Depression

What are the five stages of the Treatment Pathways Model? | TREATMENT PATH STAGE I: IDENTIFYING DEPRESSION | TREATMENT PATH STAGE II: REFERRALING | TREATMENT PATH STAGE III: ASSESSING AND DIAGNOSING DEPRESSION | TREATMENT PATH STAGE IV: TREATING DEPRESSION | TREATMENT PATH STAGE V: MONITORING AND REVIEWING | RESOURCES FOR CLIENTS

This Clinical Information Guide1 is one in a series of guides designed to assist caseworkers and supervisors in identifying and managing clients who need mental health services. These guides use the treatment pathways model,2 which outlines five stages to assist you in obtaining the best possible mental health services for your clients. Each guide is designed to highlight the primary casework task that needs to be accomplished at each stage, and to address common questions that you might have as you complete each task.

What are the five stages of the Treatment Pathways Model?

In the identification stage, you gather information concerning the identified problems, consult with your supervisor and the behavioral health consultant, and decide whether or not your client needs to be referred to a mental health specialist. In the referral stage, you follow established procedure by completing required documentation and selecting the appropriate mental health specialist. In the assessment and diagnosis stage, you assist the specialist by furnishing relevant information concerning your client. In the treatment stage, you work collaboratively with the clinician to identify treatment goals and secure the most effective treatment available for your client. In the monitoring and reviewing stage, you ensure that reasonable treatment goals are achieved.

TREATMENT PATH STAGE I: IDENTIFYING DEPRESSION

Primary Casework Task: To gather information to decide whether or not your client exhibits the symptoms of depression and to consult with your supervisor and the behavioral health consultant to determine if a referral for an evaluation or clinical intervention is needed.

What is depression?

Depression is a psychiatric disorder in which the person affected typically displays several symptoms, often including sadness, a loss of interest in normal daily activities, as well as feelings of helplessness and hopelessness. The depressed person may have frequent crying spells or, in the case of a child, may exhibit increased irritability. Clinical depression differs from "feeling blue" in that the symptoms are more severe and longer lasting. Many effective treatments exist for depression. Without treatment, depression can last for weeks, months, or even years.

How common is depression?

Currently, over 19 million Americans suffer from a depressive illness; as many as 2 million of these are children and adolescents. Depression is twice as common in women as in men. Among the general adult population, the lifetime risk of developing depression is between 10% and 25% for women and between 5% and 12% for men. The frequency of depression appears to be unrelated to ethnicity, education, income level, or marital status.

What causes depression?

Major depression has many causes. Researchers believe that genes, biology, psychology, and life stress all play a role. Biochemical research has indicated that irregularities in specific brain chemicals called neurotransmitters may be important. Personality characteristics such as chronic pessimism or low self-esteem may contribute to the development of depression. Stressful life events such as death, divorce, or financial difficulties can also play a role. A familial pattern appears to be present in depression: biological relatives of persons with depression are more likely to suffer from the disorder than individuals whose relatives do not suffer from depression.

What are the symptoms of depression?

The most common symptoms of depression include:

Do symptoms differ in children?

While the symptoms of depression in children and adolescents are similar to those in adults, children often do not have the vocabulary to describe their feelings and therefore express these feelings through their behavior. Preschoolers or children in early elementary school may appear less active or spontaneous, or may voice vague complaints of being sick. A young child may say negative things about him or herself and may demonstrate self-destructive behavior.

Early identification of depression in adolescents is critical, because since 1950, the suicide rate among adolescents has risen four fold. Older elementary school children or adolescents may exhibit irritability. They may engage in disruptive behavior, have problems with friendships, or the quality of their schoolwork may diminish. Adolescents may complain about hating themselves or others. Other symptoms include:

TREATMENT PATH STAGE II: REFERRAL

Primary Casework Task: To complete the required referral process, including gathering supporting documentation, and to select the appropriate mental health specialist to assess, diagnose, and treat your client.

What kinds of mental health specialists can evaluate my client?

Psychologists (Ph.D., Psy.D.) , physicians (M.D., including psychiatrists), licensed clinical social workers (L.C.S.W.), and psychiatric nurses (R.N.) have the training and background to conduct an initial evaluation for depression. Once depression is diagnosed, your client should be evaluated by a physician to rule out the possibility of medical problems causing the depression (see next section).

