Treatment of Depression in Primary Care: A Motivational Interviewing, Stepped-Care Approach
ABSTRACT: Encounters with persons who have depressive disorders are prevalent in primary care. With all of the complexities of these encounters, these experiences can prove difficult for health care providers and patients alike. Patient-provider collaboration is an essential component to improved outcomes. This article presents a motivational interviewing, stepped-care approach that can be utilized to improve these encounters and decrease frustrations for all involved.
Key words: depression, primary care, motivational interviewing, stepped care
Depression is the most common mental health disorder seen in primary care,1 and numerous treatment options are available. Regardless of the treatment “prescribed” (ie, pharmacologic, psychotherapeutic, etc), there remains the clinical challenge of effectively engaging the patient in steps that will lead to behavior change, whether that be taking a medication consistently, seeing a therapist, or some other agreed-upon treatment.
Medication is often the first-line treatment for depression in primary care. Some of the obstacles/barriers to change for patients who are presented with medication as the primary treatment option include cost, unwanted side effects, sub-therapeutic relief, risk of polypharmacy, and limited symptom reduction without remission. There are also many factors that contribute to or exacerbate depression that medication alone cannot address (eg, marital/relational strife, difficulties with children, grief or loss, chronic or terminal illnesses, poor coping strategies), which often necessitate adjunctive treatment approaches and modalities.
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Primary care physicians need to take a broad and systemic approach—including an evidence-based approach for presenting options that increase the likelihood of behavior change (some step toward treatment). In this article we review a stepped-care approach to engaging patients in conversations that may lead to change, including the presentation of nonpharmacologic options for treatment.
AN OVERVIEW OF THE STEPPED-CARE APPROACH
Research on depression has revealed varying levels of effectiveness by modality, with medication, psychotherapy, or a combination of both consistently reported in the literature as first-line treatments.2,3 The severity of the depression and functional impairment reported by the patient often determines the recommendation provided by the physician, such as:
• Start with medication and psychotherapy for patients with severe depression who have high functional impairment.
• Consider starting with psychotherapy and add medication as needed for those with moderate depression and modest functional impairment.
• Begin with psychotherapy for those with mild depression and use medication only if depression becomes more severe and disabling.
A frequent clinical challenge, even if unstated by patients, is that they often have subjective concerns or obstacles that hamper them from adhering to recommendations made by providers.
George Engel, MD, the noted psychiatrist, argued several decades ago that there is no substitute for a thorough biopsychosocial assessment of the patient.4 Gathering relevant information from each of the biopsychosocial-spiritual domains will help physicians engage with the patient and collect relevant systemic data to develop a plan for treatment.5 Addressing one dimension of depression treatment alone (eg, the biological) is often insufficient.
Despite physicians’ best efforts to diagnose and treat depression, patients often encounter obstacles to receiving the level or type of care necessary to experience significant remission of depressive symptoms. This may, in part, be due to a lack of behavior change (compliance) or motivation to change (health behaviors) by patients. Herein lies the problem: how do we engage patients in a nonjudgmental, non-directive/prescriptive, collaborative, and open manner such that we can have a conversation that will lead to change, and ultimately effective treatment of depression?
This article presents a stepped-care approach that is collaborative and systemic with specific skills for primary care providers to engage patients around the care of their depression. Screening tools and measures and the diagnostic process for recognizing depression in primary care will not be discussed here because this has been addressed elsewhere.6
The following case vignette will be used to illustrate a stepped-care approach to the treatment of depression utilizing elements of motivational interviewing, a collaborative person-centered form of guiding to elicit and strengthen motivation for change. Motivational interviewing is an evidence-based style of partnering with patients that has been shown to outperform giving advice.7,8 The intent of incorporating motivational interviewing skills and principles into this article is solely to provide an introduction to components of this model; it is not meant to be comprehensive or substantively complete. For a more thorough discussion and overview of this approach, see Motivational Interviewing: Helping People Change by Miller and Rollnick.8
The case vignette that follows describes a patient with mild to moderate depression, a scenario in which there are often multiple approaches and options as a first treatment step. This clinical scenario is offered as an example of a patient-centered interview, using elements of motivational interviewing that are more likely to promote change. For cases in which depression is severe and/or suicidal or homicidal ideation is present, a more directive and preventative approach is advised (eg, direct transport to an emergency department or call to a mental health deputy).
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CASE VIGNETTE: JUANITA
Juanita, a 32-year-old Hispanic woman comes to you with a chief complaint of low mood, low energy, increased appetite, and loss of interest in previously enjoyed activities for the past 2 months. Her Patient Health Questionnaire–9 (PHQ-9) score is 14, indicating depressive symptoms of moderate severity.9 For personal reasons (ie, wanting to start a family), she prefers to avoid medications.
