Online Depression CME Curriculum Plan

Online Depression CME Curriculum Plan

Project Overview

Online Depression Curriculum Plan Cover Page

DepressionClinic.com: CME on Best Practice in Depression Care for Primary Care Practitioners
Grant #2 R44-MH-57604
Principal Investigator: T. Bradley Tanner, MD

Last Modified: January, 2004

Clinical Tools, Inc.
431 W. Franklin Street, Suite 24
Chapel Hill, NC 27516
www.clinicaltools.com
919-960-8118

Prepared by
Ellen Stoltzfus, Ph.D
Jennifer Ratcliffe, Ph.D, MSc
Jared Weinberger
Jaime Smith

Note: This document is under active development and is being revised as Phase II progresses. It can be found on the Internet at DepressionClinic.com Print this Report

Funding: Funding for this work is provided by the National Institute of Mental Health (NIMH) under Grant #2 R44-MH-57604.

Project Summary

The Need:Primary care physicians are responsible for the recognition and treatment of depression, yet there is little evidence that they follow standards or achieve expected results given available treatment modalities.

Target Audience:Primary Care Physicians.

Mission:Our mission is to enhance the quality of screening, detection, diagnosis, referral, treatment, management, and education for depressed adults who are treated in primary care.

Approach: We will educate primary care physicians about clinically-relevant aspects of depression, and provide tools and patient education materials so that doctors can provide more effective depression care in their own practices. A high quality, interactive online CME curriculum for depression education will be designed specifically for practicing primary care providers (PCPs).Our courses will emphasize best practice guidelines for evidence-based depression detection and treatment, and will address current needs in depression care.

Funding Source: This project is funded by an NIMH SBIR grant to Brad Tanner (PI) and Clinical Tools, Inc. (Grant #R44-MH-57604).

Target Audience

The audience for this project includes physicians working in primary-care settings. Our specific primary-care audience is physicians in family practice and internal medicine, physician assistants, and others who provide first contact and continuing care of patients. Individual courses can meet the needs of physicians in other medical specialties (e.g., ob/gyn), medical students, pharmacists, and nurse practitioners.

There might be two separate audiences within our target audience. Some physicians might need more comprehensive training in depression care, while others may already have background and experience and want to know more about specific issues, or improve specific skills to make a big impact on the effectiveness of their care. Our curriculum addresses both of these audiences.

Writing for a primary-care audience means:

  • Making the content clinically relevant
  • Understanding how time constraints influence the options that physicians have in their practices
  • Using simple and clear prose
  • Avoiding an overly academic style of writing that goes overboard with details, references, and technical/methodological details

Technology

The primary purpose of DepressionClinic.com is to offer continuing medical education via the Internet. Therefore, the courses will be designed for online viewing. They must comply with the latest web site standards, including 508 standards. The current Internet/computer skills of the typical user, as well as available technology, must be taken into account. Currently, the website must be viewable on a 15" monitor at a resolution of 1024 x 768 pixels. The courses must be viewable with both Internet Explorer and Netscape Web browsers. There will be minimal use of audio and video on the website, but no restrictions on the use of appropriate graphics and other interactive features. Each course will be designed and tested for ease of navigation.

A secondary goal is for each course to be easily printable; each course will have both HTML and PDF print versions.

Budget

Our current budget will allow ample funds for both the development and evaluation phases of this project.

Project Goals

Clinical Tools will develop, evaluate, and implement an Internet-based continuing medical education (CME) program to teach primary care physicians about depression screening, detection, diagnosis, treatment, and management, as well as the scope of the problem of depression. In addition, we will provide tools to support implementation of change in detection and treatment of depression in adults in primary care settings.

The curriculum will be available via the Internet and will provide a high quality experience that is rare in web-based CME. Our courses will include both didactic and case-based material designed to help develop clinical skills, information/handouts for physicians to give to their patients, a complete learning environment including support materials, references, and other resources, and interactive exercises built into each course to encourage engagement with the material. In addition to providing the opportunity to develop knowledge and skills, users will also have the opportunity to complete a "practice plan" which will outline concrete steps to improve an individual user''s own primary care practice.

While our courses may be completed individually, our curriculum is designed to be completed as a whole in order to provide comprehensive depression education in areas that have been identified as current needs in primary care. CME credit will be available through Clinical Tools for successful completion of each course, and a certificate in "Depression Detection and Treatment in Primary Care" will be offered for those who complete the entire curriculum as well as the Practice Plan module.

Project Mission

Upon completion of this curriculum, primary care physicians should show enhancements in their knowledge, clinical skills, attitudes, intended behaviors, and self-efficacy in relation to understanding depression and caring for depressed patients. They will be better prepared to effectively incorporate screening, detection, treatment, and management of depression into their clinical practice, which should translate into enhanced quality of care and better patient outcomes.

Timeframe

The original NIMH SBIR grant period was 8/31/01 to 8/31/03, but an extension was requested (during early August, 2003) to lengthen our funding period to 8/31/04. We expect to finish the entire curriculum proposed in this document by the end of our extended grant period.

Key Personnel and Responsibilities

CME.DepressionClinic.com Project Team:

Principal Investigator: Brad Tanner
Project Director: Ellen Stoltzfus, PhD
Research Associate and Major Course Author: Jennie Ratcliffe, PhD, MS
Research Associate: Jared Weinberger, MA
Research Assistant: Jaime Smith

Internal Consultants:

Shannon Magee, MS, Usability/ Accessibility Evaluation
Tracy Shaw, MS, Course and Program Evaluation
June McDermott, MSPharm, MBA, CE Administrator and Course Reviewer Vonnie Perry, Graphic Artist/Web Designer
Mary P. Metcalf, PhD, Course Reviewer
Elisabeth Sullivan, MS, Course Author and Researcher
Meg Coulehan, MPH, Course Author

Expert Consultants and Course Reviewers: Medical residents, primary care physicians, and content experts (Psychiatrists and Psychologists) will serve as reviewers for the curriculum plan and for each individual course as it is developed.

Family Physicians:

Private Practice Physician
Mebane, NC

Peter Curtis, MD
Clinical Professor of Family Medicine
University of North Carolina School of Medicine
Chapel Hill, NC

Yulia Koltzova, MD
Private Practice Physician
San Francisco, CA

Giang Nguyen, MD, MPH
Clinical Instructor and Research Fellow
Department of Family Practice and Community Medicine
University of Pennsylvania
Philadelphia, Pennsylvania

Kamla Jain, M.D
Medstaffing Placement Agency

Psychiatry/Mental Health Experts:

Brad Gaynes, MD
Assistant Professor, Department of Psychiatry
University of North Carolina
Chapel Hill, NC

Bob Golden, MD
Professor and Chair of Psychiatry
University of North Carolina
Chapel Hill, NC.

Ravinder Reddy, MD
Director, General and Adult Psychiatry Training
University of Pittsburgh
Pittsburgh, PA

Brandi Woods, MA
Research Associate
Clinical Tools, Inc.
Chapel Hill, NC

Mary Morreale, MD
Psychiatry Resident
University of North Carolina
Chapel Hill, NC

Brad Tanner, MD
President
Clinical Tools, Inc.
Chapel Hill, NC

Curriculum Review and Finalization Process

The curriculum plan has been developed by the CME.DepressionClinic.com Project Team, and will be reviewed by the following internal CTI personnel: Steve Applegate, (Curriculum Consultant), June McDermott (CE Administrator), Gail Zona (Copy Editor), and Brad Tanner (PI).

After internal review, the curriculum plan will be reviewed by at least a content expert consultant and a consultant in the fields of primary practice medicine. Consultant comments will be incorporated into the curriculum plan by the project team, the document will be copy-editted by CTI personnel, and the document will be submitted to Dr. Tanner for final approval.

Targeted Patients Disclaimer

The curriculum will help physicians meet the needs of adult patients; it expressly excludes children and young adolescents. Nor is the content focused on the unique needs of older adults. We aim to give our target audience the detection and diagnostic skills necessary to determine which patients they can elect to treat for depression (our target patients) and which should be referred to a specialist. Patients who are not likely to be best served by depression treatment in primary care include: 1) Patients with serious medical or psychiatric comorbidities, 2) Patients who have substance abuse problems, 3) Psychotic or suicidal patients, 4) Children and younger adolescents

Project Need

Project Need: Depression Detection and Treatment

Prevalence:The prevalence of depression is very high--higher than most psychological and medical disorders. Lifetime prevalence is estimated at about 17% (Kessler et al., 1994). At any given time, 5-10% of primary care patients have major depression (Spitzer et al., 1995; Skaer et al., 2000; Wittchen et al., 2002). Many patients (e.g., older adults) tend to suffer from milder forms of depression (dysthymia or minor depression) which are still associated with functional impairment and/or significant distress, and could benefit from treatment (USDHHS, 1999; NIMH, 2000). As many as 16% of primary care patients have subsyndromal depression (Williams et al.,1995).

Related Medical Conditions:Depression is a disorder that affects multiple systems of the brain and body (such as the endocrine, cardiovascular and immune systems) (Insel and Charney, 2003), and can be a significant cause, correlate, or consequence of a number of other medical conditions. Up to 40% of patients with medical problems (e.g., asthma, diabetes, stroke, cancer, HIV/AIDS) or who have a high rate of utilization of health care services, have depression (Pincus and Pettit, 2001). Evidence is also accumulating that depression is an independent risk factor for some medical conditions such as cardiovascular disease and stroke, and can adversely affect prognosis for many medical conditions.

Poor Outcomes:If untreated, approximately 40% of people with MDD will still have symptoms of depression one year later, and approximately 20% will still be symptomatic two years later (Keller et al., 1992). One study showed that 85% of patients experienced a recurrence of depression over a 15 year period, with patients reporting varying amounts of treatment during and between episodes (Mueller et al., 1999; Keller and Berndt, 2002).

Costs:Depressive disorders are estimated to become the second leading cause of disability worldwide by the year 2020 (Murray and Lopez 1996; 1997). In comparison with other chronic illnesses, only heart disease results in a greater number of hospital days of treatment and disability days (Wells et al., 1989). In a study of primary care patients, those with a depressive disorder reported an average of eight days of disability in the previous month compared to two days for those with a nonpsychiatric illness (Ormel et al., 1994). Depressed employees in a major U.S. corporation took approximately nine sick days per year, a significantly higher rate than for four other major chronic health conditions (Druss et al., 2000). Annual per capita treatment and disability costs for patients suffering from depression are estimated at about $5500 (Druss et al., 2000). Annual treatment costs in primary care for anxiety or depressive disorders were approximately double those for other disorders, and a considerable proportion of these costs were associated with higher utilization of general medical services rather than mental health costs per se (Simon et al., 1995).

Personal costs are also significant; in addition to the personal suffering caused by depression, an estimated 15% of depressed patients will commit suicide (USDHHS, 1999). Depressed mothers/parents affect their infants and older children; familial depression is a significant risk factor for depression in offspring, and family members also bear a burden in coping with depression.

Poor Quality of Diagnosis and Treatment:Primary care physicians provide the majority of treatment for depressive disorders (Katon and Schulberg, 1992; Schulberg and Burns, 1988). Unfortunately, this care is often inadequate (Simon and Von Korff, 1995; Coyne et al, 1995). Depression is also significantly under detected in the primary care setting.

Undertreatment is a significant problem:

  • The average number of office visits per treatment has declined in the past decade, a change that Olfson et al. (2002) attribute in part to increased penetration of managed care.
  • Physicians may institute treatment plans that do not follow clinical guidelines and employ inadequate monitoring and follow-up of the course of treatment, particularly for chronic and recurrent depression (Keller and Berndt, 2002; Dawson et al., 1999).
  • Lin et al. (1998), in a large study of primary care patients, found a 37% relapse rate in a 12-month period, which the authors attribute in part to under-treatment.
  • Treatment is increasingly confined to pharmacotherapy, principally SSRIs or newer drugs, with less attention paid to psychotherapies and complementary approaches.
    • The number of depressed patients receiving pharmacotherapy approximately doubled from 1987 to 1997, compared to a 15% decline in those receiving psychotherapy (Olfson et al., 2002).
    • An estimated 75% of depressed patients were treated with medication in 1997 compared to approximately 60% with some form of psychotherapy (Olfson et al., 2002).
    • Antidepressants remained the top-selling category of drugs in the U.S. in 2001, up by 20.1% over the previous year (NIHCM, 2002).

In some cases under-treatment may be attributable to suboptimal use of antidepressant therapy (Keller and Berndt, 2002). In addition, physicians may stop treatment after remission of the depressive episode, leading to an increased likelihood of recurrence (Geddes et al., 2003). In a meta-analysis of randomized trials by Geddes et al (2003), continuing treatment after initial recovery, beyond the recommended 4 to 9 months of continuation treatment, was associated with a 70% reduction in the odds of recurrence. In addition, failure to utilize adequate long-term maintenance therapy for patients with a history of repeated episodes increases the likelihood of recurrence (AHCPR, 1993).

Needs: Target Audience

The problem of inadequate detection and treatment of depression in the primary care setting is attributable to many factors that could potentially be addressed in educational interventions directed at primary care physicians. These factors include:

  1. Poor detection.Relatively few primary care practices utilize routine screening to detect depression, even though it is shown to be helpful in detecting depression (Pignone et al., 2002). Patients may present with somatic symptoms or they may deny having depressive symptoms because of fear of stigmatization. Educating doctors about risk factors would also help in detection of depressed patients.

  2. Physician misinformation.Providers may not consider psychiatric disorders as "real" illnesses (Hirschfeld 1997). Some primary care physicians may believe that major depression is not a significant medical condition, will go away on its own, or is the result of character weakness (Preskorn, 1999). Other physicians believe that treatment of major depression and other psychiatric disorders is mysterious and beyond their understanding, although they understand the reality and severity of the illness (Preskorn 1999, Hirschfeld 1997).

  3. Failure to follow practice guidelines.Although the development and distribution of evidence-based clinical practice guidelines has been widespread, their use and practitioner belief in them remains substantially low (Lomas et al, 1989; Weingarten et al, 1994; Tunis et al, 1995; Walker et al, 1994). Failure to follow guidelines may also be due to lack of knowledge or obstacles that make the guidelines impractical.

  4. Bias against psychosocial and complementary treatments.Physicians fail to consider psychotherapeutic approaches in favor of medical (usually pharmacotherapeutic) treatments, and they fail to consider other possible avenues for treatment such as stress management, exercise, and nutrition.

  5. Physician skills and confidence.Physicians may have limited training in interpersonal skills or limited confidence in their ability to discuss such issues with patients that would enable them to help manage patients'' emotional distress or provide aid in finding help from other mental health resources.

