Guideline:
Depression
Bibliographic Source(s)
- American Medical Directors Association (AMDA). Depression. Columbia (MD): American Medical Directors Association (AMDA); 2003. 36 p. [45 references]
Guideline Status
This is the current release of the guideline.
This guideline updates a previous version: American Medical Directors Association (AMDA). Depression. Columbia (MD): American Medical Directors Association (AMDA); 1996. 20 p.
Guideline Category
Diagnosis
Evaluation
Management
Risk Assessment
Screening
Treatment
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Dietitians
Health Care Providers
Nurses
Occupational Therapists
Pharmacists
Physical Therapists
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Social Workers
Speech-Language Pathologists
Guideline Objective(s)
- To improve the quality of care delivered to patients with depression in long-term care settings
- To guide care decisions and to define roles and responsibilities of appropriate care staff
Target Population
Elderly residents of long-term care facilities with depression
Interventions and Practices Considered
Diagnosis/Assessment
- Patient history
- Depression screening tests (Geriatric Depression Scale [GDS] Cornell Scale for Depression in Dementia [CSDD] Center for Epidemiologic Studies of Depression Scale [CES-D] Patient Health Questionnaire 9 [PHQ 9])
- Evaluation of patient for signs or symptoms of depression
- Evaluation of patient for risk factors for depression
- Monitoring of patient periodically for development of signs and symptoms of depression
- Medical work-up as indicated for factors that may be contributing to signs and symptoms of possible depression
- Chemistry profile (electrolytes blood urea nitrogen creatinine glucose)
- Complete blood count
- Serum levels of anticonvulsant or tricyclics antidepressant if taking either type of medication
- Thyroid function (T3 T4 thyroid stimulating hormone [TSH])
- Other possible tests (electrocardiogram folate level serum calcium level serum level of digoxin or theophylline if taking either medication urinalysis vitamin B 12 level)
- Evaluation of patient for medications that might cause or contribute to depression
- Adjusting or stopping problematic medications or indicating clearly why this is not feasible
- Evaluation of patient for conditions that may increase the likelihood of depression or that may cause depressive symptoms; if present managing conditions
- Evaluation of patient's response to treatment of comorbid condition(s)
- Clarifying the diagnosis using Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition (DSM-IV) definitions and diagnostic tools (same as screening tools previously listed above)
Management/Treatment
- Consultative support with psychiatric specialist as indicated
- Evaluation of potential for complications that may pose a risk to the patient or to others; if present addressing complications
- Individualized treatment for the patient's depression
- Psychotherapy (cognitive-behavioral therapy interpersonal therapy problem-solving therapy supportive therapy)
- Medications (short-acting selective serotonin reuptake inhibitors [SSRIs] [paroxetine sertraline citalopram]; tricyclic antidepressants; bupropion; venlafaxine; methylphenidate; trazodone nefazodone; mirtazapine)
- Electroconvulsive therapy (ECT)
- Psychosocial interventions (bereavement groups family counseling participation in social events psychoeducation)
- Combinations of above therapies
- Monitoring of patient's response to treatment
Major Outcomes Considered
- Treatment response recovery remission relapse and recurrence
- Risk of relapse or recurrence of depression
- Safety of medications used to treat depression
Methods Used to Collect/Select Evidence
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
Not stated
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Rating Scheme for the Strength of the Evidence
Not applicable
Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence
Not stated
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
Original guidelines are developed by interdisciplinary workgroups using a process that combines evidence- and consensus-based approaches. The workgroups were comprised of practitioners and others involved in patient care in long-term care facilities. Beginning with a general guideline developed by an agency association or organization such as the Agency for Healthcare Research and Quality (AHRQ) pertinent articles and information and a draft outline the group worked to make a concise usable guideline tailored to the long-term care setting. Because scientific research in the long-term care population is limited many recommendations were based on the expert opinion of practitioners in the field.
Rating Scheme for the Strength of the Recommendations
Not applicable
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation
All American Medical Directors Association (AMDA) clinical practice guidelines undergo external review. The draft guideline is sent to approximately 175+ reviewers. These reviewers include AMDA physician members and independent physicians specialists and organizations that are knowledgeable of the guideline topic and the long-term care setting.
Major Recommendations
The algorithm Depression is to be used in conjunction with the clinical practice guideline. The numbers next to the different components of the algorithm correspond with the steps in the text. Refer to the "Guideline Availability" field for information on obtaining the full text guideline.
Clinical Algorithm(s)
An algorithm is provided for Depression.
Type of Evidence supporting the Recommendations
The guideline was developed by an interdisciplinary work group using a process that combined evidence-and consensus-based thinking.
Potential Benefits
This guideline recommends processes that if followed will help to ensure that depression among long-term care patients is adequately recognized assessed treated and monitored.
Potential Harms
Adverse effects of antidepressant agents:
- Short-acting selective serotonin reuptake inhibitors (SSRIs) (paroxetine sertraline citalopram): insomnia agitation somnolence decreased appetite initial weight loss. Specific agents have potential for interaction with components of cytochrome system.