These mental health specialists can be found at community mental health agencies, the psychiatry department of hospitals or clinics, employee assistance programs, health maintenance organizations, university or medical school-affiliated programs, state hospital outpatient clinics, family service or social service agencies, or private clinics.

TREATMENT PATH STAGE III: ASSESSING AND DIAGNOSING DEPRESSION

Primary Casework Task: To assist the mental health specialist by furnishing relevant information concerning your client's mental health.

The first step to getting appropriate diagnosis and treatment for depression is a thorough diagnostic evaluation by a mental health specialist. The clinician will gather a complete history of symptoms, including when they started, how long they have lasted, how severe they are, whether the patient had them before and, if so, whether the symptoms were treated, and what treatment was given. The clinician should ask about alcohol and drug use, and if the patient has thoughts about death or suicide. Further, a history will include questions about whether other family members have had a depressive illness and, if treated, what treatments they may have received and which were effective. Last, the clinician will conduct a mental status examination to determine if speech or thought patterns or memory have been affected, as sometimes happens in the case of a depressive or manic-depressive illness.

Once depression is diagnosed, the individual should be examined by a Physician. Certain medications as well as some medical conditions such as a viral infection can cause the same symptoms as depression, and the physician should rule out these possibilities through examination, interview, and lab tests.

Are there different kinds of depression?

The two most common forms of depression for adults and children are Major Depressive Disorder and Dysthymic Disorder. Major Depressive Disorder, which is more acute and potentially disabling than Dysthymic Disorder, usually causes significant impairment in mood, work or school, sleep, and appetite. It may involve suicidal thoughts or plans. Dysthymic Disorder is a less acute form of depression that typically involves depressive symptoms of lesser severity and does not involve suicidal ideation. People with Dysthymic Disorder may also experience a Major Depressive Disorder at different times of their lives.

TREATMENT PATH STAGE IV: TREATING DEPRESSION

Primary Task: To secure the most effective treatment available for your client's depression and to work collaboratively with the treating clinician to identify treatment goals and objectives.

What kinds of treatment are available?

The two most common kinds of treatment for depression are psychotherapy and medication. The choice of treatment depends on the type and severity of symptoms, the preferences of the patient, and the history of treatment responses during prior episodes of depression. Some people with milder forms of depression may do well with psychotherapy alone. People with moderate to severe depression most often benefit from antidepressants. Most people do best with combined treatment: medication to gain relatively quick symptom relief and psychotherapy to learn more effective ways to deal with life's problems and to minimize recurrence of depressive symptoms.

What are the most effective kinds of psychotherapy?

Several types of psychotherapy are effective for treating depression. These include:

· Cognitive-behavioral Psychotherapy. Cognitive-behavioral therapy focuses on how negative thoughts, assumptions, and behaviors contribute to the development and maintenance of depression. In this form of psychotherapy, depressed patients develop new ways of thinking, and increasing the frequency of positive behaviors. Cognitive-behavioral therapy is short-term, usually requiring 16 sessions.

· Interpersonal Psychotherapy. This type of therapy focuses on how current interpersonal problems or deficits contribute to the development and maintenance of depression. Treatment, which typically lasts 16 sessions, focuses on developing ways of coping with or managing these interpersonal difficulties.

· Psychodynamic Psychotherapy. This type of therapy focuses on the ways in which unresolved internal conflicts contribute to the development and maintenance of depression. Treatment focuses on talking with the therapist to resolve these internal conflicts, which often have their origins in childhood. There is less evidence supporting the efficacy of psychodynamic therapy for depression than for cognitive-behavioral or interpersonal therapy.

What kinds of medications are used?

Several different kinds of antidepressant medications are utilized to treat depression. These include selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants, and monoamine oxidase inhibitors (MAOIs). Sometimes the physician will try a variety of antidepressants before finding the most effective medication or combination of medications. Sometimes the dosage must be increased to be effective. Although some improvements may be seen in the first few weeks, antidepressant medications must be taken regularly for three to four weeks (in some cases, as many as eight weeks) before the full therapeutic effect occurs.