  6. Practical obstacles.Time constraints on doctors as well as poor mental health insurance coverage present significant barriers to appropriate treatment. While these constraints are not under the control of physicians, there are ways to care for depressed patients more effectively within these constraints.

  7. Undertreatment, poor follow-up, and poor management of depression.Many researchers report that even when depression is detected, it is undertreated. Physicians may prescribe inadequate doses of antidepressant medication for inadequate durations, and often fail to follow up adequately. Between 20% and 50% of patients stop taking medication within the first month of treatment (Rand, 2000). Only about 50% of patients successfully completed guideline-based acute phase treatments, in part due to a lack of structured follow-up programs and systematic monitoring of treatment adherence (Schulberg et al., 1998). Relapse and recurrence are common; 50%-85% of patients who have had an episode of depression will have another, usually within 2-3 years (Keller and Berndt, 2002). At least part of this failure to maintain remission may be preventable by more rigorous follow-up and management (Keller and Berndt, 2002; APA, 2002). In general, there appears to be inadequate understanding of depression as a recurrent, chronic problem for many patients, which also leads to undertreatment.

  8. Poor patient education.Physicians need to understand the importance of educated, empowered patients, and realize that outcomes for depressed people can be improved through better education. Medication compliance, for example, is a problem that doctors can help address by educating patients about side effects, the normal length of time to reach therapeutic results with drugs, and the importance of maintaining their regimen even if it doesn''t seem to help immediately. In addition, patients may be unaware of the role that brief problem solving and related psychotherapies can play in dealing with depression, as well as the importance of exercise, nutrition and other complementary approaches to depression.

Target Audience

Proposed Curriculum

Curriculum Objectives

The overarching goal of our curriculum is to educate primary care providers about depression screening, detection, diagnosis, referral, treatment, and patient education, in order to improve outcomes for depressed patients. Other specific curriculum goals are as follows:

1. Provide relevant CME content that intersects a) what physicians need in their practice and b) provides unique material and approaches not covered extensively by other online depression CME. For example, the use of depression screening tools, use of brief psychotherapies, use of complementary approaches, drug monitoring during later stages of treatment, and knowledge and utilization of mental health resources are particular weaknesses in depression care (as well as current CE offerings), so we will offer short courses focused on these topics.

2. Provide quality content that is: integrative, organized, accurate, comprehensive, unbiased, and recent. We will use a variety of sources (scientific and clinical studies, the latest clinical guidelines, government publications, and literature reviews) to provide comprehensive coverage. In addition, we will cover this information in a way that is independent and unbiased, to provide an alternative to many depression CME which are funded by pharmaceutical companies. Courses will be peer-reviewed to ensure quality.

3. Provide courses that are evidence-based, but also have clear clinical relevance.

4. Promote change and integration of new practice habits. Going one step beyond clinical relevance, our courses will encourage doctors to systemically and efficiently integrate the material they learn into their own practices. Within each course we will provide suggestions for applying guidelines in their practice and integrating best practices into their office routines. Our "Practice Plan" module will help each physician generate a customized plan for practice improvement and will provide resources to support change.

5. Provide skills training. The courses will include content and activities designed to help physicians develop skills in identifying and treating depression, as well as providing patient education. The activities will be built into mini case studies with interactive questionning and feedback.

6. Change attitudes about depression, and increase doctor confidence in diagnosing and treating depression.We hope to change physician attitudes about the seriousness and pervasiveness of depression as a medical issue, and increase physician confidence in ability to treat depressed patients appropriately in primary care. We also hope to reinforce positive attitudes about comprehensive approaches to treatment, especially concerning brief psychotherapy, but also other possible complementary therapeutic approaches such as nutrition and exercise.

7. Provide a high quality web-based user experience that is interesting, interactive, and effective. A major goal of this curriculum is to provide an educational experience that is of higher quality and more effective than current CME teaching methods, which involve lecturing or reading articles by experts in depression research and practice. We intend to exploit the full capability of web-based learning by providing users with interactivity, as well as links to additional information and resources beyond the course material.

8. Offer high quality patient education materials.

9. Provide comprehensive depression education that has a better chance of improving patient outcomes than one-shot CME. We will offer a certificate on Best Practice in Depression Care for Primary Care Practitioners for users who complete our whole course curriculum, along with the Practice Plan module.

Proposed Curriculum Structure Overview

This CME certificate program is designed for people who desire comprehensive training and/or improvement in how to detect and treat depression in primary care. While users may take any single course or combination of courses and receive CME credit, the courses are designed to complement each other and be taken together. The certificate program will be of use to experienced practitioners as well as those at the beginning of their career. The courses were specifically designed to meet current problemmatic aspects of care when depression is treated in the primary care setting. By addressing these current needs, the courses are designed to have a high impact on treatment outcomes in the primary care setting.

Description of Practice Plan Module

Research on CME effectiveness consistently shows that even when CE courses enhance knowledge of participants, they do not necessarily translate into changes in clinical behavior or patient outcomes. In order to increase the probability that physicians will translate knowledge and skills gained from our courses into their own practices, our curriculum offers a tool that allows physicians to generate a customized implementation plan for improving their depression care.

The Practice Plan consists of several modules, based on sections of content on clinical depression issues (e.g., detection and screening, treatment, or diagnosis). Each module presents users with a list of questions, some of which will be open-ended "thought" questions for the user to consider (e.g., what are the needs in my current practice for better detection of depression?). Other types of questions will be specific prompts triggering customized feedback based on the choices made by the user. For example, in the detection/screening module users are asked what kind of staff they have available in their offices, which dictates parameters of their suggested depression screening implementation plan. Each module has a series of such questions, and after answering all relevant questions and receiving feedback, a user can print out their customized answers to each question. In addition, futher customized resources, patient education materials, and other helpful tools can automatically print out, based on the user''s own responses. The printed version of the practice plan will be organized such that it can serve as a resource and guide to implementation of changes the user has identified that they would like to make in their practice.

Overarching Goals of the Practice Plan:

  1. Provide tools and advice that are customized to the practice setting''s demands, resources, patient population, support staff, available expertise, etc.
  2. Provide opportunities to think through the physician''s own practice needs, as well as the relevance of important guidelines, evidence, and concepts to a user''s own practice.
  3. Provide and/or generate customized versions of various tools to aid in implementation.
    • specific resources necessary for implementing recommendations of the courses (e.g., screening instruments, patient education tools/handouts, referral resources, etc.).
    • decision and memory supports (e.g., chart pages with treatment flow charts and a support tool for deciding on treatment options for particular patients).
    • office supports for recommended new practices (e.g., chart reminder notes, training materials and instructions for staff who are significant in meeting best practice recommendations).
  4. Provide specific advice on how to overcome common obstacles to implementation of best practices for depression care.
  5. Provide advice and/or plans for evaluating new practices (or guide a user in generating a customized evaluation plan).
  6. Describe where to get further help (i.e., how to get expert advice, where to find further resources and reading).

Proposed Courses

Course Development Process

Development of our courses will proceed as follows:

  1. Perform a thorough literature review.
  2. Generate an outline, learning objectives, and brief overview paragraph for each course.
  3. Have expert consultant and PI review the course outline and objectives.
  4. Choose the course model (e.g., didactic or case-based format), write the content, and design the interactive and non-interactive course features that will best present and convey the content.
  5. Two expert consultants (psychiatrists or psychologists) will review the draft to ensure thoroughness, accuracy, and clarity of the content.
  6. A primary care physician consultant will review course for content and relevance to primary care.
  7. When necessary, implement in-house and online usability testing to collect qualitative preference data from users about the navigation, design, and organization of the course.
  8. Finalize the course in keeping with Clinical Tools criteria for accreditation.
  9. Provide Clinical Tools'' ACCME Category I Accreditation and make courses available on the Internet.
  10. Assess each course individually for usability as well as impact on knowledge, self-efficacy, attitude, and intended behavior outcomes. Make revisions as necessary.

hide title: Proposed Course Descriptions

1. Depression in Primary Care: Prevalence, Risk Factors, and Impact (1.5)
Course goal: Introduce physicians to the prevalence, importance, and impact of depressive disorders.
Overview: Which of your patients are most likely to suffer from depressive disorders? This course discusses the prevalence of major depression and dysthymia in various populations, emphasizing information that is most relevant and helpful to the primary care practitioner. The course explains the major risk factors for depression as well as common psychiatric and medical comorbidities. Health professionals can use this information as background for our other CME courses on screening and treatment of depression in primary care and our medical cases.

2. Screening for Depression in Adults in Primary Care (1.5)
Course goal: To teach physicians about the importance of screening, and how they can implement a screening program in their practice.
Overview:
Between 5% and 10% of primary care patients may be depressed, yet many physicians do not screen patients for depression. The US Preventive Services Task Force has recently recommended routine depression screening for all adults in primary care. This course has been developed specifically for primary care physicians who wish to learn about best practice guidelines for depression screening and ways to integrate screening into their practices. A range of screening instruments is described, together with ways to select an instrument to fit your practice needs. Printable versions of several screening instruments and an interactive tool for implementing screening in your own primary care setting are also provided.

3. Diagnosis and Referral of Primary Care Patients with Depression (1.0)
Course goal:
To help physicians identify their depressed patients, differentiate depression from substance abuse and other psychiatric and medical disorders, and know when to refer patients for urgent intervention or specialist treatment.
Overview:
Depression is often undetected or misdiagnosed in the primary care setting. This course has been developed specifically for primary care physicians who wish to learn about best practice guidelines for detecting and diagnosing depression. The course will discuss (i) detection of symptoms of Major Depressive Disorder (MDD) and Dysthymic Disorder (DD), (ii) differential diagnosis of these disorders, (iii) special considerations for diagnosis in older adults, (iv) assessment of patients for urgent intervention, and (v) referral of patients to a mental health specialist or therapist. Patient education materials and other resources will also be provided.

4. Treatment of Depression in Primary Care, Including Acute, Continuation and Maintenance Phase Treatments (2.0) Course goal: To help physicians plan and implement guideline-based depression treatment plans.
Overview: Ten percent or more of primary care patients may suffer from major depression or dysthymia, yet these disorders are frequently undertreated. This course discusses the treatment and clinical management of major depression and dysthymia in adults. The course material is specifically designed for primary care practitioners but may also be helpful for pharmacists and other health professionals. Current clinical guidelines for best practice in depression treatment are described, along with research supporting the recommendations. The course covers drug therapies and psychotherapies and includes discussion of complementary and new approaches to treatment. Physician resources and patient education materials are also provided.

5. Psychosocial Approaches to the Treatment of Depression (1.5) Course goal:Help physicians integrate psychotherapeutic and related psychosocial approaches into their treatment programs for depressed patients.
Overview:
The treatment of major depression and dysthymia in primary care has focused primarily on pharmacotherapy. Many patients may prefer psychotherapeutic interventions instead of, or as a complement to, medication. In fact, psychotherapeutic interventions can be highly effective. There are other psychosocial approaches, such as support groups, stress reduction techniques, and other modalities, that can also be effective as adjuncts in symptom reduction and longer-term relapse prevention. This course discusses which psychosocial approaches are effective and how to integrate them into your practice with your patients, according to evidence-based research and best practice guidelines. A range of resources for physicians and printable patient education materials about formal therapies, counseling, support groups and self-help approaches complement the research discussion throughout the course.

6. The Follow-up and Management of Depression in Primary Care (1.5)
Course goal:Help physicians learn to more effectively follow-up, monitor, and evaluate depression treatment, and to work with patients to manage their depression more effectively.
Overview:
Careful follow-up and monitoring are essential for depression treatment in order to achieve recovery and prevent recurrence. This course describes guidelines and strategies for clinical management of adult cases of depression which are treated in the primary care setting. Recommended timing and content of followup appointments, patient education throughout treatment, management of side effects, strategies for promoting treatment adherence, and tips for comanagement with mental health professionals are all addressed. The course emphasizes treating depression as a chronic condition, and avoiding common problems in management of depression in primary care settings.

7. The Wellness Approach to Depression Prevention and Treatment (1.5)
Course goal: Expose physicians to a comprehensive, integrative approach to treating and preventing depression.
Overview: This course describes a comprehensive wellness approach to the prevention and treatment of depression in primary care. Ways that patients can help prevent and cope with depression include changes in exercise and sleep habits, improved nutrition, stress management, the use of mind-body techniques such as meditation or massage, and spiritual practices. In addition, supplements such as St. John''s wort, which are increasingly used to self-medicate depressive symptoms, can be safely and effectively integrated into a prevention and treatment strategy for some patients.
Our primary goals are to 1) provide physicians with evidence regarding the effectiveness of these approaches in preventing and treating depression and 2) to provide tools to integrate these approaches into an effective holistic approach, along with more traditional approaches, for patients. A range of resources for physicians about wellness and depression complement the research discussion throughout the course. Printable patient education materials are also provided so that providers can help patients learn to use wellness approaches to prevent and cope with depression.

8. A Case of Depression in Primary Care: Debra, a 32-Year-Old Female, Complains of Fatigue (1.5)
Course goal: Provide physicians with a simple medical case study to take them through four stages of managing depression in primary care.
Overview: A patient with depressive symptoms is followed through 4 phases of care. First the patient is screened for depression. More information about the case is then gathered through the patient''s chart, physical exam, laboratory tests, and clinical interview. The physician then follows DSM-IV diagnostic criteria to assess symptoms and rule out various mental and medical disorders. Finally, treatment and follow-up strategies are discussed. The course is presented in an interesting, interactive format, and helpful patient education information is provided.

hide title: Course Features

  • Course Organization
    • Clear and articulated goal of the course that relates to the overall curriculum goals
    • A course content page
    • Learning objectives stated on first page of course
    • An overview of general and course-specific features at the start of the course
    • Complete credits for authors, reviewers, and content experts along with full disclosure statements for each author

  • Course Features
    • Questions of various kinds (clinical-decision making, think-ahead, knowledge, and opinion) interspersed throughout the course with customized feedback based on user selections
    • Users can view optional pop-up pages containing details that further develop the core content or that contain material of related interest
    • In-text links to web pages of interests (governmental reports, official guidelines, etc.)
    • Some courses will include case study vignettes or will carry one case study throughout the entire course--these case studies will emphasize development of clinical skills
    • Key learning points provided on various pages throughout the course
    • Key course points summarized at the end of the course
    • Post-Test questions to assess knowledge

  • Resources
    • Printable practice resources (e.g., printable screening tools)
    • Printable patient resources and informational worksheets/handouts
    • Helpful links page with a list of websites and a brief description of each site
    • Recommended reading page with a list of journals, books, and articles with a brief description of each resource

  • Feedback
    • A detailed survey about the course covering content, usability, relevance to clinical practice, and satisfaction
    • The ability to send feedback directly to the site-development team

We have generated more detailed listing of our course features, comparing them to other online CME offerings.

