Managing Major Depressive Disorder and Identifying Residual Symptoms

Activity Progress
Pre-Activity Survey
Page 1
Page 2
Page 3
Page 4
Page 5
Page 6
Page 7
Post-Activity Survey
CME Evaluation/Print Certificate

Problem: This activity is closed.

Managing Major Depressive Disorder and Identifying Residual Symptoms

Bradley N. Gaynes MD, MPH
W. Clay Jackson, MD, DipTh

Release Date: September 16, 2015
Expiration Date: September 15, 2016 (THIS ACTIVITY IS NO LONGER AVAILABLE FOR CREDIT)

Continue to Activity

ACTIVITY DESCRIPTION

Family physicians (FPs) are on the frontline for depression care, often being the first line of defense for diagnosis and management. This 0.5-hour, CME-certified activity will guide clinicians through a brief patient case, challenging the learner to address questions on the following:

Clinical factors in the primary-care setting that influence treatment outcomes in major depressive disorder (MDD)
Identification and management of residual symptoms
Tools for effective monitoring of treatment outcomes
Nonpharmacologic and pharmacologic therapies to treat patients to goal: symptomatic remission and recovery
Strategies to promote patient-centered care and adherence

LEARNING OBJECTIVES

Upon completion of this educational activity, participants should be able to:

Diagnose MDD based on the recommended DSM-5 guidelines
Evaluate the safety and efficacy of available pharmacologic agents for initial antidepressant therapy in patients with MDD
Identify the effects of residual symptoms on the symptomatic remission and recovery of patients with MDD

FACULTY

Bradley N. Gaynes, MD, MPH
Professor and Associate Chair of Research Training and Education
Department of Psychiatry
University of North Carolina School of Medicine
Chapel Hill, NC

W. Clay Jackson, MD, DipTh
Clinical Assistant Professor of Family Medicine and Psychiatry
University of Tennessee College of Medicine
Memphis, TN

FACULTY BIOGRAPHIES

Bradley N. Gaynes, MD, MPH, is Professor and Associate Chair of Research Training and Education in the Department of Psychiatry at the University of North Carolina (UNC) at Chapel Hill. Dr Gaynes earned his medical degree from the University of Virginia School of Medicine, and completed his residency in psychiatry at the University of Colorado Health Sciences Center. His postgraduate training has included a Robert Wood Johnson Clinical Scholar Fellowship at UNC, where he also received his Master of Public Health degree in epidemiology and completed a fellowship in preventive medicine. Dr Gaynes works at the crossroads between clinical trials research and mental health services research (including comparative effectiveness reviews), and he focuses his clinical and research efforts on treatment-resistant depression and improving the delivery of depression care in nonpsychiatric settings, including primary care, obstetrical, and HIV practices.

As a clinical trials researcher, Dr Gaynes has participated in seminal work on primary care depression management. He has been funded through a National Institute of Mental Health (NIMH) Career Development Award (K23) entitled, “Targeting Treatment-Resistant Depression in Primary Care” and served as the Director of the UNC Regional Center for the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study. Currently, Dr Gaynes is Principal Investigator (PI) on an NIMH-funded R34 Planning Grant adapting measure-based care to manage depressed patients with HIV in Cameroon. He is co-PI on an NIMH-funded R01 Research Project Grant Program assessing whether HIV outcomes in depressed patients with HIV are better after randomization to measure-based care compared to usual care.

As a mental health services researcher, Dr Gaynes has previously served as PI for the US Preventive Services Task Force’s evidence report on screening for suicide risk in primary care; as Co-investigator on a Task Force report on screening for depression in primary care; and as PI on a recently completed AHRQ-funded comparative effectiveness review of nonpharmacologic interventions in the management of treatment-refractory depression. He is currently an investigator on the UNC/RTI collaborative project, “Comprehensive EPC Comparative Effectiveness Reviews for Effective Health Care.”

