Depression Essay

Depression can be a debilitating disease that affects a person’s mind, body and spirit. For some, depressive symptoms are fleeting, but for others, they can become a severe clinical disorder. The symptoms of depression are often overlooked but can complicate any medical diagnosis. Depressive symptoms treated early help to ensure a more positive outcome. The purpose of my paper is to analyze depression and its effect on a patient’s well-being.

Investigated Disease Process

Depression is extremely common, and I have personally dealt with mild depressive symptoms throughout my adult life. Twenty to thirty percent of all men and women will have an episode of major depression in their lifetime (Li et al., 2018). According to the National Institute of Mental Health [NIMH], 2018), depression is the most common mental disorder in the United States. Women are twice as likely to suffer from depression as men (Oyama & Piotrowski, 2019). Most often, a depressive disorder is first recognized in people in their twenties, but a major depressive episode can occur at any time in one’s life (Oyama & Piotrowski, 2019). Often, people with depression also suffer from anxiety. Depression can also lead to substance abuse when a person attempts to self-medicate.

The impact of depression on the world is extremely significant, and loss in productive years due to depression is three times higher than diabetes, eight times more than heart disease, and forty times higher than cancer (Clarke, Skoufalos, Medalia, & Fendrick, 2016). According to Mental Health America (MHA, 2019), 18.57% or 45 million adults in America are suffering

from a mental health issue. Of these Americans, 4.38% are dealing with severe mental health illnesses. The percentage of adults with mental illness per state in America ranges from New Jersey with 16.9%, to Idaho with 5.03% (MHA, 2019). The percentage of Americans exhibiting suicidal ideation in 2017 was 4.19%, which has increased from 3.77% in 2012 (MHA, 2019).

Depression affects how we think, feel, and handle daily activities (NIMH, 2018). According to NIMH (2018), depression is a mood disorder characterized by symptoms that are present every day for at least two weeks. Symptoms include depressed mood, loss of interest in activities, guilt feelings and thoughts of death or suicide. Depression can also cause fatigue, decreased concentration and changes in appetite and sleep. Durbin (2014) states to receive a depression diagnosis, a person must exhibit at least five depressive symptoms, and at least one symptom must be either depressed mood or anhedonia.  People are diagnosed with depression when their emotional states are uncontrollable and chronic (Huether & McCance, 2019).

Pathophysiology

“U.S. Current research suggests that depression is caused by a combination of genetic, biological, environmental, and psychological factors” (NIMH, 2018). According to Levy et al. (2018), the pathophysiology and underlying neurobiological factors that cause depression are still widely misunderstood. Depression remains one of the great mysteries involving the human mind (Li et al., 2018). Modern neuroimaging techniques and brain connectivity analysis are helping to make it possible to determine the brain systems linked to depression and how the different systems interact with one another (Li et al., 2018).

Cellular Changes

On a cellular level, studies have linked depression to changes like neuron loss and synaptic dysfunction in parts of the brain that control mood and emotion (Levy et al., 2018). But determining what causes this cellular change remains a mystery and is the source of ongoing studies. Most commonly, reference studies show that increasing the synaptic concentration of brain monoamine neurotransmission (serotonin, norepinephrine, and dopamine) can decrease depression (Fekadu, Shibeshi, & Engidawork, 2017). Recent literature suggests that depression is caused by widespread human system network dysconnectivity instead of issues with individual portions of the brain (Li et al., 2018). Understanding how the affected network's work can help us determine the best treatment (Li et al., 2018).

The body responds to these hormonal deficits by exhibiting symptoms of unrelenting sadness, fatigue, and overall lack of interest in daily activities. A person with depression also exhibits inefficient tolerance to adverse life events and ineffective concentration. Untreated depression is linked to the development of other medical conditions such as obesity, cardiovascular disease, thyroid problems and diabetes (Huether & McCance, 2018).

Disease Process

According to Huether and McCance (2018), modern studies conclude that the monoamine hypothesis of depression describes the underlying cause of depression. The hypothesis states that decreased hormone levels of norepinephrine, dopamine, and serotonin in the brain are the underlying cause of depression (Huether & McCance, 2019). The monoamine hypothesis states that increasing monoamine neurotransmitter levels within the synapse ultimately decreases depressive symptoms (Huether & McCance, 2019).  When deficits of these hormones occur the effects on the human mind can be devastating.

