Activity 1: Cultural Nuances and Challenges in Diagnosing and Treating Depression

Practice recommendations discussed in this program are from the following sources:

Institute for Clinical Systems Improvement

Source: Institute for Clinical Systems Improvement. May 2009. Depression, Major, in Adults in Primary Care.
Strength of Evidence: The strength of evidence is indicated following each recommendation. See table below for description of evidence levels.

Recommendation #1: The PHQ-9 has been validated for measuring depression severity. The factor structure of the 9 items is comparable when tested with African Americans, Chinese Americans, Latino and non-Hispanic white patient groups. (C)

Recommendation #2: The PHQ-9 is an effective management tool and should be used routinely for subsequent visits to monitor treatment outcomes and severity. It can help the provider decide if/how to modify the treatment plan. (C)

Recommendation #3: The concept of depression varies across cultures. For example, in many cultures, for depression to become a problem for which a person seeks medical treatment, symptoms may include psychosis, conversion disorders or significant physical ailments. (D)

Recommendation #4: Psychotherapy, especially focused psychotherapy, can significantly reduce symptoms, restore psychosocial and occupational functioning, and prevent relapse in patients with major depression. (M)

Recommendation #5: Because both antidepressants and psychotherapy are effective, careful consideration to patient preference for mode of treatment is appropriate. (A)

Recommendation #10: 10%–75% of patients are non-compliant with medication use, and rates are higher in intercultural settings because of cultural expectations and communication problems. (R)

American College of Physicians

Source: American College of Physicians. Using Second-Generation Antidepressants to Treat Depressive Disorders: A Clinical Practice Guideline from the American College of Physicians Qaseem A, et al. Ann Intern Med. 2008;149:725-733.
Strength of Evidence: The strength of evidence is indicated following each recommendation.

Recommendation #6: When choosing pharmacologic therapy to treat acute major depression, select second generation antidepressants on the basis of adverse effect profiles, cost and patient preferences. (Strong recommendation; moderate-quality evidence)

Recommendation #7: Assess patient status, therapeutic response and adverse effects of antidepressant therapy on a regular basis beginning within 1–2 weeks of initiation of therapy. (Strong recommendation; moderate-quality evidence)

Recommendation #8: Modify treatment if patient does not have adequate response to pharmacotherapy within 6–8 weeks of initiation of therapy for MDD. (Strong recommendation; moderate-quality evidence)

Recommendation #9: Continue treatment for 4–9 months after satisfactory response in patients with a first episode of MDD. For patients who have had 2 or more episodes of depression, a longer duration of therapy may be beneficial. (Strong recommendation; moderate-quality evidence)

Evidence Grading System

A. Primary Reports of New Data Collection
Class A: Randomized, controlled trial
Class B: Cohort study
Class C: Non-randomized trial with concurrent or historical controls
Case-control study
Study of sensitivity and specificity of a diagnostic test
Population-based descriptive study
Class D: Cross-sectional study
Case series
Case report
B. Reports that Synthesize or Reflect upon Collections of Primary Reports
Class M: Meta-analysis
Systematic review
Decision analysis
Cost-effectiveness analysis
Class R: Consensus statement
Consensus report
Narrative review
Class X: Medical opinion
A full explanation of ICSI’s Evidence Grading System can be found at

Institute for Clinical Systems Improvement (ICSI) 2009, Depression, Major, in Adults in Primary Care

American College of Physicians (ACP) Second Generation Antidepressant Guidelines

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