Transcript Management of Depression in the Primary Care Setting

Management of Depression
in the Primary Care Setting
Alan L. Podawiltz, D.O., M.S.
Chair, Psychiatry and Behavioral Health
www.jpsbehavioralhealth.org
Learning Objectives
After your participation in this session you should be able to:
• DESCRIBE the epidemiology of depressive disorders.
• DESCRIBE symptoms of depressive disorders.
• DIFFERENTIATE/DIAGNOSE the characteristics of depressive
disorders
• DESCRIBE drugs and medical illnesses that may induce depression
• DESCRIBE physiologic abnormalities caused by psychotropic
medications:
• DESCRIBE common adverse effects of psychotropic agents
• DESCRIBE strategies to assist the compliance of patients with
recommended treatment.
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Impact of illness on activities of daily living,
Early development
Access to diagnosis and treatment
Cultural influence on illness
Biopsychosocial
Affect
Environment
Cognition
Behavior
Biopsychosocial
Affect
Environment
Behavior
Cognition
Major Depressive Disorder
• Lifetime prevalence in women: 21.3%1
• Lifetime prevalence in men: 12.7%1
• Most prevalent in women between onset
of menstruation and menopause2
1.
2.
Kessler RC et al. Prevalence of and risk factors for lifetime suicide attempts in the National Comorbidity Survey. Arch Gen Psychiatry.
1999;56(7):617-626.
Cohen LS et al. H. Diagnosis and management of mood disorders during the menopausal transition. Am J Med. 2005;118 Suppl 12B:93-97.
Risk of Depression by Age &
Sex
0.014
Hazard rate
0.012
Female
Male
0.010
0.008
0.006
0.004
0.002
0.000
0-4
5-9
10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54
Age (y)
Kessler R, et al. J Affect Disord. 1993; 29:85-96.
Comorbidity and Depression
• 72.1% of those with lifetime MDD and 64% of
those with 12-month MDD have at least one
additional mood disorder
• Primarily anxiety disorder, substance abuse
disorder, or impulse control disorder
Kessler RC et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA.
2003;289(23):3095-3105.
Major Depressive Disorder
(MDD)
• One or more major depressive episodes
• Absence of any history of manic, mixed, or hypomanic
episodes
• Relapsing and remitting
• Episodes may last months or, more rarely, years
• Half of all episodes fully remit within 6 to 12 months
with or without treatment
• Up to 20% of those who experience an initial episode
may develop chronic depression
• After an initial episode, the patient is predisposed to
additional episodes which become more severe and
last longer
Moore DP, Jefferson JW. Mood Disorders. In: Moore & Jefferson: Handbook of Medical Psychiatry, 2nd ed. Philadelphia: Mosby; 2004
Depression
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Very common
Associated with significant dysfunction
Under diagnosed
Often chronic or recurrent
Commonly present with other GMC
Highly treatable
Multiple safe and effective treatments are available
Major Depressive Disorder
Relapsing and remitting course
• May eventually become chronic
Minimum duration ≥ two weeks
Clear distinction between episodes and interepisodic function
• Often well or at least much better between episodes
Two Questions
Over the last two weeks:
1. Have you felt down, depressed, or
hopeless? (Mood)
2. Have you felt little interest or pleasure in
doing things? (Interest)
Two-Steps for Depression
Screening
Step One:
Two-Question Depression
Screen
• Over the past 2 weeks have
you felt down, depressed,
or hopeless?
• Over the past 2 weeks have
you felt little interest or
pleasure in doing things?
A “yes” to either question
is a positive initial screen
for depression…
Step Two: If Screen is
Positive…
• Probe deeper, be proactive,
engage in conversation about
mood and changes in
behavior
• 24% - 40% of patients with
positive screen receive MDD
diagnosis
• Others may have dysthmia,
subsyndromal depressive
disorders, anxiety, PTSD,
substance abuse, panic
disorder, or grief disorder
US Preventive Services Task Force. Screening for depression: recommendations and rationale. Ann Intern Med. 2002;136(10):760-764
Visual Screening Tool
Ask the patient to point to the
face that best represents how she/he
has felt in the past 2 weeks.