Proposed Course Outlines

Web Pages in Course Outlines

1: Course 1: Scope of the problem
2: Course 2: Screening
3: hide title: Course 3: Diagnosis
4: Course 4: Treatment
5: hide title: Course 5: Integrating Psychosocial Approaches
6: hide title: Course 6: Follow-Up & Management
7: hide title: Course 7: General Health & Wellness
8: Course 8: Case Study

Course 1: Scope of the problem

Course 1: Scope of the problem: Prevalence, Impact, and Risk Factors

Estimated number of pages:
Estimated credit hours:
1.5
Estimated number of clinical cases: None
Writer:
Jennifer Ratcliffe, PhD, MSc
Other expected authors: Elisabeth Sullivan, MS
Content (expert) reviewers: Bradley N. Gaynes, MD, MPH; Ravinder D. Reddy, MD; T. Bradley Tanner, MD
Basis of the content:
Course goal: Introduce physicians to the prevalence, importance, and impact of depressive disorders.

Overview
This course identifies which patients are most likely to suffer from depressive disorders. It discusses the prevalence of major depression and dysthymia in various populations, emphasizing information that is most relevant and helpful to the primary care practitioner. The course explains the major risk factors for depression as well as common psychiatric and medical comorbidities. This course provides a background for our other courses.

Learning Objectives

  • understand the prevalence rates of major depression and dysthymia in the general population and within specific populations
  • know the prevalence rates of comorbid psychiatric and medical illnesses
  • understand the major risk factors for depression

Outline of Content

  • General Population Prevalence of Mood Disorders
  • Prevalence of Depressive Disorders
  • Social and Economic Costs of Depression
  • Prevalence in Primary Care
  • Depression and Gender
  • Depression in Children and Adolescents
  • Depression in Older Adults
  • Depression and Ethnicity, Race, and Culture
  • Comorbid Substance Abuse and Dependence
  • Comorbid Anxiety
  • Comorbid Eating Disorders
  • Medical Comorbidities
  • Risk Factors for Depression
  • Assessing Risk: Medical History
  • Assessing Risk: Demographics
  • Assessing Risk: Medical and Psychiatric Conditions
  • Assessing Risk: Psychological and Social Factors
  • Key Points for Clinical Practice
  • References, Helpful Links, and CME Credit

Printable Practice Resources

  • MacArthur Foundation. MacArthur Initiative Depression Toolkit. 2001. http://www.depression-primarycare.org/. The MacArthur Foundation Initiative on Depression is a website designed to provide primary care physicians and health care organizations with knowledge and tools to enhance the recognition and care of patients with depression.
  • National Institutes of Health (NIH) and the National Library of Medicine (NLM). MEDLINEPlus: Depression. http://www.nlm.nih.gov/medlineplus/depression.html. This website provides regularly updated links to statistics, clinical trials, research and drug treatment and related resources on depression.
  • National Institute of Mental Health (NIMH). Depression Research at the NIMH: Fact Sheet. 2001. http://www.nimh.nih.gov/publicat/depresfact.cfm. This page provides a summary of descriptive facts on depression and its treatment in different populations and provides links to other NIMH resources dealing with depression.
  • National Institute of Mental Health (NIMH). For Practitioners. 2003. http://www.nimh.nih.gov/practitioners/index.cfm. This site provides links for practitioners to NIMH resources on the treatment of depression and other mental disorders, together with research updates and patient education materials.

Printable Patient Resources

  • MacArthur Foundation. MacArthur Initiative Depression Toolkit. 2001. http://www.depression-primarycare.org/. The MacArthur Foundation Initiative on Depression is a website designed to provide primary care physicians and health care organizations with knowledge and tools to enhance the recognition and care of patients with depression.
  • National Institutes of Health (NIH) and the National Library of Medicine (NLM). MEDLINEPlus: Depression. http://www.nlm.nih.gov/medlineplus/depression.html. This website provides regularly updated links to statistics, clinical trials, research and drug treatment and related resources on depression.
  • National Institute of Mental Health (NIMH). Depression Research at the NIMH: Fact Sheet. 2001. http://www.nimh.nih.gov/publicat/depresfact.cfm. This page provides a summary of descriptive facts on depression and its treatment in different populations and provides links to other NIMH resources dealing with depression.

References and Recommended Reading

Kessler RC, McGonagle KA, Swartz M, Blazer DG, Nelson CB. Sex and depression in the National Comorbidity Survey. I: Lifetime prevalence, chronicity and recurrence. J Affect Disord. 1993;29: 85-96.

Kessler RC, Walters EE. Epidemiology of DSM-III-R major depression and minor depression among adolescents and young adults in the National Comorbidity Survey. Depress Anxiety. 1998;7:3-14.

Piccinelli M, Wilkinson G. Gender differences in depression: Critical review. Br J Psychiatry. 2000;177:486-92.

Pincus HA, Pettit AR. The societal costs of chronic major depression. J Clin Psychiatry. 2001;62 Suppl 6:5-9.

Roose SP, Glassman AH, Seidman SN. Relationship Between Depression and Other Medical Illnesses. JAMA. 2001;286(14), 1687-1690

Stoppard J. Understanding Depression: a feminist social constructionist approach. New York: Routledge; 2000.

Weissman MM, Bland RC, Canino GJ, Faravelli C, Greenwald S, Hwu HG, Joyce PR, Karam EG, Lee CK, Lellouch J, Lepine JP, Newman SC, Rubio-Stipec M, Wells JE, Wickramaratne PJ, Wittchen H, Yeh EK. Cross-national epidemiology of major depression and bipolar disorder. JAMA. 1996;276(4):293-9.

U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General.Rockville, MD: U.S.;1999. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health.

Course 2: Screening

Course 2: Screening for Depression in Adults in Primary Care

Estimated number of pages:
Estimated credit hours: 1.5
Estimated number of clinical cases: None
Principal writer: Jennifer Ratcliffe, PhD, MSc
Other expected authors: Elisabeth Sullivan, MS; Ellen R. Stoltzfus, PhD; Jared Weinberger, MS
Content (expert) reviewers: T. Bradley Tanner, MD
Basis of the content:
Course goal: To teach physicians about the importance of screening, and how they can implement a screening program in their practice

Overview
In 2002, the USPSTF recommended screening for depression in all adults in primary care. This course describes the best practice guidelines for depression screening and gives evidence for why screening should be implemented in primary care. The basic issues in evaluating and comparing screening instrument are covered, and several common screening instruments are included in the course (in printable version). The course has an interactive tool for implementing screening into the physician''s own primary care setting.

Learning Objectives
After completing this course, the learner will be able to:

  • Apply depression screening guidelines for primary care practice
  • Evaluate the impact of screening on the diagnosis of depression
  • Compare the effectiveness of different screening instruments used in primary care
  • Understand the limitations of screening instruments
  • Select a useful screening instrument and integrate a screening program into your practice

Outline of Content

  • Introduction
  • Guidelines for Screening
  • Effectiveness of Screening
  • Evaluating Screening Instruments
  • Selecting an Instrument
  • Instrument Effectiveness Comparison
  • Brief vs Longer Instruments
  • Advantages of Detailed Instruments
  • Implementing Screening in a Primary Care Practice
  • Depression Screening Instruments for Adults
  • General Screening Instruments
  • Screening in Older Adults
  • Summary of Key Points
  • References, Helpful Links, and CME Credit

Printable Practice Resources

  • American Medical Association. Guidelines for Adolescent Preventive Services. Recommendations Monograph. AMA 1997. http://www.ama-assn.org/ama/upload/mm/39/gapsmono.pdf
  • MacArthur Foundation. MacArthur Initiative Depression Toolkit. 2001. http://www.depression-primarycare.org/
  • NIH. MEDLINEPlus: Depression. http://www.nlm.nih.gov/medlineplus/depression.html
  • NIMH. Depression Research at the NIMH: Fact Sheet. 2001. http://www.nimh.nih.gov/publicat/depresfact.cfm

Printable Patient Resources

General Information
  • Depression(http://www.nimh.nih.gov/publicat/depressionmenu.cfm) (National Institute of Mental Health) The NIMH site has resources on depression, with resources that target children, women, older adults, and those seeking alternative medicinal treatments.
  • Men and Depression(http://menanddepression.nimh.nih.gov/) (National Institute of Mental Health) Here you can view public service announcements and learn more about the signs and symptoms of depression.
  • Consumer.DepressionClinic.com(http://consumer.depressionclinic.com) (Clinical Tools Inc.) This CTI site answers questions such as what depression is, how it is diagnosed, and the treatments and medications available.
  • Mental Health(http://www.surgeongeneral.gov/Library/MentalHealth/) (A Report of the Surgeon General) Health report from the surgeon general with fundamentals of mental illness, children/adults and how they deal with mental health, and how to finance mental health services.
  • Factsheets(http://www.nmha.org/infoctr/factsheets/) (National Mental Health Association) NMHA site presents facts on anxiety disorders, children''s mental health, depression, the elderly, suicide risks, substance abuse, schizophrenia, mental illness in the family, and research studies.
  • Depression(http://www.ndmda.org/depression.html) (National Depressive and Manic-Depressive Association) This NDMA page answers questions about depression, including the differences between depression and bipolar disorder, SAD, treatments, and support groups.
  • Let''s Talk Facts About Depression(http://www.psych.org/public_info/pdf/depress.pdf) (The American Psychiatric Association) A pdf file that answers questions about the types of depression, theoretical causes, and medications.
  • Understanding Major Depression: What You Need to Know About This Medical Illness(http://www.nami.org/helpline/UnderstandingMajorDepression.pdf) (National Alliance for the Mentally Ill) A pdf file that covers the basic of depression and its effects.
Support groups
  • Depression: Family, Friends and Loved Ones(http://boards.webmd.lycos.com/roundtable_topic/40) (Lycos Health with WebMD) Discussion group for family, friends, and loved ones of people living with depression.
  • Chapter and Support Group Directory (http://www.ndmda.org/findsupport.html) (National Depressive and Manic-Depressive Association) This NDMA site gives a directory of support groups for those living with depression or those who are close to someone living with depression.
Mental Health Locators
  • Mental Health Services Locator(http://www.mentalhealth.org/databases/default.asp) (Substance Abuse and Mental Health Services Administration) This map locates mental health services in your area.
  • State and Provincial Psychological Associations (http://www.apa.org/practice/refer.html) (The American Psychological Association) A list of psychological associations.

References and Recommended Reading

Gilbody SM, House AO, Sheldon TA. Routinely administered questionnaires for depression and anxiety: systematic review. Br Med J. 2001;322(7283):406-9.

Gotlib, IH, Hammen, CL, eds. Handbook of Depression. New York: The Guilford Press; 2002.

Pignone MP, Gaynes BN, Rushton JL, Burchell CM, Orleans CT, Mulrow CD, Lohr KN. Screening for depression in adults: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002;136:765-76.

U.S. Department of Health and Human Services. (1999). Mental Health: a Report of the Surgeon GeneralRockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health.

U.S. Preventive Services Task Force. Screening for depression: recommendations and rationale. Ann Internal Med. 2002;136: 760-764.

hide title: Course 3: Diagnosis

Course 3: Depression Diagnosis and Referral

Estimated number of pages: 25
Estimated credit hours: 1.0
Estimated number of clinical cases: 4
Principal writers:
Jennie Ratcliffe, PhD, MS
Other expected authors:
Ellen R. Stoltzfus, PhD
Content (expert) reviewers: Mary Morreale, MD, Brandi Woods, MA, Brad Tanner, MD

Course goal:
To help physicians identify their depressed patients, differentiate depression from substance abuse and other psychiatric and medical disorders, and know when to refer patients for urgent intervention or specialist treatment.

Overview
Depression is often undetected or misdiagnosed in the primary care setting. This course has been developed specifically for primary care physicians who wish to learn about best practice guidelines for detecting and diagnosing depression. The course begins by discussing barriers to accurate detection of depression. The course then covers (i) DSM-IV criteria and the detection of symptoms of major depressive disorder (MDD) and dysthymia; (ii) differential diagnosis of these disorders; (iii) diagnosis in special populations (older adults, adolescents); (iv) assessment of patients for urgent intervention; and (v) referral of patients to a mental health specialist or therapist. Patient education materials and other resources will also be provided.

Learning Objectives
After completing this course, the learner will be able to:

  • Avoid common obstacles to depression detection
  • Use the DSM-IV guidelines for the diagnosis of Major Depression and Dysthymia
  • Recognize risk factors for depression, and use this information during the detection and diagnosis process
  • Know how to use screening, the clinical interview, and patient charts to help detect symptoms of depression
  • Conduct a differential diagnosis to rule out other major psychiatric disorders, general medical conditions and substance abuse as reasons for their symptoms
  • Assess patients for suicidality and need for immediate intervention
  • Understand when to refer patients to other specialists

Outline of Content

  • Scope of the Problem
  • Barriers to Detection and Diagnosis
  • Steps in the Detection and Diagnosis of Depression
  • Step 1: Preparation
  • Step 2: Detecting Symptoms and Risk Factors
    • Incorporating Screening Results
    • Detecting Symptoms
    • Detecting Symptoms (Chart Review)
    • Detecting Symptoms (Clinical Interview)
  • Step 3: Differential Diagnosis
    • Ruling out Other Psychiatric Disorders
    • Coexisting Psychiatric Disorders
    • Ruling out Substance Abuse
    • Ruling out Medical Conditions
    • Physical Exam
    • Ruling out Medical Conditions: Lab Tests
    • Ruling out Effects of Medications
  • Diagnosis in Special Populations: Older Adults and Adolescents
  • When to Refer Your Patient: Assess for Urgent Intervention
  • When to Refer Your Patient: Special Cases
  • Where to Refer Your Patient

Printable Practice Resources

Printable Patient Resources

  • Depression(http://www.nimh.nih.gov/publicat/depressionmenu.cfm) (National Institute of Mental Health) The NIMH site has resources on depression, with resources that target children, women, older adults, and those seeking alternative medicinal treatments.
  • Men and Depression(http://menanddepression.nimh.nih.gov/) (National Institute of Mental Health) Here you can view public service announcements and learn more about the signs and symptoms of depression.
  • Consumer.DepressionClinic.com(http://consumer.depressionclinic.com) (Clinical Tools Inc.) This CTI site answers questions such as what depression is, how it is diagnosed, and the treatments and medications available.
  • Mental Health(http://www.surgeongeneral.gov/Library/MentalHealth/) (A Report of the Surgeon General) Health report from the surgeon general with fundamentals of mental illness, children/adults and how they deal with mental health, and how to finance mental health services.
  • Factsheets(http://www.nmha.org/infoctr/factsheets/) (National Mental Health Association) NMHA site presents facts on anxiety disorders, children''s mental health, depression, the elderly, suicide risks, substance abuse, schizophrenia, mental illness in the family, and research studies.
  • Depression(http://www.ndmda.org/depression.html) (National Depressive and Manic-Depressive Association) This NDMA page answers questions about depression, including the differences between depression and bipolar disorder, SAD, treatments, and support groups.
  • Let''s Talk Facts About Depression(http://www.psych.org/public_info/pdf/depress.pdf) (The American Psychiatric Association) A pdf file that answers questions about the types of depression, theoretical causes, and medications.
  • Understanding Major Depression: What You Need to Know About This Medical Illness(http://www.nami.org/helpline/UnderstandingMajorDepression.pdf) (National Alliance for the Mentally Ill) A pdf file that covers the basic of depression and its effects.
  • Depression: Family, Friends and Loved Ones(http://boards.webmd.lycos.com/roundtable_topic/40) (Lycos Health with WebMD) Discussion group for family, friends, and loved ones of people living with depression.
  • Chapter and Support Group Directory (http://www.ndmda.org/findsupport.html) (National Depressive and Manic-Depressive Association) This NDMA site gives a directory of support groups for those living with depression or those who are close to someone living with depression.
  • Mental Health Services Locator(http://www.mentalhealth.org/databases/default.asp) (Substance Abuse and Mental Health Services Administration) This map locates mental health services in your area.
  • State and Provincial Psychological Associations (http://www.apa.org/practice/refer.html) (The American Psychological Association) A list of psychological associations.

