Depression Remission at Twelve Months

The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event.

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Ages 12 to 17
Ages 18 and older

None

None

Adults:
Depression is a common and treatable mental disorder. 8.1% of American adults age 20 and over had depression in a given 2 week period. Women (10.4%) were almost twice as likely as men (5.5%) to have had depression. The prevalence of depression among adults decreased as family income levels increased. About 80% of adults with depression reported at least some difficulty with work, home, or social activities because of their depression symptoms (Centers for Disease Control and Prevention, 2018).

Persons with a current diagnosis of depression and a lifetime diagnosis of depression or anxiety were significantly more likely than persons without these conditions to have cardiovascular disease, diabetes, asthma and obesity and to be a current smoker, to be physically inactive and to drink heavily (Strine et al., 2008).

People who suffer from depression have lower incomes, lower educational attainment and fewer days working each year, leading to seven fewer weeks of work per year, a loss of 20% in potential income and a lifetime loss for each family who has a depressed family member of $300,000 (Smith & Smith, 2010).

The incremental economic burden of individuals with major depressive disorder (MDD) increased by 21.5% (from $173.2 billion to $210.5 billion, inflation-adjusted dollars). The composition of these costs remained stable, with approximately 45% attributable to direct costs, 5% to suicide-related costs, and 50% to workplace costs. Only 38% of the total costs were due to MDD itself as opposed to comorbid conditions. (Greenberg, 2015).

Adolescents and Adults:
The Centers for Disease Control and Prevention states that during 2009-2012 an estimated 7.6% of the U.S. population aged 12 and over had depression, including 3% of Americans with severe depressive symptoms. Almost 43% of persons with severe depressive symptoms reported serious difficulties in work, home and social activities, yet only 35% reported having contact with a mental health professional in the past year.
Depression is associated with higher mortality rates in all age groups. People who are depressed are 30 times more likely to take their own lives than people who are not depressed and five times more likely to abuse drugs. Depression is the leading cause of medical disability for people aged 14 to 44. Depressed people lose 5.6 hours of productive work every week when they are depressed, fifty percent of which is due to absenteeism and short-term disability.

Adolescents:
In 2014, an estimated 2.8 million adolescents age 12 to 17 in the United States had at least one major depressive episode (MDE) in the past year. This represented 11.4% of the U.S. population. The same survey found that only 41.2 percent of those who had a MDE received treatment in the past year. The 2013 Youth Risk Behavior Survey of students grades 9 to 12 indicated that during the past 12 months 39.1% (F) and 20.8% (M) indicated feeling sad or hopeless almost every day for at least 2 weeks, planned suicide attempt 16.9% (F) and 10.3% (M), with attempted suicide 10.6% (F) and 5.4% (M). Adolescent-onset depression is associated with chronic depression in adulthood. Many mental health conditions (anxiety, bipolar, depression, eating disorders, and substance abuse) are evident by age 14. The 12-month prevalence of MDEs increased from 8.7% in 2005 to 11.3% in 2014 in adolescents and from 8.8% to 9.6% in young adults (both P < .001). The increase was larger and statistically significant only in the age range of 12 to 20 years. The trends remained significant after adjustment for substance use disorders and sociodemographic factors. Mental health care contacts overall did not change over time; however, the use of specialty mental health providers increased in adolescents and young adults, and the use of prescription medications and inpatient hospitalizations increased in adolescents. In 2015, 9.7% of adolescents in MN who were screened for depression or other mental health conditions, screened positively.

Adults:
Source: Institute for Clinical Systems Improvement (ICSI) Health Care Guideline for Adult Depression in Primary Care (Trangle et al., 2016)

Major depression is a treatable cause of pain, suffering, disability and death, yet primary care clinicians detect major depression in only one-third to one-half of their patients with major depression (Williams et al. 2002; Schonfeld et al., 1997).

Usual care for depression in the primary care setting has resulted in only about half of depressed adults getting treated (Kessler et al., 2005) and only 20-40% showing substantial improvement over 12 months (Unutzer et al., 2002; Katon et al., 1999).

