1. 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

2. Overview
Background
Protocol Development
Protocol
Results
Conclusion

3. 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

4. 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, : A review. Am J Psychiatry 2001; 158:

5. 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)

6. 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:

7. 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

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

14. 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?

15. 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

16. 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

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

18. 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

19. 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?

20. 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