title: Managing high-acuity-depressed adults in primary care.
abstract: OBJECTIVE
  To identify strategies for managing high-acuity-depressed adults in primary care settings. Patients who do not achieve remission with initial treatment, patients at risk for suicide, and patients with co-occurring substance use disorders are specifically addressed.
  
  
  METHODS
  Scientific literature and evidence-based practice guidelines.
  
  
  CONCLUSIONS
  Accurate diagnosis is best accomplished using screening instruments as an adjunct to a thorough history and assessment. The goal of interventions is remission of symptoms as opposed to a partial response. Patient preferences regarding choice of intervention must be considered. Initial pharmacotherapy must include adequate doses and a trial of adequate duration. Patients who do not respond to two medication trials are at risk for suicide and/or have a co-occurring substance use disorder may require: (a) a combination of medications coupled with psychotherapy; or (b) referral to mental health specialists to achieve the best outcomes.
  
  
  CONCLUSIONS
  High-acuity patients with mental health needs will continue to be seen in primary care settings. Through educational preparation and a patient-centered focus, advanced practice nurses in primary care settings are in an optimal position to set a high standard of care for complex mental health patients.
authors: College of Nursing, Upstate Medical University, Syracuse, New York 13210, USA. sobczakj@upstate.edu
authors: Janet Ambrogne
authors: JA
authors: Sobczak
mesh_terms: D000928:Antidepressive Agents / Q000627:therapeutic use*; D000929:Antidepressive Agents, Tricyclic / Q000627:therapeutic use; D003863:Depression / Q000188:drug therapy / Q000451:nursing*; D055318:Evidence-Based Nursing; D006801:Humans; D009722:Nurse Practitioners; D011320:Primary Health Care; D011594:Psychometrics; D012307:Risk Factors; D017367:Selective Serotonin Reuptake Inhibitors / Q000627:therapeutic use; D012720:Severity of Illness Index; D000092864:Suicide Prevention
chemical_list: D000928:Antidepressive Agents; D000929:Antidepressive Agents, Tricyclic; D017367:Selective Serotonin Reuptake Inhibitors