Recommendations and algorithm notations supporting depression outcomes and duration of treatment according to ICSI's Health Care Guideline:

Recommendation: Clinicians should establish and maintain follow-up with patients.  Appropriate, reliable follow-up is highly correlated with improved response and remission scores. It is also correlated with the improved safety and efficacy of medications and helps prevent relapse.

Proactive follow-up contacts (in person, telephone) based on the collaborative care model have been shown to significantly lower depression severity (Unutzer et al., 2002).  In the available clinical effectiveness trials conducted in real clinical practice settings, even the addition of a care manager leads to modest remission rates (Trivedi et al., 2006; Unutzer et al., 2002).  Interventions are critical to educating the patient regarding the importance of preventing relapse, safety and efficacy of medications, and management of potential side effects.  Establish and maintain initial follow-up contact intervals (office, phone, other) (Hunkeler et al., 2000; Simon et al., 2000).

PHQ-9 as monitor and management tool.  The PHQ-9 is an effective management tool, as well, and should be used routinely for subsequent visits to monitor treatment outcomes and severity. It can also help the clinician decide if/how to modify the treatment plan (Duffy et al., 2008; Lowe et al., 2004).  Using a measurement-based approach to depression care, PHQ-9 results and side effect evaluation should be combined with treatment algorithms to drive patients toward remission.  A five-point drop in PHQ-9 score is considered the minimal clinically significant difference (Trivedi, 2009).

Every time that the PHQ-9 is assessed, suicidality is assessed, as well. If the suicidality was indeed of high risk, urgent referral to crisis specialty health care is advised. In case of low suicide risk, the patient can proceed with treatment in the primary care practice (Huijbregts et al., 2013).

Care Algorithm:  Has patient reached remission?

The goals of treatment should be to achieve remission, reduce relapse and recurrence, and return to previous level of occupational and psychosocial function.

Full remission is defined as a two-month period devoid of major depressive signs and symptoms (American Psychiatric Association, 2013). If using a PHQ-9 tool, remission translates to PHQ-9 score of less than 5 (Kroenke, 2001). Results from the STAR*D study showed that remission rates lowered with more treatment steps, but the overall cumulative rate was 67% (Rush et al., 2006).

Response is defined as a 50% or greater reduction in symptoms (as measured on a standardized rating scale). Partial response is defined as a 25-50% reduction in symptoms. This definition is based on how the depression literature defines response.

Response and remission take time. In the STAR*D study, longer times than expected were needed to reach response or remission. In fact, one-third of those who ultimately responded did so after six weeks. Of those who achieved remission by Quick Inventory of Depressive Symptomatology (QIDS), 50% did so only at or after six weeks of treatment (Trivedi et al., 2006). If the primary care clinician is seeing some improvement, continue working with that patient to augment or increase dosage to reach remission. This can take up to three months.

A reasonable criterion for extending the initial treatment: assess whether the patient is experiencing a 25% or greater reduction in baseline symptom severity at six weeks of therapeutic dose. If the patient's symptoms are reduced by 25% or more, but the patient is not yet at remission, and if medication has been well tolerated, continue to prescribe. Raising the dose is recommended (Trivedi et al., 2006).

Improvement with psychotherapy is often a bit slower than with pharmacotherapy. A decision regarding progress with psychotherapy and the need to change or augment this type of treatment may require 8 to 10 weeks before evaluation (Schulberg et al., 1998).

Care Algorithm: Continuation and Maintenance Treatment Duration Based on Episode

Acute therapy is the treatment phase focused on treating the patient to remission. Acute therapy typically lasts 6-12 weeks but technically lasts until remission is reached (American Psychiatric Association, 2010). Full remission is defined as a two-month period devoid of major depressive signs and symptoms (American Psychiatric Association, 2013).

Continuation therapy is the four-to-nine month period beyond the acute treatment phase during which the patient is treated with antidepressants, psychotherapy, ECT or other somatic therapies to prevent relapse (American Psychiatric Association, 2010). Relapse is common within the first six months following remission from an acute depressive episode; as many as 20-85% of patients may relapse (American Psychiatric Association, 2010).

