Table 1.

Components of the protocolized and clinical acumen depression care models

	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.