Depression in Women Series, PACE, 2007
Recommended Instruments
• QIDS:
Quick Inventory of
Depressive
Symptomatology
(http://www.ids-qids.org)
• PHQ-9:
Patient Health
Questionnaire-9
(www.phqscreeners.com)
Both instruments
are…
• Validated
• Quickly and easily
administered and scored
• Available to download
• Available in English
and Spanish
• Helpful for initial
screening AND evaluation
of treatment response
SIGECAPS
S
I
G
E
C
A
P
S
- Changes in sleep pattern
- Changes in interests or activity
- Feelings of guilt or increased worry
- Changes in energy
- Changes in concentration
- Changes in appetite
- Psychomotor disturbances
- Suicidal ideation
Major Depressive Disorder
Core symptoms: SIGECAPS
• Depressed mood (sad, down, blue) AND/OR
• Reduced interest or pleasure (I)
Somatic symptoms:
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Change in appetite (A)
Change in sleep pattern (S)
Reduced energy level (E)
Psychomotor agitation/retardation (P)
Cognitive symptoms:
• Poor concentration/easy distraction (C)
• Inappropriate guilt/self reproach (G)
• Thoughts of death, dying, suicide (S)
5 out of 9 for at least two weeks
The Suicide Question
If an adult, child, or adolescent says, “I want to kill myself,
or I'm going to commit suicide”
Always take this statement seriously
and immediately seek assistance
from a qualified mental health professional
People often feel uncomfortable talking about death.
However, asking the adult, child, or adolescent whether he
or she is depressed or thinking about suicide can be
helpful.
Rather than putting thoughts in the person's head, such a
question will provide assurance that somebody cares and
will give the person the chance to talk about problems
U.S. Suicides
11th leading cause of death
8th leading cause of death for males
19th leading cause of death for females
1.3% deaths suicide
• 29% heart diseases
• 23% malignant neoplasms
• 6.8% cerebrovascular disease
Suicide Risk Screening
Measure Suicide Risk Screening Questions
Score
Ideation
Have you had thoughts of taking your own life
1
Plans
Have made any plans to take your life?
1
Means
Do you have access to the tools or situation to take
your life according to your plan?
1
Intent
Do you intend to commit suicide? When?
1
History
Have you ever tried to take your own life?
1
Total
Depression in Women Series, PACE, 2007
Suicide Risk Assessment
Score
Suicide Risk
0
Low Risk
1-2
3-5
Treatment Recommendation
Follow Up as needed
Moderate Risk
Assess suicide risk at each visit.
Refer as needed
High Risk
Implement protective measures
and emergent management
Depression in Women Series, PACE, 2007
Explore the Differentials
Depressive Disorders
• Psychiatric
– Major Psychoses
– Adjustment D/O w/ depression
– Bereavement (up to 2 months)
• General Medical
– Hypothyroidism = classic rule-out
– Post-CVA, Post-MI
– Ca of head of pancreas
• Substance-Related
– Alcohol abuse, cocaine/amphetamine withdrawal
– Rx meds: steroids, b-blockers, a-methyldopa
Comorbid Medical Conditions
Asthma1
Pain2
Arthritis1
Cardiovascular disease1
Stroke3
Diabetes1
Obesity1
1. Chapman DP et al. The vital link between chronic disease and depressive disorders. Prev Chronic Dis. 2005;2(1):A14.
2. Gureje O et al. A cross-national study of the course of persistent pain in primary care. Pain. 2001;92(1-2):195-200.
3. Gillen R et al. Depressive symptoms and history of depression predict rehabilitation efficiency in stroke patients. Arch Phys Med Rehabil.
2001;82(12):1645-1649.
Substances Related to Sexual
Dysfunction
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Antidepressants
Lithium
Sympathomimetics
 and  - adrenergic
antagonists
• Anticholinergics
• Antihistamines
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Anti-anxiety agents
Alcohol
Opioids
Hallucinogens
Cannabis
Barbiturates
Sedative hypnotics
Sexual Dysfunction and
Antidepressants
Selective Serotonin Reuptake Inhibitors
(SSRIs)
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Increases serotonin levels in both sexes
Decreases sex drive
Impairs orgasm
5HT2A Agonist
Tricyclic Antidepressants (TCAs)
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Drying of mucosal membranes
Reduction of lubrication
Stimulation of 5HT2A receptors
Inhibits erection and ejaculation
CVD and Depression
• Patients with cardiovascular disease (CVD)
more likely to experience depression1
• Patients with depression 1.6 times more likely
to develop coronary artery disease (CAD); even
more likely with MDD1
• Also 4 times more likely to experience a
myocardial infarction (MI)1
• Post-MI patients with depression less likely to
follow lifestyle changes2
1. Pratt LA et al. Depression, psychotropic medication, and risk of myocardial infarction. Prospective data from the Baltimore ECA follow-up.