This measure assesses achievement of remission, which is a desired outcome of effective depression treatment and monitoring.

Adult Depression in Primary Care - Guideline Aims
- Increase the percentage of patients with major depression or persistent depressive disorder who have improvement in outcomes from treatment for major depression or persistent depressive disorder.
- Increase the percentage of patients with major depression or persistent depressive disorder who have follow-up to assess for outcomes from treatment.
- Improve communication between the primary care physician and the mental health care clinician (if patient is co-managed).

Adolescents:
Source: American Academy of Child and Adolescent Psychiatry Practice Parameter for the Assessment and Treatment of Children and Adolescents with Depressive Disorders (2007)
http://www.jaacap.com/article/S0890-8567(09)62053-0/pdf

Recommendations:
Recommendations supporting depression outcomes and duration of treatment according to AACAP guideline:
- Treatment of depressive disorders should always include an acute and continuation phase; some children may also require maintenance treatment. The main goal of the acute phase is to achieve response and ultimately full symptomatic remission (definitions below).
- Each phase of treatment should include psychoeducation, supportive management, and family and school involvement.
- Education, support, and case management appear to be sufficient treatment for the management of depressed children and adolescents with an uncomplicated or brief depression or with mild psychosocial impairment.
- For children and adolescents who do not respond to supportive psychotherapy or who have more complicated depressions, a trial with specific types of psychotherapy and/or antidepressants is indicated.

Sources:
Guidelines for Adolescent Depression in Primary Care (GLAD-PC) (2018) http://pediatrics.aappublications.org/content/141/3/e20174081
Guidelines for adolescent depression in primary care (GLAD-PC): II. Treatment and ongoing management
http://pediatrics.aappublications.org/content/141/3/e20174082

Recommendations supporting depression outcomes and duration of treatment according to GLAD-PC:
Recommendations for Ongoing Management of Depression:
- Mild depression: consider a period of active support and monitoring before starting other evidence based treatment
- Moderate or severe major clinical depression or complicating factors:
  -- consultation with mental health specialist with agreed upon roles
  -- evidence based treatment (CBT or IPT and/or antidepressant SSRI)
- Monitor for adverse effects during antidepressant therapy
  -- clinical worsening, suicidality, unusual changes in behavior
- Systematic and regular tracking of goals and outcomes
  -- improvement in functioning status and resolution of depressive symptoms
Regardless of the length of treatment, all patients should be monitored on a monthly basis for 6 to 12 months after the full resolution of symptoms

Higher score indicates better quality

American Psychiatric Association. (2010). Practice guideline for the treatment of patients with panic disorder. 2nd edition. Washington, DC: Author.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5). 5th edition. Washington, DC: Author.

Birmaher, B., & Brent, D. (2007). Practice parameter for the assessment and treatment of children and adolescents with depressive disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 46(11), 1503-1526. Retrieved from http://www.jaacap.com/article/S0890-8567(09)62053-0/pdf

Brody, D. J., Pratt, L. A., & Hughes, J. P. (2018). Prevalence of depression among adults aged 20 and over: United States, 2013–2016. NCHS Data Brief No. 303. Atlanta, GA: Centers for Disease Control and Prevention. 

Cheung, A. H., Zuckerbrot, R. A., Jensen, P. S., et al. (2018, March). Guidelines for adolescent depression in primary care (GLAD-PC): Part II. Treatment and ongoing management. Pediatrics, 141(3). Retrieved from http://pediatrics.aappublications.org/content/141/3/e20174082

Duffy, F. F., Chung, H., Trivedi, M., et al. (2008, October). Systematic use of patient-rated depression severity monitoring: Is it helpful and feasible in clinical psychiatry? Psychiatric Services, 59(10), 1148-1154. 

