Assessment

Assessment is a comprehensive evaluation of a client’s needs, strengths and weaknesses based upon their history, diagnosis, resources and disabilities.  When making an assessment it is important to evaluate the client’s environment and support system. Often, a screening instrument is used for making an initial assessment. A screener is a short, standardized questionnaire that measures symptoms to determine if a person might need help.

One screener which providers often use to make an assessment is called the Patient Health Questionnaire 9 (PHQ-9). It’s important to keep in mind that the PHQ-9 is a screen and not a diagnosis—only a clinician (such as a primary care provider or a therapist) can make a depression diagnosis and decide whether treatment is needed. However, by doing an assessment providers can help clients learn whether they might have symptoms that could suggest that they may need an evaluation for depression treatment.

Care Management

The goal of Care Management is to help clients engage in services, consider different treatment options, and to track their progress. In Care Management one gets to know clients, document provider treatment recommendations, follow up on client progress and use of recommended services, support wellness and client co-management, and provide summaries of progress across clients for review by the care team. These tasks are typically performed by a Care Manager (CM).

A Care Manager is a staff member who works within a services agency that also provides treatments through a licensed provider, or who works closely with another partnering agency which provides treatment. The Care Manager may be a provider such as a nurse, social worker, or a trained lay person who is supported or supervised by a provider. The Care Manager is a key resource in communication of goals between the agency and the client. The Care Manager  also serves as a client supporter and advocate to help assure that the client’s goals of recovery from depression can be achieved through working with the agency.

Some of the key goals for the Care Manager include:

• Support the effectiveness of the client’s meeting with their provider
• Help communicate the provider’s recommendations for care
• Help clients implement their care plan through regular follow-up

Patient Education

Patient education is meant to promote awareness on mental health and wellness for both patients and the community-at-large. Patient education helps to reduce stigma of mental disorders, symptoms, and of seeking help.

The CPIC toolkit includes several patient education materials including:

• ”Beating Depression: The Journey to Hope”; This book is for people who are experiencing the symptoms of depression as well as for someone who is caring for another individual suffering from depression like a patient, friend, or family member. “Beating Depression” addresses the causes and symptoms of depression, treatment options, how to get care, and ways to help oneself get well and stay well.
• An educational video titled “Beyond Depression” that was previously developed for the Partners in Care (PIC) study. The video is available both in English and Spanish and can be viewed free of charge on this page. This material is copyrighted by the RAND Corporation and has been posted with their permission. Please scroll to the bottom of this page to view either language versions.
• A brochure, also from the PIC study, which asks the question “Are you feeling tired, sad, angry, irritable, hopeless?”. This brochure is also available in both English and Spanish in an easy-to-print format so that providers can give a copy to patients for them to take home and share with their loved ones if they so choose.

Primary Care

Depression affects from 5 to 10% of primary care patients and there are several key treatment challenges that Clinicians may encounter.

1. Recognizing and diagnosing depression- Up to 50% of all cases of current major depression or dysthymia (acute or chronic depression) go undetected in primary care visits.

2. Educating the patient- Clear up misconceptions about the stigma and treatability of depression.

3. Reaching an agreement with patients on diagnosis and treatment- Patients and physicians often have different explanatory models for what is wrong and different expectations for treatment.

4. Starting with the most effective treatment- Use antidepressant medication or psychotherapy. Avoid long-term use of minor tranquilizers.

5.  If you use antidepressants:

• Use an adequate dosage level. Primary care physicians often ‘undertreat’ depression with subtherapeutic doses.
• Continue medications for 6 to 9 months after recovery to ensure long-term success. About 35% of patients stop taking their antidepressants in the first month of treatment.

6.  If you use psychotherapy:

• Use a type known to be successful for depression.
• Continue monitoring psychotherapy patients for relapse during the 6 to 9 months after treatment

7. Following outcomes closely and adjust treatment as needed- Many patients do not respond to the initial treatment chosen, and require a change at week 6 – 10. In some cases, patients’ symptoms improve, but they continue to function poorly. If patients are not significantly improved at 8 – 10 weeks, consider increasing, augmenting, changing the medication, adding psychotherapy, and/or get a psychiatric consultation.

