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  • Measure Summary
  • NQMC:010197
  • Jan 2013

Major depressive disorder (MDD): percentage of patients aged 18 years and older with a diagnosis of MDD who have a depression severity classification and who receive, at a minimum, treatment appropriate to their depression severity classification at the most recent visit during the measurement period.

American Psychiatric Association (APA), American Medical Association-convened Physician Consortium for Performance Improvement® (PCPI®). Adult major depressive disorder performance measurement set. Washington (DC): American Psychiatric Association (APA); 2013 Jan. 53 p. [32 references]

This is the current release of the measure.

This measure updates a previous version: Physician Consortium for Performance Improvement®. Adult major depressive disorder physician performance measurement set. Chicago (IL): American Medical Association (AMA); 2010 Sep. 28 p.

Primary Measure Domain

Clinical Quality Measures: Process

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the percentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) who have a depression severity classification and who receive, at a minimum, treatment appropriate to their depression severity classification at the most recent visit during the measurement period.

Rationale

Given the variation in the presentation of depression, ensuring the appropriate treatment method is of great importance. For those with active depression, the appropriate treatment method can induce remission and help patients achieve a return to a baseline level of functioning. For those for whom depression is in remission, the appropriate choice of treatment method can help prevent future relapse.

González and colleagues (2010) found that guideline adherence for depression treatment is well below standards; the prevalence of past-year depression care use among patients meeting major depressive disorder (MDD) criteria showed that only 34% of patients received pharmacotherapy, 44% received psychotherapy, 51% received any depression therapy, and only 28% of patients received combined depression therapy. Other studies have shown that 84% of depressed patients receive therapy that is appropriate for their depression presentation, while only 80% of depressed patients with comorbid anxiety or panic receive the appropriate treatment (Hepner et al., 2007). Of more concern, only 38% of patients unresponsive to treatment receive treatment adjustment, and, amongst the elderly, only 26% of depressed patients receive any appropriate treatment (Hepner et al., 2007).

The following evidence statements are quoted verbatim from the referenced clinical guidelines. Only selected portions of the clinical guidelines are quoted here; for more details, please refer to the full guideline.

Treatment in the acute phase should be aimed at inducing remission of the major depressive episode and achieving a full return to the patient's baseline level of functioning (American Psychiatric Association [APA], 2010).

Acute phase treatment may include pharmacotherapy, depression-focused psychotherapy, the combination of medications and psychotherapy, or other somatic therapies such as electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), or light therapy, as described in the sections that follow. Selection of an initial treatment modality should be influenced by clinical features (e.g., severity of symptoms, presence of co-occurring disorders or psychosocial stressors) as well as other factors (e.g., patient preference, prior treatment experiences) (APA, 2010).

Antidepressant medication could also include a mood stabilizer.

Any treatment should be integrated with psychiatric management and any other treatments being provided for other diagnoses (APA, 2010).

Patients who are diagnosed with mild-moderate MDD should receive an initial trial of monotherapy that incorporates either an antidepressant medication or psychotherapy.

  1. Patient preferences, resources, and tolerability of treatment should be considered in determining the choice between an antidepressant and psychotherapy.
  2. Monotherapy should be optimized before proceeding to subsequent strategies by monitoring outcomes, maximizing dosage (medication or psychotherapy), and allowing sufficient response time (8 to 12 weeks) (Management of MDD Working Group, 2009).

Evidence for Rationale

American Psychiatric Association (APA), American Medical Association-convened Physician Consortium for Performance Improvement® (PCPI®). Adult major depressive disorder performance measurement set. Washington (DC): American Psychiatric Association (APA); 2013 Jan. 53 p. [32 references]

American Psychiatric Association (APA). Practice guideline for the treatment of patients with major depressive disorder. 3rd ed. Arlington (VA): American Psychiatric Association (APA); 2010 Oct. 152 p.

González HM, Vega WA, Williams DR, Tarraf W, West BT, Neighbors HW. Depression care in the United States: too little for too few. Arch Gen Psychiatry. 2010 Jan;67(1):37-46. PubMed External Web Site Policy

Hepner KA, Rowe M, Rost K, Hickey SC, Sherbourne CD, Ford DE, Meredith LS, Rubenstein LV. The effect of adherence to practice guidelines on depression outcomes. Ann Intern Med. 2007 Sep 4;147(5):320-9.

