Anti-depressant Medication Management

Percentage of patients 18 years of age and older who were treated with antidepressant medication, had a diagnosis of major depression, and who remained on an antidepressant medication treatment. Two rates are reported. 
a. Percentage of patients who remained on an antidepressant medication for at least 84 days (12 weeks). 
b. Percentage of patients who remained on an antidepressant medication for at least 180 days (6 months).

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Depression affects over 17 million adults in the U.S. (NIMH, 2021) and is estimated to affect nearly a quarter of adults in their lifetime (Burcusa & Iacono, 2007). Symptoms of depression include disturbances in appetite and sleep, anxiety, decreased concentration, and suicidal ideation (NAMI, 2017; Charbonneau et al., 2005). When left untreated, depression can have a dramatic effect on one’s quality of life, causing constant feelings of hopelessness, loss of interest in daily activities and in some cases suicidal ideation (SAMHSA, 2014).

The American Psychiatric Association (APA) recommends use of antidepressant medication and behavioral therapies, such as psychotherapy, for the treatment and management of depression (APA, 2010). For the past 60 years, antidepressant medication has proven to be effective, especially for patients with more severe symptoms (Fournier, 2010). However, studies analyzing adherence to antidepressant medications found that prevalence of nonadherence was high, ranging from 13 percent to 55.7 percent (Sansone, 2012). 

Clinical guidelines for depression emphasize the importance of effective clinical management in increasing patients’ medication compliance, monitoring treatment effectiveness, and identifying and managing side effects. If pharmacological treatment is initiated, appropriate dosing and continuation of therapy through the acute and continuation phases decrease recurrence of symptoms. Thus, the evaluation of the duration of pharmacological treatment serves as an important indicator in understanding patient compliance with establishing and maintaining an effective medication regimen.

American Psychological Association (2019): 
- "For initial treatment of adult patients with depression, the panel recommends the following in the context of sharing decision-making with the patient when considering options: 
1. That clinicians offer either psychotherapy or second-generation antidepressant.
2. If considering combined treatment, the panel recommends cognitive-behavioral therapy or interpersonal psychotherapy plus a second-generation antidepressant.”
	
- “For initial treatment of older adult patients with depression, the panel recommends the following in the context of shared decision-making with the patient: 
1. Either group life review treatment or Group Cognitive Behavioral Therapy (either alone or added to usual care) over no treatment 
2. Combined pharmacotherapy and interpersonal psychotherapy (IPT) over IPT alone. Of note, while the study upon which this is based used nortriptyline, the panel recommends a second-generation antidepressant due to the reduced risk of side effects.”

American Psychiatric Association (2010): 
- “An antidepressant medication is recommended as an initial treatment choice for patients with mild to moderate major depressive disorder [I: Recommended with substantial clinical confidence] and definitely should be provided for those with severe major depressive disorder unless electroconvulsive therapy (ECT) is planned [I: Recommended with substantial clinical confidence].” 

- Patients should be given a realistic notion of what can be expected during the different phases of treatment, including the likely time course of symptom response and the importance of adherence for successful treatment and prophylaxis [I]. 

- During the acute phase of treatment, patients should be carefully and systematically monitored on a regular basis to assess their response to pharmacotherapy, identify the emergence of side effects (e.g., gastrointestinal symptoms, sedation, insomnia, activation, changes in weight, and cardiovascular, neurological, anticholinergic, or sexual side effects), and assess patient safety [I]. 

- “During the continuation phase of treatment, the patient should be carefully monitored for signs of possible relapse [I: Recommended with substantial clinical confidence]. Systematic assessment of symptoms, side effects, adherence, and functional status is essential [I: Recommended with substantial clinical confidence], and may be facilitated through the use of clinician- and/or patient-administered rating scales [II: Recommended with moderate clinical confidence]. To reduce the risk of relapse, patients who have been treated successfully with antidepressant medications in the acute phase should continue treatment with these agents for 4–9 months [I: Recommended with substantial clinical confidence].”

Department of Veterans Affairs, and Health Affairs, Department of Defense (2022): 
- “For patients with major depressive disorder (MDD), we suggest using a quantitative measure of depression severity in the initial treatment planning and to monitor treatment progress at regular intervals to guide shared treatment decision making.” [Weak for]
	
- “In patients with MDD who achieve remission with antidepressant medication, we recommend continuation of antidepressants at the therapeutic dose for at least six months to decrease risk of relapse.”

