Table 1.
Protocolized model | Clinical acumen | |
---|---|---|
Training |
•One day training for all involved cadre |
•One day training for all involved cadre |
•On-site training and oversight by study staff during first four weeks of implementation |
•On-site training and oversight by study staff during first four weeks of implementation |
|
•Periodic training schedule to train new staff that emerge (typically site specific) |
•Periodic training schedule to train new staff that emerge (typically site specific) |
|
STEP 1: Routine Screening |
•All adults screened with 2-item PHQ-2 at each clinic visit |
•All adults screened with 2-item PHQ-2 at each clinic visit |
•Performed at triage station (Expert-clients/VHTs) |
•Performed at triage station (Expert-clients/VHTs) |
|
•PHQ-2 > 2 signifies depression, continue to Step 2 |
•PHQ-2 > 2 signifies depression, continue to Step 2 |
|
Documentation: Clinic’s triage book |
Documentation: Clinic’s triage book |
|
STEP 2: Diagnosis |
•Is patient’s treatment status (either ART or OI treatment) in flux (about to start or newly started)? (Nurse) YES = not medically stable, so wait and monitor NO = medically stable, administer PHQ-9 |
•PHQ-2 score is relayed to prescribing clinician |
•Prescribing clinician uses their judgment to determine whether to further evaluate depression, rather than a protocol | ||
•Administer PHQ-9 (Nurse) |
•However, prescribing clinicians are trained to follow-up positive PHQ-2 screens with: |
|
•PHQ-9 > 9 signifies clinical depression |
1) Assessment of medical stability |
|
•Consider MINI criteria to determine diagnosis |
2) PHQ-9 |
|
•If meets criteria for diagnosis, continue to Step 3 |
3) Consider MINI criteria |
|
Documentation: Patient’s medical chart |
Documentation: Patient’s medical chart |
|
STEP 3: Prescribe treatment |
•Provide psychoeducation to client about depression and what to expect from antidepressant treatment (Nurse) |
•Provide psychoeducation to client about depression and what to expect from antidepressant treatment (Prescribing Clinician) |
•Select most appropriate antidepressant |
•Select most appropriate antidepressant |
|
•Prescribe antidepressant |
•Prescribe antidepressant |
|
•Schedule follow-up visit two weeks later |
•Schedule follow-up visit two weeks later |
|
Documentation: Depression Treatment Registry |
Documentation: Depression Treatment Registry |
|
STEP 4: Monitor treatment |
•Follow-up at Week 2 and then monthly until responding, then scheduled with routine clinic visit |
•Follow-up at Week 2 and then monthly until responding, then scheduled with routine clinic visit |
•At each follow-up, assess side effects, symptoms and need for medication or dose change (Nurse) |
•At each follow-up, assess side effects, symptoms and need for medication or dose change (Prescribing Clinician) |
|
Documentation: Depression Treatment Registry |
Documentation: Depression Treatment Registry |
|
STEP 5: Stop treatment |
•Stop treatment once patient responding for six months (unless patient has had 2+ prior episodes, then continue for two years) |
•Stop treatment once patient responding for six months (unless patient has had 2+ prior episodes, then continue for two years) |
•Taper down dosage using dosing protocol |
•Taper down dosage using dosing protocol |
|
|
Documentation: Depression Treatment Registry |
Documentation: Depression Treatment Registry |
Supervision | •Psychiatrist assigned to each clinic |
•Psychiatrist assigned to each clinic |
•Supervision visits are done monthly | •Supervision visits are done monthly |
Legend: ART, antiretroviral therapy; OI, opportunistic infection; MINI, Mini Neuropsychiatric Interview; PHQ, Patient Health Questionnaire; VHT, village health team.