• Primary Care
• Initial Assessment
• Pathways to Care
• Clinical Pathways
• Monitoring
• Patient Preference
• Professional Roles
• Audit and Monitoring

Monitoring and follow-up

KEY MESSAGES

1. All patients treated for depression should have a planned schedule of contacts in order to assess response to treatment and ongoing progress. The exact schedule will depend on the severity of depression and other relevant factors.
2. Scheduled contacts should include the use of objective outcome measures as a marker of progress and an aid to clinical decision making.
3. Decisions may involve change of treatment within steps, or moving patients up to new steps if they have failed to progress.

PHASES IN DEPRESSION TREATMENT

At a broad level, depression can be thought of as having three phases:

• Acute phase - the aim of treatment is reducing symptoms and achieving remission (approximately 8-12 weeks if treatment successful)
• Continuation phase - the aim is prevention of the return of symptoms during the current period (approximately 6 months from the end of the acute phase)
• Maintenance - the aim is prevention of new episodes of depression (approximately 6 months from the end of the continuation phase)

The enhanced service model recommends regular, proactive contact with patients throughout these phases. The schedule will depend on the severity of the problem, and the phase. Figures 3-6 shows suggested schedules of contacts for patients at the different steps.

Monitoring response in acute phase treatment

The goal of acute phase treatment is remission of symptoms. The definition of remission will depend on the assessment instruments used. A variety of tools are available (some of which have cost implications). In Appendix 9 there is a copy of a questionnaire called the PHQ-9 which can be used freely (further information can be found at www.depression-primarycare.org/). Appendix 10 includes definitions of initial response to treatment and remission which can be used in further clinical decision making. The Clinical Outcome in Routine Evaluation (CORE) outcome measure is often used in primary care in the UK , and may be another useful measure of progress. Whatever instrument is used, it is important that there are appropriate and agreed systems for defining response to treatment and remission, similar to those in Appendix 10.

Monitoring response may be undertaken by the GP (e.g. during watchful waiting) or another health professional (e.g. practice nurse, graduate worker, primary care mental health professional or a counsellor). In some cases, the professional providing the treatment may differ from the person monitoring progress. In all cases, information is shared with the GP.

Decision making about acute phase treatment

The result of the assessment of response to acute phase treatment feeds into decision making about further care. As the goal is remission, patients who improve, but do not remit, and those who do not improve will need their treatment reviewing. Patients who improve, but do not remit, may simply need more time on the same treatment. However, patients who fail to benefit at all may be more likely to need an alternative treatment within a step, or stepping up (see Figures 3-6).

Periodic monitoring in the continuation and maintenance phases (Steps 3/4 only)

Patients with more moderate and severe depressions require longer term monitoring. Some patients who achieve remission may relapse, while others may have a recurrent episode. Following remission and during the continuation and maintenance phases, patients should be proactively followed-up in order to monitor their status.

Figures 3-6 summarise the structure of care at each of the 4 initial steps, and detail:

1. The initial treatment
2. The proposed schedule of contacts involved in the initial treatment, plus appropriate professionals to deliver this treatment
3. The suggested point at which patient progress during the acute phase is reviewed, together with the appropriate professional to conduct the review
4. The possible decisions to be made on the basis of the progress review, and which professionals might be involved in the decision making
5. The proposed schedule of contacts involved in the maintenance and continuation phases (where appropriate)
6. The suggested point at which longer term patient progress is reviewed, together with the appropriate professional to conduct the review

The exact nature of each step, the professionals involved and the treatments provided will depend on local resources and current service structure.