Huether and McCance (2018) state that decreased norepinephrine levels have been linked to attention and concentration issues, sleep disorder, and “arousal disturbances in depression” (p. 607). Serotonin regulates homeostasis, and decreased levels can people to feel emotional and the inability to tolerate negative experiences (Huether & McCance, 2018). Decreased dopamine is thought to affect the control and reward pleasure center of the brain. Decreased dopamine is thought to cause a dulling of mood and emotional affect.

Standard of Practice 

Before a diagnosis is made and treatment is prescribed, a thorough psychiatric assessment must be performed. A diagnostic evaluation should include a verbal interview, physical examination, and possible laboratory testing (American Psychiatric Association [APA], 2019). The psychiatric assessment should include a discussion about family history, drug and alcohol use, stressors, lifestyle, coping mechanisms, and depression symptoms. The evaluator should

also review medication the patient may currently be taking and rule out medical causes that could be contributing to symptoms. It is very important to determine an accurate diagnosis to ensure proper treatment. There is no one size fits all treatment as individuals respond differently to medication and psychotherapy.

The gold standard treatment for depression is typically antidepressant medication or psychotherapy, used either individually or concurrently (NIMH, 2018). According to the APA (2019), mild depression can often be treated with psychotherapy alone, but for a major depressive episode medication in conjunction with psychotherapy is the standard. Electroconvulsive therapy (ECT) can be used for patients with severe depression that hasn’t responded to other treatments. Light therapy and transcranial magnetic stimulation (TMS), can also be used in patients in conjunction with other therapies.

Pharmacological Treatments

Since there are many different theories as to what the cause of depression is, there are also different ways to treat symptoms and different outcomes. Often, trial and error guide the medication regime for an individual. Antidepressant medication therapy aims to increase monoamine neurotransmitter levels within the synapse. Increasing monoamine levels is done by “blocking their reuptake into the presynaptic neuron by binding to the respective neurotransmitter transporter or through inhibition of the monoamine degrading enzyme MAO reversibly or irreversibly” (Fekadu, Shibeshi, & Engidawork, 2017). Certain antidepressants also alter the transmission of neurotransmitter pre or postsynaptic receptors (Fekadu, Shibeshi, & Engidawork, 2017).

The major classes of drugs used for this action are monoamine oxidase inhibitors (MAOI), tricyclic antidepressants (TCA), selective serotonin reuptake inhibitors (SSRI) and serotonin-norepinephrine reuptake inhibitor (SNRI) (Huether & McCance, 2018). Treatment using these types of medications is currently the accepted standard of practice. At this time, SSRIs and SNRIs are the most commonly used first-line treatment of the medications listed above.

SSRI

SSRIs are first-line treatment for depression and work by increasing serotonin levels in the brain. SSRIs such as Fluoxetine and Sertraline are commonly used and people who take them typically exhibit minimal side effects. Some people taking SSRI medication may have feelings of agitation and sexual dysfunction (Huether & McCance, 2018). Other common side effects include nausea, vomiting, dry mouth, insomnia, dizziness and headache (Huether & McCance, 2018).

SSRI medication should be taken in the morning to lessen the chance of insomnia. SSRI medication should not be taken with other antidepressants due to the risk of serotonin syndrome. Overdose of serotonin (serotonin syndrome) can cause autonomic hyperactivity, abdominal pain, elevated temperature, coma, and ultimately death (Huether & McCance, 2019). SSRI’s should never be stopped abruptly as the patient may feel symptoms of withdrawal.

SNRI

SNRI medications are also considered another fist line medication treatment for individuals with depression. SNRIs increase the amount of serotonin and norepinephrine in the brain by inhibiting the amount of reuptake in the synapses. The SNRIs most commonly used are Venlafaxine, Desvenlafaxine, and Duloxetine. Side effects of SNRIs are essentially the same SSRI side effects.