W. Clay Jackson, MD, DipTh, is a Clinical Assistant Professor of Family Medicine and Psychiatry at the University of Tennessee College of Medicine in Memphis, where he maintains a private practice in family and palliative medicine. He is Medical Director of Comprehensive Primary Care and Medical Director for Methodist Hospice and Palliative Services, also in Memphis. In addition, Dr Jackson is the Fellowship Director for Palliative Medicine at the University of Tennessee College of Medicine. From this professional platform, he has led a team of dedicated clinicians who have helped to transform the experience of seriously ill patients in the Mid-South.

Dr Jackson earned his medical degree at the University of Tennessee Health Science Center in Memphis and completed his residency at the University of Tennessee/Baptist Tipton Family Medicine. He earned his Diploma in Theology at Oxford University in England. He is a Fellow of the American Academy of Family Physicians, holds a Certificate of Added Qualification in Hospice and Palliative Medicine, and is a member of the Alpha Omega Alpha Medical Honor Society.

Dr Jackson has been the recipient of many clinical and teaching awards and has had his research published in numerous journals, including Family Medicine, Journal of Affective Disorders, and JAMA. A frequently invited speaker at national and international professional meetings, he has also been featured in several multimedia projects concerning the treatment of affective disorders and chronic pain.

DISCLOSURE STATEMENTS

In accordance with the Accreditation Council for Continuing Medical Education, the NCAFP requires that any person who is in a position to control the content of a CME activity must disclose all relevant financial relationships they have with a commercial interest.

Activity Planning Faculty
The activity content was developed by Bradley N. Gaynes, MD, MPH, and W. Clay Jackson, MD, DipTh.

Activity Faculty
Bradley N. Gaynes, MD, MPH
Nothing to disclose with regard to commercial support

W. Clay Jackson, MD, DipTh
Advisory Board: Forest Pharmaceuticals, Inc; Merck & Co; Otsuka America Pharmaceutical, Inc; Sunovion Pharmaceuticals Inc; Takeda Pharmaceutical Company Ltd
Chief Medical Officer: Halio Health
Speakers Bureau: Sunovion Pharmaceuticals Inc

In order to resolve conflict of interest, presentations of this activity were peer reviewed by an independent reviewer. The reviewer has no relationship with a commercial interest. The resulting certified activity was found to provide educational content that is current, evidence-based, and commercially balanced.

Independent Reviewer
Alisa C. Nance, MD
Nothing to disclose with regard to commercial support

Educational Planning Committee
NCAFP
Marietta Ellis
Nothing to disclose with regard to commercial support

Spire Learning
Erin Franceschini, MS, and Kashemi D. Rorie, PhD
Nothing to disclose with regard to commercial support

Karin McAdams
Nothing to disclose with regard to commercial support

Jeanne Prater
Shareholder (Spouse/Partner): Johnson & Johnson
Employee (Spouse/Partner): Novo Nordisk

DISCLAIMER

The content and views presented in this educational activity are those of the presenter and do not necessarily reflect those of the NCAFP, Spire Learning, Takeda Pharmaceuticals International, Inc., U.S. Region and Lundbeck. This material is prepared based upon a review of multiple sources of information, but it is not exhaustive of the subject matter. Therefore, healthcare professionals and other individuals should review and consider other publications and materials on the subject matter before relying solely upon the information contained within this educational activity.

OFF-LABEL STATEMENT

The faculty presenter does not intend to discuss non–FDA-approved use of pharmacologic agents for the treatment of MDD. The opinions expressed in the educational activity are those of the faculty. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings. Further, attendees/participants should appraise the information presented critically and are encouraged to consult appropriate resources for any product or device mentioned in this program.

LEVELS OF EVIDENCE

Levels of evidence are provided for any patient care recommendations made during this activity. The following levels of clinical confidence are provided by the American Psychiatric Association Practice Guideline for the Treatment of Patients With Major Depressive Disorder (3rd edition):

[I] Recommended with substantial clinical confidence

[II] Recommended with moderate clinical confidence

[III] May be recommended on the basis of individual circumstances

TARGET AUDIENCE

• Family physicians
• Other healthcare providers who treat MDD patients

ACCREDITATION

This enduring activity, Managing Major Depressive Disorder and Identifying Residual Symptoms, from 09/16/2015 - 09/15/2016, has been reviewed and is acceptable for up to 0.50 Prescribed credit(s) by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

AMA/AAFP Equivalency:
AAFP Prescribed credit is accepted by the American Medical Association as equivalent to AMA PRA Category 1 Credit(s)™ toward the AMA Physician’s Recognition Award.

