Depression Clinical Pathway — Outpatient Behavioral Health and Primary Care

Course of Treatment

Behavioral Health Specialist

Initial Acute Phase: Weeks 0-8 Reassess symptoms and functioning at least every 4 weeks to monitor response	At some point between weeks 4-8, assess overall progress If started with supportive psychotherapy If clinical response, continue as is If still mildly depressed, then a trial of CBT or IPT-A is recommended. If now moderately or severely depressed, then medication and/or CBT or IPT-A is recommended. If started with CBT or IPT-A If clinical response, continue as is If now moderately or severely depressed, consider adding medication.
Acute Phase: Months 3-9 Reassess symptoms and functioning at least every 4 weeks to monitor response	If CBT, IPT-A or supportive psychotherapy If clinical response continue to treat until remission then move to continuation treatment or discharge If minimal, no response, or worsening provider may choose to increase the level of care, switch to (or augment with) a different therapy modality, or augment the therapy with medication. If treating solely with medication If clinical response continue treatment until remission then move to continuation treatment or discharge If minimal, no response, or worsening provider may choose to increase the level of care, change the medication, and/or or augment with CBT or IPT-A If combined treatment (medication and therapy) If clinical response continue treatment until remission then move to continuation treatment or discharge If minimal, no response, or worsening provider may choose to increase the level of care, switch to (or augment with) a different therapy modality, and/or change the medication
Continuation Phase: Reassess symptoms and functioning every 3 months to monitor response	Continue continuation treatment for 6-12 months or at least until recovery. At this point options include Discharge Maintenance Treatment
Maintenance Phase: Reassess symptoms and functioning every 3 months to monitor response	Continue continuation treatment for 6-12 months or at least until recovery. At this point options include Continue maintenance treatment for 6-12 month until discharge.

Pediatrician

	Mild MDD/ Other Specified Depressive Disorder	Moderate MDD	Severe MDD
Initial Evaluation Phase: Week 0- 3 Initial assessment through completion of full assessment	Screening Tool Depression Evaluation Active Monitoring Link to Counseling (if needed)	Screening Tool Depression Evaluation Active Monitoring Safety Planning (if needed) Link to Counseling Consider medication	Screening Tool Depression Evaluation Active Monitoring Safety Planning (if needed) Medication Refer to psychiatry Link to counseling or refer to IOP
Acute Phase: Week 4 - 8 Ongoing through referral therapy/program	Follow-Up Assessment If clinical response continue Active Monitoring and/or supportive psychotherapy every 2-4 weeks Telephone Support If no clinical response, link to counseling if not already done, otherwise, coordinate with outside therapies.	Follow-Up Assessment Active Monitoring Link to Counseling Monitor side effects to medications Telephone Support If no clinical response, recommend increase medications, refer to psychiatry or consult by phone, drug screen, consider IOP Office visits every 2 -4 weeks	Follow-Up Assessment Active Monitoring Link to counseling – coordinate with outside provider Coordinate with outpatient psychiatrist If no longer seeing psychiatry, monitor medication response ongoing. If no clinical response, increase medications, refer to psychiatry or consult by phone, drug screen, weekly phone call/ email check ins, consider increase in intensity of psychotherapy, or refer to IOP or PHP. Schedule office visit for 2-4 weeks with recommended telephone support between visits
Active Monitoring Phase: Week 8 through 12 Months or until Remission Ongoing in coordination with counseling/program	Follow-Up Assessment Active Monitoring Repeat Screening Tool If no clinical response, consider medication and link to counseling if not already done, otherwise consult with outside therapist Telephone Support Schedule every 2-4 weeks. If stable, schedule every 4-8 weeks.	Follow-Up Assessment Active Monitoring Repeat Screening Tool Link to Counseling – coordinate with outside therapist Monitor side effects to medications Telephone Support If no clinical response, increase or change medication, refer to psychiatry or consult by phone, drug screen, consider IOP Schedule every 2-4 weeks. If stable reschedule every 4-8 weeks	Follow-Up Assessment Active Monitoring Repeat Screening Tool Link to Counseling Telephone Support If no longer seeing psychiatry, monitor medication response ongoing. If no clinical response, increase or change medication, refer back to psychiatry or consult by phone, drug screen, consider increase in intensity of psychotherapy, or refer to IOP or PHP Schedule every 2-4 weeks. If stable reschedule every 4-8 weeks
Maintenance Phase: 1 -2 years	Active Monitoring Repeat screening tool every 2 - 3 months Continue medication for 6-12 months after remission, with monthly visits. Continue to complete follow-up assessment. After 12 months, consider weaning off medications, be aware of future challenges before medication wean - i.e. starting college, changing schools, divorce. Maintain contact with mental health specialist, if such treatment continues At any point, if patient relapses or has a recurrence of major depression, return to start of timeline

At any point, if patient relapses or has a recurrence of major depression, return to start of timeline

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.