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04.01.2014

Major depressive disorder screening tests, naturally pure tinnitus herbal treatment - Review

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Depression is a common problem in the veteran patient population; nearly one third of patients have elevated scores on depression screening measures. The barriers to using depression screening information in primary care settings may explain these mixed results. To evaluate the impact of our new follow-up strategy for positive findings on depression screening, we compared the medical records of the 160 patients with positive findings in a 3-month period before the intervention (October to December 1999) with records of the 97 patients with positive findings in the first 3 months after the intervention began (May to July 2000).
A nurse screens patients for depression when they come to the clinic for their usual appointments. The depression screening instrument originally consisted of two questions on sadness and anhedonia.
During the intervention, if patients screened positive for depression, the nurse gave them a blue-shaded PHQ to complete while waiting for their primary care provider (Figure 1).
The mental health nurse scored the PHQs and reviewed providers' electronic progress notes to determine whether the provider had addressed depression and whether they had taken reasonable actions. We examined the record of each preintervention and postintervention patient to confirm that the patient had a positive finding on depression screening and had not received active treatment for depression in the preceding 12 months. Providers documented discussion of depression symptoms and took some type of action (including deciding that no further action was indicated) for 36 (92%) of the patients for whom we received PHQ forms.
In the preintervention group, primary care providers documented addressing depression symptoms in 48% of cases and suicidal ideation in 14% of cases (Table 2).
Although the mental health nurse received PHQ forms for only 40% of postintervention patients, the intervention significantly affected the frequency with which providers documented depression (72% of the postintervention group vs.
Our results suggest that a limited change in the follow-up strategy for patients with positive findings on depression screening can improve provider recognition and initial management of depression in a Veterans Affairs primary care setting. Despite a relatively low rate of implementation, this limited practical intervention was associated with significantly improved documentation of depression and suicidal ideation and initiation of treatment.
We developed and evaluated a limited intervention to improve provider response to depression screening information in a Veterans Affairs primary care clinic.
The intervention consisted of administering a follow-up questionnaire to patients who had positive findings on depression screening; patients then handed these questionnaires to providers, which were subsequently reviewed by a mental health nurse. A simple intervention can improve provider performance in identifying and managing depression. Patient information: See related handout on postpartum depression, written by the authors of this article.
Risk of postpartum depressive symptoms with elevated corticotropin- releasing hormone in human pregnancy. Validation of the Edinburgh Postnatal Depression Scale (EPDS) in a sample of women with high-risk pregnancies in France. Identifying depression in the first postpartum year: guidelines for office-based screening and referral.
Fragmented maternal sleep is more strongly correlated with depressive symptoms than infant temperament at three months postpartum. A randomized controlled trial of culturally relevant, brief interpersonal psychotherapy for perinatal depression. Prevention and treatment of post-partum depression: a controlled randomized study on women at risk. A controlled study of fluoxetine and cognitive-behavioural counselling in the treatment of postnatal depression. A depression preventive intervention for rural low-income African-American pregnant women at risk for postpartum depression. To determine whether limited follow-up of positive findings on depression screening improves provider recognition and initial management of depression.