References and Recommended Reading

Birmaher B, Brent DA, Benson RS. Related summary of the practice parameters for the assessment and treatment of children and adolescents with depressive disorders. J Am Acad Child Adolesc Psychiatry. 1998;37(11):1234-8.

Farmer AE, Griffiths H. Labelling and illness in primary care: comparing factors influencing general practitioners'' and psychiatrists'' decisions regarding patient referral to mental illness services. Psychol Med. 1992 Aug;22(3):717-23.

Lin EH, Katon W. Beyond the diagnosis of depression. Gen Hosp Psychiatry. 1998 Jul;20(4):207-8.

Rosenberg E, Lussier MT, Beaudoin C, Kirmayer LJ, Dufort GG. Determinants of the diagnosis of psychological problems by primary care physicians in patients with normal GHQ-28 scores. Gen Hosp Psychiatry. 2002 Sep-Oct;24(5):322-7.

Staab JP, Datto CJ, Weinrieb RM, Gariti P, Rynn M, Evans DL. Detection and diagnosis of psychiatric disorders in primary medical care settings. Med Clin North Am. 2001;85:579-96.

Course 4: Treatment

Course 4: The Treatment of Depression in Primary Care: Acute, Continuation and Maintenance Phase Treatments

Estimated number of pages:
Estimated credit hours: 2.0
Estimated number of clinical cases: 4 mini-cases
Principal writers: Jennifer Ratcliffe, PhD, MSc
Other expected authors: Jared Weinberger, MS
Content (expert) reviewers: T. Bradley Tanner, MD

Course goal: To help physicians understand, plan, and implement comprehensive treatment plans for their depressed patients.

Overview
This course outlines the phases of depression treatment (acute, continuation, and maintenance), and guides the physician through the various components of planning and implementing a comprehensive treatment plan, focusing on the major treatment modalities (medication and psychotherapy). Best practices for followup and monitoring during treatment are also discussed.

Learning Objectives
After completing this course, the learner will be able to:

  • apply clinical guidelines for effective acute, continuation and maintenance phases of treatment for depression in adults
  • evaluate different treatment modalities, including pharmacotherapies, psychotherapies, and newer treatments
  • plan and implement a comprehensive treatment strategy with your patient
  • monitor and evaluate patients during treatment and determine when to switch or augument therapies
  • identify resources and educational materials on treatment for your patients

Outline of Content

  • Scope of the Problem
  • Aims of Treatment
  • Phases of Treatment
  • Overview of Steps in the Treatment of Depression
  • Planning the Treatment Strategy
  • Evaluate for Immediate Intervention or Referral
  • Extended Evaluation and Supportive Counseling
  • Choosing a Formal Treatment Modality
  • Types of Psychotherapy
  • Pharmacotherapy: Overview
  • Prescribing Principles
  • Complementary and Alternative Approaches
  • Monitoring Acute Phase Treatment
  • Symptom Assessment and Treatment Modification
  • Continuation Treatment
  • Maintenance Treatment
  • Key Points for Clinical Practice

Printable Practice Resources

  • American Medical Association. Guidelines for Adolescent Preventive Services. Recommendations Monograph. AMA 1997. http://www.ama-assn.org/ama/upload/mm/39/gapsmono.pdf
  • MacArthur Foundation. MacArthur Initiative Depression Toolkit. 2001. http://www.depression-primarycare.org/
  • NIH. MEDLINEPlus: Depression. http://www.nlm.nih.gov/medlineplus/depression.html
  • NIMH. Depression Research at the NIMH: Fact Sheet. 2001. http://www.nimh.nih.gov/publicat/depresfact.cfm

Printable Patient Resources

General Information
  • Depression(http://www.nimh.nih.gov/publicat/depressionmenu.cfm) (National Institute of Mental Health) The NIMH site has resources on depression, with resources that target children, women, older adults, and those seeking alternative medicinal treatments.
  • Men and Depression(http://menanddepression.nimh.nih.gov/) (National Institute of Mental Health) Here you can view public service announcements and learn more about the signs and symptoms of depression.
  • Consumer.DepressionClinic.com(http://consumer.depressionclinic.com) (Clinical Tools Inc.) This CTI site answers questions such as what depression is, how it is diagnosed, and the treatments and medications available.
  • Mental Health(http://www.surgeongeneral.gov/Library/MentalHealth/) (A Report of the Surgeon General) Health report from the surgeon general with fundamentals of mental illness, children/adults and how they deal with mental health, and how to finance mental health services.
  • Factsheets(http://www.nmha.org/infoctr/factsheets/) (National Mental Health Association) NMHA site presents facts on anxiety disorders, children''s mental health, depression, the elderly, suicide risks, substance abuse, schizophrenia, mental illness in the family, and research studies.
  • Depression(http://www.ndmda.org/depression.html) (National Depressive and Manic-Depressive Association) This NDMA page answers questions about depression, including the differences between depression and bipolar disorder, SAD, treatments, and support groups.
  • Let''s Talk Facts About Depression(http://www.psych.org/public_info/pdf/depress.pdf) (The American Psychiatric Association) A pdf file that answers questions about the types of depression, theoretical causes, and medications.
  • Understanding Major Depression: What You Need to Know About This Medical Illness(http://www.nami.org/helpline/UnderstandingMajorDepression.pdf) (National Alliance for the Mentally Ill) A pdf file that covers the basic of depression and its effects.
Support groups
  • Depression: Family, Friends and Loved Ones(http://boards.webmd.lycos.com/roundtable_topic/40) (Lycos Health with WebMD) Discussion group for family, friends, and loved ones of people living with depression.
  • Chapter and Support Group Directory (http://www.ndmda.org/findsupport.html) (National Depressive and Manic-Depressive Association) This NDMA site gives a directory of support groups for those living with depression or those who are close to someone living with depression.
Mental Health Locators
  • Mental Health Services Locator(http://www.mentalhealth.org/databases/default.asp) (Substance Abuse and Mental Health Services Administration) This map locates mental health services in your area.
  • State and Provincial Psychological Associations (http://www.apa.org/practice/refer.html) (The American Psychological Association) A list of psychological associations.

References and Recommended Reading

Agency for Health Care Policy and Research. Depression in Primary Care: Treatment of Major Depression. Clinical Practice Guideline 1993; Vol.2 No. 5. Rockville, MD: USDHHS, AHCPR.

Agency for Health Care Policy and Research. Treatment of Depression--Newer Pharmacotherapies. Rockville, MD: 1999;AHCPR Pub No. 99-E014.

Goldman LS, Nielsen NH, Champion HC. Awareness, Diagnosis, and Treatment of Depression. J Gen and Intern Med. 1999;14:569-580.

Gotlib, IH, Hammen, CL, eds. Handbook of Depression. New York: The Guilford Press; 2002.

Keller MB, Berndt ER Depression treatment: a lifelong commitment? Psychopharmacol Bull. 2002;36: Suppl 2: 133-41.

McCullough JP. Treatment for chronic depression. New York: Guilford Press; 1999.

Mulrow CD, Williams JW Jr, Chiquette E, Aguilar C, Hitchcock-Noel P, Lee S, Cornell J, Stamm K. Efficacy of newer medications for treating depression in primary care patients. Am J Med. 2000;108(1):54-64.

Schulberg HC, Katon WJ, Simon GE, Rush AJ. Best clinical practice: guidelines for managing major depression in primary medical care. J Clin Psychiatry.

Schulberg HC, Pilkionis PA, Houck, P. The severity of depression and choice of treatment in primary care practice. J Consult Clin Psyhcol. 1998;66: 932-38.

Thase ME. Treatment of severe depression. J Clin Psychiatry. 2000;61 Suppl 1:17-25.

U.S. Department of Health and Human Services. (1999). Mental health: a Report of the Surgeon General.Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health.

hide title: Course 5: Integrating Psychosocial Approaches

Course 5: Integrating Psychosocial Approaches to Depression Treatment into your Primary Care Practice

Estimated number of pages: 25
Estimated credit hours: 1.5
Estimated number of clinical cases: 5
Principal writers: Jennifer Ratcliffe, Ph.D.
Other expected authors: Ellen Stoltzfus, PhD
Content (expert) reviewers:

Course goal: To enable primary care physicians to understand the role of brief psychotherapies, counseling, and related psychosocial support in the treatment of depression. To enable physicians to discuss these options with their patients and to incorporate such approaches into the treatment and management of depression.

Overview
This course educates primary care physicians about available psychosocial approaches to depression treatment and how and when to integrate these approaches into their treatment strategy. Approaches covered include: formal psychotherapies such as cognitive-behavioral, interpersonal, marital and family therapy; counseling; support groups; stress management, and coping skills training. The supportive roles of family, alternative and complementary approaches, and spiritual techniques are also discussed. Evidence for the role of psychosocial factors in the etiology of depression and the effectiveness of psychosocial treatment approaches is presented. The course also covers critical aspects of patient education, how to locate therapists, and how to co-manage treatment with a psychotherapist or other mental health worker. Resources for referrals and patient information are provided.

Learning Objectives

  • Apply best practice guidelines for the treatment and management of depression using formal psychotherapies and other psychosocial approaches.
  • Understand and evaluate the major types of formal psychotherapy for effectiveness in the prevention and treatment of depression.
  • Consider other psychosocial approaches such as supportive counseling, stress reduction, coping skills and self-help groups.
  • Integrate psychotherapies and other approaches into a treatment plan with your patients.
  • Monitor and follow-up an integrated treatment plan.
  • Identify resources and educational materials for yourself and your patients.

Outline of Content

  • Evidence for the role of psychosocial risk factors in the etiology of depression
  • Formal psychotherapies suitable for depression treatment
  • Evidence for the effectiveness of brief psychotherapies
  • Supportive counseling
  • Support groups, stress mangement, and other approaches
  • Matching patients to treatments
  • How to integrate, co-manage, monitor and follow-up treatment in collaboration with a therapist/counselor
  • Resources for physicians and patients to learn about and locate therapists, other mental health resources, self-help groups
  • Providing supportive counselling through diagnosis and treatment
  • Using a "wizard" to help decide on the best treatment option with your patient
  • When and where to refer and follow-up on a treatment plan

Printable Practice Resources

Printable Patient Resources and Links

  • American Psychological Association Help Center:http://helping.apa.org/index.html. The site provides information on how to locate a therapist.
  • NAMI: Find Support: http://www.nami.org/Template.cfm?section=Find_Support. Provides assistance with finding support groups and information.
  • American Psycohological Association Help Center: http://helping.apa.org/index.html. Provides information on the effects of stress and when to seek help. Also provides information on the benefits of exercise.
  • Mayo Clinic: http://www.mayoclinic.com. Provides information on stress and stress management with links to the following related topics: workplace stress; meditation; yoga; massage and pain management.
  • NAMI: Stress: Coping with Everyday Problems: http://www.nmha.org/infoctr/factsheets/41.cfm. Discusses the symptoms of stress, how to control it and how to find help.
  • NASD: Dealing with Stress: http://www.cdc.gov/nasd/docs/d001501-d001600/d001558/d001558.html. Provides information on effects of stress and strategies to manage stress.
  • National Mental Health Information Center: http://www.mentalhealth.org/. Provides a mental health services locator.

References and Recommended Reading

Brown C, Schulberg HC. The efficacy of psychosocial treatments in primary care. A review of randomized clinical trials. Gen Hosp Psychiatry. 1995 Nov;17(6):414-24. Review.

Huibers MJ, Beurskens AJ, Bleijenberg G, van Schayck CP. The effectiveness of psychosocial interventions delivered by general practitioners. Cochrane Database Syst Rev. 2003;(2):CD003494. Review

Kebbon L, Swartling PG, Smedby B. Psychiatric symptoms and psychosocial problems in primary health care as seen by doctors. Scand J Prim Health Care. 1985 Feb;3(1):23-30.

Klausner EJ, Alexopoulos GS. The future of psychosocial treatments for elderly patients. Psychiatr Serv. 1999 Sep;50(9):1198-204. Review.

Klinkman MS. Competing demands in psychosocial care. A model for the identification and treatment of depressive disorders in primary care. Gen Hosp Psychiatry. 1997 Mar;19(2):98-111. Review.

hide title: Course 6: Follow-Up & Management

Course 6: Follow-up and Management of Depression after the Acute Phase of Treatment

Estimated number of pages:
Estimated credit hours: 1.0
Estimated number of clinical cases: 2
Principal writers:Mary Morreale, Ellen Stoltzfus, Jennie Ratcliffe
Other expected authors:
Content (expert) reviewers: Bob Golden, Brad Tanner

Course goal: Help physicians do more effective monitoring, evaluation, and education of patients during the continuation and maintenance phases of treatment.

Overview
Primary care physicians seem to do a poor job of monitoring depressed patients through their course of treatment. This course covers APA standards for monitoring care of depressed patients and discusses specific followup practices that will aid patients. The course addresses important challenges in use of antidepressant drug treatments in primary care, including managing side effects, underdosing, and treatment adherence. It also addresses issues of relapse, recurrence, chronic depression, and long-term maintenance treatment.