TCA

TCA medications are used to decrease depression in individuals. TCAs act by blocking the reuptake of serotonin and norepinephrine in the brain, thereby improving mood. TCAs are not used as a first-line treatment due to the potential for serious side effects. TCA medications are not indicated for people with a history of cardiovascular issues or cardiac conduction defects. (Huether & McCance, 2018).

TCAs may cause sedation or insomnia, orthostatic hypotension, seizures, and weight gain. Some TCAs also have moderate anticholinergic side effects, so it is especially important to consider this in older adults (Huether & McCance, 2018).

MAOI

MAOI’s such as Marplan, Parnate and Nardil are often used for the treatment of depression. Because of the potential for serious side effects, this medication is not a first line treatment for depression. The most common side effects of MAOIs are sedation, agitation, insomnia, dry mouth, impotence, and weight gain (Huether & McCance, 2018). MAOIs may cause rapid and serious elevations in blood pressure after eating foods high in tyramine, such as sour cream, liver, raisins and avocados (Huether & McCance, 2018). MAOIs also interact with TCAs, SSRIs, stimulants, and some OTC medications, so mixing of these medications should be avoided (Huether & McCance, 2018).

Atypical Antidepressants

Atypical antidepressants are another type of medication used to treat depression. Atypical antidepressants such as Nefazodone, Trazodone, and Mirtazapine, are thought to work by blocking specific receptors like 5-HT2A in the brain (Huether & McCance, 2018). These medications are not first-line treatment. Side effects include sedation, dry mouth, weight gain, and constipation (Huether & McCance, 2018). Hepatic toxicity has been noted with the use of Nefazodone and Trazodone (Huether & McCance, 2018).

Patient Education

Patients should know that when taking antidepressants, it can take to two to four weeks before they feel any changes in their mood or reduction in symptoms. It is important to take the medication regularly for some time for several weeks before concluding that it isn’t working. It is important not to discontinue the medication abruptly and to instead gradually decrease the dose, so withdrawal symptoms do not occur. Even after the depression has decreased, it is important to continue the medication for at least six to twelve months to limit the reoccurrence of symptoms.

Impact of Medication

In the clinic where I work, patients with depression are typically started on an SSRI such as Lexapro or an SNRI such as Venlafaxine. According to the physicians in the clinic, treating patients with medication early in their depressive episode can lessen the amount of time a patient suffers. Starting medication early aligns with the current standard of care recommended by the APA. Treating patients early in their illness is important to avoid chronic issues with the disease (Prasko et al., 2019). Patients who are compliant when treated with multidisciplinary approach of medications and outpatient therapy seem to appreciate the best outcome and avoid hospitalizations.

Clinical Guideline Assessment

Guidelines for the evidence-based diagnosis and care for depression has been developed around the world (Heddaeus, Steinmann, Daubmann, Härter & Watzke, 2018). Recommendations include screening high-risk groups, distinguishing depression severity, providing monitoring and assessing self-harm risk (Heddaeus et al., 2018). It is extremely important to take a full verbal history and perform a physical assessment to rule out any medical cause for depression before determining the treatment course. Patients should be assessed for clinical symptoms such as depressed mood, loss of interest in activities, guilt feelings, fatigue, decreased concentration, and disturbance in daily activities and suicidal thoughts.

Diagnosis

The main goal to treat a patient effectively is to ensure proper diagnosis (Clark et al., 2016). To be diagnosed with depression, a person must exhibit at least five depressive symptoms almost all day, every day, for two weeks. To meet the criteria for clinical diagnosis, a patient must exhibit depressed mood or anhedonia. Once all assessment findings are reviewed, a proper diagnosis is made.

Patient Education

Patients should be made aware that it is important to treat depression early. The gold standard for treatment of a major depressive episode is treatment with SSRI or SNRI medication and psychotherapy. It is important to know that it can take several weeks before depressive symptoms decrease after starting medication. Patients should be aware to avoid mixing antidepressants due to the high chance of interaction.

Patients should also be cautioned to avoid over the counter supplements such as St Johns wort and Sam-e, as they may interfere with prescription medication. It is important to note that some patients may experience an increase in suicidal thoughts with medication treatment, especially in the first few weeks (NIMH, 2019). Patients must know to notify their health care provider if these feelings should occur.

