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Anxiety and Depression Practice Standard Summary

The Anxiety and Depression (A&D) Practice Standard supports the diagnosis and treatment of common behavioral health conditions. These include adjustment disorders, generalized anxiety disorder, panic disorder, major depressive disorder, postpartum depression, stable obsessive-compulsive disorder, and suicidal ideation. It supports screening for alcohol and substance use disorders that may require referral for diagnosis or treatment. It supports screening for conditions that complicate straightforward primary care behavioral health including bipolar disorder, hallucination symptoms, active eating disorders, seizures, and post-traumatic stress disorder (PTSD). 

Background 

The A&D Practice Standard will launch if all of the following criteria are met:

  • A patient is between the ages of 18 and 60.

  • Based on the patient’s chief complaint, the diagnoses predicted by machine learning relate to anxiety disorder, major depressive disorder, adjustment disorder, bipolar disorder, panic disorder, acute stress reaction, psychophysiologic insomnia, unspecified mood disorder, other somatoform disorders, obsessive-compulsive disorder, other situational type phobia, and postpartum depression. 

Clinical Content

Medical Interview Summary

The A&D Practice Standard starts by asking every patient the General Anxiety Disorder-7 questionnaire (GAD-7). Then it will ask either the Patient Health Questionnaire (PHQ-9) or Edinburgh Postnatal Depression Scale questionnaire (EPDS) if the patient is within 6 months postpartum. Whether completing PHQ-9 or EPDS, Question #9 of the PHQ-9 is asked to all patients to assess for suicide (see table below).

If the patient responds affirmatively to question #9 on the PHQ-9, they will receive the Ask Suicide-Screening Questions (ASQ). Patients with low/moderate or high/imminent risk factors for suicide according to the ASQ will be immediately exited out of the A&D Practice Standard to the clinician for urgent evaluation, and no further questions will be asked. 

If the patient responds negatively to question #9 on the PHQ-9 or has no risk factors for suicide according to the ASQ, patients will be asked about active eating disorders, hallucinations, alcohol use, marijuana, illegal substance use, and history of bipolar, seizures, or PTSD. If risk factors are identified, the A&D Practice Standard will screen for alcoholism with the Brief Michigan Alcohol Screening Test (bMAST), bipolar disorder with the Mood Disorder Questionnaire (MDQ), and substance use with the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). 

At the end of the automated interview, a diagnosis will be presented for the clinician’s consideration, along with relevant suggested medication options, and documentation to support the clinician’s medical decision making. In addition, referrals will be displayed. Some diagnoses may identify patients who would warrant a referral to non urgent care (in person primary care, psychiatry, addiction medicine), or the emergency department for appropriate evaluation and treatment. In those cases, the clinician will see a recommendation for the appropriate referral. Based on the diagnosis selected by the clinician, some care plans will be entered in for the patient’s education. The clinician can choose to use the suggestions provided, or change them based on their clinical decision making. 

Screening tool references:

GAD-7: Anxiety

PHQ-9: Depression

EPDS: Postpartum depression

ASQ: Suicide risk

MDQ: Bipolar disorder

bMAST: Alcoholism

ASSIST: Substance use

Virtual Care Management Pearls

  • Pregnancy and breastfeeding

    • Female patients are asked if they are currently pregnant, if they are breastfeeding, and if they have given birth in the last 6 months

      • PHQ-9 is asked if they have not given birth in the last 6 months

      • EPDS is asked if they have given birth in the last 6 months

  • Patients not currently taking a mood disorder medication will receive an automated diagnosis based on the questionnaire scores (GAD-7 and PHQ-9 / EPDS) and duration of symptoms as follows:

