An Outpatient Teaching Protocol for the Treatment of Unipolar Depression Suzanne Allen, MD, MPH Jeralyn Jones, MD Catherine Serio, PhD March 2, 2006 Austin, Texas

Overview Background Protocol Development Protocol Results Conclusion

Background – Our Program 9-9-9 Residency – focusing on rural and underserved care No community mental health center in Boise or Idaho Entire state a HPSA for mental health Joint survey (FMRI/IAFP) of rural doctors identified Depression as number one priority for mental health training/treatment

Background – Primary Care Psychiatry Training Model Psychiatry taught in adult psychiatric clinics or C&L services Topics chosen by psychiatrists Teaching strategy focused on brief didactics, passive learning, and lack of contextual relevance. Hodges, Inch, Silver: Improving Psychiatric Knowledge, Skills, and Attitudes of Primary Care Physicians, 1950-2000: A review. Am J Psychiatry 2001; 158: 1579-1586

Background – FMRI Model Title VII grant to redesign our primary care psychiatry curriculum Longitudinal design Evidence Based Contextual Relevance Experiential Education (ACGME: Systems-Based Practice; Practice-Based Learning)

Background – The IMPACT Model Evidence-based protocol for outpatient management of depression Routine screening; Rx formulary; close f/u, multidisciplinary team w/psychiatric oversight; “treat to remission.” Largest multi-center trial for late life depression (funded by RWJF) Robust results compared to “usual care” for depression Unutzer, J et al. (2002). Collaborative care management of late life depression in the primary care setting: A randomized control trial; JAMA; 288:2836-2845.

Protocol Development Protocol committee Review of IMPACT protocol Review of PHQ-9 and MDQ Review of clinic resources Review of medications Preliminary protocol Request for funding for medications Protocol finalized

Protocol Diagram of protocol PHQ-9 MDQ Appointment Encounter Sheet Flowsheet

Preliminary Results How well does an algorithm model work for teaching family medicine residents how to diagnose and treat depression? Does using an algorithm model to treat depression improve patient outcomes in a training clinic?

Limitations Delay between introducing and initiating the protocol Electronic Health Record administration Provider access for follow-up Social work staffing Confusion on technical aspects of protocol

Resident Report Survey sent to all residents asking about effect of using the Depression Protocol 6 out of 27 residents responded Unanimously agreed on one item: Increased use of measurement tools (PHQ9) to assess treatment R1s felt helpful in diagnosis and treatment R2s and R3s were split Survey represents small sample

Didactic Presentation Up to 100% improved knowledge 3-28% improved knowledge 1-25% improved knowledge Half-day presentation by Wayne Katon and faculty

PHQ9 Results at 2 weeks R1 R2 R3 4 patients 2 patients 6 patients Don’t have data for further follow-up, up to 90% improvement People are getting in within 2 weeks R3s using more(more clinics or more comfortable) and getting good improvement rates, appropriate management decisions Social Work has not been collecting data past 2 weeks Self-report data

Resident Questions R1—Should I use the PHQ9 in a woman who lost her husband a month ago? R2—Is there evidence to support increasing medication dose at 2 weeks? R3—How do I treat Bipolar Disorder? R1—How do I utilize? R2-How do you know? R3-I know all that, now what?

Conclusions Research shows an algorithm approach to the treatment of depression improves patient outcomes The effect on treatment outcomes is unclear although initial results are promising Setting up a protocol in the residency setting requires resident and staff understanding of the protocol Protocol requires extensive staff resources Protocol shows promise for increasing resident ability in diagnosing and treating depression