Standard Practice of Disease Management

According to the Centers for Disease Control and Prevention (CDC, n.d.), suicide was the 10th leading cause of death in America in 2017. The total number of deaths by suicide was 47,173 (CDC, n.d.) the same year. In 2017, 918 residents of Wisconsin died by suicide, which is an increase of 40% from 2000-2017 (Wisconsin Department of Health Services [WDHS], 2019- a). Wisconsin’s action plan to decrease the suicide rate is to increase and enhance protective factors and access to care, implement best practices and improve surveillance of prevention programs (WDHS, 2019-a),

This geographical area examined for this paper is in Walworth County, a rural community in southeastern Wisconsin. The Walworth county department of health and human services (WHHS, n.d.) offers services such as case management and emergency mental health assessment. The WHHS also offers therapy, medication management, and psychiatric evaluation (WHHS, n.d.). However, the system is so overwhelmed with patients in need that many services are not readily available. The fact that the county cannot keep up with the demands for treatment differs greatly from the goal of the Wisconsin action plan.

The standard of practice for a major depressive episode is medication therapy with SSRI or SNRI and psychotherapy. First, a patient must have a thorough physical assessment and verbal interview. The patient’s diagnosis is made based on the number of symptoms, severity, and length of time symptoms have been present. This standard is for a major depressive episode and not for mild depression that can be treated with psychotherapy alone (Heddaeus et al., 2018).

Family Practice clinicians usually start treatment with first-line antidepressants and plan that the psychiatrist will take over medication management when they assume care of the patient. In the private clinic where I am employed, standard primary treatment seems to be with medication alone. Primary treatment in the clinic is with medication alone because it is very difficult to obtain a new patient appointment for outpatient treatment at WHHS. The assumption is that it is better to treat with medications early, so symptoms do not progress and worsen before they can be seen by a mental health professional. Caregivers also offer recommendations for lifestyle changes including stress management, proper nutrition, good sleep health and avoidance of drugs and alcohol. Most times, patients must wait at least a month to be seen for the first time.

Managed Disease Process

A well-managed disease process includes lifestyle changes such as a healthy sleep cycle, proper nutrition, avoiding drugs and alcohol, stress management and compliance with prescribed medication regime and psychotherapy. Ideally loved ones are included in outpatient care planning and symptom care. It is important for patients and family members to monitor for side effects and report any changes in mood or worsening of symptoms such as suicidal ideation to the clinician. An individual with a managed disease process will be compliant with their medication regime and maintain a regular psychotherapy schedule.

Patients in the clinic where I work are made aware of the county crisis line phone number as another option for enhancement of treatment. This option is available for anyone with or without insurance and without a wait. It is not a substitution for therapy but can help someone through a crisis. The human services department of Walworth County offers group therapy and support to individuals in crisis situations (WHSS, n.d.). They also offer grief counseling, homeless shelters and food pantries for help with life stressors (WHSS, n.d.). A well-managed person will take advantage of resources, seek out help when they are in a crisis and verbalize their feelings and concerns.

Patients with a well-managed disease process will have a better overall health outcome than unmanaged. People with managed disease tend to live longer than unmanaged (Clarke et al., 2016). Clark et al. (2016), concludes that life expectancy is decreased with unmanaged disease due to comorbidities and the lack of integration of care between primary care and behavioral health providers. Studies have shown that depression has a causal effect on many chronic medical conditions including diabetes, heart disease and arthritis (Jia, Zack, Gottesman, & Thompson, 2018).

According to a recent American study, individuals with depression lived 16.4 years less than people without depression (Jia et al., 2018). People with depression also averaged a 28.9- year loss of quality adjusted life expectancy (Jia et al., 2018) than people free from symptoms of depression. People with depression, starting at aged 18 years old, had a more than 50% decrease in adjusted quality of life expectancy than those without (Jia et al., 2018).

National and International Disparities

According to the World Health Organization (WHO, 2019), in 2015 the number of people suffering from depression around the globe was estimated to exceed 300 million. Diagnosis and treatment methods vary from country to country. It is important to be aware of the differences and similarity in country practices. Prevalence rates of depression should reflect genetic, hormonal and lifestyle factors, but rates could be readily affected by the differences in health care systems and criteria used for diagnosis (Link et al., 2011).