    • Adjustment disorder, unspecified

      • GAD-7 = Minimal / none

      • PHQ-9 / EPDS = Minimal

      • Any duration of symptoms

    • Adjustment disorder, unspecified

      • GAD-7 and/or PHQ-9 / EPDS = mild or greater

      • Duration of symptoms < 14 day

    • Adjustment disorder with anxiety

      • GAD-7 = mild or greater

      • PHQ-9 / EPDS = Minimal

      • Duration of symptoms 14 days to 6 months

    • Generalized anxiety disorder

      • GAD-7 = mild or greater

      • PHQ-9 / EPDS = Minimal

      • Duration of symptoms > 6 months

  • Major depressive disorder

    • GAD-7 = Minimal or none

    • PHQ-9 = mild or greater

    • Duration of symptoms ≥ 14 days

  • Major depressive disorder and Adjustment disorder with anxiety

    • GAD-7 = mild or greater

    • PHQ-9 = mild or greater

    • Duration of symptoms 14 days to 6 months

  • Major depressive disorder and Generalized anxiety disorder

    • GAD-7 = mild or greater

    • PHQ-9 = mild or greater

    • Duration of symptoms > 6 months

  • Postpartum depression

    • GAD-7 = Minimal or none

    • EPDS = mild or greater

    • WIthin 6 months postpartum

    • Duration of symptoms > 14 days

  • Postpartum depression and Adjustment disorder with anxiety

    • GAD-7 = mild or greater

    • EPDS = mild or greater

    • WIthin 6 months postpartum

    • Duration of symptoms 14 days to 6 months

  • Postpartum depression and Generalized anxiety disorder

    • GAD-7 = mild or greater

    • EPDS = mild or greater

    • WIthin 6 months postpartum

    • Duration of symptoms > 6 months

  • Suicidal Ideation risk 

    • If PHQ-9 question #9 is positive (≥1), ASQ is run

    • High/imminent risk factors for suicide 

      • Patients are considered high/imminent risk if both of these criteria are satisfied

        • Answer “Yes” to questions 1, 2, 3, or 4 

        • Answer “Yes” to question 5 

      • The automated interview will exit immediately to the clinician

      • Referral: Emergency department

    • Low/moderate risk factors for suicide 

      • Patients are considered low/moderate risk if both of these criteria are satisfied

        • Answer “Yes” to question 1, 2, 3, or 4 

        • Answer “No” to question 5

      • Interview: The automated interview will exit immediately to the clinician

      • Referral: Psychiatry

    • No risk factors for suicide

      • Patients are considered no risk if

        • Answer “No to questions 1, 2, 3, and 4 of the ASQ

    • The automated interview will continue until a diagnosis is reached

  • Patients currently taking a mood disorder medication receive the GAD-7 and PHQ-9 / EPDS questionnaires and if indicated will be evaluated for suicidal factors 

    • If low risk factors for suicide are present, they are asked what they take the medication for (anxiety, depression, OCD, panic, other)

    • They will receive an automated diagnosis of generalized anxiety disorder, major depressive disorder, panic disorder, or obsessive compulsive disorder according to their response, unless diagnosed with suicidal ideation and referred for in person care

    • No patients are evaluated for new panic disorder or OCD diagnoses.

  • Bipolar disorder

    • Patients are screened with MDQ if there is a family history of bipolar disorder, or no mental health medications have helped the patient feel better in the past

    • Positive bipolar disorder screen:

  • MDQ Question #1 ≥ 7 and

  • MDQ Question #2 = yes and

  • MDQ Question #3 = moderate or serious problem

  • Alcohol use disorder

    • Every patient is asked about using alcohol more than a threshold amount for their sex

      • Threshold for male: >14 alcoholic beverages in a week

      • Threshold for female: >7 alcoholic beverages in a week

      • If over threshold, screen for alcoholism with bMAST

      • Positive alcohol use disorder screen: bMAST ≥6

  • Substance use disorder

    • Every patient is asked about current use of illegal drugs or past addiction, and if they have ever been diagnosed with a substance use disorder

    • If either is positive and the patient indicates current illegal substance use, they are screened for substance use disorder with ASSIST

    • Positive substance use disorder screen:  ASSIST >27

  • Other conditions

    • Patients are asked if they are being treated for an eating disorder, if they have hallucinations or a past history of self harm, PTSD diagnosis, or seizure history

    • Treatment is not recommended, and an appropriate referral is recommended

Medication Guidelines

Automated diagnosis and medication recommendations for patients not currently taking medication for anxiety or depression are summarized in the tables below

  • Patients currently taking medication for anxiety or depression

    • Diagnosis: Generalized anxiety disorder or Major depressive disorder, recurrent, unspecified

    • No automated medication recommendation

    • Continue, adjust, or change medication (clinician to use clinical judgment)

  • Bipolar disorder positive screening

    • Diagnosis: Unspecified mood [affective] disorder

    • Medication management is not recommended (Referral: In person primary care for diagnosis and medication management)

  • Panic disorder

    • New panic disorder diagnosis or patients not currently taking medication for prior panic diagnosis

      • New panic disorder diagnosis is not evaluated separately from the anxiety evaluation above

      • No automated medication recommendations

    • Patients currently taking medication for panic disorder

      • Diagnosis: Panic disorder [episodic paroxysmal anxiety]

      • Continue, adjust, or change medication if stable and taking medication appropriate for telehealth (clinician to use clinical judgment)