When applying for the AMA PRA, Prescribed credit earned must be reported as Prescribed, not as Category 1.

METHOD OF PARTICIPATION

This activity has no fee and should take approximately 30 minutes to complete. Participants should first read the objectives and other introductory CME information, then complete the pre-assessment and participate in the online case activity. To receive credit for this activity, participants must complete the post-assessment with a passing score of 80% and then complete the evaluation. This credit is valid through September 15, 2016. No credit will be given after this date. In the event you have questions about this activity or are unable to print the certificate, please e-mail Marietta Ellis at mellis@ncafp.com, and a certificate will be e-mailed within 2 weeks.

This educational activity is jointly provided by the North Carolina Academy of Family Physicians (NCAFP) and Spire Learning.

Supported by an educational grant from Takeda Pharmaceuticals International, Inc., U.S. Region and Lundbeck.

References for Managing Major Depressive Disorder and Identifying Residual Symptoms

American Psychiatric Association. Practice Guideline for the Treatment of Patients With Major Depressive Disorder (3rd edition.) http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf.
Kupfer DJ. Long-term treatment of depression. J Clin Psychiatry. 1991;52(suppl):28-34.
Judd LL, Akiskal HS, Maser JD, et al. Major depressive disorder: a prospective study of residual subthreshold depressive symptoms as predictor of rapid relapse. J Affect Disord. 1998;50:97-108.
Kroenke K, Spitzer R. The PHQ-9: a new depression diagnostic and severity measure. Psych Ann. 2002;32(9):508-515.
Cho HJ, Lavretsky H, Olmstead R, et al. Sleep disturbance and depression recurrence in community-dwelling older adults: a prospective study. Am J Psychiatry. 2008;165:1543-1550.
Fawcett J. Antidepressants: partial response in chronic depression. Br J Psychiatry Suppl. 1994;26:37-41.
Blumenthal JA, Babyak MA, Doraiswamy PM, et al. Exercise and pharmacotherapy in the treatment of major depressive disorder. Psychosom Med. 2007;69(7):587-596.
Trivedi MH, Greer TL, Church TS, et al. Exercise as an augmentation treatment for nonremitted major depressive disorder: a randomized, parallel dose comparison. J Clin Psychiatry. 2011;72(5):677-684.
Papakostas GI, Nutt DJ, Hallett LA, et al. Resolution of sleepiness and fatigue in major depressive disorder: A comparison of bupropion and the selective serotonin reuptake inhibitors. Biol Psychiatry. 2006;60(12):1350-1355.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR), 4th ed. Washington, DC: American Psychiatric Association; 2000.
Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16:606-613.
Halverson JL, Bhalla RN, Moraille-Bhalla P, et al. Depression differential diagnoses. Medscape. May 7, 2015. www.emedicine.medscape.com/article/286759-differential. Accessed May 29, 2015.
Roca M, Gili M, Garcia-Garcia M, et al. Prevalence and comorbidity of common mental disorders in primary care. J Affect Disord. 2009;119(1-3):52-58.
Wang PS, Lane M, Olfson M, et al. Twelve-month use of mental health services in the United States: results from the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):629-640.
Pence BW, O’Donnell JK, Gaynes BN. The depression treatment cascade in primary care: a public health perspective. Curr Psychiatry Rep. 2012;14:328-335.
Gaynes B. Identifying difficult-to-treat depression: differential diagnosis, subtypes, and comorbidities. J Clin Psychiatry. 2009;70(S6):10-15.
Trivedi MH, Rush AJ, Wisniewski SR, et al. Evaluation of outcomes with citalopram for depression using measurement-based care in STAR*D: implications for clinical practice. Am J Psychiatry. 2006;163(1):28-40.