Management of MDD Working Group. VA/DoD clinical practice guideline for management of major depressive disorder (MDD). Washington (DC): Department of Veteran Affairs, Department of Defense; 2009 May. 203 p.

Primary Health Components

Major depressive disorder (MDD); depression severity classification; appropriate treatment

Denominator Description

All patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Adult patients who have a depression severity classification and who receive, at a minimum, treatment appropriate to their depression severity classification at the most recent visit during the measurement period (see the related "Numerator Inclusions/Exclusions" field)

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A clinical practice guideline or other peer-reviewed synthesis of the clinical research evidence
  • A formal consensus procedure, involving experts in relevant clinical, methodological, public health and organizational sciences
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

Prevalence and Incidence

  • Major depressive disorder affects approximately 14.8 million American adults, or about 6.7 percent of the U.S. population aged 18 and older in a given year (National Institute of Mental Health [NIMH], 2010).
  • While major depressive disorder can develop at any age, the median age at onset is 32 (NIMH, 2010).
  • Major depressive disorder is more prevalent in women than in men (NIMH, 2010).
  • Depressive disorders are more common among persons with chronic conditions (e.g., obesity, cardiovascular disease, diabetes, asthma, arthritis, and cancer) and among those with unhealthy behaviors (e.g., smoking, physical inactivity, and binge drinking) (Centers for Disease Control and Prevention [CDC], 2010).

Disability

  • Major depressive disorder is the leading cause of disability in the U.S. for ages 15 to 44 (NIMH, 2010).

Suicide

  • Research has shown that more than 90% of people who kill themselves have depression or another diagnosable mental or substance abuse disorder (Conwell & Brent, 1995).
  • Depression is the cause of over two-thirds of the 30,000 reported suicides in the U.S. each year (Depression and Bipolar Support Alliance, 2010).
  • The suicide rate for older adults is more than 50% higher than the rate for the nation as a whole. Up to two-thirds of older adult suicides are attributed to untreated or misdiagnosed depression (Depression and Bipolar Support Alliance, 2010).

Disparities

  • Non-Hispanic blacks, Hispanics, and non-Hispanic persons of other races are more likely to report major depression than non-Hispanic whites, based on responses to the Patient Health Questionnaire 8 (PHQ-8), which covers eight of the nine criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) for diagnosis of major depressive disorder (CDC, 2010).
  • For individuals who experienced a depressive disorder in the past year, 63.7% of Latinos, 68.7% of Asians, and 58.8% of African Americans, compared with 40.2% of non-Latino whites, did not access any mental health treatment in the past year (Alegría et al., 2008).

Special Populations: Geriatrics

  • The rate of depression in adults older than 65 years of age ranges from 7% to 36% in medical outpatient clinics and increases to 40% in the hospitalized elderly (Institute for Clinical Systems Improvement [ICSI], 2010).
  • Comorbidities are more common in the elderly. The highest rates of depression are found in those with strokes (30% to 60%), coronary artery disease (up to 44%), cancer (up to 40%), Parkinson's disease (40%), and Alzheimer's disease (20% to 40%) (ICSI, 2010).
  • Similar to other groups, the elderly with depression are more likely than younger patients to underreport depressive symptoms (ICSI, 2010).

Evidence for Additional Information Supporting Need for the Measure

Alegría M, Chatterji P, Wells K, Cao Z, Chen CN, Takeuchi D, Jackson J, Meng XL. Disparity in depression treatment among racial and ethnic minority populations in the United States. Psychiatr Serv. 2008 Nov;59(11):1264-72. PubMed External Web Site Policy

American Psychiatric Association (APA), American Medical Association-convened Physician Consortium for Performance Improvement® (PCPI®). Adult major depressive disorder performance measurement set. Washington (DC): American Psychiatric Association (APA); 2013 Jan. 53 p. [32 references]

Centers for Disease Control and Prevention (CDC). Current depression among adults---United States, 2006 and 2008. MMWR Morb Mortal Wkly Rep. 2010 Oct 1;59(38):1229-35. PubMed External Web Site Policy

Conwell Y, Brent D. Suicide and aging. I: Patterns of psychiatric diagnosis. Int Psychogeriatr. 1995 Summer;7(2):149-64. PubMed External Web Site Policy

Depression and Bipolar Support Alliance. Depression statistics. [internet]. Chicago (IL): Depression and Bipolar Support Alliance; [accessed 2010 Nov 22].