A factorial experiment was performed from 2001-2006 to compare diagnosis rates of depression by physicians in Germany, Great Britain, and America. The results determined that diagnosis rates were different in all three countries. When patient (actors) presented to the physician with the exact same symptoms, the diagnosis was often different. American physicians were twice as likely to prescribe an antidepressant than in the other countries (Link et al., 2011). The physicians diagnosed differently even with the same symptoms based on gender (Link et al.,

2011).

American physicians follow APA guidelines for diagnosis. German physicians follow the German Guidelines for the Treatment of Unipolar Depression in Adults tool. Physicians in Great Britain follow the government based-National Health Services guidelines. American physicians seemed to ask more questions than the other physicians, while Germans asked the fewest (Link et al., 2011).

British physicians were least likely to prescribe medication or refer a patient to psychotherapy, and the type of referrals to different providers varied in all cases (Link et al., 2011). Germans were more likely to prescribe an herbal supplement and least likely to prescribe an SSRI or SNRI (Link et al., 2011). Physicians from America and Great Britain were most likely to prescribe an SSRI or SNRI (APA first line treatment) and least likely to prescribe an herbal supplement (Link et al., 2011). German physicians were more likely to see the patient for follow up within a week and British and American physicians after two weeks (Link et al., 2011). German physicians only spend an average of five minutes with each patient, and Americans spend eighteen minutes (Link et al., 2011).

Managed Disease Factors

There are many factors that can influence a patient’s ability to manage their depression. Ease in access to care, positive socioeconomic status and knowledge of health literacy is especially important in managing the disease process.  A well-managed disease process has a beneficial long term effect in any patient with depression.

Access to Care

According to (Clarke et al., 2016), 60% of Americans who need mental health care do not receive any. Of those who do receive care, only 20% see a specialist in behavioral health (Clarke et al., 2016). Many physicians state that there is limited access to mental health services. According to Clark et al. (2016), primary care physicians provide almost half of all mental health services in the US. Of the 30 million people prescribed an antidepressant in the primary care setting, only 25% report a reduction in symptoms (Clarke et al., 2016).

The health care system in America seems to be lacking in provider numbers, especially in rural areas. Primary care physicians are not adequately trained to provide mental health services, yet they provide most of the care (Clark et al., 2016). Patients that receive early and consistent treatment with mental health services have a better outcome than those treated solely by a primary care physician. Separate facilities for physician and mental health services can also greatly decrease access for patients in a rural setting.

Socioeconomic Status

Clark et al. (2016) state that a recent study concluded that having a mental health diagnosis was associated with a 3.5 times highest cost for treatment. This is mostly due to a lack of effective integration of primary care and mental health services (Clark et al., 2016). Many people with depression have missed work or lost their jobs. Mental Health disorders are listed as the costliest condition in America (Clark et al., 2016). Also, there is a stigma and discrimination that some feel related to mental health disorders, which can also affect one’s desire to seek costly treatment.

Patients with managed depression either have insurance or are involved in a program that provides affordable care for office visits and medication. Insurance plans that offer coverage for different services are ideal. Patients with managed disease will continue working or have minimal time lost from work.

Health Literacy

Managing one’s healthcare can be a time consuming, confusing task. Patients that understand and manage their disease well understand their diagnosis and seek out help if they don’t. Managed patients are fully aware of the disease process, treatment options, and prognosis. The ability to understand health care terms related to diagnosis, medications, and symptoms enables patients to take control of their care. Care needs to be patient and family-centered, and health literacy is an important aspect of being able to care for one’s self.

In 2015, the Food and Drug Administration revised its guidelines for advertising, and companies must use a non-technical common language to discuss medication benefits and risks (Clark et al., 2016). The Department of Health and Human Services has granted patients access to their lab results, thereby enabling them to review their results (Clark et al., 2016). Patient's access to their records and being able to understand medical terminology is at the forefront of managing their disease.