Trivedi MH, Hollander E, Nutt D, Blier P. Clinical evidence and potential neurobiological underpinnings of unresolved symptoms of depression. J Clin Psychiatry. 2008;69(2):246-258.
Beck AT, Ward CH, Mendelson M, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4:561-571.
Citrome L. Vortioxetine for major depressive disorder: a systematic review of the efficacy and safety profile for this newly approved antidepressant—what is the number needed to treat, number needed to harm and likelihood to be helped or harmed? Int J Clin Pract. 2014;68(1):60-82.
Gaynes BN, Lux L, Lloyd S, et al. Nonpharmacologic interventions for treatment-resistant depression in adults. Comparative effectiveness review no. 33. 2011. www.effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productid=787
Dobson KS, Hollon SD, Dimidjian S, et al. Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the prevention of relapse and recurrence in major depression. J Consult Clin Psychol. 2008;76(3):468-477.
Freeman MP, Fava M, Lake J, et al. Complementary and alternative medicine in major depressive disorder: the American Psychiatric Association Task Force report. J Clin Psychiatry. 2010;71(6):669-681.
Gartlehner G, Hansen RA, Morgan LC, et al. Comparative benefits and harms of second-generation antidepressants for treating major depressive disorder: an updated meta-analysis. Ann Intern Med. 2011;155(11):772-785.
Teter CJ, Kando JC, Wells BG. Major Depressive Disorder. 9th ed. New York, NY: McGraw Hill; 2014.
Anderson IM, Ferrier IN, Baldwin RC, et al. Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 2000 British Association for Psychopharmacology guidelines. J Psychopharmacol. 2008;22(4):343-396.
Deardorff WJ, Grossberg GT. A review of the clinical efficacy, safety and tolerability of the antidepressants vilazodone, levomilnacipran and vortioxetine. Expert Opin Pharmacother. 2014;15(17):2525-2542.
Olfson M, Marcus SC, Tedeschi M, Wan GJ. Continuity of antidepressant treatment for adults with depression in the United States. Am J Psychiatry. 2006;163:101-108.
Gensichen J, Beyer M, Muth C, et al. Case management to improve major depression in primary health care: a systematic review. Psychol Med. 2006;36:7-14.
Judd LL, Paulus MJ, Schettler PJ, et al. Does incomplete recovery from first lifetime major depressive episode herald a chronic course of illness? Am J Psychiatry. 2000;157(9):1501-1504.
Paykel ES, Ramana R, Cooper Z, et al. Residual symptoms after partial remission: an important outcome in depression. Psychol Med. 1995;25(6):1171-1180.
Paykel ES. Remission and residual symptomatology in major depression. Psychopathology. 1998;31(1):5-14.
US FDA. Fluoxetine hydrochloride NDA 018936 Label 10/10/2014.
US FDA. Sertraline hydrochloride NDA 019839 Label 09/12/2014.
US FDA. Paroxetine hydrochloride NDA 020031 Label 07/18/2014.
US FDA. Citalopram hydrobromide NDA 020822 Label 07/08/2014.
US FDA. Escitalopram oxalate NDA 021323 Label 10/31/2014.
US FDA. Vilazodone hydrochloride NDA 022567 Label 06/11/2015.
US FDA. Vortioxetine hydrobromide NDA 204447 Label 09/08/2014.
US FDA. Bupropion hydrochloride NDA 020358 Label 12/16/2014.
US FDA. Bupropion hydrochloride NDA 021515 Label 12/30/2014.
US FDA. Duloxetine hydrochloride NDA 021427 Label 11/25/2014.
US FDA. Mirtazapine NDA 020415 Label 07/18/2014.
US FDA. Venlafaxine hydrochloride NDA 020699 Label 12/17/2014.
US FDA. Levomilnacipran hydrochloride NDA 020822 Label 07/18/2014.
Gaynes BN, Rush AJ, Trivedi MH, et al. Primary versus specialty care outcomes for depressed outpatients managed with measurement-based care: results from STAR*D. J Gen Intern Med. 2008;23(5):551-560.

Suggested Related Content:
Click here to access practice guidelines for the management of patients with MDD.

American Psychiatric Association Practice Guideline for the Treatment of Patients With Major Depressive Disorder (3rd edition).