Given the prevalence of clinical depression in the United States (the Centers for Disease Control and Prevention estimated that from 2009-2012, 7.6% of Americans ages 12 and over had depression), it is vital for primary care physicians to appropriately screen patients suspected of having a depressive disorder to determine the severity and the most suitable treatment plan. Harvard Pilgrim recommends using the Patient Health Questionnaire (PHQ-9) for this purpose.
Depending on the frequency and severity of the depressive symptoms present, some patients may require antidepressant medications or a combination of antidepressants and psychotherapy, while others may benefit most from psychotherapy alone. In patients for whom the prescription of antidepressant medications is necessary, the treatment plan for depression should include regular monitoring of any potential side effects.
PHQ-9 and other depression screening tools
Primary care physicians play an important role in identifying and treating depression, appropriately screening patients, and using the findings to develop a comprehensive treatment plan. Harvard Pilgrim recommends using the PHQ-9, which is a reliable, efficient tool for assessing and monitoring the severity of depression in behavioral health patients. The questionnaire, which can be completed by the patient in minutes, rates the frequency of depressive symptoms and serves as a strong base for diagnosis and coordination of follow-up care. A non-scored follow-up question on the PHQ-9 assesses the degree to which the patient’s depression has affected his or her level of function.
The treating physician can score the results of the questionnaire rapidly, and can administer the PHQ-9 multiple times throughout the course of treatment to monitor improvement or worsening of depressive symptoms.
Additionally, the Substance Abuse and Mental Health Services Administration (SAMHSA) offers screening tools for drug and alcohol use to be used during regular screenings in primary care and other healthcare settings. SBIRT (Screening, Brief Intervention, and Referral to Treatment) is one such tool. SBIRT is a comprehensive public health approach to the delivery of early intervention and treatment services for people with substance abuse disorder. Visit the SBIRT website for more information and resources.
Potential side effects of antidepressants
The care for a patient diagnosed with depression may involve collaboration between the PCP and behavioral health practitioners, and may consist of referring the patient for psychotherapy, prescribing antidepressants, or a combination of elements, depending on the severity of the depressive symptoms. PHQ-9 scores of 5, 10, 15, and 20 represent mild, moderate, moderately severe, and severe depression, respectively. Patients with scores in the mild-to-moderate range may benefit more from psychotherapy alone; antidepressants may not be needed as a starting treatment, and can be introduced, if need be, after an initial evaluation of the effectiveness of the original treatment plan.
The treatment plan for patients prescribed antidepressant medications should include close monitoring of potential side effects, which are often minor and subside on their own over time, but may be persistent and debilitating in certain patients. Common side effects include:
Other, more severe side effects that may occur in some patients taking antidepressants are:
- Decreased sex drive
- Dry mouth
- Difficulty sleeping at night
- Daytime drowsiness
- Weight gain
- Constipation or diarrhea
- Dizziness and/or headaches
- Increased anxiety or restlessness
- Chest pain
- Shortness of breath, trouble swallowing, or other signs of a serious allergic reaction
- Manic behavior
- Suicidal thoughts or feelings
If a patient displays any sign of one of these more severe side effects, or any side effects that persist or interfere with daily life, he or she should be referred to a specialist for further behavioral health treatment.
How Optum/UBH can help your patients — For complex clinical situations, Optum/UBH is available to provide consultative assistance. Practitioners can call the Optum/UBH Physicians Consultation Service at
800-292-2922. To refer a patient for behavioral health services and to facilitate the coordination of care, call Optum at 888-777-4742.