Patients often are tempted to stop medication too soon. They may feel better and think they no longer need the medication. Or they may think the medication isn't helping at all. It is important to keep taking medication until it has a chance to work, though side effects may appear before antidepressant activity does. Once the individual is feeling better, it is important to continue the medication for four to nine months to prevent a recurrence of the depression. Some medications must be stopped gradually to give the body time to adjust, and many can produce withdrawal symptoms if discontinued abruptly. For individuals with bipolar disorder and those with chronic or recurrent major depression, medication may have to be maintained indefinitely.

Antidepressant drugs are not habit-forming. However, as is the case with any type of medication prescribed for more than a few days, antidepressants have to be carefully monitored to see if the correct dosage is being given. The doctor will check the dosage and its effectiveness regularly. For the small number of people for whom MAO inhibitors are the best treatment, it is necessary to avoid certain foods that contain high levels of tyramine, such as many cheeses, wines, and pickles, as well as medications such as decongestants. The interaction of tyramine with MAOIs can bring on a hypertensive crisis, a sharp increase in blood pressure that can lead to a stroke. The doctor should furnish a complete list of prohibited foods that the patient should carry at all times. Other forms of antidepressants require no food restrictions.

What other treatments are available?

· Electroconvulsive Therapy (ECT) is often used when other kinds of treatment have failed. ECT can be extremely effective for patients with severe depression and when rapid lifting of depression is considered necessary to prevent suicide. ECT is conducted in a medical setting and involves the administration of a short duration anesthetic, followed by medications to relax the muscles. Electrodes are then placed on the patient's scalp and an electric current is passed through them, producing a seizure, which lasts 30 to 45 seconds. Because muscle relaxants are used, there is generally little movement or chance of injury. The most common side effects of ECT are headache and transient memory disturbances; memory problems generally disappear over a few weeks to a few months. The total number of treatments given is usually between eight and twelve, with two to three treatments per week. Often, antidepressant medication or periodic "maintenance ECT" is recommended following the conclusion of treatments.

What kinds of treatment are available for children and adolescents?

Research on the treatment of depression in children and adolescents has lagged behind research in adults. However, given the frequency of child and adolescent suicide, early diagnosis and treatment of depression is imperative. Similar to treatment of depression in adults, treatment in children and adolescents often includes short-term psychotherapy, medication, or a combination of the two, as well as interventions targeting the home and/or school environment.

What might interfere with my client receiving treatment?

Although over 19 million Americans suffer from a depressive illness, two thirds of these never receive any treatment. Numerous barriers to receiving treatment exist. Unfortunately, considerable stigma persists with regard to mental illnesses. Symptoms of depression may be attributed to personal weakness, and the person suffering may be chastised to pull himself or herself "up by the bootstraps." Shame and the fear of being labeled with a mental illness prevent many people from seeking help. Often, people do not accurately report symptoms to their health care providers, leading to misdiagnosis and incorrect treatment.

People may be reluctant to seek help because they are concerned about the cost of treatment. Many are uninsured, or their insurance plans may not cover, or pay a limited amount toward the treatment of psychiatric disorders. Others do not know where to look for help.

During the course of a depressive episode, symptoms may be disabling enough to prevent a person from reaching out for help. Social withdrawal is common in depression, and may lead to a lack of contact with those who might recognize the symptoms and help the person receive appropriate treatment. Often, energy levels and motivation are so low that the person is unable to take the necessary steps to receive help. The hopelessness and helplessness that accompany depression may lead people to believe that they are "beyond hope," or that "nothing will work, anyway."

Even when people do seek treatment, barriers exist to their achieving remission of symptoms. In the case of psychopharmacologic treatment, side effects of some medications may dissuade a person from continuing therapy. Compliance with medication regimens may also pose a problem. In addition, once symptoms begin to be relieved, people sometimes stop taking the medication, leading to relapse. At times, appropriate follow-up such as maintenance medication or psychotherapy is not provided or utilized, leading to recurrence.

Where can my client obtain information about depression?

There are numerous sources for information concerning the diagnosis and treatment of depression. Some of these sources are outlined in the Resources for Clients section at the end of this Clinical Information Guide.

