Antidepressant Medication Management in Primary Care
Antidepressant Medication Management in Primary Care
Primary care nurse practitioners can manage antidepressant medications in a moderate amount of patients with major depression. Standardized depression screening instruments can identify symptom severity, engage patients and families, and monitor antidepressant treatment response. Medical conditions need to be ruled out before diagnosing a patient with major depression. It is critical to screen for substance use problems, suicidal ideation, and history of mania. Major depression care management includes knowing cytochrome P450 drug-to-drug interactions, improving medication adherence, developing follow-up plans, determining need for maintenance therapies, deciding when to augment antidepressants, and consulting or referring to mental health specialists.
Depression is a common disorder found in primary care. Of all adults diagnosed with depressive disorder in the United States, 54.6% were diagnosed and managed in primary care. Nurse practitioners (NPs) can contribute to early diagnosis and antidepressant medication management of major depression, thereby limiting the disorder's long-term consequences. This article focused on antidepressant medication management for adults only because children require additional management considerations.
Major depression is a mood disorder that may impact patients' daily functioning, physical health, and quality of life. A diagnosis of major depressive episode must include depressed mood or loss of interest in normal activities for at least 2 weeks and at least 5 other symptoms (weight loss/gain, insomnia/hypersomnia, psychomotor agitation/retardation, fatigue, feelings of worthlessness or guilt, decreased ability to concentrate, or recurrent thoughts of death or suicidal ideation). Changes in previous functioning (eg, family responsibilities, work attendance) are also necessary for the diagnosis.
The US Preventive Services Task Force recommends universal screening for depression in adults only when staff-assisted depression care supports are available, such as frequent telephone follow-up, clinical evaluation, and patient education. The Task Force bases the recommendation on strong evidence of formal care improving patient outcomes. Routine screening is not recommended if these supports are not in place, but screening may be supported in an individual patient suspected of having depression based on clinical observation, patient self-report, or risk factors for depression.Patients with medical comorbidities—in particular diabetes, cardiovascular disease (CVD), stroke, and chronic pain—are at high risk for developing this mood disorder. Other risk factors include family or personal history of major depression or substance abuse, recent loss, stressful life or traumatic events, major life changes, and intimate partner violence.
One of the most used instruments for screening and assessing treatment response is the Patient Health Questionnaire-9 (PHQ-9). The PHQ-9 consists of 9 questions on a range of "not at all" to "nearly every day" for the past 2 weeks. An additional question addresses functional impairment in home, work, and social situations. If 5 or more questions are in the "more than half the days" or "nearly every day" category, the diagnosis of major depression should be evaluated. The scale measures symptom presence and severity. This patient self-report instrument is quick to complete and does not require any clinician training for administering or scoring the tool. Clinician assessment through history and physical exam is critical for appropriate diagnosis. Patients may not initially disclose their symptoms; observation during office visits may lead to suspicion of major depression.
Abstract and Introduction
Abstract
Primary care nurse practitioners can manage antidepressant medications in a moderate amount of patients with major depression. Standardized depression screening instruments can identify symptom severity, engage patients and families, and monitor antidepressant treatment response. Medical conditions need to be ruled out before diagnosing a patient with major depression. It is critical to screen for substance use problems, suicidal ideation, and history of mania. Major depression care management includes knowing cytochrome P450 drug-to-drug interactions, improving medication adherence, developing follow-up plans, determining need for maintenance therapies, deciding when to augment antidepressants, and consulting or referring to mental health specialists.
Introduction
Depression is a common disorder found in primary care. Of all adults diagnosed with depressive disorder in the United States, 54.6% were diagnosed and managed in primary care. Nurse practitioners (NPs) can contribute to early diagnosis and antidepressant medication management of major depression, thereby limiting the disorder's long-term consequences. This article focused on antidepressant medication management for adults only because children require additional management considerations.
Major depression is a mood disorder that may impact patients' daily functioning, physical health, and quality of life. A diagnosis of major depressive episode must include depressed mood or loss of interest in normal activities for at least 2 weeks and at least 5 other symptoms (weight loss/gain, insomnia/hypersomnia, psychomotor agitation/retardation, fatigue, feelings of worthlessness or guilt, decreased ability to concentrate, or recurrent thoughts of death or suicidal ideation). Changes in previous functioning (eg, family responsibilities, work attendance) are also necessary for the diagnosis.
The US Preventive Services Task Force recommends universal screening for depression in adults only when staff-assisted depression care supports are available, such as frequent telephone follow-up, clinical evaluation, and patient education. The Task Force bases the recommendation on strong evidence of formal care improving patient outcomes. Routine screening is not recommended if these supports are not in place, but screening may be supported in an individual patient suspected of having depression based on clinical observation, patient self-report, or risk factors for depression.Patients with medical comorbidities—in particular diabetes, cardiovascular disease (CVD), stroke, and chronic pain—are at high risk for developing this mood disorder. Other risk factors include family or personal history of major depression or substance abuse, recent loss, stressful life or traumatic events, major life changes, and intimate partner violence.
One of the most used instruments for screening and assessing treatment response is the Patient Health Questionnaire-9 (PHQ-9). The PHQ-9 consists of 9 questions on a range of "not at all" to "nearly every day" for the past 2 weeks. An additional question addresses functional impairment in home, work, and social situations. If 5 or more questions are in the "more than half the days" or "nearly every day" category, the diagnosis of major depression should be evaluated. The scale measures symptom presence and severity. This patient self-report instrument is quick to complete and does not require any clinician training for administering or scoring the tool. Clinician assessment through history and physical exam is critical for appropriate diagnosis. Patients may not initially disclose their symptoms; observation during office visits may lead to suspicion of major depression.