Giedd, J. N., Keshavan, M., & Paus, T. (2008). Why do many psychiatric disorders emerge during adolescence? Nature Reviews Neuroscience, 9(12), 947-957. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2762785/

Greenberg, P. E. (2015, February). The growing economic burden of depression in the U.S. Journal of Clinical Psychiatry, 76(2), 155-162.

Huijbregts, K. M. L., de Jong, F. J., van Marwijk, H. W. J., et al. (2013). A target-driven collaborative care model for major depressive disorder is effective in primary care in the Netherlands: A randomized clinical trial from the depression initiative. Journal of Affective Disorders, 146(3), 328-337.

Hunkeler, E. M., Meresman, J. F., Hargreaves, W. A., et al. (2000, August). Efficacy of nurse telehealth care and peer support in augmenting treatment of depression in primary care. Archives of Family Medicine, 9(8), 700-708.

Joiner, T. (2010). Myths about suicide. Cambridge: Harvard University Press.

Katon, W., Von Korff, M., Lin, E., et al. (1999). Stepped collaborative care for primary care patients with persistent symptoms of depression: A randomized trial. Archives of General Psychiatry, 56(12), 1109-1115.

Kessler, R. C., Chiu, W. T., Demler, O., et al. (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 617-627.

Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606-613. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495268/

Lewinsohn, P. M., Rohde, P., Klein, D. N., et al. (1999). Natural course of adolescent major depressive disorder: I. Continuity into young adulthood. Journal of the American Academy of Child and Adolescent Psychiatry, 38(1), 56-63.

Lowe, B., Unutzer, J., Callahan, C. M., et al. (2004). Monitoring depression treatment outcomes with the Patient Health Questionnaire-9. Medical Care, 42(12), 1194-1201.

Minnesota Community Measurement. (2015, October). New measures evaluate rates of obesity counseling for kids, depression screening for teens. Retrieved from http://mncm.org/news/new-measures-evaluate-rates-of-obesity-counseling-for-kids-depression-screening-for-teens/

National Institute of Mental Health. (2014). Prevalence of major depressive episode among adolescents. Retrieved from https://www.nimh.nih.gov/health/statistics/prevalence/major-depression-among-adolescents.shtml

Pratt, L. A., & Brody, D. J. (2014). Depression in the U.S. household population, 2009-2012. NCHS data brief no. 172. Hyattsville, MD: National Center for Health Statistics.

Ramin, M., Olfson, M., & Han, B. (2016). National trends in the prevalence and treatment of depression in adolescents and young adults. Pediatrics, 138(6), e20161878. http://pediatrics.aappublications.org/content/early/2016/11/10/peds.2016-1878

Rush, A. J., Trivedi, M. H., Wisniewski, S. R., et al. (2006). Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: A STAR*D report. American Journal of Psychiatry, 163, 1905-1917.

Schonfeld, W. H., Verboncoeur, C. J., Fifer, S. K., et al. (1997). The functioning and well-being of patients with unrecognized anxiety disorders and major depressive disorder. Journal of Affective Disorders, 43, 105-119.

Schulberg, H. C., Katon, W., Simon, G. E., et al. (1998). Treating major depression in primary care practice: An update of the agency for health care policy and research practice guidelines. Archives of General Psychiatry, 55, 1121-1127.

Shain, B. (2016). Suicide and suicide attempts in adolescents. Pediatrics, 138(1), e1-11. Retrieved from http://pediatrics.aappublications.org/content/138/1/e20161420

Simon, G. E., Van Korff, M., Rutter, C., et al. (2000). Randomised trial of monitoring, feedback, and management of care by telephone to improve treatment of depression in primary care. BMJ, 320, 550-554.

Smith, J. P., & Smith, G. C. (2010). Long-term economic costs of psychological problems during childhood. Social Science & Medicine, 71(1), 110-115. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2887689/

Stewart, W. F., Ricci, J. A., Chee, E., et al. (2003). Cost of lost productive work time among U.S. workers with depression. JAMA, 289, 3135-3144.

Stewart WF, Ricci JA, Chee E, Hahn SR, Morganstein D. Cost of lost productive work time among US workers with depression. JAMA 2003;289:3135-44.