Learning Objectives
After completing this course, the learner will be able to:

  • Know guidelines for the follow-up of depressed patients treated solely with pharmacological approaches, psychotherapeutic approaches, and other approaches.
  • Know when to schedule follow-up visits and how to conduct an effective followup visit during the continuation and maintenance phases of treatment.
  • Be able to use tools and techniques to assess symptom improvement, side effects, and drug interactions.
  • Know when to modify treatment based on assessments of improvement, side effects, and drug interactions.
  • Know what options to pursue in cases of inadequate response to the first drug of choice.
  • Know what to do when patients do not respond to two successive antidepressant treatments, i.e., how to refer treatment-resistant depression.
  • Monitor patient compliance, and consider the use of intensified case management to promote compliance and monitoring of adverse effects.
  • Be able to co-manage patient care with a mental health care provider.
  • Consider the appropriate role for long-term comprehensive treatment approaches, including sleep, exercise, diet, and stress management.
  • Create and implement a relapse prevention plan with the patient if treatment is discontinued.
  • Provide appropriate patient education throughout treatment.

Outline of Content

  • Overview of Current Problems with Depression Management in Primary Care
  • Challenges in Drug Monitoring, Changes, and Dosing Issues
  • Timing, Structure, and Content of a Followup Appointment
    • Supportive Counselling and Patient Education
    • Assessment of Symptom Improvement
    • Assessment of Side Effects, (esp. sex and weight)
    • Assessment of Patient Compliance
    • Case Example
  • Enhancing Patient Compliance
  • Incorporating Psychosocial Components in Treatment and Co-Managing Care
    • patient education
    • communication/co-management with mental health professionals
  • Comprehensive Treatment for Relapse Prevention
    • maintenance therapy
    • healthy lifestyles for mental and physical health
  • Treatment Resistant Depression
  • Chronic/Recurrent Depression

Printable Practice Resources

Printable Patient Resources

References and Recommended Reading

Brown C, Schulberg HC, Prigerson HG. Factors associated with symptomatic improvement and recovery from major depression in primary care patients. Gen Hosp Psychiatry. 2000 Jul-Aug;22(4):242-50.

Frank E, Rucci P, Katon W, Barrett J, Williams JW Jr, Oxman T, Sullivan M, Cornell J. Correlates of remission in primary care patients treated for minor depression. Gen Hosp Psychiatry. 2002 Jan-Feb;24(1):12-9.

Fritzsche K, Sandholzer H, Brucks U, Cierpka M, Deter HC, Harter M, Hoger C, Richter R, Schmidt B, Larisch A, Wirsching M. Psychosocial care by general practitioners--where are the problems? Results of a demonstration project on quality management in psychosocial primary care. Int J Psychiatry Med. 1999;29(4):395-409.

Gilbody SM, Whitty PM, Grimshaw JM, Thomas RE. Improving the detection and management of depression in primary care. Qual Saf Health Care. 2003 Apr;12(2):149-55. Review.

Korsen N, Katz SE. The management of depression in primary care. Introduction. Psychiatr Q. 2003 Spring;74(1):43-4.

Matalon A, Nahmani T, Rabin S, Maoz B, Hart J. A short-term intervention in a multidisciplinary referral clinic for primary care frequent attenders: description of the model, patient characteristics and their use of medical resources. Fam Pract. 2002 Jun;19(3):251-6.

Miller NS, Ninonuevo F, Hoffmann NG, Astrachan BM. Prediction of treatment outcomes: lifetime depression versus the continuum of care. Am J Addict. 1999 Summer;8(3):243-53.

Rowland N, Bower P, Mellor C, Heywood P, Godfrey C. Counselling for depression in primary care. Cochrane Database Syst Rev. 2001;(1):CD001025. Review.

Walsh M. Management of depression in a primary care office setting. QRC Advis. 1999 Dec;16(2):1-4.

Wittchen HU, Kessler RC, Beesdo K, Krause P, Hofler M, Hoyer J. Generalized anxiety and depression in primary care: prevalence, recognition, and management. J Clin Psychiatry. 2002;63 Suppl 8:24-34.

Strategies for effective management of depression in primary care. Based on a presentation by Michael S. Klinkman, MD. Am J Manag Care. 1999 Sep;5(13 Suppl):S783-8; discussion S788-93.

Monitoring, feedback, and care management improve treatment of depression BMJ. 2000 Feb 26;320(7234):F

Zimmerman M, Lish JD, Farber NJ, Hartung J, Lush D, Kuzma MA, Plescia G. Screening for depression in medical patients. Is the focus too narrow? Gen Hosp Psychiatry. 1994 Nov;16(6):388-96.

hide title: Course 7: General Health & Wellness

Course 7: The Wellness and Total Health Approach to Depression Treatment and Prevention

Estimated number of pages:
Estimated credit hours: 1.0
Estimated number of clinical cases: 4 mini case studies
Principal writers: June McDermott, MSPharm, MBA
Other expected authors: Jennie Ratcliffe, PhD; Ellen R. Stoltzfus, PhD
Content (expert) reviewers:

Course goal: Expose physicians to a comprehensive approach to depression treatment so that they have treatment and prevention options other than, and in addition to, drugs.

Overview: This course describes a comprehensive/wellness approach to depression in primary care, in which exercise, stress management, nutrition, and sleep habits are part of the treatment strategy. The course also discusses the role of these lifestyle factors in depression prevention. The emphasis in the course is on educating physicians as to the available evidence about the role these factors play in mental health so that they can plan with their patients a depression treatment strategy that incorporates these elements as well as comprehensive patient education about wellness.

Learning Objectives

  • Be able to discuss the mind/body axis with patients.
  • Feel comfortable recommending from a series of "alternative" treatments to complement medication.
  • Convince patients of the numerous immediate and future benefits that general wellness and fitness have in addition their role in depression treatment and mood improvement.
  • Supply patients with printed and online resources for self-help, stress management.
  • Understand and discuss with patients the role that sleep habits, diet, exercise, and a positive outlook have on mood.
  • Develop depression treatment plans in collaboration with patients who play an active role in implementation.

Outline of Content

  • The mind/body axis (psychoneuroimmunology, etc)
  • Defining the "complementary" approach
  • Empowering patients to take an active part in treatment
  • Evidence for lifestyle factors affecting depression
    • Exercise
    • Diet
      • Importance of good nutrition (DHA, EPA)
      • Vitamins, coffee, dietary supplements (SJW)
    • Sleep habits
    • Stress
      • the self-help approach
      • stress management
      • relaxation techniques
      • importance of a positive outlook
      • support groups
    • Mind/Body integration
      • Spirituality
      • Meditation
      • Energy healing (Reiki, polarity, healing touch)
    • Massage
    • Other complementary treatments (light therapy, writing, movement - Alexander technique, Feldenkreis-, art, etc.)
  • Resources for physicians
  • Handouts for patients
  • Wellness Wizard

Printable Practice Resources

Printable Patient Resources

References and Recommended Reading

Alpert JE. Mischoulon D. Nierenberg AA. Fava M. Nutrition and depression: focus on folate. [Review] Nutrition. 2000;16(7-8):544-6.

Bilia AR. Gallori S. Vincieri FF. St. John''s wort and depression: efficacy, safety and tolerability-an update. [Review] Life Sci. 2002;70(26):3077-96.

Blackburn-Munro G. Blackburn-Munro RE. Chronic pain, chronic stress and depression: coincidence or consequence? [Review] J Neuroendocrinol. 2000;13(12):1009-23.

Demura S. Sato S. Relationships between depression, lifestyle and quality of life in the community dwelling elderly: a comparison between gender and age groups. J Physiol Anthropol Appl Human Sci. 2003;22(3):159-66.

Hall M. Buysse DJ. Nowell PD. Nofzinger EA. Houck P. Reynolds CF 3rd. Kupfer DJ. Symptoms of stress and depression as correlates of sleep in primary insomnia. Psychosom Med. 2000;62(2):227-30.

Miller AH. Neuroendocrine and immune system interactions in stress and depression. [Review] Psychiatr Clin North Am. 1998;21(2):443-63.

Moore KA. Blumenthal JA. Exercise training as an alternative treatment for depression among older adults. [Review] Altern Ther Health Med. 1998;4(1):48-56.

Musselman DL. Nemeroff CB. Depression really does hurt your heart: stress, depression, and cardiovascular disease. [Review] Prog Brain Res. 2000;122:43-59.

Parkerson GR Jr, Broadhead WE, Tse CK. Quality of life and functional health of primary care patients. J Clin Epidemiol. 1992 Nov;45(11):1303-13.

Strawbridge WJ, Deleger S, Roberts RE, Kaplan GA. Physical activity reduces the risk of subsequent depression for older adults. Am J Epidemiol, 2002;156:328-34.

Scully D. Kremer J. Meade MM. Graham R. Dudgeon K. Physical exercise and psychological well being: a critical review. Br J Sports Med. 1998;32(2):111-20.

Course 8: Case Study

Course 8: Introduction to Screening, Diagnosis, and Treatment of Depression in Primary Care: Debra, a 32-Year-Old Female, Complains of Fatigue

Estimated number of pages:
Estimated credit hours: 1.5
Estimated number of clinical cases: 1
Principal writers: Jennifer Ratcliffe, PhD, MSc
Other expected authors:; Elisabeth Sullivan, MS; June McDermott, MS Pharm, MBA, FASHP; Meghan Coulehan, MPH; Ellen R. Stoltzfus, PhD; Jared Weinberger, MS
Content (expert) reviewers: T. Bradley Tanner, MD; Ravinder D. Reddy, M.D.; An anonymous psychiatry expert

Course goal: Provide physicians with a simple medical case study to model the through four stages of managing depression in primary care.

Overview:
The various stages of care for depressed patients are outlined in case study form in this course. "Debra" is followed through Screening ( using and interpreting the PRIME-MD PHQ-9 as a depression screen in primary care), Detection ( gathering relevant information from screening, clinical interview, physical exam, and laboratory tests in order to make an appropriate diagnosis), Diagnosis (evaluating gathered information, applying DSM criteria for depression, and ruling out other possible diagnoses), and Treatment (determining what treatment strategies to use, when they are appropriate, and how to follow-up and monitor treatment).

Learning Objectives

  • Understand how screening for depression is used
  • Apply the DSM-IV criteria for major depression and make a differential diagnosis
  • Develop, implement, monitor, and/or modify an appropriate treatment plan for an initial episode of moderate major depression uncomplicated by comorbidities
  • Provide patients with educational materials about depression

Outline of Content

  • Screening: Using and interpreting the PRIME-MD PHQ-9 as a depression screen in primary care.
  • Detection:Gathering relevant information from screening, clinical interview, physical exam, and laboratory tests in order to make an appropriate diagnosis.
  • Diagnosis: Evaluating gathered information, applying DSM criteria for depression, and ruling out other possible diagnoses.
  • Treatment: Determining what kinds of treatment strategies to use, when they are appropriate, and how to follow-up and monitor treatment.

Printable Practice Resources

  • View our CME course Screening for Depression in Primary Carewhich has information about research on screening, a list screening instruments, and describes how to evaluate various screening instruments. This course has an Implementation Wizard that lets you create a step-by-step checklist for implementing screening in your own practice.
  • American Medical Association. Guidelines for Adolescent Preventive Services. Recommendations Monograph. AMA 1997. http://www.ama-assn.org/ama/upload/mm/39/gapsmono.pdf
  • MacArthur Foundation. MacArthur Initiative Depression Toolkit. 2001. http://www.depression-primarycare.org/toolkit2.html
  • NIH. MEDLINEPlus: Depression. http://www.nlm.nih.gov/medlineplus/depression.html
  • NIMH. Depression Research at the NIMH: Fact Sheet. 2001. http://www.nimh.nih.gov/publicat/depresfact.cfm

Printable Patient Resources

General Information
  • Depression(http://www.nimh.nih.gov/publicat/depressionmenu.cfm) (National Institute of Mental Health) The NIMH site has resources on depression, with resources that target children, women, older adults, and those seeking alternative medicinal treatments.
  • Men and Depression(http://menanddepression.nimh.nih.gov/) (National Institute of Mental Health) Here you can view public service announcements and learn more about the signs and symptoms of depression.
  • Consumer.DepressionClinic.com(http://consumer.depressionclinic.com) (Clinical Tools Inc.) This CTI site answers questions such as what depression is, how it is diagnosed, and the treatments and medications available.
  • Mental Health(http://www.surgeongeneral.gov/Library/MentalHealth/) (A Report of the Surgeon General) Health report from the surgeon general with fundamentals of mental illness, children/adults and how they deal with mental health, and how to finance mental health services.
  • Factsheets(http://www.nmha.org/infoctr/factsheets/) (National Mental Health Association) NMHA site presents facts on anxiety disorders, children''s mental health, depression, the elderly, suicide risks, substance abuse, schizophrenia, mental illness in the family, and research studies.
  • Depression(http://www.ndmda.org/depression.html) (National Depressive and Manic-Depressive Association) This NDMA page answers questions about depression, including the differences between depression and bipolar disorder, SAD, treatments, and support groups.
  • Let''s Talk Facts About Depression(http://www.psych.org/public_info/pdf/depress.pdf) (The American Psychiatric Association) A pdf file that answers questions about the types of depression, theoretical causes, and medications.
  • Understanding Major Depression: What You Need to Know About This Medical Illness(http://www.nami.org/helpline/UnderstandingMajorDepression.pdf) (National Alliance for the Mentally Ill) A pdf file that covers the basic of depression and its effects.
Support groups
  • Depression: Family, Friends and Loved Ones(http://boards.webmd.lycos.com/roundtable_topic/40) (Lycos Health with WebMD) Discussion group for family, friends, and loved ones of people living with depression.
  • Chapter and Support Group Directory (http://www.ndmda.org/findsupport.html) (National Depressive and Manic-Depressive Association) This NDMA site gives a directory of support groups for those living with depression or those who are close to someone living with depression.
Mental Health Locators
  • Mental Health Services Locator(http://www.mentalhealth.org/databases/default.asp) (Substance Abuse and Mental Health Services Administration) This map locates mental health services in your area.
  • State and Provincial Psychological Associations (http://www.apa.org/practice/refer.html) (The American Psychological Association) A list of psychological associations.

References and Recommended Reading

  • American Psychiatric Association. Diagnostic and Statistical Manual of Mental disorders (4th ed.). Text Revision. Washington DC: American Psychiatric Association; 2000.
  • Goldman LS, Nielsen NH, Champion HC. Awareness, Diagnosis, and Treatment of Depression. J Gen and Intern Med. 1999;14:569-580.
  • MacArthur Foundation (2001). MacArthur Initiative Depression Toolkit. at http://www.depression-primarycare.org/toolkit2.html.
  • Mulrow CD, Williams JW Jr, Chiquette E, Aguilar C, Hitchcock-Noel P, Lee S, Cornell J, Stamm K. Efficacy of newer medications for treating depression in primary care patients. Am J Med. 2000;108(1):54-64.
  • Schulberg HC, Katon WJ, Simon GE, Rush AJ. Best clinical practice: guidelines for managing major depression in primary medical care. J Clin Psychiatry. 1999;60 Suppl 7:19-26; discussion 27-8.