Consecutive patients with positive findings on depression screening in a Veterans Affairs primary care clinic in Oregon during the 3 months before (n = 160) and the 3 months after (n = 97) the intervention began. Patients with positive findings on depression screening completed a self-administered questionnaire (Patient Health Questionnaire), which they turned in to their provider. Documentation of depression or suicidal ideation and actions taken for depression (prescription of antidepressant medication, mental health referral, watchful waiting) at the clinic visit. A limited intervention can improve provider recognition and initial management of depression in a Veterans Affairs primary care setting. First, the screening information is not immediately accessible, and as a result providers must often actively search the patient's record for this information. Before patient appointments, clinic nurses administer a brief screening test for these conditions and record the results in electronic progress notes. If a provider documented discussion of depression symptoms and acted accordingly, the nurse took no further action. We then determined whether the primary care provider documented the following information: the positive depression screening results or responses to specific questions about depression, exploration for suicidal ideation, and a plan of action.
The preintervention group included more patients because the Portland Veterans Affairs Medical Center initiated system-wide annual depression screening in mid-1999 along with implementation of an electronic medical record system. Some providers began to use the PHQ form to track depression severity in patients who had not been screened or who were already being treated for depression.
Table 2 shows that the subgroup of patients who received the intervention had higher rates of documentation of depression (92% vs.
First, our before-after study design raises concerns that the recognition and treatment of depression improved because of secular trends rather than the intervention. 34 Psychotherapy can also be used as adjunct therapy with medication in moderate to severe postpartum major depression. A thorough risk-benefit discussion with each patient is essential before deciding on treatment for postpartum major depression.
While systematic screening has the potential to improve recognition, providers may overlook screening results because of barriers to accessing the information and the need to address multiple health care issues.
A mental health nurse subsequently reviewed the records of patients who completed questionnaires and contacted providers when depression was not mentioned in the visit note. Next, providers are under substantial pressure to address multiple and competing health care issues, and they may place a lower priority on depression screening information than on other clinical activities. When depression screening is due, patients are first asked if they have been treated for depression in the past year. From a review of 9030 patients who were screened for depression in all clinics of the medical center between 1999 and 2000, we determined that the rate of positive response (8%) to the two types of screening did not significantly differ. This nine-item questionnaire was derived from the criteria for major depression from Diagnostic and Statistical Manual of Mental Disorders, fourth edition. In one case, the provider had addressed depression during the visit but had not documented it. Specifically, the increased attention to depression in the Veterans Affairs clinic may have changed behaviors independently of the intervention. Interventions to improve provider diagnosis and treatment of mental disorders in primary care. The role of competing demands in the treatment provided primary care patients with major depression. Some women with postpartum major depression may experience suicidal ideation or obsessive thoughts of harming their infants, but they are reluctant to volunteer this information unless asked directly.
We initiated a study to determine whether documentation, initial recognition, and management of depression could be improved by following positive findings on depression screening with the self-administered Primary Care Evaluation of Mental Disorders Patient Health Questionnaire-Depressive Disorders (PHQ) (11) and medical record review by a mental health nurse.


Providers can refer patients to an on-site multidisciplinary mental health team for assistance in treating patients with depression. Patients who report that they have been receiving treatment are excluded from further depression screening. Among patients whose PHQs were received by the mental health nurse, 77% had scores of 10 or greater (12) and 56% met Spitzer and colleagues' criteria for diagnosis of major depression.
In addition, simply teaching providers and nursing staff about the intervention may have raised their awareness of depression. Epidemiologic catchment area prospective 1-year prevalence rates of disorders and services. We believe that use of this form drew the provider's attention to depressive symptoms and facilitated an active discussion of these symptoms between patient and provider. Although the intervention increased rates of provider initiation of treatment and referral to mental health services, previous studies of screening and feedback interventions have shown inconsistent and often limited effects on patient outcomes. In patients with moderate to severe postpartum major depression, psychotherapy may be used as an adjunct to medication.
In the third case, the provider had not documented addressing depression, but the PHQ score was only 6 and no suicidal ideation was noted. Since patients and providers are often reluctant to discuss depression, (10) the process of completing and reviewing PHQ questionnaires may have made it easier for this discussion to occur. The Edinbugh Postnatal Depression Scale may be photocopied by individual researchers or clinicians for their own use without seeking permission from the publishers. Instead, we observed that patients for whom the PHQ was received were much more likely to have depression documented or treated than were patients for whom the PHQ was not received. If left untreated, postpartum major depression can lead to poor mother-infant bonding, delays in infant growth and development, and an increased risk of anxiety or depressive symptoms in the infant later in life. The strongest risk factor is a history of postpartum major depression with a previous pregnancy. Decreased energy and disrupted sleep related to infant care may be difficult to differentiate from symptoms of depression. Maternal depression or problems within the mother-infant dyad can also be associated with these symptoms.45,46 Formula feeding should be considered in women with severe postpartum major depression that requires medication implicated in adverse effects for the infant.
Up to 60 percent of women with postpartum major depression have obsessive thoughts focusing on aggression toward the infant.29 These thoughts are intrusive and similar to those in obsessive-compulsive disorder. Tapering over two weeks, especially for paroxetine, extended-release venlafaxine (Effexor XR), and extended-release desvenlafaxine (Pristiq), can prevent the influenza-like symptoms of discontinuation syndrome.Estrogen therapy has been studied as a treatment for postpartum major depression. Physicians should ask about these symptoms as part of the diagnosis of postpartum major depression. Mothers who score above 13 are likely to be suffering from a depressive illness of varying severity. However, women with mild to moderate postpartum major depression may have passive suicidal ideation, defined as a desire to die but no plan. The scale will not detect mothers with anxiety neuroses, phobias or personality disorders.Women with postpartum depression need not feel alone. However, as depression worsens, she may view herself as a bad mother and believe that her child would be better off without her.




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