SKILL NO. 1: PROVIDING CLINICAL FEEDBACK
The conversation from the point of assessment to establishing the first step in treatment is important. The skill of providing clinical feedback in an objective, nonjudgmental manner includes the following:
• Use a visual graphic to represent the patient score/value and what is expected (eg, PHQ-9).
• Explain the number in a simple, matter-of-fact manner.
• Ask patient what he or she thinks or feels about the information. This allows the patient to disclose current thoughts and feelings about the information without any judgment or interpretation by the physician.
Physician: “Based on your PHQ-9, your score is a 14. Looking at this scale here, that score is in the range of a mild depressive disorder. What are your thoughts or reactions to that?”
Patient: “Not too surprised. I’ve been feeling pretty low lately.”
SKILL NO. 2: ELICIT-PROVIDE-ELICIT
When treating mental health disorders, it is essential to first explore patient preferences10 and to establish what the patient already knows (including existing beliefs and practices) about depression and treatment options. Once the extent of the patient’s existing knowledge is established, the physician asks permission to provide additional information (responsive to what has been said by the patient). After sharing brief, concise information, the physician then explores the patient’s thoughts and feelings about what has been shared. The following dialogue provides an example:
Physician: “What are some of the things you already know about that can help depression.”
Patient: “I know medicines can help, but I really don’t want to take anything.”
Physician: “What else have you heard or know about treating depression?”
Patient: “I have heard about herbal remedies. I just don’t know what would be most helpful.”
Physician: “Research and my own clinical experience have shown that different treatments have different degrees or levels of evidence and effectiveness for helping depression. Would you be interested in learning more about some of these?”
The physician provides brief, concise information about options for treatment (the Table lists various nonpharmacologic options).
Physician: “From what I’ve explained, what are your thoughts at this point?”
Patient: “From what you’ve presented, I think exercise and marital therapy sound best.”
SKILL NO. 3: TREATMENT OPTION CIRCLE CHART
At this point of the conversation another approach might be to use a “treatment option circle chart” (Figure) with the patient. In this scenario, the physician first lists the treatment options the patient is aware of in separate circles (based on the previous skill/question exploring existing knowledge) and then lists other recommended treatment options. In that case the dialogue would proceed as follows:
Figure – an example of a treatment option circle chart is shown here. In this scenario, the clinician first lists in separate circles the treatment options the patient is aware of and then lists other recommended options.
Physician: “I’ve drawn several circles on this sheet and in them I’ve written the things you’ve mentioned so far. Would you like to hear about other treatment options?”
Physician: “Based on my clinical experience and what we know from existing research, I would add the following to our chart.” (The physician writes options from the Table based on level of evidence, preference, etc, into the other circles.)
Physician: “From what we’ve written together on this chart, is there a circle that stands out to you as something you would like to discuss?”
Patient: “I think the ones with exercise and marital therapy stand out the most.”
Physician: “Can you tell me more?”
Patient: “I like the idea of starting an exercise program as I want to be healthy for pregnancy and I think my husband and I would benefit from working together at this stressful time. I do think my mood is connected to our relationship difficulties.”
The advantage of using the treatment option circle chart is that it can help physicians start where patients truly are, not where they think they are or where they should be. Consequently, this approach allows for patient autonomy and self-efficacy to be central because they are offered choices and a chance to examine what treatments, if any, they are ready to start with. The patient directs the next step with support, thereby increasing confidence and readiness to start in a positive direction.
This approach does not diminish the physician’s responsibility to make recommendations based on clinical evidence. However, the physician recognizes that it is the patient’s choice when and how he or she will begin the treatment process, if at all. Presenting all the treatment options based on what information is needed allows patients to make an informed choice that will increase the likelihood of behavior change. Patients are more likely to follow through with behavior change when all options are presented.11,12 Then, if the initial treatment they select is not effective after an agreed-upon time frame, there is still room in the conversation to explore what the next step will be. Physicians can continue to support patients’ right to choose and direct the steps they will take, which may include changing the treatment modality or strategies.