Circulation. 1996;94(12):3123-3129.
2. Ziegelstein RC et al. Patients with depression are less likely to follow recommendations to reduce cardiac risk during recovery from a
myocardial infarction. Arch Intern Med. 2000;160(12):1818-1823.
Depression and Diabetes
• Depression twice as prevalent in those
with diabetes
• More prevalent in women with diabetes
than in men with diabetes
Anderson RJ et al. The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care. 2001;24(6):1069-1078.
Depression and Obesity
• 65% of the US population is overweight or
obese
• More obese women than men (54% vs.
46%)1
• BMI ≥30 in women associated with nearly
50% increase in lifetime prevalence of
depressive disorders2
1. Ogden CL et al. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA. 2006;295(13):1549-1555.
2. Chapman DP et al. The vital link between chronic disease and depressive disorders. Prev Chronic Dis. 2005;2(1):A14.
Practice Recommendation
Screen patients with any chronic health
condition for depression, especially
patients with diabetes, cardiovascular
disease, or chronic pain.
US Preventive Services Task Force. Screening for depression: recommendations and rationale. Ann Intern Med. 2002;136(10):760-764
AAFP Approved source: Institute for Clinical Systems Improvement
Website: http://www.icsi.org/depression_5/depression__major__in_adults_in_primary_care_3.html
Strength of Evidence: Grade A (randomized, controlled trials)
Study of Women’s Health Across
the Nation (SWAN)
Depression risk highest in:
• Early or late perimenopause
• Using hormone therapy (OR=1.30 – 1.71)
• Late vs. early perimenopause
Bromberger JT et al. Depressive symptoms during the menopausal transition: The Study of Women's Health Across the Nation (SWAN). J Affect
Disord. 2007
Harvard Study of Moods and
Cycles
• Nearly twofold increased risk of depression in
women entering perimenopause (OR=1.8)
• Hot flushes associated with greater risk of MDD
(OR=2.2)
Cohen LS et al. Diagnosis and management of mood disorders during the menopausal transition. Am J Med. 2005;118 Suppl 12B:93-97.
Major Neurotransmitters
Serotonin
Norepinephrine
Energy
Interest
Anxiety
Irritability
Impulsivity
Mood, Emotion,
Cognitive
Sex
function
Appetite
Motivation
Aggression
Drive
Dopamine
Role of Serotonin in the CNS
Serotonin influences a wide variety of brain
functions
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Mood
Sleep
Cognition
Sensory perception
Temperature regulation
Nociception (e.g., migraine headache)
Appetite
Sexual behavior
Kaplan HI, Sadock BJ. In: Synopsis of Psychiatry: Behavioral Sciences,Clinical Psychiatry, 8th ed. 1998.
Hardman JG, et al. In: Goodman & Gilman’s The Pharmacological Basis of Therapeutics, 9th ed. 1996.
Nemeroff C. Scientific American. June 1998;42-49.
Role of Dopamine in the CNS
Dopamine modulates various brain functions
• Mood
• Cognition
• Motor function
• Drive
• Aggression
• Motivation
Kaplan HI, Sadock BJ. In: Synopsis of Psychiatry: Behavioral Sciences,Clinical Psychiatry, 8th ed. 1998.
Hardman JG, et al. In: Goodman & Gilman’s The Pharmacological Basis of Therapeutics, 9th ed. 1996.
Role of Norepinephrine in the
CNS
Norepinephrine plays an important role in the brain
affecting
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Mood
Learning and memory
Regulation of sleep-wake cycle
Regulation of hypothalamic-pituitary axis
Regulation of sympathetic nervous system
Kaplan HI, Sadock BJ. In: Synopsis of Psychiatry: Behavioral Sciences,Clinical Psychiatry, 8th ed. 1998.
Nemeroff C. Scientific American. June 1998;42-49.
Frazer A. J Clin Psychiatry. 2000;61(suppl 10)25-30.
Undertreatment Evidence
Lewis, et al.
Lin, et al.
Simon, et al.