Course Outlines

Course 1: Scope of the problem

Course 1: Scope of the problem: Prevalence, Impact, and Risk Factors

Estimated number of pages:
Estimated credit hours:
1.5
Estimated number of clinical cases: None
Writer:
Jennifer Ratcliffe, PhD, MSc
Other expected authors: Elisabeth Sullivan, MS
Content (expert) reviewers: Bradley N. Gaynes, MD, MPH; Ravinder D. Reddy, MD; T. Bradley Tanner, MD
Basis of the content:
Course goal: Introduce physicians to the prevalence, importance, and impact of depressive disorders.

Overview
This course identifies which patients are most likely to suffer from depressive disorders. It discusses the prevalence of major depression and dysthymia in various populations, emphasizing information that is most relevant and helpful to the primary care practitioner. The course explains the major risk factors for depression as well as common psychiatric and medical comorbidities. This course provides a background for our other courses.

Learning Objectives

  • understand the prevalence rates of major depression and dysthymia in the general population and within specific populations
  • know the prevalence rates of comorbid psychiatric and medical illnesses
  • understand the major risk factors for depression

Outline of Content

  • General Population Prevalence of Mood Disorders
  • Prevalence of Depressive Disorders
  • Social and Economic Costs of Depression
  • Prevalence in Primary Care
  • Depression and Gender
  • Depression in Children and Adolescents
  • Depression in Older Adults
  • Depression and Ethnicity, Race, and Culture
  • Comorbid Substance Abuse and Dependence
  • Comorbid Anxiety
  • Comorbid Eating Disorders
  • Medical Comorbidities
  • Risk Factors for Depression
  • Assessing Risk: Medical History
  • Assessing Risk: Demographics
  • Assessing Risk: Medical and Psychiatric Conditions
  • Assessing Risk: Psychological and Social Factors
  • Key Points for Clinical Practice
  • References, Helpful Links, and CME Credit

Printable Practice Resources

  • MacArthur Foundation. MacArthur Initiative Depression Toolkit. 2001. http://www.depression-primarycare.org/. The MacArthur Foundation Initiative on Depression is a website designed to provide primary care physicians and health care organizations with knowledge and tools to enhance the recognition and care of patients with depression.
  • National Institutes of Health (NIH) and the National Library of Medicine (NLM). MEDLINEPlus: Depression. http://www.nlm.nih.gov/medlineplus/depression.html. This website provides regularly updated links to statistics, clinical trials, research and drug treatment and related resources on depression.
  • National Institute of Mental Health (NIMH). Depression Research at the NIMH: Fact Sheet. 2001. http://www.nimh.nih.gov/publicat/depresfact.cfm. This page provides a summary of descriptive facts on depression and its treatment in different populations and provides links to other NIMH resources dealing with depression.
  • National Institute of Mental Health (NIMH). For Practitioners. 2003. http://www.nimh.nih.gov/practitioners/index.cfm. This site provides links for practitioners to NIMH resources on the treatment of depression and other mental disorders, together with research updates and patient education materials.

Printable Patient Resources

  • MacArthur Foundation. MacArthur Initiative Depression Toolkit. 2001. http://www.depression-primarycare.org/. The MacArthur Foundation Initiative on Depression is a website designed to provide primary care physicians and health care organizations with knowledge and tools to enhance the recognition and care of patients with depression.
  • National Institutes of Health (NIH) and the National Library of Medicine (NLM). MEDLINEPlus: Depression. http://www.nlm.nih.gov/medlineplus/depression.html. This website provides regularly updated links to statistics, clinical trials, research and drug treatment and related resources on depression.
  • National Institute of Mental Health (NIMH). Depression Research at the NIMH: Fact Sheet. 2001. http://www.nimh.nih.gov/publicat/depresfact.cfm. This page provides a summary of descriptive facts on depression and its treatment in different populations and provides links to other NIMH resources dealing with depression.

References and Recommended Reading

Kessler RC, McGonagle KA, Swartz M, Blazer DG, Nelson CB. Sex and depression in the National Comorbidity Survey. I: Lifetime prevalence, chronicity and recurrence. J Affect Disord. 1993;29: 85-96.

Kessler RC, Walters EE. Epidemiology of DSM-III-R major depression and minor depression among adolescents and young adults in the National Comorbidity Survey. Depress Anxiety. 1998;7:3-14.

Piccinelli M, Wilkinson G. Gender differences in depression: Critical review. Br J Psychiatry. 2000;177:486-92.

Pincus HA, Pettit AR. The societal costs of chronic major depression. J Clin Psychiatry. 2001;62 Suppl 6:5-9.

Roose SP, Glassman AH, Seidman SN. Relationship Between Depression and Other Medical Illnesses. JAMA. 2001;286(14), 1687-1690

Stoppard J. Understanding Depression: a feminist social constructionist approach. New York: Routledge; 2000.

Weissman MM, Bland RC, Canino GJ, Faravelli C, Greenwald S, Hwu HG, Joyce PR, Karam EG, Lee CK, Lellouch J, Lepine JP, Newman SC, Rubio-Stipec M, Wells JE, Wickramaratne PJ, Wittchen H, Yeh EK. Cross-national epidemiology of major depression and bipolar disorder. JAMA. 1996;276(4):293-9.

U.S. Department of Health and Human Services. Mental Health: A Report of the Surgeon General.Rockville, MD: U.S.;1999. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health.

Course 2: Screening

Course 2: Screening for Depression in Adults in Primary Care

Estimated number of pages:
Estimated credit hours: 1.5
Estimated number of clinical cases: None
Principal writer: Jennifer Ratcliffe, PhD, MSc
Other expected authors: Elisabeth Sullivan, MS; Ellen R. Stoltzfus, PhD; Jared Weinberger, MS
Content (expert) reviewers: T. Bradley Tanner, MD
Basis of the content:
Course goal: To teach physicians about the importance of screening, and how they can implement a screening program in their practice

Overview
In 2002, the USPSTF recommended screening for depression in all adults in primary care. This course describes the best practice guidelines for depression screening and gives evidence for why screening should be implemented in primary care. The basic issues in evaluating and comparing screening instrument are covered, and several common screening instruments are included in the course (in printable version). The course has an interactive tool for implementing screening into the physician''s own primary care setting.

Learning Objectives
After completing this course, the learner will be able to:

  • Apply depression screening guidelines for primary care practice
  • Evaluate the impact of screening on the diagnosis of depression
  • Compare the effectiveness of different screening instruments used in primary care
  • Understand the limitations of screening instruments
  • Select a useful screening instrument and integrate a screening program into your practice

Outline of Content

  • Introduction
  • Guidelines for Screening
  • Effectiveness of Screening
  • Evaluating Screening Instruments
  • Selecting an Instrument
  • Instrument Effectiveness Comparison
  • Brief vs Longer Instruments
  • Advantages of Detailed Instruments
  • Implementing Screening in a Primary Care Practice
  • Depression Screening Instruments for Adults
  • General Screening Instruments
  • Screening in Older Adults
  • Summary of Key Points
  • References, Helpful Links, and CME Credit

Printable Practice Resources

  • American Medical Association. Guidelines for Adolescent Preventive Services. Recommendations Monograph. AMA 1997. http://www.ama-assn.org/ama/upload/mm/39/gapsmono.pdf
  • MacArthur Foundation. MacArthur Initiative Depression Toolkit. 2001. http://www.depression-primarycare.org/
  • NIH. MEDLINEPlus: Depression. http://www.nlm.nih.gov/medlineplus/depression.html
  • NIMH. Depression Research at the NIMH: Fact Sheet. 2001. http://www.nimh.nih.gov/publicat/depresfact.cfm

Printable Patient Resources

General Information
  • Depression(http://www.nimh.nih.gov/publicat/depressionmenu.cfm) (National Institute of Mental Health) The NIMH site has resources on depression, with resources that target children, women, older adults, and those seeking alternative medicinal treatments.
  • Men and Depression(http://menanddepression.nimh.nih.gov/) (National Institute of Mental Health) Here you can view public service announcements and learn more about the signs and symptoms of depression.
  • Consumer.DepressionClinic.com(http://consumer.depressionclinic.com) (Clinical Tools Inc.) This CTI site answers questions such as what depression is, how it is diagnosed, and the treatments and medications available.
  • Mental Health(http://www.surgeongeneral.gov/Library/MentalHealth/) (A Report of the Surgeon General) Health report from the surgeon general with fundamentals of mental illness, children/adults and how they deal with mental health, and how to finance mental health services.
  • Factsheets(http://www.nmha.org/infoctr/factsheets/) (National Mental Health Association) NMHA site presents facts on anxiety disorders, children''s mental health, depression, the elderly, suicide risks, substance abuse, schizophrenia, mental illness in the family, and research studies.
  • Depression(http://www.ndmda.org/depression.html) (National Depressive and Manic-Depressive Association) This NDMA page answers questions about depression, including the differences between depression and bipolar disorder, SAD, treatments, and support groups.
  • Let''s Talk Facts About Depression(http://www.psych.org/public_info/pdf/depress.pdf) (The American Psychiatric Association) A pdf file that answers questions about the types of depression, theoretical causes, and medications.
  • Understanding Major Depression: What You Need to Know About This Medical Illness(http://www.nami.org/helpline/UnderstandingMajorDepression.pdf) (National Alliance for the Mentally Ill) A pdf file that covers the basic of depression and its effects.
Support groups
  • Depression: Family, Friends and Loved Ones(http://boards.webmd.lycos.com/roundtable_topic/40) (Lycos Health with WebMD) Discussion group for family, friends, and loved ones of people living with depression.
  • Chapter and Support Group Directory (http://www.ndmda.org/findsupport.html) (National Depressive and Manic-Depressive Association) This NDMA site gives a directory of support groups for those living with depression or those who are close to someone living with depression.
Mental Health Locators
  • Mental Health Services Locator(http://www.mentalhealth.org/databases/default.asp) (Substance Abuse and Mental Health Services Administration) This map locates mental health services in your area.
  • State and Provincial Psychological Associations (http://www.apa.org/practice/refer.html) (The American Psychological Association) A list of psychological associations.

References and Recommended Reading

Gilbody SM, House AO, Sheldon TA. Routinely administered questionnaires for depression and anxiety: systematic review. Br Med J. 2001;322(7283):406-9.

Gotlib, IH, Hammen, CL, eds. Handbook of Depression. New York: The Guilford Press; 2002.

Pignone MP, Gaynes BN, Rushton JL, Burchell CM, Orleans CT, Mulrow CD, Lohr KN. Screening for depression in adults: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002;136:765-76.

U.S. Department of Health and Human Services. (1999). Mental Health: a Report of the Surgeon GeneralRockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health.

U.S. Preventive Services Task Force. Screening for depression: recommendations and rationale. Ann Internal Med. 2002;136: 760-764.

hide title: Course 3: Diagnosis

Course 3: Depression Diagnosis and Referral

Estimated number of pages: 25
Estimated credit hours: 1.0
Estimated number of clinical cases: 4
Principal writers:
Jennie Ratcliffe, PhD, MS
Other expected authors:
Ellen R. Stoltzfus, PhD
Content (expert) reviewers: Mary Morreale, MD, Brandi Woods, MA, Brad Tanner, MD

Course goal:
To help physicians identify their depressed patients, differentiate depression from substance abuse and other psychiatric and medical disorders, and know when to refer patients for urgent intervention or specialist treatment.

Overview
Depression is often undetected or misdiagnosed in the primary care setting. This course has been developed specifically for primary care physicians who wish to learn about best practice guidelines for detecting and diagnosing depression. The course begins by discussing barriers to accurate detection of depression. The course then covers (i) DSM-IV criteria and the detection of symptoms of major depressive disorder (MDD) and dysthymia; (ii) differential diagnosis of these disorders; (iii) diagnosis in special populations (older adults, adolescents); (iv) assessment of patients for urgent intervention; and (v) referral of patients to a mental health specialist or therapist. Patient education materials and other resources will also be provided.

Learning Objectives
After completing this course, the learner will be able to:

  • Avoid common obstacles to depression detection
  • Use the DSM-IV guidelines for the diagnosis of Major Depression and Dysthymia
  • Recognize risk factors for depression, and use this information during the detection and diagnosis process
  • Know how to use screening, the clinical interview, and patient charts to help detect symptoms of depression
  • Conduct a differential diagnosis to rule out other major psychiatric disorders, general medical conditions and substance abuse as reasons for their symptoms
  • Assess patients for suicidality and need for immediate intervention
  • Understand when to refer patients to other specialists

Outline of Content

  • Scope of the Problem
  • Barriers to Detection and Diagnosis
  • Steps in the Detection and Diagnosis of Depression
  • Step 1: Preparation
  • Step 2: Detecting Symptoms and Risk Factors
    • Incorporating Screening Results
    • Detecting Symptoms
    • Detecting Symptoms (Chart Review)
    • Detecting Symptoms (Clinical Interview)
  • Step 3: Differential Diagnosis
    • Ruling out Other Psychiatric Disorders
    • Coexisting Psychiatric Disorders
    • Ruling out Substance Abuse
    • Ruling out Medical Conditions
    • Physical Exam
    • Ruling out Medical Conditions: Lab Tests
    • Ruling out Effects of Medications
  • Diagnosis in Special Populations: Older Adults and Adolescents
  • When to Refer Your Patient: Assess for Urgent Intervention
  • When to Refer Your Patient: Special Cases
  • Where to Refer Your Patient

Printable Practice Resources

Printable Patient Resources

  • Depression(http://www.nimh.nih.gov/publicat/depressionmenu.cfm) (National Institute of Mental Health) The NIMH site has resources on depression, with resources that target children, women, older adults, and those seeking alternative medicinal treatments.
  • Men and Depression(http://menanddepression.nimh.nih.gov/) (National Institute of Mental Health) Here you can view public service announcements and learn more about the signs and symptoms of depression.
  • Consumer.DepressionClinic.com(http://consumer.depressionclinic.com) (Clinical Tools Inc.) This CTI site answers questions such as what depression is, how it is diagnosed, and the treatments and medications available.
  • Mental Health(http://www.surgeongeneral.gov/Library/MentalHealth/) (A Report of the Surgeon General) Health report from the surgeon general with fundamentals of mental illness, children/adults and how they deal with mental health, and how to finance mental health services.
  • Factsheets(http://www.nmha.org/infoctr/factsheets/) (National Mental Health Association) NMHA site presents facts on anxiety disorders, children''s mental health, depression, the elderly, suicide risks, substance abuse, schizophrenia, mental illness in the family, and research studies.
  • Depression(http://www.ndmda.org/depression.html) (National Depressive and Manic-Depressive Association) This NDMA page answers questions about depression, including the differences between depression and bipolar disorder, SAD, treatments, and support groups.
  • Let''s Talk Facts About Depression(http://www.psych.org/public_info/pdf/depress.pdf) (The American Psychiatric Association) A pdf file that answers questions about the types of depression, theoretical causes, and medications.
  • Understanding Major Depression: What You Need to Know About This Medical Illness(http://www.nami.org/helpline/UnderstandingMajorDepression.pdf) (National Alliance for the Mentally Ill) A pdf file that covers the basic of depression and its effects.
  • Depression: Family, Friends and Loved Ones(http://boards.webmd.lycos.com/roundtable_topic/40) (Lycos Health with WebMD) Discussion group for family, friends, and loved ones of people living with depression.
  • Chapter and Support Group Directory (http://www.ndmda.org/findsupport.html) (National Depressive and Manic-Depressive Association) This NDMA site gives a directory of support groups for those living with depression or those who are close to someone living with depression.
  • Mental Health Services Locator(http://www.mentalhealth.org/databases/default.asp) (Substance Abuse and Mental Health Services Administration) This map locates mental health services in your area.
  • State and Provincial Psychological Associations (http://www.apa.org/practice/refer.html) (The American Psychological Association) A list of psychological associations.