  • Obsessive compulsive disorder

    • New OCD diagnosis or patients not currently taking medication for prior OCD diagnosis

      • New OCD diagnosis is not evaluated

      • Medication management is not recommended

    • Patients currently taking medication for OCD

      • Diagnosis: Obsessive-compulsive disorder, unspecified

      • No automated medication recommendation

      • Continue, adjust, or change medication if stable and taking selective serotonin reuptake inhibitor (SSRI) (Clinician to use clinical judgment)

  • Pregnancy

    • Diagnosis: Adjustment disorder, Generalized anxiety disorder, Major depressive disorder, or Postpartum depression based on results of GAD-7 and PHQ-9 / EPDS

    • Medication management is not recommended (Referral: in person maternity care provider for medication management)

  • Alcohol use disorder positive screening

    • Diagnosis: Alcohol use, unspecified with other alcohol-induced disorder

    • Medication management is not recommended

  • Substance use disorder positive screening

    • Diagnosis: Other psychoactive substance abuse, uncomplicated

    • Medication management is not recommended

  •  Other conditions

    • Active eating disorder,  hallucinations or a past history of self harm, PTSD diagnosis, or seizure history

      • Diagnosis: Counseling unspecified

      • Medication management is not recommended

Follow-up Recommendations to be Discussed with the Patient

  • Adjustment disorders not treated with new prescription medication

    • Referral: Counseling

    • Follow up: 2-4 weeks

  • Adjustment disorders, Generalized anxiety disorder, Major depressive disorder, or Postpartum depression with new or ongoing medication treatment:

    • GAD-7, PHQ-9, and EPDS provide longitudinal measures for interval improvement or worsening of symptoms

    • Treatment goal should prioritize depression if both anxiety and depression are present

    • Follow up: 2 weeks after new prescription started to review side effects, sooner if symptoms are worsening

    • Follow up: Every 4 weeks until remission is achieved.

      • Increase medications as tolerated to achieve improvement with each visit (clinician to use clinical judgment)

      • Remission targets: 

        • GAD-7 < 5 (Minimal/none)

        • PHQ-9 < 5 (Minimal)

        • EPDS < 12 (Minimal)

        • If not in remission, consider increased dose or augmentation (clinician to use clinical judgment)

      • If in remission and not ready to wean

        • Medication refill for 90 days (clinician to use clinical judgment)

        • Follow up: Every 3 months (clinician to use clinical judgment)

    • Referral: Counseling at first visit

    • Review counseling recommendations at every visit

  • Suicide Risk Factors

    • High/imminent risk factors

      • Referral: Emergency department

    • Moderate/low risk factors

      • Referral: Psychiatry

  • Bipolar disorder positive screening

    • Referral: In person primary care

  • Alcohol use positive screening

    • Referral: In person primary care

  • Substance use positive screening

    • Referral: Addiction medicine

  • Obsessive compulsive disorder

    • Stable treated OCD

      • No referral recommended

      • Medication refill and follow up per clinician’s clinical judgment

    • New OCD diagnosis

      • Diagnosis, referral, and follow up per clinician’s clinical judgment

  • Panic disorder

    • New panic disorder diagnosis or patients not currently taking medication for prior panic diagnosis

      • No referral recommended

      • Follow up per anxiety evaluation and clinician’s clinical judgment

    • Patients currently taking medication for panic disorder

      • No referral recommended

      • Follow up per anxiety evaluation and clinician’s clinical judgment

  • Other conditions

    • Active eating disorder,  hallucinations or a past history of self harm, PTSD diagnosis, or seizure history

    • Referral: In person primary care, emergency department or Psychiatry (clinician to use clinical judgment)

ICD-10 Codes Provided

In coding these visits, we recommend “unspecified” rather than the degree of symptoms so that visits are coded with consistency. Based on diagnostic criteria:

Associated Available TextExpanders (if needed)

Please see your institution's Text Snippet document on available options.

Chat and Documentation Suggestions

In addition to presenting diagnostic and treatment suggestions for consideration by the clinician, the A&D Practice Standard presents chat and documentation suggestions to the clinician for consideration based on previous machine learning. The suggestions are tied to the selection of a  diagnosis suggested for consideration by the clinician. For example, if the A&D Practice Standard suggests Suicidal Ideations as the ICD-10 diagnosis AND the clinician selects Suicidial Ideations as the ICD-10 diagnosis, the chat and documentation suggestions will relate primarily to suicidal ideation diagnosis and treatment.

Citations

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