Managing depression for residents in nursing facilities.
OBJECTIVE
Review the current Centers for Medicare & Medicaid Services' (CMS) Interpretive Guidelines from the State Operations Manual (SOM) in light of evidence for management of depression found in the literature.


METHODS
Articles indexed in PubMed for the last 20 years, American Psychiatric Association Guidelines, CMS Interpretive Guidelines from the SOM, and The American Medical Directors Association (AMDA) Guidelines.


METHODS
Forty published papers were reviewed, and criteria supporting the primary objective were used to identify useful resources.


RESULTS
The literature included guidelines regarding the management of late-life depression (e.g., dosage and duration of therapy). This literature was examined in relation to the current CMS Interpretive Guidelines, which are provided to state surveyors to help them evaluate whether a nursing facility is in compliance with federal regulations. These guidelines provide explanation and clarification of the actual regulations and so are used during evaluation of the facility.


CONCLUSIONS
Current recommendations indicate that a first episode of depression should be treated for 12 months beyond full remission, according to AMDA guidelines. Longer treatment durations (maintenance phase) are needed depending on the resident's situation (e.g., severity or number of episodes). In addition, evidence suggests that antidepressants should remain at the same dose through the maintenance phase of treatment. The Interpretive Guidelines require a dosage reduction to the lowest effective dose by decreasing the dose two times in the first year unless "clinically contraindicated to discontinuation" is documented. This correlates to a dosage reduction within the first nine months of antidepressant treatment. This necessitates that in the majority of depressive episodes, clinicians document their rationale for continuing treatment. Clinicians must commit to this process, and surveyors must acknowledge this appropriate approach to depression management.
South Dakota State University College of Pharmacy, Brookings, SD, USA. Jane.Mort@sdstate.edu
Jane R
JR
Mort
Kristen E
KE
Remund
Bridget
B
Bradley
D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000928:Antidepressive Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D014487:Centers for Medicare and Medicaid Services, U.S.; D003863:Depression / Q000188:drug therapy*; D004305:Dose-Response Relationship, Drug; D005260:Female; D006707:Homes for the Aged; D006801:Humans; D009735:Nursing Homes; D017410:Practice Guidelines as Topic; D013997:Time Factors; D014481:United States
D000928:Antidepressive Agents