References and Recommended Reading

Birmaher B, Brent DA, Benson RS. Related summary of the practice parameters for the assessment and treatment of children and adolescents with depressive disorders. J Am Acad Child Adolesc Psychiatry. 1998;37(11):1234-8.

Farmer AE, Griffiths H. Labelling and illness in primary care: comparing factors influencing general practitioners'' and psychiatrists'' decisions regarding patient referral to mental illness services. Psychol Med. 1992 Aug;22(3):717-23.

Lin EH, Katon W. Beyond the diagnosis of depression. Gen Hosp Psychiatry. 1998 Jul;20(4):207-8.

Rosenberg E, Lussier MT, Beaudoin C, Kirmayer LJ, Dufort GG. Determinants of the diagnosis of psychological problems by primary care physicians in patients with normal GHQ-28 scores. Gen Hosp Psychiatry. 2002 Sep-Oct;24(5):322-7.

Staab JP, Datto CJ, Weinrieb RM, Gariti P, Rynn M, Evans DL. Detection and diagnosis of psychiatric disorders in primary medical care settings. Med Clin North Am. 2001;85:579-96.

Course 4: Treatment

Course 4: The Treatment of Depression in Primary Care: Acute, Continuation and Maintenance Phase Treatments

Estimated number of pages:
Estimated credit hours: 2.0
Estimated number of clinical cases: 4 mini-cases
Principal writers: Jennifer Ratcliffe, PhD, MSc
Other expected authors: Jared Weinberger, MS
Content (expert) reviewers: T. Bradley Tanner, MD

Course goal: To help physicians understand, plan, and implement comprehensive treatment plans for their depressed patients.

Overview
This course outlines the phases of depression treatment (acute, continuation, and maintenance), and guides the physician through the various components of planning and implementing a comprehensive treatment plan, focusing on the major treatment modalities (medication and psychotherapy). Best practices for followup and monitoring during treatment are also discussed.

Learning Objectives
After completing this course, the learner will be able to:

  • apply clinical guidelines for effective acute, continuation and maintenance phases of treatment for depression in adults
  • evaluate different treatment modalities, including pharmacotherapies, psychotherapies, and newer treatments
  • plan and implement a comprehensive treatment strategy with your patient
  • monitor and evaluate patients during treatment and determine when to switch or augument therapies
  • identify resources and educational materials on treatment for your patients

Outline of Content

  • Scope of the Problem
  • Aims of Treatment
  • Phases of Treatment
  • Overview of Steps in the Treatment of Depression
  • Planning the Treatment Strategy
  • Evaluate for Immediate Intervention or Referral
  • Extended Evaluation and Supportive Counseling
  • Choosing a Formal Treatment Modality
  • Types of Psychotherapy
  • Pharmacotherapy: Overview
  • Prescribing Principles
  • Complementary and Alternative Approaches
  • Monitoring Acute Phase Treatment
  • Symptom Assessment and Treatment Modification
  • Continuation Treatment
  • Maintenance Treatment
  • Key Points for Clinical Practice

Printable Practice Resources

  • American Medical Association. Guidelines for Adolescent Preventive Services. Recommendations Monograph. AMA 1997. http://www.ama-assn.org/ama/upload/mm/39/gapsmono.pdf
  • MacArthur Foundation. MacArthur Initiative Depression Toolkit. 2001. http://www.depression-primarycare.org/
  • NIH. MEDLINEPlus: Depression. http://www.nlm.nih.gov/medlineplus/depression.html
  • NIMH. Depression Research at the NIMH: Fact Sheet. 2001. http://www.nimh.nih.gov/publicat/depresfact.cfm

Printable Patient Resources

General Information
  • Depression(http://www.nimh.nih.gov/publicat/depressionmenu.cfm) (National Institute of Mental Health) The NIMH site has resources on depression, with resources that target children, women, older adults, and those seeking alternative medicinal treatments.
  • Men and Depression(http://menanddepression.nimh.nih.gov/) (National Institute of Mental Health) Here you can view public service announcements and learn more about the signs and symptoms of depression.
  • Consumer.DepressionClinic.com(http://consumer.depressionclinic.com) (Clinical Tools Inc.) This CTI site answers questions such as what depression is, how it is diagnosed, and the treatments and medications available.
  • Mental Health(http://www.surgeongeneral.gov/Library/MentalHealth/) (A Report of the Surgeon General) Health report from the surgeon general with fundamentals of mental illness, children/adults and how they deal with mental health, and how to finance mental health services.
  • Factsheets(http://www.nmha.org/infoctr/factsheets/) (National Mental Health Association) NMHA site presents facts on anxiety disorders, children''s mental health, depression, the elderly, suicide risks, substance abuse, schizophrenia, mental illness in the family, and research studies.
  • Depression(http://www.ndmda.org/depression.html) (National Depressive and Manic-Depressive Association) This NDMA page answers questions about depression, including the differences between depression and bipolar disorder, SAD, treatments, and support groups.
  • Let''s Talk Facts About Depression(http://www.psych.org/public_info/pdf/depress.pdf) (The American Psychiatric Association) A pdf file that answers questions about the types of depression, theoretical causes, and medications.
  • Understanding Major Depression: What You Need to Know About This Medical Illness(http://www.nami.org/helpline/UnderstandingMajorDepression.pdf) (National Alliance for the Mentally Ill) A pdf file that covers the basic of depression and its effects.
Support groups
  • Depression: Family, Friends and Loved Ones(http://boards.webmd.lycos.com/roundtable_topic/40) (Lycos Health with WebMD) Discussion group for family, friends, and loved ones of people living with depression.
  • Chapter and Support Group Directory (http://www.ndmda.org/findsupport.html) (National Depressive and Manic-Depressive Association) This NDMA site gives a directory of support groups for those living with depression or those who are close to someone living with depression.
Mental Health Locators
  • Mental Health Services Locator(http://www.mentalhealth.org/databases/default.asp) (Substance Abuse and Mental Health Services Administration) This map locates mental health services in your area.
  • State and Provincial Psychological Associations (http://www.apa.org/practice/refer.html) (The American Psychological Association) A list of psychological associations.

References and Recommended Reading

Agency for Health Care Policy and Research. Depression in Primary Care: Treatment of Major Depression. Clinical Practice Guideline 1993; Vol.2 No. 5. Rockville, MD: USDHHS, AHCPR.

Agency for Health Care Policy and Research. Treatment of Depression--Newer Pharmacotherapies. Rockville, MD: 1999;AHCPR Pub No. 99-E014.

Goldman LS, Nielsen NH, Champion HC. Awareness, Diagnosis, and Treatment of Depression. J Gen and Intern Med. 1999;14:569-580.

Gotlib, IH, Hammen, CL, eds. Handbook of Depression. New York: The Guilford Press; 2002.

Keller MB, Berndt ER Depression treatment: a lifelong commitment? Psychopharmacol Bull. 2002;36: Suppl 2: 133-41.

McCullough JP. Treatment for chronic depression. New York: Guilford Press; 1999.

Mulrow CD, Williams JW Jr, Chiquette E, Aguilar C, Hitchcock-Noel P, Lee S, Cornell J, Stamm K. Efficacy of newer medications for treating depression in primary care patients. Am J Med. 2000;108(1):54-64.

Schulberg HC, Katon WJ, Simon GE, Rush AJ. Best clinical practice: guidelines for managing major depression in primary medical care. J Clin Psychiatry.

Schulberg HC, Pilkionis PA, Houck, P. The severity of depression and choice of treatment in primary care practice. J Consult Clin Psyhcol. 1998;66: 932-38.

Thase ME. Treatment of severe depression. J Clin Psychiatry. 2000;61 Suppl 1:17-25.

U.S. Department of Health and Human Services. (1999). Mental health: a Report of the Surgeon General.Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health.

hide title: Course 5: Integrating Psychosocial Approaches

Course 5: Integrating Psychosocial Approaches to Depression Treatment into your Primary Care Practice

Estimated number of pages: 25
Estimated credit hours: 1.5
Estimated number of clinical cases: 5
Principal writers: Jennifer Ratcliffe, Ph.D.
Other expected authors: Ellen Stoltzfus, PhD
Content (expert) reviewers:

Course goal: To enable primary care physicians to understand the role of brief psychotherapies, counseling, and related psychosocial support in the treatment of depression. To enable physicians to discuss these options with their patients and to incorporate such approaches into the treatment and management of depression.

Overview
This course educates primary care physicians about available psychosocial approaches to depression treatment and how and when to integrate these approaches into their treatment strategy. Approaches covered include: formal psychotherapies such as cognitive-behavioral, interpersonal, marital and family therapy; counseling; support groups; stress management, and coping skills training. The supportive roles of family, alternative and complementary approaches, and spiritual techniques are also discussed. Evidence for the role of psychosocial factors in the etiology of depression and the effectiveness of psychosocial treatment approaches is presented. The course also covers critical aspects of patient education, how to locate therapists, and how to co-manage treatment with a psychotherapist or other mental health worker. Resources for referrals and patient information are provided.

Learning Objectives

  • Apply best practice guidelines for the treatment and management of depression using formal psychotherapies and other psychosocial approaches.
  • Understand and evaluate the major types of formal psychotherapy for effectiveness in the prevention and treatment of depression.
  • Consider other psychosocial approaches such as supportive counseling, stress reduction, coping skills and self-help groups.
  • Integrate psychotherapies and other approaches into a treatment plan with your patients.
  • Monitor and follow-up an integrated treatment plan.
  • Identify resources and educational materials for yourself and your patients.

Outline of Content

  • Evidence for the role of psychosocial risk factors in the etiology of depression
  • Formal psychotherapies suitable for depression treatment
  • Evidence for the effectiveness of brief psychotherapies
  • Supportive counseling
  • Support groups, stress mangement, and other approaches
  • Matching patients to treatments
  • How to integrate, co-manage, monitor and follow-up treatment in collaboration with a therapist/counselor
  • Resources for physicians and patients to learn about and locate therapists, other mental health resources, self-help groups
  • Providing supportive counselling through diagnosis and treatment
  • Using a "wizard" to help decide on the best treatment option with your patient
  • When and where to refer and follow-up on a treatment plan

Printable Practice Resources

Printable Patient Resources and Links

  • American Psychological Association Help Center:http://helping.apa.org/index.html. The site provides information on how to locate a therapist.
  • NAMI: Find Support: http://www.nami.org/Template.cfm?section=Find_Support. Provides assistance with finding support groups and information.
  • American Psycohological Association Help Center: http://helping.apa.org/index.html. Provides information on the effects of stress and when to seek help. Also provides information on the benefits of exercise.
  • Mayo Clinic: http://www.mayoclinic.com. Provides information on stress and stress management with links to the following related topics: workplace stress; meditation; yoga; massage and pain management.
  • NAMI: Stress: Coping with Everyday Problems: http://www.nmha.org/infoctr/factsheets/41.cfm. Discusses the symptoms of stress, how to control it and how to find help.
  • NASD: Dealing with Stress: http://www.cdc.gov/nasd/docs/d001501-d001600/d001558/d001558.html. Provides information on effects of stress and strategies to manage stress.
  • National Mental Health Information Center: http://www.mentalhealth.org/. Provides a mental health services locator.

References and Recommended Reading

Brown C, Schulberg HC. The efficacy of psychosocial treatments in primary care. A review of randomized clinical trials. Gen Hosp Psychiatry. 1995 Nov;17(6):414-24. Review.

Huibers MJ, Beurskens AJ, Bleijenberg G, van Schayck CP. The effectiveness of psychosocial interventions delivered by general practitioners. Cochrane Database Syst Rev. 2003;(2):CD003494. Review

Kebbon L, Swartling PG, Smedby B. Psychiatric symptoms and psychosocial problems in primary health care as seen by doctors. Scand J Prim Health Care. 1985 Feb;3(1):23-30.

Klausner EJ, Alexopoulos GS. The future of psychosocial treatments for elderly patients. Psychiatr Serv. 1999 Sep;50(9):1198-204. Review.

Klinkman MS. Competing demands in psychosocial care. A model for the identification and treatment of depressive disorders in primary care. Gen Hosp Psychiatry. 1997 Mar;19(2):98-111. Review.

hide title: Course 6: Follow-Up & Management

Course 6: Follow-up and Management of Depression after the Acute Phase of Treatment

Estimated number of pages:
Estimated credit hours: 1.0
Estimated number of clinical cases: 2
Principal writers:Mary Morreale, Ellen Stoltzfus, Jennie Ratcliffe
Other expected authors:
Content (expert) reviewers: Bob Golden, Brad Tanner

Course goal: Help physicians do more effective monitoring, evaluation, and education of patients during the continuation and maintenance phases of treatment.

Overview
Primary care physicians seem to do a poor job of monitoring depressed patients through their course of treatment. This course covers APA standards for monitoring care of depressed patients and discusses specific followup practices that will aid patients. The course addresses important challenges in use of antidepressant drug treatments in primary care, including managing side effects, underdosing, and treatment adherence. It also addresses issues of relapse, recurrence, chronic depression, and long-term maintenance treatment.