TREATMENT GOALS

How do I collaborate with the mental health specialist and my client to design treatment goals?

Developing treatment goals is a critical step in the treatment process. Clear, objective treatment goals enable the client, family, and service provider to address the client's mental health needs.

There are two broad kinds of treatment goals: Administrative and clinical. Administrative goals involve the completion or non-completion of services. Examples of administrative goals include the number of psychotherapy sessions or medication monitoring sessions that a client attends. Clinical treatment goals address two domains related to a client's overall functioning: symptom or behavior change, and changes in daily functioning ability

You will need to collaborate with your client and the mental health specialist to create treatment goals that address your client's symptoms and the areas of functioning that are critical to your client fulfilling his or her service plan. You will need to work with the mental health specialist to determine the manner and frequency with which treatment goals will be measured.

TREATMENT PATH STAGE V: MONITORING AND REVIEWING

Primary Task: To ensure that you receive timely and appropriate documentation from the mental health specialist that reviews progress towards treatment objectives.

How do I know if treatment is working?

Eighty percent of clients respond to treatment for depression. Usually within several months after starting treatment, your client will report feeling better and will probably seem more cheerful and optimistic. The client's performance at school or work may improve. Friends, family, teachers, and employers may report improvements in the client's demeanor.

Treatment Outcomes

What role do I play in monitoring my client's treatment goals?

Usually the mental health specialist will gauge the success of intervention services by observing changes in your client's behavior and functioning or by administering rating scales for depression.

Because of your extensive knowledge of the client's behavior, the specialist may ask you about the client's functional change in different areas. For example, the specialist may ask you about your client's ability to get along with peers or other family members.

If your client is not improving, you will want to talk with the mental health specialist or physician concerning factors in the client's life that could be complicating recovery. Perhaps after treatment began, additional life stress or change occurred in the client's life, such as the death of a loved one or a change of job. Sometimes a client in psychotherapy may not find the treatment helpful, and other forms of treatment may need to be added, such as medication.

Clients who have improved significantly may be able to discontinue treatment if the mental health specialist indicates. On the other hand, clients who have had many episodes of depression throughout their lives may need to continue medication well beyond the time when their symptoms diminish, or indefinitely.

Documentation

RESOURCES FOR CLIENTS

Where can my client obtain information about depression?

There are numerous resources for information concerning the diagnosis and treatment of depression. Specialty clinics that treat depression are included in Appendix B of this Clinical Information Guide. Your clients can obtain information about depression by contacting the following agencies:

National Institute of Mental Health

Office of Communications and Public Liaison

Information Resources and Inquiries Branch

6001 Executive Boulevard, Rm. 8184, MSC 9663

Bethesda, MD 20892-9663

(301) 443-4513

nimhinfo@nih.gov.

American Academy of Child and Adolescent Psychiatry

3615 Wisconsin Avenue, N.W.

Washington, DC 20016

(202) 966-7300

www.aacap.org

American Psychiatric Association

1400 K Street, N.W.

Washington, DC 20005

(202) 682-6000

www.psych.org

American Psychological Association

750 First Street, N.E.

Washington, DC 20002

(202) 336-5500

www.apa.org

National Foundation for Depressive Illness, Inc.

P.O. Box 2257

New York, NY 10116

(212) 268-4260; (800) 239-1265

www.depression.org

National Alliance for the Mentally Ill

Colonial Place Three

2107 Wilson Blvd., Suite 300

Arlington, VA 22201-3042

(800) 950-NAMI (6264)

www.nami.org

National Depressive and Manic-Depressive Association

730 N. Franklin Street, Suite 501

Chicago, IL 60610-3526

(800) 826-3632

www.ndmda.org

National Mental Health Association

1021 Prince Street

Alexandria, VA 22314

(800) 969-NMHA (-6642)

www.nmha.org

Treatment Path Stage Clinical Information Casework & Administrative

I. Identification of problem

Behavior of Depressed Individual:

· Depressed mood (or irritable mood in children or adolescents)

· Diminished interest or pleasure in almost all activities

· Significant weight loss or

weight gain, or change in

appetite

· Disrupted sleep patterns

· Loss of energy

· Feelings of worthlessness or

guilt

· Difficulty concentrating or

indecisiveness

· Thoughts of suicide or death

· Somatic complaints (especially

in young children)