Unmanaged Disease Factors

The gold standard for treatment of patients for depression is psychotherapy with or without antidepressant medications. Individuals with poor access to care are unable to obtain any of this care, and unfortunately symptoms become much worse. Many patients with depression exhibit some form of cognitive deficit, which makes it very difficult to work, have adequate understanding of health literacy and seek out care.

Limited access to care is a significant factor in unmanaged disease, and more than half the counties in America do not have even one practicing mental health professional (Clark et al., 2016). A factor that contributes to poor access to care due to socioeconomic status is the type of insurance coverage an individual has. Many mental health providers do not provide care for patients that are covered under Medicaid or Medicare because of low reimbursement rates (Clark et al., 2016). People in low socioeconomic groups may have difficulty obtaining health care insurance and cannot pay out of pocket for care. According to Clark et al. (2016), insurance prejudice exists and can affect the care and treatment a patient receives.

Unmanaged Disease Characteristics

Many patients who are depressed do not stick to their medication regime and do not follow up with psychotherapy. Many patients with depression do not have the energy or cognitive ability to keep up with appointments and treatment. This lack of energy can cause problems at work and in their home life. Some people with depression may not have access to care due to transportation issues, no health care insurance, or lack the knowledge that help is available to those who seek it.

Often patients with depression treat symptoms with drugs and alcohol. This action severely complicates their diagnosis and makes treatment difficult. Many patients with depression lack the energy or ability to care for themselves, and they may have difficulty sleeping and seem tired or sad. Sometimes people with depression do not wish to discuss their issues, so they will say they are fine when they are not. Untreated depression is one of the major factors in suicide deaths. In the US there is one suicide every fourteen minutes. This number equals more deaths in numbers than from homicides or motor vehicle accidents (Clark et al., 016).

Patients, Families, and Populations

The burden of depression is great in any community. In 2018, Wisconsin treated 73,085 patients. Walworth county saw 731 of those patients for mental health treatment. Out of 731 patients, 425 of those people needed medication management, and 245 people received outpatient counseling. As discussed in this paper, there are not enough mental health providers in the community to provide adequate treatment to people in the community.

Patient Burden

Patients deal with the significant financial burden of being treated for their depression. Patients who are underinsured or not insured must seek services that are self-pay and fee for service. Even if patients are insured, they may still be required to pay high deductibles and high out of pocket expenses for medications and laboratory testing. Patients may miss work and subsequently may have significant decrease in pay. Missing work adds stressors to their situation due to the inability to pay bills. The financial burden of depression can be overwhelming, and statistically poor people suffer from depression more than people living above the poverty line (CDC, n.d.).

Many patients with depression suffer from impaired cognitive ability related to the disease, which can make seeking resources exceedingly difficult. Patients with depression typically lack self-care in other areas, and often comorbidities cloud their perception of the need for medical care. Patients may isolate themselves and may not be able to follow through with activities of daily living.

Family Burden

Family members of patients with depression have a unique situation. They often suffer from the effects of depression also. If the depressed family member contributes to the family financially, their loss of income can be devastating. Since people with depression have issues coordinating care due to decreased inability to perform daily duties so the burden may fall onto the family. Family members may also be involved in attending meetings and group activities to support their loved ones. This kind of support could cause a loss of work time and time away from others in the family. If the depressed person is a dependent, the parent may feel the burden of covering insurance expenses and the stress of supporting the person financially.

Community Burden

Mental Health is a significant burden on the community. Sometimes services offered are free to individuals without insurance, so the burden of cost is on the community. The Wisconsin Department of Health Services places a significant amount of its budget on suicide prevention programs, outpatient psychotherapy and medication management programs. Funding for special programs is allocated according to greatest need, and making sure mental health community needs are covered can be especially challenging.

Costs for Patient, Community, and Family

Depression costs not only the person suffering from the disease but also costs the patient, family, and community. In Wisconsin, 480,008,500 was allocated for mental health services in fiscal year 2018 (WHDS, 2019-b). These funds are provided for services to benefit everyone, either directly or indirectly.