- Tricyclic antidepressants: dry mouth blurred vision constipation urinary retention inhibition of sweating cognitive dysfunction
- Bupropion: seizures (in at-risk patients) little activity on serotonin or norepinephrine axes
- Venlafaxine: same as short-acting SSRIs; risk of blood pressure elevation at higher doses (>150–225 mg/day)
- Methylphenidate: anxiety cardiac arrhythmia insomnia anorexia weight loss elevated blood pressure
- Trazodone nefazodone (direct serotonin agents): sedation postural hypotension (at high doses) priapism (rare)
- Mirtazapine: increased appetite weight gain sedation somnolence interaction with certain cytochrome pathways
Qualifying Statements
- This clinical practice guideline is provided for discussion and educational purposes only and should not be used or in any way relied upon without consultation with and supervision of a qualified physician based on the case history and medical condition of a particular patient. The American Medical Directors Association (AMDA) and the American Health Care Association their heirs executors administrators successors and assigns hereby disclaim any and all liability for damages of whatever kind resulting from the use negligent or otherwise of this clinical practice guideline.
- The utilization of the American Medical Director Association's Clinical Practice Guideline does not preclude compliance with State and Federal regulation as well as facility policies and procedures. They are not substitutes for the experience and judgment of clinicians and care-givers. The Clinical Practice Guidelines are not to be considered as standards of care but are developed to enhance the clinician’s ability to practice.
Description of Implementation Strategy
The implementation of this clinical practice guideline (CPG) is outlined in four phases. Each phase presents a series of steps which should be carried out in the process of implementing the practices presented in this guideline. Each phase is summarized below.
- Recognition
- Define the area of improvement and determine if there is a CPG available for the defined area. Then evaluate the pertinence and feasibility of implementing the CPG.
- Assessment
- Define the functions necessary for implementation and then educate and train staff. Assess and document performance and outcome indicators and then develop a system to measure outcomes.
- Implementation
- Identify and document how each step of the CPG will be carried out and develop an implementation timetable.
- Identify individual responsible for each step of the CPG.
- Identify support systems that impact the direct care.
- Educate and train appropriate individuals in specific CPG implementation and then implement the CPG.
- Monitoring
- Evaluate performance based on relevant indicators and identify areas for improvement.
- Evaluate the predefined performance measures and obtain and provide feedback.
Implementation Tools
Clinical Algorithm
Personal Digital Assistant (PDA) Downloads
Tool Kits
For information about availability see the "Availability of Companion Documents" and "Patient Resources" fields below.
IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness
Bibliographic Source(s)
- American Medical Directors Association (AMDA). Depression. Columbia (MD): American Medical Directors Association (AMDA); 2003. 36 p. [45 references]
Adaptation
Not applicable: The guideline was not adapted from another source.
Source(s) of Funding
American Medical Directors Association
Guideline Committee
Steering Committee
Composition of Group that Authored the Guideline
Not stated
Financial Disclosures/Conflicts of Interest
Not stated
Guideline Status
This is the current release of the guideline.
This guideline updates a previous version: American Medical Directors Association (AMDA). Depression. Columbia (MD): American Medical Directors Association (AMDA); 1996. 20 p.
Guideline Availability
Electronic copies: None available
Print copies: Available from the American Medical Directors Association 10480 Little Patuxent Pkwy Suite 760 Columbia MD 21044. Telephone: (800) 876-2632 or (410) 740-9743; Fax (410) 740-4572. Web site: www.amda.com.
Availability of Companion Documents
The following are available:
- Guideline implementation: clinical practice guidelines. Columbia MD: American Medical Directors Association 1998 28 p.
- We care: implementing clinical practice guidelines tool kit. Columbia MD: American Medical Directors Association 2003.
Electronic copies: None available
Print copies: Available from the American Medical Directors Association 10480 Little Patuxent Pkwy Suite 760 Columbia MD 21044. Telephone: (800) 876-2632 or (410) 740-9743; Fax (410) 740-4572. Web site: www.amda.com.
The following is also available:
- PDA application: depression. Available in Palm/PDA and PocketPC formats from the American Medical Directors Association (AMDA) Web site.
Patient Resources
None available
NGC STATUS
This NGC summary was completed by ECRI on July 6 2004. The information was verified by the guideline developer on August 4 2004. This summary was updated by ECRI on August 15 2005 following the U.S. Food and Drug Administration advisory on antidepressant medications. This summary was updated by ECRI on May 31 2006 following the U.S. Food and Drug Administration advisory on Paxil (paroxetine hydrochloride). This summary was updated by ECRI on November 22 2006 following the FDA advisory on Effexor (venlafaxine HCl). This summary was updated by ECRI Institute on November 6 2007 following the U.S. Food and Drug Administration advisory on Antidepressant drugs.
COPYRIGHT STATEMENT
This NGC summary is based on the original guideline which is subject to the guideline developer's copyright restrictions. For more information please contact the American Medical Directors Association (AMDA) at (800) 876-2632.
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