8. Preventing relapse and recurrence among patients with prior episodes of depression

More appropriate care for depression often means more cost-effective care. If depressed patients do not receive appropriate care, they will still tend to make costly visits, but they will not improve in functioning outcomes. Addressing the challenges above will make care more efficient and effective.

The above mentioned information and much more on depression assessment and management can be found in the CPIC Clinician Guide. This guide is intended to increase the skills, confidence, and adherence to national guidelines for depression among primary care clinicians, including physicians, nurse practitioners, physician assistants, and nurses. It is also intended as a foundation for collaboration between mental health specialists and primary care clinicians. The Guide represents the application of mental health knowledge and evidence to the management of the population of patients seen in primary care settings.

Download: Clinician Toolkit

Psychotherapy/CBT Manuals

Psychotherapy is a form of therapy, in this case for depression, where talking is key. Psychotherapy typically occurs between a mental health professional and a patient, and it can be done in a one-to-one session or group setting.

There are various types of psychotherapy, but the focus in the CPIC initiative is on Cognitive Behavioral Therapy (CBT). CPIC offers a number of BRIGHT CBT manuals in english and spanish to help therapists and other types of providers with the process of treating depression.

BRIGHT can be provided in both group and individual treatment sessions. Each manual includes a provider guidebook and client workbook. In the group session, treatment can be done in an open or closed format. In a closed format, group membership remains the same throughout the entire treatment program, starting from the first module onto the second and third. In an open format members can join at whichever module and do not necessarily have to wait 12 weeks for the next program to begin. 

The CBT Therapist toolkit provided includes a variety of clinical tools and forms like Intake/Assessments Worksheets and Forms, Therapy Process and Outcome Tracking, Coordination of Care, and Forms for Patients.

You may download Group Therapy Manuals for Group Leaders and Members in English here:
CBT Manual for Member closed group (English)
CBT Manual for Leader English_Closed Group
CBT Manual for Member open group (English)
CBT Manual for Leader open group (English)

and Group Therapy Manuals for Group Leaders and Members in Spanish here:
CBT Manual for Member closed group (Spanish)
CBT Manual for Leader closed group (Spanish)
CBT Manual for Member open group (Spanish)
CBT Manual for Leader open group (Spanish)

You may download Individual Therapy Manuals for Providers and Clients in English here:
CBT Manual Client Individual Session (English)
CBT Manual Provider Individual Session (English)

and Individual Therapy Manuals for Providers and Clients in Spanish here:
CBT Manual for Client Individual session (Spanish)
CBT Manual for Provider Individual session (Spanish)

Screening

Screening involves the use of a simple questionnaire to evaluate whether a client may be in need for an assessment for depression. This type of questionnaire is simple enough to be administered and scored by non-clinical/non-mental health professionals. Screening is necessary because many people are not aware of the fact that they might be experiencing depression symptoms. 

There are different tools that can be used to aid in screening for depression. Once such tool is the Patient Health Questionnaire 9 (PHQ-9). It consists of 9 questions about different depression symptoms. After the questionnaire is administered to the client or completed by the client, one can use the PHQ-9 scoring card to make an assessment. 

There can be two possible outcomes from the questionnaire, either positive or negative, which should be explained in detail to the client. If the outcome is positive, it’s important to let the client know that  further evaluation from a clinician or a counselor would be highly recommended. If the outcome is negative, it’s important to let the client know that there could be a possibility that symptoms might reoccur if he/she has a history of depression but that at that moment there are no drastic indicating signs that immediate treatment is required. 

When using any screening tool, it’s important to take and discuss it in a private setting that is comfortable for the client.

The PHQ-9 screening tool as well as the PHQ-9 scoring card are available in english and in spanish for your use.

Consultations

The CPIC Clinical Services Workgroup was composed of psychiatrists, therapists, AOD counselors, depression care managers, a primary care physician, and a registered nurse. This group worked together to develop the CPIC resources and they provided telephone consultation sessions to providers participating in CPIC. 

Consultation sessions also addressed questions that arose during implementation of the CPIC resources in community-based agencies.