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.
Data Sources: 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.
Study Selection and Data Extraction: Forty published papers were reviewed, and criteria supporting the primary objective were used to identify useful resources.
Data Synthesis: 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.
Conclusion: 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.