· Social isolation

Casework Tasks:

a) Obtain input from caregivers, teachers, and others who have on-going contact with client.

b) Observe client

c) Review clinical records

d) Consult with supervisor & behavioral health team

Administrative Task:

· Document in case record

II. Referral

Licensed mental health specialists that evaluate for depression are:

a) Physicians (M.D., including psychiatrists)

b) psychologists (Ph.D., Psy.D.)

c) Licensed clinical social workers (LCSW)

d) Psychiatric Nurses (RN)

Administrative Tasks:

a) Complete referral to licensed mental health specialist.

b) Include relevant clinical and case records with your referral.

c) Document in case record.

III A. Assessment

Assessment by mental health specialist must include:

a) Interview of client, parent, and teacher

b) Review of case and clinical records

Assessment may also include:

a) Observation of client in different settings

b) Clinical assessment using rating scales or other psychological tests

Administrative Task:

    · Ensure mental health specialist

    has all relevant casework and clinical records.

III B. Diagnosis

Diagnosis must meet DSM-IV criteria. Criteria include either depressed mood or loss of interest or pleasure, and four or more of the following symptoms:

· Significant weight loss or

weight gain, or change in

appetite

· Disrupted sleep patterns

· Loss of energy

· Feelings of worthlessness or

guilt

· Difficulty concentrating or

indecisiveness

· Thoughts of suicide or death

Additional diagnostic criteria:

· Symptoms are not due to substance abuse or other medical condition

· Symptoms cause clinically

    significant distress or

impairment of functioning

If diagnosed, physical exam is required to rule-out other medical disorders that exhibit same symptoms as depression, such as thyroid problems.

Administrative Task:

    · Ensure mental health specialist

    has all relevant casework and

clinical records.

IV. Treatment

· Medication and psychotherapy

are both effective treatments.

Combining the two is often the

most effective.

· Severe depression usually

requires medication.

· Hospitalization may be needed

if the individual is suicidal.

The two most effective kinds of psychotherapy are:

a) Cognitive-behavioral

b) Interpersonal

The two most widely used classes of medication are:

a) Selective Serotonin reuptake inhibitors (SSRIs)

b) Tricyclics

· When medication and psychotherapy aren't effective, Electroconvulsive Therapy (ECT) may be used.

· Phototherapy can be useful for individuals with seasonal depression.

Casework Task:

Work collaboratively with mental health specialist to establish clear, measurable treatment goals that assess your client's attendance and their change in:

    a) depressive symptoms

    b) functioning in areas relevant to the case plan. These areas might include home, school, work, and relations with family and friends.

V. Monitoring & Review of

Treatment

· Approximately 80% of

individuals with depression

respond to treatment with

medication or psychotherapy.

· The frequency and method of

monitoring treatment goals

depends on the kind of

treatment:

a) Medication -- Physician monitors by reports from client and significant others and by conducting laboratory tests.

b) Psychotherapy -- Mental health specialist collects data from client by interview and rating scales and from reports by significant others (including caseworker).

Casework Tasks:

a) Work with mental health specialist and client to evaluate progress toward treatment goals.

b) If necessary, work with specialist to revise treatment goals or to consider other kinds of treatment.

Administrative Tasks:

a) Obtain copies of written treatment summaries from mental health specialist.

b) Document client's progress in case record.

1 Portions of this Clinical Information Guide are adapted from Depression, a patient information guide published by the National Institute of Mental Health, and Major Depressive Disorder: A Patient and Family Guide, which is published by the American Psychiatric Association.

2 The treatment pathway for depression is summarized in Appendix A.

What are the five stages of the Treatment Pathways Model? | TREATMENT PATH STAGE I: IDENTIFYING DEPRESSION | TREATMENT PATH STAGE II: REFERRALING | TREATMENT PATH STAGE III: ASSESSING AND DIAGNOSING DEPRESSION | TREATMENT PATH STAGE IV: TREATING DEPRESSION | TREATMENT PATH STAGE V: MONITORING AND REVIEWING | RESOURCES FOR CLIENTS