Institute for Clinical Systems Improvement (ICSI). Major depression in adults in primary care. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2010 May. 99 p. [246 references]

National Institute of Mental Health (NIMH). The numbers count: mental disorders in America. [internet]. Chicago (IL): National Institute of Mental Health (NIMH); [accessed 2010 Nov 22].

Extent of Measure Testing

This measure is being made available without any prior testing. The Physician Consortium for Performance Improvement (PCPI) recognizes the importance of testing all of its measures and encourages testing of the Adult Major Depressive Disorder measurement set by organizations or individuals positioned to do so. The Measure Testing Protocol was approved by the PCPI in 2010 and is available on the PCPI Web site (see Position Papers at http://www.ama-assn.org/ama/pub/physician-resources/physician-consortium-performance-improvement.page External Web Site Policy); interested parties are encouraged to review this document.

Evidence for Extent of Measure Testing

American Psychiatric Association (APA), American Medical Association-convened Physician Consortium for Performance Improvement® (PCPI®). Adult major depressive disorder performance measurement set. Washington (DC): American Psychiatric Association (APA); 2013 Jan. 53 p. [32 references]

National Guideline Clearinghouse Link

Practice guideline for the treatment of patients with major depressive disorder, third edition. External Web Site Policy

State of Use

Current routine use

Current Use

Internal quality improvement

Professional certification

Measurement Setting

Ambulatory/Office-based Care

Behavioral Health Care

Professionals Involved in Delivery of Health Services

Advanced Practice Nurses

Physician Assistants

Physicians

Psychologists/Non-physician Behavioral Health Clinicians

Least Aggregated Level of Services Delivery Addressed

Individual Clinicians or Public Health Professionals

Statement of Acceptable Minimum Sample Size

Unspecified

Target Population Age

Age greater than or equal to 18 years

Target Population Gender

Either male or female

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Getting Better

Living with Illness

IOM Domain

Effectiveness

Case Finding Period

Unspecified

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Clinical Condition

Patient/Individual (Consumer) Characteristic

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
All patients aged 18 years and older with a diagnosis of major depressive disorder (MDD)

Exclusions
Unspecified

Exceptions

  • Documentation of medical reason(s) for not receiving treatment appropriate to MDD severity classification (e.g., patient allergy, other medical reasons)
  • Documentation of patient reason(s) for not receiving treatment appropriate to MDD severity classification (e.g., patient declined, patient preference*, other patient reasons)
  • Documentation of system reason(s) for not receiving treatment appropriate to MDD severity classification (e.g., treatment not covered by insurance, other system reasons)

*Documented patient preference could include (but is not limited to) preference information related to prior treatment response, family history of treatment response, treatment administration method, treatment side effects, or other personal concerns (financial, functional, etc.).

Exclusions/Exceptions

Medical factors addressed

Patient factors addressed

System factors addressed

Numerator Inclusions/Exclusions

Inclusions
Percentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) who have a depression severity classification and who receive, at a minimum, treatment appropriate to their depression severity classification* at the most recent visit during the measurement period

*Refer to the original measure documentation for a table of appropriate treatments for corresponding severity classifications.

Exclusions
Unspecified

Numerator Search Strategy

Encounter

Data Source

Electronic health/medical record

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

Unspecified

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a higher score

Allowance for Patient or Population Factors

Unspecified

Standard of Comparison

Internal time comparison

Original Title

Measure #4: treatment for depression.