• 1/3 discontinued
medication
• 50% received no follow-up visit
• More than 1/3 had not refilled
antidepressant
• Fewer than half had adequate
treatment for their depression
1. Lewis E, et al. Patients' early discontinuation of antidepressant prescriptions. Psychiatr Serv. 2004;55(5):494.
2. Lin EH et al. Low-intensity treatment of depression in primary care: is it problematic? Gen Hosp Psychiatry. 2000;22(2):78-83.
3. Simon GE et al. Treatment process and outcomes for managed care patients receiving new antidepressant prescriptions from psychiatrists
and primary care physicians. Arch Gen Psychiatry. 2001;58(4):395-401.
Patient Adherence
Patients are often reluctant to engage in therapy.1
More than half of patients treated for depression in
primary care practices stopped drug treatment
within 3 weeks. 2
Why??
Weren’t told how long it would take to feel better
Weren’t warned about side effects
Weren’t told I needed to continue once I felt better2
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2.
Hirschfeld RM et al. The National Depressive and Manic-Depressive Association consensus statement on the undertreatment of depression.
JAMA. 1997;277(4):333-340.
Stimmel GL. How to counsel patients about depression and its treatment. Pharmacotherapy. 1995;15(6 Pt 2):100S-104S.
Antidepressant Warnings
All patients being treated with antidepressants for
any indication should be monitored closely for:
• Clinical worsening
• Suicidality
• Unusual changes in behavior
Monitor these patients especially during the initial
few months of a course of drug therapy, or at times
of dose changes, either increases or decreases.
Antidepressant Use in Children, Adolescents, and Adults http://www.fda.gov/cder/drug/antidepressants/default.htm
Practice Recommendation
• Base a choice of antidepressant on the patient’s
prior response, patient and clinician preference,
potential side effects, and cost.
• Choose any class of antidepressant as a firstline treatment for MDD.
• Ask patients from different ethnic
groups about their treatment preference for
MDD.
AAFP Approved source: National Guideline Clearinghouse. http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=9632&nbr=5152
Maintenance
• Patients with one lifetime episode of MDD who
achieve remission on antidepressants should
continue to take them for another 6 to 12
months.
• Patients with two or more episodes should be
maintained an additional 15 months to 3 years.
• Patients with chronic MDD or MDD with
concurrent dysthymia should be continued on
antidepressants an additional 15 to 28 months
after the acute phase treatment.
Kaiser Permanente Care Management Institute. Depression clinical guidelines.
http://www.guideline.gov/summary/summary.aspx?doc_id=9632&nbr=5152&ss=6&xl=999
Practice Recommendation
Follow up with patients on antidepressants for
MDD:
• At least once within the first month
• At least once more 4 to 8 weeks after the first contact
Assess for adherence, side effects, suicidal
ideation, and response.
AAFP Approved Source: National Guideline Clearinghouse. http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=9632&nbr=5152
Strength of evidence: Consensus-based. A practice is recommended based on the consensus or expert opinion of the Guideline Development
Team.
Practice Recommendation
Advise patients that:
• Most people need to be on antidepressant medication for
at least 6 months.
• It may take 2 to 6 weeks to see any improvement.
• It is very important to take the medication as prescribed,
even after they start feeling better.
• They should not stop taking the medication without
calling the provider first.
• Changing the dose or dose schedule can help manage
side effects.
AAFP Approved Source: Institute for Clinical Systems Improvement.
http://www.icsi.org/depression_5/depression_major_in_adults_in_primary_care_3.html
Steps for Choosing an Effective
Antidepressant
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Recognize that some antidepressants may be more
effective in certain populations even though most are
generally of equal effectiveness.
Ask about personal or family history of treatment with
antidepressants, particularly about side effects.
Consider the burden of side effects, particularly weight
gain and sexual side effects in midlife women.
Consider drug-drug interactions with other medications
the patient is taking or may take.
Consider the potential lethality of the antidepressant in
the case of an overdose.
Use antidepressant side effects for efficacy.
Moore DP, Jefferson JW. Mood Disorders. In: Moore & Jefferson: Handbook of Medical Psychiatry, 2nd ed. Philadelphia: Mosby; 2004.
Treatment Recommendation
Base a choice of antidepressant on the
patient’s prior response, patient and
clinician preference, potential side effects,
and cost.
