Improving Patient-Centered Care for Veterans With Treatment-Resistant Depression Using Shared Decision-Making Tools

Treatment-resistant depression (TRD) exists when patient depression continues without remission or reduction despite treatment. There are no standardized guidelines for identifying TRD, but one failed antidepressant treatment at an adequate dose and duration can constitute TRD, especially in cases of severe depression or suicidality. TRD rates for depressed patients average approximately 50% to 60% of the general population. These numbers are higher in the military population and are often complicated by comorbidities. Chart audits revealed 68% of psychiatric clinic outpatient veterans met criteria for TRD. Only 25% of patients were being treated adequately for TRD, and 0% were offered other options for treatment. This project aimed to improve patient-centered TRD care at a veteran’s hospital to 80% within 90 days. This quality improvement project was implemented using plan-do-study-act (PDSA) cycles. Interventions were tested over four rapid-cycle phases with improvements for screening, handouts, surveys, and team meetings over 8 weeks. Four core interventions were followed throughout the project: screening for TRD, right-care case management tracking, patient engagement with shared decision-making (SDM), and team engagement. Starting from a baseline right-care score of 25%, the project attained an overall mean of 99.6% representing improved patient-centered TRD care and surpassing the 80% goal defined in the aim. Overall TRD care was improved using SDM options and inter-clinic teamwork and communication.