sherbourne C, Schoenbaum M, Lagomasino I, Jackson-Triche M, Wells KB Improving care for minorities: can quality improvement
interventions improve care and outcomes for depressed minorities? Results of a randomized clinical trial Health Serv Res 2003;38:613-30.
18. Lima MS, Moncrieff J. Drugs versus placebo for dysthymia (Cochrane Review) In; The Cochrane Library, Issue 2, 2003. Oxford: Update Software. 19. Gilbody S, Whitty P, Grimshaw J, and Thomas R. Educational and Organizational Interventions to Improve the Management of Depression in Primary
Care: A Systematic Review JAMA. 2003; 289:3145-3151.
20. Olivarius N, Beck-Nielsen H., Andreasen A, Horder M., and Pedersen P. Randomised controlled trial of structured personal care of type 2 diabetes
21. Renders CM, Valk GD, Franse LV, Schellevis FG, van Eijk JT, van der Wal G.
Long-term effectiveness of a quality improvement program for patients with type 2 diabetes in general practice. Diabetes Care. 2001 Aug;24(8):1365-70.
22. Norris SL, Engelgau MM, Narayan KM. Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials.
Diabetes Care. 2001 Mar;24(3):561-87. Review.
23. Maly RM, Leake B, Frank JC, DiMatteo MR, Reuben DB. Implementation of consultative geriatric recommendations: the role of patient-primary care
concordance. Jrnl Amer Ger Soc 2002;50:1372-1380.
24. Heisler M, Bouknight RR, Hayward RA, Smith DM, Kerr EA. The relative importance of physician communication, participatory decision-making and
patient understanding in diabetes self-management. J Gen Inter Med 2002;17:243-252.
25. Lorig KR, Sobel DS, Stewart AL, Brown Jr BW, Ritter PL, González VM, Laurent DD, Holman HR. Evidence suggesting that a chronic disease self-
management program can improve health status while reducing utilization and costs: A randomized trial. Medical Care. 37(1):5-14, 1999
26. Löwe B, Unutzer J, Callahan CM, Perkins AJ, Kroenke K. Monitoring depression treatment outcomes with the PHQ-9 Med Care (in press).
27. Löwe B, Kroenke K, Herzog W, Gräfe K. Measuring depression outcome with a short self-report instrument: sensitivity to change of the Patient Health Questionnaire (PHQ-9). J Affective Disorders 2004;78:131-140.
Skoj i en enda röra Del 1 Du håller just nu i din hand resultatet av mer än 40 års samlande av, vad jag, författaren, tycker trevliga historier, som kan användas i olika sammanhang. Jag har inte hitta på dem själv utan jag har bara samlat vad jag har läst och hört samt sammanställt materialet. Jag har försökt sortera bort alltför fula ord och försökt förfina historierna så
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