The evidence about concordance or discordance of patient expectations and treatment is another aspect of the change process worth noting (evidence on placebo and expectancy factors, being in accord with the provider about the direction of treatment).13 Specifically, when patients’ and physicians’ expectations for treatment outcome are congruous and there is confidence in the approach and treatment being provided, positive clinical outcomes are more likely. This “effect” has been largely dismissed in the medical literature (despite the placebo effect being much of what medicine had to offer patients until the 19th century) but remains a potent factor for change in clinical encounters.14
(Click to enlarge table)
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SKILL NO. 4: ASSESSING “IMPORTANCE” AND “CONFIDENCE”
The use of scaling questions to assess importance and confidence allows for a more nuanced, continuous approach to assessing readiness to change rather than a dichotomous one (yes/no; ready/not ready). Patients usually feel ambivalent about change and are often having an inner dialogue about the pros and cons of behavior change. Scaling questions purposefully explore the patient’s needs, desire, ability, and readiness to change and are designed to evoke from the patient statements toward change or “change talk.” Patients are more likely to build self-motivation based on their own, rather than others’, arguments for change.
Follow-up questions using “importance and confidence rulers” should strategically evoke statements that argue for change. Research in motivational interviewing shows a correlation between patients’ “change talk” and behavior change outcomes.15,16 Exploring patients’ readiness to change is done in a collaborative spirit and with full support of the patient’s autonomy in decision-making. The conversation should lead to a first step forward with improved patient self-efficacy.
Physician: “On a scale from 0 to 10, with ‘0’ being ‘not at all important’ and ‘10’ being ‘extremely important,’ how important is it for you to incorporate exercise into your life for the treatment of your depressive symptoms?”
Patient: “It would be an 8, something I feel that I have to do, to get unstuck.”
Physician: “You want to move on with your life. Now, on that same scale, from 0 to 10, how confident do you feel about being able to start exercising: ‘0’ being ‘not at all confident’ and ‘10’ being ‘extremely confident’?”
Patient: “That would be less, maybe a 5.”
Physician: “What makes it a 5?”
Patient: “I am very busy; I don’t know where I would find time to do that.”
Physician: “You wonder how to make space for it. I’m curious, what makes it a 5 and not a 3?”
Patient: “Well . . . I’ve done it before. When I exercise, I have more energy. I also want to be in good shape in preparation for pregnancy.”
Physician: “So, if you were able to find time to exercise, it would have some added health benefits.”
Patient: “Yes, I think so.”
Physician: “How do you feel about exploring specific, achievable goals and steps? We can also explore the option of counseling in more detail. How does that sound to you?”
Patient: “Sounds like a good place to start.”
SKILL NO. 5: COLLABORATE/PARTNER AND EXPAND SYSTEM
We are best able to assist our patients when they have the support and knowledge they need to change. Routinely, patients with depression are given an antidepressant, then asked to follow up in 4 to 6 weeks (about the time it takes most of these medications to have an effect). The problem with this plan is that persons with depression need additional support during that time to help them cope with difficulties such as side effects, lack of improvement, suicidal thoughts, discouragement, and fear of failure. Often, patients will fail to fill a prescription or take medication at a frequency or dose other than prescribed, or they may discontinue medication because of cost, side effects, and/or non-relief of depressive symptoms. Further, patients may not follow up according to treatment recommendations.
Patients with mild to moderate depression who choose medication as a starting place for treatment should be seen again within 2 weeks. Patients with severe depression that does not warrant immediate hospitalization should have weekly contact.3
Developing a team approach to treatment is the most effective way to assist patients with depression. Physicians, nurses, psychotherapists, nutritionists, and others can work to create a team to:
•Address the specific needs of the patient.
•Increase contact with the patient without putting a large burden on one health care provider.
• Provide support for the patient and providers alike.
Through this process of collaboration, patients who are already struggling can be supported in their decisions and receive guidance not only in an effort to decrease their depressive symptoms but also to develop healthy lifestyles. This may result in improved overall health and provide patients with strategies that may decrease future depressive episodes.
For larger medical settings, this can easily be done by incorporating professionals from a variety of disciplines, which is the foundation of the medical home model. For smaller offices, this approach helps independent medical providers to partner with their patients to identify the key strategies the patients are most likely to use.
Depression is highly prevalent in primary care. In this article, we have presented an alternative paradigm for treating depression that addresses the nuances of patient behavior change to increase patient autonomy and choice and to improve adherence. The treatment strategies and skills outlined in this article are evidence based.
In summary, this approach:
• Incorporates clinical feedback to discuss diagnosis and severity.
• Aids the clinician in eliciting patient preferences.
• Provides guidance and elicits patients’ choice.
• Assists the provider in identifying common strategies that are in accord with patient preferences through the use of a treatment option circle chart.
• Guides the clinician in assessing the importance and confidence/readiness of the patient to begin treatment.
• Highlights the need to engage in a collaborative approach with patients and involve other professionals as needed.
Through these processes, primary care providers can improve their ability to work collaboratively and confidently with patients and other health care providers to decrease the burden of depression with better clinical outcomes. ■
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