Nonpharmacologic Treatment of Depression

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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

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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

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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

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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

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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

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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

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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

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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

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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

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Primary Care

• Education
• Supportive Counseling
• Care Management
• Self-management
• Adherence Monitoring
• Progress Monitoring

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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

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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

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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

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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

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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

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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

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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

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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

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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

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BATHE pneumonic

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

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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

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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

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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

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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

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Care Management Definitions cont.

• C. Care Management as part of primary clinician
  (PCP, social worker, Nurse, etc.)
  responsibilities.

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Care Management Process

• BASICS
• Initial follow up call/visit (1-3 weeks) to
  monitor patient adherence and progress
• Ensure educational materials are given or can be
  sent in mail and reinforce if needed
• 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

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Care Management Process

• 4. Communicate results to Primary Care clinician
  and coordinate before next visit or if more
  urgent intervention is needed
• 5. 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

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Figure II-C TYPICAL CARE MANAGER
ACTIVITIESACROSS 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

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Figure II-C TYPICAL CARE MANAGER
ACTIVITIESACROSS 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

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Figure II-C TYPICAL CARE MANAGER
ACTIVITIESACROSS 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

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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

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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

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CARE MANAGEMENT PLUS

• MOTIVATIONAL INTERVIEWING
• Five Stages of Change
• 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)

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CARE MANAGEMENT PLUSPROBLEM SOLVING
TECHNIQUESBREAK 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

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CARE MANAGEMENT PLUSPROBLEM SOLVING
TECHNIQUESBREAK 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

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CARE MANAGEMENT PLUSPROBLEM SOLVING
TECHNIQUESBREAK 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

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CARE MANAGEMENT PLUSPROBLEM SOLVING
TECHNIQUESBREAK 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

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CARE MANAGEMENT PLUSPROBLEM SOLVING
TECHNIQUESBREAK 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