Patient Costs

According to Kessler (2012), in 2010, the incremental cost to people with depression was estimated at 210.5 billion dollars. That number is sure to rise. People with depression typically have concurrent medical issues related to their disease, which increases the cost and complicates the picture. A vast number of patients suffering from depression have chronic and recurrent symptoms, which increases cost to the individual as time progresses. If patients have medical insurance, they must pay for medical insurance deductibles, and copay’s for medication. Another consideration is the cost of time spent on coordinating their services. This is time that a patient is not able to be productive at work because it can be very time consuming to weave through the web of obtaining services. Patients often must take time off work for appointments and hospitalizations.

Family Costs

The family of a person with depression can have significant stress, especially when the patient is the primary breadwinner of the family. Often family members are the main support for the depressed person. The family member is left paying for copay’s, deductibles, and covering the costs at home without financial support from the patient. Family members may need to miss work to bring patients to appointments. The families can become very overwhelmed and stressed and develop depression of their own, complicating the burden further.

Community Costs

A significant amount of money in the community is spent on mental health resources. The community suffers if staff in a company is dealing with issues related to depression. Patients or family members of a loved one who is suffering with major depression may need excessive amounts of time off work. This results in loss of productivity and businesses may suffer.

Best Practices

There is a lack of outpatient services for psychotherapy in Walworth County, Wisconsin. Patients with depression are generally diagnosed and managed by their family practice and internal medicine physician. Physicians who do not specialize in mental health are not adequately trained in diagnosis or treatment of this disease. It is extremely important to provide a proper diagnosis before starting any type of treatment. Besides starting medication, there is no follow through with any ancillary services or psychotherapy for patients. Most patients follow up in two weeks or a month but are not given any other support or referrals. They are placed on a waiting list to meet with a mental health provider.

While the first-line medication treatment is typically prescribed for patients with depression, the psychotherapy component is generally unavailable to individuals in the community due to high volume of patients in need. It is important for patient with depression to have psychotherapy and follow up. I would like to see an improvement in the availability of ancillary services to give patients all the resources they need to improve their quality of life.

Plan Implementation

The first strategy that will be implemented is the use of the Patient Health Questionnaire-9 (PHQ-9) during the patient’s office visit for proper diagnosis. The second strategy will be to provide patients who are diagnosed with depression written information regarding websites and telephone hotline resource information. The last strategy is to provide patients diagnosed with depression the antidepressant skills workbook.

PHQ-9

The PHQ-9 is a nine-question depression scale that physicians can implement during their patient assessment. The tool can help with diagnosing and then monitoring a patient’s response to treatment with reassessment. The questions are based on the criteria for depression in the DSM-IV manual.

Written Resources

MHS Health Wisconsin provides a toolkit that offers a plan of care for primary care providers. U.S. Department of Health and Human Services (n.d.) toolkit provides resources online and information for download to provide to patients. Patients would be given the written information with websites and telephone numbers for crisis and online counseling services.

Antidepressant Skills Workbook

The antidepressant skills workbook from PH+S (n.d.) is available free to download and print. The workbook will be provided to each patient diagnosed with depression. This workbook has valuable information regarding self-help and support. The book aims to provide information about depression to patients and their family members.

Plan Evaluation

It is very important to determine if the plan of action is effective. The cost to implement these interventions is minimal and can provide patients with better screening and information about their disease. The interventions will empower patients to manage their disease.

PHQ-9

To determine the effectiveness of the depression tool, it should be repeated at every visit. The patient answered questions that gauge how their treatment and disease process is progressing. The tool can help providers determine if the treatment is working or not, and plans can be made according to results. Physicians can also determine if other treatment options may help the patient by evaluating the results and reviewing the DSM-IV for guidance.

Written resources

To determine if written resources are beneficial, a quick survey will be given to patients diagnosed with depression. The initial survey, given before leaving after their first office visit will test the knowledge of the available resources. Patients will then be given written information on resources and asked to reach out to at least one website or phone number for support. Patients will be given a survey at the follow-up visit to determine if patients are more knowledgeable about the resources available.

Antidepressant Skills Workbook

Patients will be asked to utilize the workbook as an important part of their treatment. Patients will be asked to bring the workbook with them to every follow-up visit and the results will be reviewed. The workbook has important information to empower patients and is useful in treating the whole patient.

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