Department of Veterans Affairs, and Health Affairs, Department of Defense (2016):
- ”In patients at high risk for recurrent depressive episodes and who are treated with pharmacotherapy, we recommend offering maintenance pharmacotherapy for at least 12 months and possibly indefinitely.” [Strong For] 
 
- “After initiation of therapy or a change in treatment, we recommend monitoring patients at least monthly until the patient achieves remission. At minimum, assessments should include a measure of symptoms, adherence to medication and psychotherapy, and emergence of adverse effects.” [Strong For] 

- “In patients with MDD who achieve remission with antidepressant medication, we recommend continuation of antidepressants at the therapeutic dose for at least six months to decrease risk of relapse.” [Strong For]

Higher score indicates better quality

Reference Type: CITATION

Reference Text: 'American Psychiatric Association. (2010). Practice guideline for the treatment of patients with major depressive disorder, 3rd edition. Arlington: Author.'

Reference Type: CITATION

Reference Text: 'American Psychological Association. (2019). Clinical practice guideline for the treatment of depression across three age cohorts. Retrieved from https://www.apa.org/depression-guideline'

Reference Type: CITATION

Reference Text: 'Burcusa, S. L., & Iacono, W. G. (2007). Risk for recurrence in depression. Clinical Psychology Review, 27(8), 959-985.'

Reference Type: CITATION

Reference Text: 'Charbonneau, A., Bruning, W., Titus-Howard, T., et al. (2005). The community initiative on depression: report from a multiphase work site depression intervention. Journal of Occupational and Environmental Medicine, 47(1), 60-67.'

Reference Type: CITATION

Reference Text: 'Department of Veterans Affairs and the Department of Defense (VA/DoD). (2022). VA/DoD Clinical Practice Guidelines for the Management of Major Depressive Disorder. Version 4.0 . Retrieved from: https://www.healthquality.va.gov/guidelines/MH/mdd/VADoDMDDCPGFinal508.pdf'

Reference Type: CITATION

Reference Text: 'Department of Veterans Affairs and the Department of Defense (VA/DoD). (2016). VA/DoD Clinical Practice Guidelines for the Management of Major Depressive Disorder. The Management of Major Depressive Disorder Working Group. Retrieved from: https://www.healthquality.va.gov/guidelines/MH/mdd/VADoDMDDCPGFINAL82916.pdf'

Reference Type: CITATION

Reference Text: 'Fournier, J. C., DeRubeis, R. J., Hollon, S. D., et al. (2010). Antidepressant drug effects and depression severity: a patient-level meta-analysis. JAMA, 303(1), 47-53.'

Reference Type: CITATION

Reference Text: 'National Alliance on Mental Illness (NAMI). (2017). Depression. Retrieved from: https://www.nami.org/About-Mental-Illness/Mental-Health-Conditions/Depression'

Reference Type: CITATION

Reference Text: 'NIMH. (2021). Major Depression. Retrieved from: https://www.nimh.nih.gov/health/statistics/major-depression.shtml'

Reference Type: CITATION

Reference Text: 'Sansone, R. A., & Sansone, L. A. (2012). Antidepressant adherence: are patients taking their medications? Innovations in Clinical Neuroscience, 9(5–6), 41–46.'

Reference Type: CITATION

Reference Text: 'Substance Abuse and Mental Health Services Administration (SAMHSA). (2014). Results from the 2013 National Survey on Drug Use and Health: Mental Health Findings, NSDUH Series H-49, HHS Publication No. (SMA) 14-4887. Rockville, MD: Substance Abuse and Mental Health Services Administration.'

Intake Period: The 12-month window starting on May 1 of the year prior to the measurement period and ending on April 30 of the measurement period.

Index Prescription Start Date (IPSD): The date of the earliest prescription dispensing event for an antidepressant medication during the Intake Period.

The "continuous treatment" described in this measure allows for gaps in medication treatment up to a total 31 days during the 115-day period (numerator 1) or 52 days during the 232-day period (numerator 2). Gaps can include either gaps used to change medication, or treatment gaps to refill the same medication.

To identify new treatment episodes for major depression, there must be a 105-day negative medication history (a period during which the patient was not taking antidepressant medication) prior to the dispensing event associated with the IPSD.

This eCQM is a patient-based measure.
 
This version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

TBD

Patients 18 years of age and older as of April 30 of the measurement period who were dispensed antidepressant medications during the Intake Period, and were diagnosed with major depression 60 days prior to, or 60 days after the dispensing event and had a visit 60 days prior to, or 60 days after the dispensing event

Equals Initial Population

Patients who were actively on an antidepressant medication in the 105 days prior to the IPSD.

Exclude patients who are in hospice care for any part of the measurement period.

Numerator 1: Patients who have received antidepressant medication for at least 84 days (12 weeks) of continuous treatment beginning on the IPSD through 114 days after the IPSD (115 total days).

Numerator 2: Patients who have received antidepressant medications for at least 180 days (6 months) of continuous treatment beginning on the IPSD through 231 days after the IPSD (232 total days).

Not Applicable

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For every patient evaluated by this measure also identify payer, race, ethnicity and sex

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