AAFP Approved Source: National Guideline Clearinghouse. http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=9632&nbr=5152
Strength of evidence: Consensus-based. A practice is recommended based on the consensus or expert opinion of the Guideline Development
Team.
Follow-Up Considerations In The
First Three Months
Week
Treatment Actions
2
Check patient compliance to medication usage. Assess for
adherence, side effects, suicidal ideation, and patient response.
Adjust, as appropriate, medication and dosage.
4
Re-check patient compliance to medication usage. Assess for
adherence, side effects, suicidal ideation, and patient response.
6
Adjust, as appropriate, medication and dosage.
7 - 12
Monthly communication with patient; Patients Appointments every
3rd or 4th week; Further Medication or Medication Dosage
Adjustments; Goal: Remission
Other Options Include . . .
• Combine antidepressants and psychotherapy
• Increase dose of initial antidepressant
• Combine treatment with SSRI and low-dose
desipramine (monitoring for TCA toxicity)
• Switch to different antidepressant of same or
different class
• Augment with low-dose (300–600 mg/day)
lithium in consultation with psychiatrist
• Switch from psychotherapy to antidepressants,
or antidepressants to psychotherapy
Kaiser Permanente Care Management Institute. Depression clinical practice guidelines.
http://www.guideline.gov/summary/summary.aspx?doc_id=9632&nbr=5152&ss=6&xl=999. Accessed May 2, 2007.
Treatment Goal
The goal of treatment with antidepressant
medication in the acute phase is the
remission of major depressive disorder
symptoms
APA Practice Guidelines for the Treatment of Psychiatric Disorders.
Follow Up after Initial Treatment
Follow up with patients on antidepressants for
MDD:
• Individualize visit frequency for each patient
• Patient’s starting or switching to a new RX should be
seen every two weeks until stable
• Patient’s at increased risk for suicidality or self-injury
seen more frequently
• Contact all patients in early phase of treatment to
assess for suicidality or self-injury
• Assess response with validated tool
Texas Medication Algorithm Project (TMAP) Treatment of Major Depressive Disorder Clinician’s Manualhttp://www.dshs.state.tx.us/mhprograms/tmapover.shtm
Maintenance
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50% of MDD patients will experience recurrence after
initial episode without long-term treatment
3< episodes – maintain AD therapy as preventative
Duration varies depending on risk factors from 1 year
to lifetime
Consider maintenance after 2 episodes for patients
with high risk factors, PTSD, co-morbid anxiety,
chronic depression or serious personality disorder
Increased stressors may warrant longer maintenance
Weilburg JB, O'Leary KM, Meigs JB, Hennen J, Stafford RS. Evaluation of the adequacy of outpatient antidepressant treatment. Psychiatr Serv.
2003;54(9):1233-1239.
Texas Medication Algorithm Project (TMAP) Treatment of Major Depressive Disorder Clinician’s Manualhttp://www.dshs.state.tx.us/mhprograms/tmapover.shtm
Continuation
• Continuation bridges remission to
recovery
• Patients who remit should continue RX at
least 6-9 months after remission at same
dosage at which response was achieved
• Visits every 3 months
Texas Medication Algorithm Project (TMAP) Treatment of Major Depressive Disorder Clinician’s Manualhttp://www.dshs.state.tx.us/mhprograms/tmapover.shtml
Increasing the Likelihood of
Remission
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Measurement-based care
Optimize dose/extend trial
Selection of antidepressant
Role of adherence
Pharmacologic adjuncts
Role of psychotherapy
Rush AJ, et al. J Clin Psychiatry. 1997;58(suppl 13):14-22.
Thase ME, et al. Am J Psychiatry. 1999;60(suppl 22):3-6.
Trivedi M et al. Am J Psychiatry. 2006;163(1):28-40.
Adherence to Treatment
Having depression generally increases the risk of
nonadherence three to four-fold
Hispanic patients may be less likely to comply with
antidepressant treatment than whites
To improve adherence:
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Understand the patient’s model of the illness
Identify social and financial barriers to adherence
Address patient concerns about the medication
Discuss patient understanding about treatment and ability to
follow through (i.e. health literacy)
Lewis-Fernandez R et al; JABEFP; 2005:18;282-296; Wagner GJ et al. Psychiatr Serv. 1998;49(2):239-40; Harman JS et al. Psychiatr Serv.
2004;55(12):1379-85; Sleath B et al. Compr Psychiatry. 2003;44(3):198-204.
