Three Component Model for Depression

Omer Zulfiqar MSIII

Case Presentation
A 22 year old male comes into the clinic with CC of a cough and runny nose. The patient denies any sputum production, chills, weight loss, or night sweats. ROS yields hx of seasonal allergies, but no significant finding. PE shows bp of 114/70, pulse of 68, T of 99.2. Mucous membranes are moist. No inflammation of the pharynx. Remainder of exam reveals no significant findings.

Case cont.
CC is addressed first, while the underlying emotional issue, the real reason they are in the clinic is not revealed until the majority of the time has already been spent Need an efficient method of detecting or monitoring depression before stepping foot in the examination room

Pathophysiology of Depression
Biological or Environmental Factors Biological explanation suggests that mood is controlled by neurotransmitters such as serotonin. One theory explains depression due to brain anatomy. These individuals are said to have a smaller hippocampus with fewer serotonin receptors. Environmental explanation is based on the interactions within ones family. Bottom line it Is caused by many factors.

Depression
World Health Organization estimates that depression will be the second leading cause of disability by the year 2020 In the late 90s the US General Surgeon stated that 60 percent of people with mental illnesses do not receive treatment and that primary care is an important portal for getting these individuals help

Depression and Primary Care

Over 50 percent of depressed patients are treated by primary care physicians However, nearly 28 percent of patients who are depressed are not diagnosed by their primary care physician Major barriers for primary care physicians include time limitation per patient and lack of a well organized system for screening and managing depressed patients

Macurther Initiative
Macurther initiative was started in 1995 to better understand management of depression in the primary care setting and to develop strategies to enhance that management As a result, the project RESPECT- DEPRESSION was started. The project relied on a model called the THREE COMPONENT MODEL (3CM).

THREE COMPONENT MODEL (3CM)

Replaces the usual unstructured approach for treating depression with a more collaborative approach. The model consists of: primary care physician, a care manager and a psychiatrist working together.

PCP responsibilities
(1)Recognition, (2)Treatment, and (3)Education (1)Recognition: Using the Patient Health Questionnaire (PHQ 9) PHQ 9: consists of 9 items based directly on the diagnostic criteria in the DSM IV Two components to the PHQ 9: 1) to identify symptoms and functional impairment of depression 2)to interpret how severe the depression is

PHQ 9

Symptom and Functional Impairment

For a patient to be considered positive for a symptom a minimum rating of 2 is required except for symptom number 9 where a rating of one can be considered positive To be considered for depression you need to be positive on 5 symptoms, one of which has to be symptom number 1 or 2 Functional impairment is item number 10

Severity Score
Count each item in the column labeled several days and multiply by one Count each item in the column labeled more than half the days and multiply by two Count each item in the column labeled nearly every day and multiply by three Add the three columns to get the severity score

Evaluating the severity score

PHQ 9 Score 5-9 Diagnosis Minimal symptoms Recommendation Support and educate Follow up in 1 month Support Antidepressants or psychotherapy

10-14

Minor depression Dysthmyia (atleast 2 yrs.) Major Depression (mild)

15-19

Major Depression (moderately severe)

Major Depression (severe)

Antidepressant or psychotherapy
Antidepressant and psychotherapy

20 or greater

Using the PHQ 9 to evaluate response to treatment (after 4-6 wks of antidepressant)
PHQ 9 Score Treatment Response Treatment Plan

Drop of 5 or more points

Drop of 2-4 points Drop of 1 point or no change

Adequate
Probably Inadequate Inadequate

No change needed Follow up in 4 weeks

Increase the dosage Increase dosage and add psychological counseling.

Using the PHQ 9 to evaluate response to treatment (after psychological counseling)

PHQ 9 Score Drop of 5 pts. or more Treatment Response Adequate Treatment Plan No change Follow up in 4 weeks

Drop of 2-4 pts.

Probably Inadequate

Possibly no change or share the score with counselor Consider adding an antidepressant or switching therapy styles (cognitive behavioral, problem solving, or interpersonal)

Drop of 1 pts. or no change Inadequate

(2)Treatment
Supportive Counseling and Problem Solving treatment Antidepressants Referral to Psychiatrist

Supportive Counseling
Active Listening Giving Advice Showing Empathy Developing coping strategies

Problem Solving Treatment

Problem Solving Treatment: PCP and the patient meet for 4-6 thirty minutes sessions over 10 weeks to A) identify problems B) set realistic goals and generate solutions C) evaluate progress and renew problem solving efforts However this requires formal training for the PCP but patients have higher satisfaction and are more compliant

Antidepressants Factors to consider when prescribing

History of response to medication in patient or first degree relative Patient preference Side effects Drug Interactions (avoid TCAs in patients with cardiac conditions) Cost (TCAs and generic SSRI are more affordable)

(3)Education
Handout for patients. Help to save time Should emphasize important concepts such as the efficacy and side effects of the medications. As well as helping the patient understand that antidepressants take time to work. Keep in mind that 1 out of 5 Americans read at the 5th grade or below levels.

Care Managers Responsibilities

Ensure that a treatment plan is being followed by calling the patient at certain intervals Collect information on symptoms and side effects Communicate the results with the PCP and the psychiatrist in the three component model Typical ex. If a patient has not filled a prescription for an antidepressant by one week then the care manager will call to address barriers such as cost or possible side effects from the last treatment

3CM Psychiatrists Responsibilities

Supervise the care managers by phone Providing informal consultation to primary care physicians Improving the communication between the PCP and the mental health specialist that the patient is seeing

Does this method really work?

In 2004 British Medical Journal conducted research that compared 3CM with usual care

Patient Response after 3 months

100

90
80 70 60 50 40 30

usual care
3CM

20
10 0

usual care

3CM

Remission Rate After 3 months

100

90
80 70 60 50 40 30

usual care
3cm

20
10 0

usual care

3cm

More results!!
By 6 months 60 percent had responded to 3CM and 90 percent of these individuals rated their care as good or excellent The Defense Department will use a modified version of this initiative on soldiers coming back from war

Issues with the 3CM

Money: who will reimburse the care manager and the psychiatrist. The money for conducting this research came from medical groups and insurance plans. It will be challenging to convince insurance companies to spend extra money on patient care because each patient in the 3CM plan cost $150 more dollars than usual care However, the researchers for 3CM defend this issue by citing the long term productivity of helping depressed patients

Conclusion
While there are weaknesses with this model, it is showing a better response than the traditional method of managing depression The biggest hurdle is the financial investment But it wont cost anything to learn more about it: www.depression-primarycare.org

References
Chakraburtty Amal. Causes of Depression. http://www.webmd.com/depression/guide/causesdepression. March 2010. Dietrich et. al. Re-engineering Systems for the Treatment of Depression in Primary Care: Cluster Randomized Controlled Trial. British Medical Journal 2004 Sep 11; 329 (7466): 605. Diertrich et. al. Depression Management Tool Kit. www.depression-primarycare.org 2009 Oxman et. al. A Three-Component Model for Reengineering Systems for the Treatment of Depression in Primary Care. Psychosomatics 2002. 43: 441-450. Yapko Michael. What causes depression? Psychology Today. July 2003.

Any Questions ?