| 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 |