Learning Objectives
After completing this course, the learner will be able to:

  • Know guidelines for the follow-up of depressed patients treated solely with pharmacological approaches, psychotherapeutic approaches, and other approaches.
  • Know when to schedule follow-up visits and how to conduct an effective followup visit during the continuation and maintenance phases of treatment.
  • Be able to use tools and techniques to assess symptom improvement, side effects, and drug interactions.
  • Know when to modify treatment based on assessments of improvement, side effects, and drug interactions.
  • Know what options to pursue in cases of inadequate response to the first drug of choice.
  • Know what to do when patients do not respond to two successive antidepressant treatments, i.e., how to refer treatment-resistant depression.
  • Monitor patient compliance, and consider the use of intensified case management to promote compliance and monitoring of adverse effects.
  • Be able to co-manage patient care with a mental health care provider.
  • Consider the appropriate role for long-term comprehensive treatment approaches, including sleep, exercise, diet, and stress management.
  • Create and implement a relapse prevention plan with the patient if treatment is discontinued.
  • Provide appropriate patient education throughout treatment.

Outline of Content

  • Overview of Current Problems with Depression Management in Primary Care
  • Challenges in Drug Monitoring, Changes, and Dosing Issues
  • Timing, Structure, and Content of a Followup Appointment
    • Supportive Counselling and Patient Education
    • Assessment of Symptom Improvement
    • Assessment of Side Effects, (esp. sex and weight)
    • Assessment of Patient Compliance
    • Case Example
  • Enhancing Patient Compliance
  • Incorporating Psychosocial Components in Treatment and Co-Managing Care
    • patient education
    • communication/co-management with mental health professionals
  • Comprehensive Treatment for Relapse Prevention
    • maintenance therapy
    • healthy lifestyles for mental and physical health
  • Treatment Resistant Depression
  • Chronic/Recurrent Depression

Printable Practice Resources

Printable Patient Resources

References and Recommended Reading

Brown C, Schulberg HC, Prigerson HG. Factors associated with symptomatic improvement and recovery from major depression in primary care patients. Gen Hosp Psychiatry. 2000 Jul-Aug;22(4):242-50.

Frank E, Rucci P, Katon W, Barrett J, Williams JW Jr, Oxman T, Sullivan M, Cornell J. Correlates of remission in primary care patients treated for minor depression. Gen Hosp Psychiatry. 2002 Jan-Feb;24(1):12-9.

Fritzsche K, Sandholzer H, Brucks U, Cierpka M, Deter HC, Harter M, Hoger C, Richter R, Schmidt B, Larisch A, Wirsching M. Psychosocial care by general practitioners--where are the problems? Results of a demonstration project on quality management in psychosocial primary care. Int J Psychiatry Med. 1999;29(4):395-409.

Gilbody SM, Whitty PM, Grimshaw JM, Thomas RE. Improving the detection and management of depression in primary care. Qual Saf Health Care. 2003 Apr;12(2):149-55. Review.

Korsen N, Katz SE. The management of depression in primary care. Introduction. Psychiatr Q. 2003 Spring;74(1):43-4.

Matalon A, Nahmani T, Rabin S, Maoz B, Hart J. A short-term intervention in a multidisciplinary referral clinic for primary care frequent attenders: description of the model, patient characteristics and their use of medical resources. Fam Pract. 2002 Jun;19(3):251-6.

Miller NS, Ninonuevo F, Hoffmann NG, Astrachan BM. Prediction of treatment outcomes: lifetime depression versus the continuum of care. Am J Addict. 1999 Summer;8(3):243-53.

Rowland N, Bower P, Mellor C, Heywood P, Godfrey C. Counselling for depression in primary care. Cochrane Database Syst Rev. 2001;(1):CD001025. Review.

Walsh M. Management of depression in a primary care office setting. QRC Advis. 1999 Dec;16(2):1-4.

Wittchen HU, Kessler RC, Beesdo K, Krause P, Hofler M, Hoyer J. Generalized anxiety and depression in primary care: prevalence, recognition, and management. J Clin Psychiatry. 2002;63 Suppl 8:24-34.

Strategies for effective management of depression in primary care. Based on a presentation by Michael S. Klinkman, MD. Am J Manag Care. 1999 Sep;5(13 Suppl):S783-8; discussion S788-93.

Monitoring, feedback, and care management improve treatment of depression BMJ. 2000 Feb 26;320(7234):F

Zimmerman M, Lish JD, Farber NJ, Hartung J, Lush D, Kuzma MA, Plescia G. Screening for depression in medical patients. Is the focus too narrow? Gen Hosp Psychiatry. 1994 Nov;16(6):388-96.

hide title: Course 7: General Health & Wellness

Course 7: The Wellness and Total Health Approach to Depression Treatment and Prevention

Estimated number of pages:
Estimated credit hours: 1.0
Estimated number of clinical cases: 4 mini case studies
Principal writers: June McDermott, MSPharm, MBA
Other expected authors: Jennie Ratcliffe, PhD; Ellen R. Stoltzfus, PhD
Content (expert) reviewers:

Course goal: Expose physicians to a comprehensive approach to depression treatment so that they have treatment and prevention options other than, and in addition to, drugs.

Overview: This course describes a comprehensive/wellness approach to depression in primary care, in which exercise, stress management, nutrition, and sleep habits are part of the treatment strategy. The course also discusses the role of these lifestyle factors in depression prevention. The emphasis in the course is on educating physicians as to the available evidence about the role these factors play in mental health so that they can plan with their patients a depression treatment strategy that incorporates these elements as well as comprehensive patient education about wellness.

Learning Objectives

  • Be able to discuss the mind/body axis with patients.
  • Feel comfortable recommending from a series of "alternative" treatments to complement medication.
  • Convince patients of the numerous immediate and future benefits that general wellness and fitness have in addition their role in depression treatment and mood improvement.
  • Supply patients with printed and online resources for self-help, stress management.
  • Understand and discuss with patients the role that sleep habits, diet, exercise, and a positive outlook have on mood.
  • Develop depression treatment plans in collaboration with patients who play an active role in implementation.

Outline of Content

  • The mind/body axis (psychoneuroimmunology, etc)
  • Defining the "complementary" approach
  • Empowering patients to take an active part in treatment
  • Evidence for lifestyle factors affecting depression
    • Exercise
    • Diet
      • Importance of good nutrition (DHA, EPA)
      • Vitamins, coffee, dietary supplements (SJW)
    • Sleep habits
    • Stress
      • the self-help approach
      • stress management
      • relaxation techniques
      • importance of a positive outlook
      • support groups
    • Mind/Body integration
      • Spirituality
      • Meditation
      • Energy healing (Reiki, polarity, healing touch)
    • Massage
    • Other complementary treatments (light therapy, writing, movement - Alexander technique, Feldenkreis-, art, etc.)
  • Resources for physicians
  • Handouts for patients
  • Wellness Wizard

Printable Practice Resources

Printable Patient Resources

References and Recommended Reading

Alpert JE. Mischoulon D. Nierenberg AA. Fava M. Nutrition and depression: focus on folate. [Review] Nutrition. 2000;16(7-8):544-6.

Bilia AR. Gallori S. Vincieri FF. St. John''s wort and depression: efficacy, safety and tolerability-an update. [Review] Life Sci. 2002;70(26):3077-96.

Blackburn-Munro G. Blackburn-Munro RE. Chronic pain, chronic stress and depression: coincidence or consequence? [Review] J Neuroendocrinol. 2000;13(12):1009-23.

Demura S. Sato S. Relationships between depression, lifestyle and quality of life in the community dwelling elderly: a comparison between gender and age groups. J Physiol Anthropol Appl Human Sci. 2003;22(3):159-66.

Hall M. Buysse DJ. Nowell PD. Nofzinger EA. Houck P. Reynolds CF 3rd. Kupfer DJ. Symptoms of stress and depression as correlates of sleep in primary insomnia. Psychosom Med. 2000;62(2):227-30.

Miller AH. Neuroendocrine and immune system interactions in stress and depression. [Review] Psychiatr Clin North Am. 1998;21(2):443-63.

Moore KA. Blumenthal JA. Exercise training as an alternative treatment for depression among older adults. [Review] Altern Ther Health Med. 1998;4(1):48-56.

Musselman DL. Nemeroff CB. Depression really does hurt your heart: stress, depression, and cardiovascular disease. [Review] Prog Brain Res. 2000;122:43-59.

Parkerson GR Jr, Broadhead WE, Tse CK. Quality of life and functional health of primary care patients. J Clin Epidemiol. 1992 Nov;45(11):1303-13.

Strawbridge WJ, Deleger S, Roberts RE, Kaplan GA. Physical activity reduces the risk of subsequent depression for older adults. Am J Epidemiol, 2002;156:328-34.

Scully D. Kremer J. Meade MM. Graham R. Dudgeon K. Physical exercise and psychological well being: a critical review. Br J Sports Med. 1998;32(2):111-20.

Course 8: Case Study

Course 8: Introduction to Screening, Diagnosis, and Treatment of Depression in Primary Care: Debra, a 32-Year-Old Female, Complains of Fatigue

Estimated number of pages:
Estimated credit hours: 1.5
Estimated number of clinical cases: 1
Principal writers: Jennifer Ratcliffe, PhD, MSc
Other expected authors:; Elisabeth Sullivan, MS; June McDermott, MS Pharm, MBA, FASHP; Meghan Coulehan, MPH; Ellen R. Stoltzfus, PhD; Jared Weinberger, MS
Content (expert) reviewers: T. Bradley Tanner, MD; Ravinder D. Reddy, M.D.; An anonymous psychiatry expert

Course goal: Provide physicians with a simple medical case study to model the through four stages of managing depression in primary care.

Overview:
The various stages of care for depressed patients are outlined in case study form in this course. "Debra" is followed through Screening ( using and interpreting the PRIME-MD PHQ-9 as a depression screen in primary care), Detection ( gathering relevant information from screening, clinical interview, physical exam, and laboratory tests in order to make an appropriate diagnosis), Diagnosis (evaluating gathered information, applying DSM criteria for depression, and ruling out other possible diagnoses), and Treatment (determining what treatment strategies to use, when they are appropriate, and how to follow-up and monitor treatment).

Learning Objectives

  • Understand how screening for depression is used
  • Apply the DSM-IV criteria for major depression and make a differential diagnosis
  • Develop, implement, monitor, and/or modify an appropriate treatment plan for an initial episode of moderate major depression uncomplicated by comorbidities
  • Provide patients with educational materials about depression

Outline of Content

  • Screening: Using and interpreting the PRIME-MD PHQ-9 as a depression screen in primary care.
  • Detection:Gathering relevant information from screening, clinical interview, physical exam, and laboratory tests in order to make an appropriate diagnosis.
  • Diagnosis: Evaluating gathered information, applying DSM criteria for depression, and ruling out other possible diagnoses.
  • Treatment: Determining what kinds of treatment strategies to use, when they are appropriate, and how to follow-up and monitor treatment.

Printable Practice Resources

  • View our CME course Screening for Depression in Primary Carewhich has information about research on screening, a list screening instruments, and describes how to evaluate various screening instruments. This course has an Implementation Wizard that lets you create a step-by-step checklist for implementing screening in your own practice.
  • American Medical Association. Guidelines for Adolescent Preventive Services. Recommendations Monograph. AMA 1997. http://www.ama-assn.org/ama/upload/mm/39/gapsmono.pdf
  • MacArthur Foundation. MacArthur Initiative Depression Toolkit. 2001. http://www.depression-primarycare.org/toolkit2.html
  • NIH. MEDLINEPlus: Depression. http://www.nlm.nih.gov/medlineplus/depression.html
  • NIMH. Depression Research at the NIMH: Fact Sheet. 2001. http://www.nimh.nih.gov/publicat/depresfact.cfm

Printable Patient Resources

General Information
  • Depression(http://www.nimh.nih.gov/publicat/depressionmenu.cfm) (National Institute of Mental Health) The NIMH site has resources on depression, with resources that target children, women, older adults, and those seeking alternative medicinal treatments.
  • Men and Depression(http://menanddepression.nimh.nih.gov/) (National Institute of Mental Health) Here you can view public service announcements and learn more about the signs and symptoms of depression.
  • Consumer.DepressionClinic.com(http://consumer.depressionclinic.com) (Clinical Tools Inc.) This CTI site answers questions such as what depression is, how it is diagnosed, and the treatments and medications available.
  • Mental Health(http://www.surgeongeneral.gov/Library/MentalHealth/) (A Report of the Surgeon General) Health report from the surgeon general with fundamentals of mental illness, children/adults and how they deal with mental health, and how to finance mental health services.
  • Factsheets(http://www.nmha.org/infoctr/factsheets/) (National Mental Health Association) NMHA site presents facts on anxiety disorders, children''s mental health, depression, the elderly, suicide risks, substance abuse, schizophrenia, mental illness in the family, and research studies.
  • Depression(http://www.ndmda.org/depression.html) (National Depressive and Manic-Depressive Association) This NDMA page answers questions about depression, including the differences between depression and bipolar disorder, SAD, treatments, and support groups.
  • Let''s Talk Facts About Depression(http://www.psych.org/public_info/pdf/depress.pdf) (The American Psychiatric Association) A pdf file that answers questions about the types of depression, theoretical causes, and medications.
  • Understanding Major Depression: What You Need to Know About This Medical Illness(http://www.nami.org/helpline/UnderstandingMajorDepression.pdf) (National Alliance for the Mentally Ill) A pdf file that covers the basic of depression and its effects.
Support groups
  • Depression: Family, Friends and Loved Ones(http://boards.webmd.lycos.com/roundtable_topic/40) (Lycos Health with WebMD) Discussion group for family, friends, and loved ones of people living with depression.
  • Chapter and Support Group Directory (http://www.ndmda.org/findsupport.html) (National Depressive and Manic-Depressive Association) This NDMA site gives a directory of support groups for those living with depression or those who are close to someone living with depression.
Mental Health Locators
  • Mental Health Services Locator(http://www.mentalhealth.org/databases/default.asp) (Substance Abuse and Mental Health Services Administration) This map locates mental health services in your area.
  • State and Provincial Psychological Associations (http://www.apa.org/practice/refer.html) (The American Psychological Association) A list of psychological associations.

References and Recommended Reading

  • American Psychiatric Association. Diagnostic and Statistical Manual of Mental disorders (4th ed.). Text Revision. Washington DC: American Psychiatric Association; 2000.
  • Goldman LS, Nielsen NH, Champion HC. Awareness, Diagnosis, and Treatment of Depression. J Gen and Intern Med. 1999;14:569-580.
  • MacArthur Foundation (2001). MacArthur Initiative Depression Toolkit. at http://www.depression-primarycare.org/toolkit2.html.
  • Mulrow CD, Williams JW Jr, Chiquette E, Aguilar C, Hitchcock-Noel P, Lee S, Cornell J, Stamm K. Efficacy of newer medications for treating depression in primary care patients. Am J Med. 2000;108(1):54-64.
  • Schulberg HC, Katon WJ, Simon GE, Rush AJ. Best clinical practice: guidelines for managing major depression in primary medical care. J Clin Psychiatry. 1999;60 Suppl 7:19-26; discussion 27-8.

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