Strine, T. W., Mokdad, A. H., Balluz, L. S., et al. (2008). Depression and anxiety in the United States: Findings from the 2006 Behavioral Risk Factor Surveillance System. Psychiatric Services, 59(12), 1383-1390. Retrieved from http://ps.psychiatryonline.org/doi/abs/10.1176/ps.2008.59.12.1383

Trangle , M., Gursky, J., Haight, R., et al. Depression, adults in primary care. (Updated 2016, March). Retrieved from https://www.icsi.org/guidelines__more/catalog_guidelines_and_more/catalog_guidelines/catalog_behavioral_health_guidelines/depression/

Trivedi, M. H. (2009). Tools and strategies for ongoing assessment of depression: A measurement-based approach to remission. Journal of Clinical Psychiatry, 70, 26-31.

Trivedi, M. H., Rush, A. J., Wisniewski, S. R., et al. (2006). Evaluation of outcomes with citalopram for depression using measurement-based care in STAR*D: Implications for clinical practice. American Journal of Psychiatry, 163(1), 28-40.

Unutzer, J., Katon, W., Callahan, C. M., et al. (2002). Collaborative care management of late-life depression in the primary care setting: A randomized controlled trial. JAMA, 288, 2836-2845.

Williams, J. W., Jr., Noel, P. H., Cordes, J. A., et al. (2002). Is this patient clinically depressed? JAMA, 287, 1160-1170.

Zuckerbrot, R. A., Cheung, A., Jensen, P. S., et al. (2018, March). Guidelines for adolescent depression in primary care (GLAD-PC): Part I. Practice preparation, identification, assessment, and initial management. Pediatrics, 141(3). Retrieved from http://pediatrics.aappublications.org/content/141/3/e20174081

Denominator Identification Period:
The period in which eligible patients can have an index event. The denominator identification period occurs prior to the measurement period and is defined as 14 months to two months prior to the start of the measurement period. For patients with an index event, there needs to be enough time following index for the patients to have the opportunity to reach remission twelve months +/- 60 days after the index event date. 

Index Event Date: 
The date in which the first instance of elevated PHQ-9 or PHQ-9M greater than nine and diagnosis of depression or dysthymia occurs during the denominator identification measurement period. Patients may be screened using PHQ-9 and PHQ-9M up to 7 days prior to the office visit (including the day of the office visit).


Measure Assessment Period:
The index event date marks the start of the measurement assessment period for each patient which is 14 months (12 months +/- 60 days) in length to allow for a follow-up PHQ-9 or PHQ-9M between 10 and 14 months following the index event. This assessment period is fixed and does not start over with a higher PHQ-9 or PHQ-9M that may occur after the index event date.

Remission is defined as a PHQ-9 or PHQ-9M score of less than five.

Twelve months is defined as the point in time from the index event date extending out twelve months and then allowing a grace period of sixty days prior to and sixty days after this date. The most recent PHQ-9 or PHQ-9M score less than five obtained during this four month period is deemed as remission at twelve months, values obtained prior to or after this period are not counted as numerator compliant (remission).

None

TBD

Adolescent patients 12 to 17 years of age and adult patients 18 years of age and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 or PHQ-9M score greater than nine during the index event. Patients may be screened using PHQ-9 and PHQ-9M up to 7 days prior to the office visit (including the day of the office visit).

Equals Initial Population

1: Patients who died
2: Patients who received hospice or palliative care services
3: Patients who were permanent nursing home residents
4: Patients with a diagnosis of bipolar disorder
5: Patients with a diagnosis of personality disorder
6: Patients with a diagnosis of schizophrenia or psychotic disorder
7: Patients with a diagnosis of pervasive developmental disorder

Adolescent patients 12 to 17 years of age and adult patients 18 years of age and older who achieved remission at twelve months as demonstrated by a twelve month (+/- 60 days) PHQ-9 or PHQ-9M score of less than five

Not Applicable

None

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

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