Major Depressive Disorder

by Michael S. Peroski, DO, CMQ, FAPA, Medical Associates Clinic Department of Psychiatry & Psychology

According to the CDC, Major Depressive Disorder (MDD) affects roughly 5% of our population and is the chief complaint of over 15 million visits annually to primary care offices. Death by suicide in the United States has continued to rise to 14.5 people per 100,000 annually. Given this, timely diagnosis, and treatment of MDD is essential. Over 50% of patients with MDD are seen and treated exclusively in primary care offices. Here, we will discuss the diagnosis and treatment of MDD.

Diagnosing MDD starts with a clinical interview. A diagnosis of MDD requires that a patient have five of the symptoms of MDD for at least two weeks, with at least one of these symptoms being either depressed mood or anhedonia (lack of enjoyment from activities). Other symptoms of MDD include sleep disturbance, feelings of guilt or worthlessness, low energy, poor concentration, changes in appetite, changes in the rate of movement and thinking or suicidal thoughts.

In diagnosing MDD, it is important to rule out underlying medical issues such as hypothyroidism, anemia, vitamin deficiencies, sleep apnea, etc. At the minimum, I would recommend checking a complete blood count w/differential, complete metabolic profile, B12, Folic Acid, Thyroid Cascade, and Vitamin D level when assessing depressed patients. It is also important to inquire about substance use and symptoms of bipolar disorder to ensure that these are not missed.

Having a diagnosis of MDD does not help us to understand the underlying issues at hand. In psychiatry, we think of patients through a biopsychosocial lens. Within this framework, we think about biological issues such as brain biology, family history, substance use, medical issues, prior diagnoses, and med trials. Within the psychological side of this we think about the ability to tolerate distress, dysfunctional thought patterns, and coping skills, among other things, and we may consider therapy to help with this if indicated. Lastly, we think about social factors such as support, housing, income, ongoing trauma, etc. Depending on which one or ones of these are most present, our treatment may vary. 

Medication management targets the biological side of the biopsychosocial model of care. For MDD, treatment usually consists of antidepressant medications. These can include Tricyclic Antidepressants (TCAs), Monoamine Oxidase Inhibitors (MAOIs), Selective Serotonin Reuptake Inhibitors (SSRIs), Selective Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs), Bupropion, Mirtazapine, Vortioxetine, Bupropion/Dextromethorphan, and Vilazodone. When monotherapy with these is not adequate, they are often either combined, where appropriate and safe, or used in combination with adjunct therapies like atypical antipsychotics.

In cases where there are no contraindications to these medications and without a specific reason to select one agent, treatment usually starts with an SSRI because of their favorable safety profile over TCAs and MAOIs. Keep in mind that paroxetine is more highly anticholinergic, and fluvoxamine has numerous medication interactions. If two SSRIs fail, then we will often move to an SNRI. Specific comorbidities may guide towards deviating from this, such as mirtazapine being selected when patients have poor sleep and appetite, an SNRI for patients with comorbid pain, or bupropion in patients with low appetite and low energy. Bupropion can sometimes paradoxically increase anxiety and it should not be used in patients with epilepsy or eating disorders.

In addition to medication management, offering transcranial magnetic stimulation (TMS) in which patients received repetitive magnetic pulses to stimulate the left dorsolateral prefrontal cortex for MDD may be an option.  This treatment is FDA approved and highly effective. TMS is also FDA approved for obsessive-compulsive disorder (OCD) and tobacco use disorder. In severely treatment resistant cases, electroconvulsive therapy (ECT) in which a seizure is induced under anesthesia remains the gold standard treatment.

The pipeline for drug discovery is very exciting for MDD. Intranasal esketamine has been approved for the treatment of acute MDD but needs to be administered by trained behavioral health professionals in a specialized setting. For the first time since the advent of SSRIs, several novel therapies are coming or have been approved. These include medications targeted at the glutamate system, the orexin system, the mechanistic target of rapamycin complex (mTORC1) , serotonin-norepinephrine-dopamine reuptake inhibitors, GABA-A modulators, psilocybin, and even Botox on frown lines.

If there are any questions or if a patient is not improving with 2-3 trials of antidepressants, a referral to a behavioral health specialist is recommended. I hope that this discussion has helped to summarize the diagnosis and treatment of MDD. 

Diabetes: Documentation and Coding to Support Quality Care

At Medical Associates Health Plans, we want providers to get credit for the quality care you are providing our members through accurate and complete documentation and coding. Your documentation should reflect the true nature of the patient’s current health status at the highest level of specificity. Per ICD-10 official guidelines for reporting and coding, “The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation, accurate coding cannot be achieved.”

Diabetes Mellitus is one of the most prevalent chronic conditions in our population. Below are some documentation and coding tips to support the documentation of this condition.

There is no default code for diabetes mellitus documented only as “uncontrolled.” The provider must document whether the diabetic patient is hypoglycemic or hyperglycemic based on clinical assessment and findings to determine the appropriate code to bill. Type 2 Diabetes Mellitus with hyperglycemia (based upon Hgb A1C results and other clinical assessments) is a very commonly missed coding opportunity.

Be sure you are documenting in detail any associated conditions/complications that the patient may have related to their diabetes so the most accurate ICD-10 code may be assigned. This may include conditions/complications such as diabetic retinopathy, neuropathy, nephropathy, chronic kidney disease, and peripheral vascular disease. Also, be sure to document the current treatment for these conditions/complications and the current response to treatment.

If you would like any additional information concerning documentation improvement, you may contact our Quality Improvement team at (563) 584-4849. 

Understanding the Crucial Role of Social Determinants of Health in Patient Care

As healthcare providers, you are at the forefront of healthcare, entrusted with the well-being of your patients. Your clinical expertise is vital in diagnosing and treating diseases. However, it is important to recognize that health outcomes are not solely determined by medical interventions. An array of factors outside the clinic walls, known as social determinants of health (SDOH), profoundly influence patients' overall well-being.

Social Determinants of Health (SDOH) are the conditions in which you and your patients live, work, and play – they are the forces and institutions shaping the conditions of daily life, public policies, and social norms – and play a fundamental role in people’s health, well-being, and quality of life. Examples of SDOH include:

• Safe housing, transportation, and neighborhoods
• Racism, discrimination, and violence
• Education, job opportunities, and income
• Access to nutritious foods and physical activity opportunities
• Polluted air and water
• Language and literacy skills

When screening for SDOH, it is important to have a plan for what to do when needs are identified. While acknowledging and documenting the needs may help a clinician better understand their patient's stressors, having a mechanism to assist with a need will provide more benefit to the patient, the clinician, and the community. Ensuring that the patient wants assistance and engaging the patient to determine what will be most helpful to them is essential.

Physicians should incorporate SDOH screening tools into routine patient assessments. By identifying patients' social risk factors, healthcare providers can better understand their unique challenges and tailor interventions accordingly. This information can guide appropriate referrals, resources, and support services.

Recognizing the influence of social determinants of health is essential for physicians striving to provide comprehensive patient care. By understanding and addressing these factors, we can promote health equity, improve patient outcomes, and work towards a healthcare system that addresses the diverse needs of all individuals. As advocates, educators, and caregivers, physicians possess the power.

To learn more about this subject, download Diversity and Cultural Competence Training