Measure Collection Name

Adult Major Depressive Disorder Performance Measurement Set

Submitter

American Psychiatric Association - Medical Specialty Society

Developer

American Psychiatric Association - Medical Specialty Society

Physician Consortium for Performance Improvement® - Clinical Specialty Collaboration

Funding Source(s)

Unspecified

Composition of the Group that Developed the Measure

Work Group Members: Richard Hellman, MD, FACP, FACE (Co-chair) (endocrinology, methodology); John S. McIntyre, MD, DFAPA, FACPsych (Co-chair) (psychiatry, methodology); Alan A. Axelson, MD (psychiatry); Stanley Borg, DO (family medicine); Andrea Bostrom, PhD, PMHCNS-BC (nursing, psychiatric nursing); Gwendolen Buhr, MD, MHS, CMD (geriatrics); Katherine A. Burson, MS, OTR/L, CPRP (occupational therapy); Mirean Coleman, MSW, LICSW, CT (social work); Thomas J. Craig, MD, MPH, DLFAPA, FACPM (psychiatry); Allen Doederlein (patient representative); William E. Golden, MD, FACP (internal medicine); Molly Finnerty, MD (psychiatry, methodology); Jerry Halverson, MD (psychiatry, methodology); Paul R. Keith, MD (health plan representative); Clifford K. Moy, MD (psychiatry); John M. Oldham, MD (psychiatry); Shaunte R. Pohl, PharmD, BCPS (pharmaceutical science); Mark A. Reinecke, PhD (psychology); Leslie H. Secrest, MD (psychiatry); Carl A. Sirio, MD (critical care medicine, methodology); Sharon S. Sweede, MD (family medicine); Roberta Waite, EdD, APRN, CNS-BC (psychiatric nursing, methodology)

Work Group Staff: Robert Plovnick, MD, MS (American Psychiatric Association); Robert Kunkle, MA; Samantha Shugarman (American Psychiatric Association); Mark Antman, DDS, MBA (American Medical Association); Katherine Ast, MSW, LCSW (American Medical Association); Keri Christensen, MS (American Medical Association); Kendra Hanley, MS (American Medical Association); Karen Kmetik, PhD (American Medical Association); Molly Siegel, MS (American Medical Association); David Marc Small, MS, MPP (American Medical Association); Kimberly Smuk, BS, RHIA (American Medical Association); Samantha Tierney, MPH (American Medical Association); Greg Wozniak, PhD (American Medical Association)

Financial Disclosures/Other Potential Conflicts of Interest

None of the members of the Adult Major Depressive Disorder Work Group had any disqualifying material interests under the Physician Consortium for Performance Improvement (PCPI) Conflict of Interest Policy. A summary of non-disqualifying interests disclosed on Work Group members' Material Interest Disclosure Statements (not including information concerning family member interests) is provided in the original measure documentation. Completed Material Interest Disclosure Statements are available upon request.

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2013 Jan

Measure Maintenance

The Physician Consortium for Performance Improvement (PCPI) stipulates a regular review of measures every 3 years or when there is a major change in scientific evidence, results from testing or other issues noted that materially affect the integrity of the measure.

Date of Next Anticipated Revision

Unspecified

Measure Status

This is the current release of the measure.

This measure updates a previous version: Physician Consortium for Performance Improvement®. Adult major depressive disorder physician performance measurement set. Chicago (IL): American Medical Association (AMA); 2010 Sep. 28 p.

Source(s)

American Psychiatric Association (APA), American Medical Association-convened Physician Consortium for Performance Improvement® (PCPI®). Adult major depressive disorder performance measurement set. Washington (DC): American Psychiatric Association (APA); 2013 Jan. 53 p. [32 references]

Measure Availability

Source not available electronically.

For more information, contact the American Psychiatric Association (APA) at 1000 Wilson Boulevard, Suite 1825, Arlington, VA 22209; Phone: 888-357-7924; E-mail: apa@psych.org; Web site: psychiatry.org External Web Site Policy.

NQMC Status

This NQMC summary was completed by ECRI on February 26, 2004. The information was verified by the measure developer on October 6, 2004.

This NQMC summary was updated by ECRI on September 28, 2005. The information was verified by the measure developer on November 9, 2005.

This NQMC summary was updated by ECRI Institute on September 19, 2008. The information was verified by the measure developer on November 5, 2008.

This NQMC summary was retrofitted into the new template on June 7, 2011.

The information was reaffirmed by the measure developer on November 30, 2011. This NQMC summary was edited by ECRI Institute on April 27, 2012.

Stewardship for this measure was transferred from the PCPI to the APA. APA informed NQMC that this measure was updated. This NQMC summary was updated again by ECRI Institute on October 8, 2015. The information was verified by the measure developer on November 25, 2015.

Copyright Statement

This NQMC summary is based on the original measure, which is subject to the measure developer's copyright restrictions.

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