If Initial Treatment Ineffective
Medication trial should last 8-12 weeks
If no side effects or tolerability issues, increase dosage
every 2-3 weeks until
• Remission achieved
• Max dose achieved
• Side effects limit titration
Combine antidepressants and psychotherapy
Combine antidepressants or consider augmentation trial
Considering tailoring your treatment for specific subpopulations (e.g., elderly, midlife women etc).
Texas Medication Algorithm Project (TMAP) Treatment of Major Depressive Disorder Clinician’s Manualhttp://www.dshs.state.tx.us/mhprograms/tmapover.shtm
Kaiser Permanente Care Management Institute. Depression clinical practice guidelines.
http://www.guideline.gov/summary/summary.aspx?doc_id=9632&nbr=5152&ss=6&xl=999.
Factors that Predispose to
Incomplete Remission
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Chronicity
Medical co morbidity
Older age
Axis I or II co morbidity
Severity
Inadequate treatment
Thase ME, et al. Am J Psychiatry. 1997;58(suppl 13):23-29.
Nierenberg AA, et al. J Clin Psychiatry. 1999;60(suppl 22):7-11.
Thase ME. J Clin Psychiatry. 1999;60(suppl 22):3-6.
Consequences of Failing to
Achieve Remission
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Increased risk of relapse
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Continued psychosocial limitations
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Continued impairments at work
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Worsened prognosis of Axis III disorders
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Increased utilization of medical services
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Sustained elevation of suicide and
substance abuse risks
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Increased risk of treatment resistance
Nierenberg AA, et al. J Clin Psychiatry. 1999;60(suppl 22):7-11.
Thase ME. J Clin Psychiatry. 1999;60(suppl 22):3-6.
In-Office Therapeutic Approaches
to Management of Depression
Supportive Treatment - Identify and reinforce
positive behaviors and coping mechanisms that
patient has used in the past or is using now
• “Even though you’ve felt lousy, you have gone to work
everyday and done what you need to do. That shows
a lot of resilience”.
• “Let’s think about ways you’ve handled situations like
that in the past and see how you can apply those
skills you already have”.
Aiding the Patient in Problem
Solving
Problem Solving – Most depressed individuals feel overwhelmed by their
emotions and their problems. Help patient identify current psychosocial
stressors and help patient formulate coping strategy. Don’t focus on
significant interpersonal problems or large life issues.
Steps in Problem Solving
1.
2.
3.
Identify stressors - “What things going on in your life bother you most right now?”
Focus on specific behavior – “You told me you feel bad because you can’t get
anything done around the house and it is a mess. If you could do one thing around
the house to help you feel like you are handling things better, what would you do?”
Break behavior down to manageable components – “That huge pile of laundry
seems really overwhelming. It would take more energy than you have to do 10
loads of laundry. How about starting by sorting some of it, maybe one basket of
laundry. Then tomorrow you may feel like throwing one load in the laundry.”
Problem Solving
Steps in Problem Solving Cont’d
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Guarantee success don’t define failure – “It may be difficult to get that
load of laundry started. Even talking about it like we are doing and
having a plan to get started is a great step. When I see you next week
we’ll see how things are going.”
Reinforce successive approximations – “Being able to sort that
laundry shows you’ve come a long way since I first saw you.”
Assess barriers to change – “When you walked into the laundry room
and saw the basket of sorted laundry, what do you think kept you from
putting it in the washer?”
Reframe barriers – “The thought of folding all that laundry seemed like
too much. Remember when even the thought of sorting it was
overwhelming but then you were able to do that. Maybe folding it
while you are watching Desperate Housewives would make it easier.”
Reinforce success and apply process to another problem – “Doing the
laundry shows that you are really starting to get better. Is there
another thing around the house that’s bothering you
Helping Patients with Mild
Depression
SPEAK
• Schedule – taking control by planning and organizing
to counteract avolitional state
• Pleasurable Activities – engaging in one
pleasurable activity a day to counteract anhedonia
• Exercise – increasing activity even slightly increases
sense of control and has positive physical benefits
• Assertiveness – engaging in small acts that set limits
and express own feelings reflects positively on sense
of self
• Kind Thoughts About Oneself – positive self talk
can negate effects of negative/irrational self
perceptions
John Christensen, Ph.D., Oregon Health Sciences University
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