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Thank you so much. Uh It's a real honor to be able to talk about uh a topic that's really uh something I care very much about. I wanna help improve the treatment of depression. And one of the most important ways to do that is to have the right kind of patient engagement and collaborative decision making. And the organization that I represent CMAT has really pioneered a particular approach to this. So I'm going to be sharing some of our insights that are derived from treatment guidelines but also adapted to specific aspects of patient engagement. First of all, you might be asking what is CMA it's an academic organization based in Canada and it's been around since uh 1995. It produces guidelines and I'm uh honored to say that Kma Depression guidelines and Kanmet bipolar guidelines are the world's most cited guidelines and really used in many, many countries in the United States. The US National Network of Depression Centers, another large organization uh coalition of 25 universities actually has an agreement with Kmet to disseminate Kanmet guidelines across the United States. So how did the guidelines get organized? Uh They are organized more in a patient friendly and clinician friendly way. They're organized around eight key questions and the questions are listed here and they're meant to follow the patient journey and the patient journey begins with who should be treated for depression. What are the basic management principles? How do you start with an initial treatment? Is there a role for digital health? How do you monitor treatment? What do you do if the patient is doing better? What if, what do you do if they're not doing better? And what are your other treatment options in really tough situations? These are the eight overarching questions which are then answered in a very simple way. We've posed a number of smaller questions under each of these master questions. And we try to deliver a two paragraph answer that is appropriately referenced and we indicate the level of evidence, but we also do something else we say, is it first line, is it second line, is it third line? And we do so by integrating the evidence and what we call clinical support. And that is a consensus decision amongst the guideline authors about practical concerns, side effect concerns tolerability issues and safety concerns about that medication. So um I'll, I'll speak more about that in a second. So here is the evidence. Again, we follow widely accepted standards, but rather than using only numerical ways of con notting that evidence, like level one is the best evidence we said, why don't we have a visual. So it's easy. So we came up with this idea of using these circles and green is good. And if the circle is fully filled in, that means there's a lot of evidence. So at the top, there you see a fully filled in green circle that means level one evidence according to the medical literature, which means that a meta analysis supports this and that meta analysis has narrow confidence intervals, Meaning that we're pretty sure that the results are accurate and meaningful. If you're a little bit less uh secure in the evidence, maybe a piece of the pie, a piece of that circle is missing. And that's level two evidence. That means that there's at least one good RCT with uh with a placebo or uh there are meta analyses, but the confidence intervals are more wide. If there are uh a simple smaller study, then that's you get half the pie and that's level three. And if there's just small studies, open uh case reports and expert opinion, then you get a little bit of evidence and that's level four in just one piece of the pie. As I mentioned, we also outlined them as first line, second line and third line treatments. And here is an example of how we do that. We know that tricyclic antidepressants and SSRI s have good evidence for the treatment of depression. But we also know that tricyclics are more dangerous in overdose and generally have slightly more side effects. So for that reason, we have downgraded tricyclics from first line treatments for depression to second line treatments for depression. And that's the kind of uh approach we take uh across all the different interventions. There may be two interventions that have similar kinds of evidence. But if there are differences on safety, tolerability, practicality, we might downgrade the one that we think is more problematic. One of the key things we did in this uh creation of a patient uh sorry of a clinician guideline for depression is we said, let's get the voice of patients in there, people with lived experience. And uh one of the sections uh of our guideline is of course, what do you do if the person's not getting better and that's usually called treatment resistant depression. But we know that there are problems with the definition of that and some of the problems and the limitations of that uh definition are there. But what our patients told us is they don't like the term T RD, treatment resistant depression. Imagine if you went to a cancer doctor and they said hi, not that you have stage three cancer or stage four cancer, but you've got treatment resistant cancer. That's a downer. So they suggested uh we didn't invent this. Others in the field had invented this. But CMD is really advocating for this, the term difficult to treat depression and where possible we're gonna call depression when things aren't working out difficult to treat depression. We also use the term difficult to treat depression in situations where the person may not even have had any depression treatment. But it's a complicated situation because they have multiple medical comorbidities or many other polypharmacy concerns outside of psychiatry. And so it's just AAA trickier situation. So that's a difficult to treat depression as well. What are the ways that we advise clinicians to treat depression? Well, the ones that are highlighted are the ones that uh are pertinent to today's discussion, collaborative decision making, uh having the patient uh uh preferences known and understanding their attitudes and making sure that they're really in informed about the various treatments before they uh select one. The other considerations for treatments that we have for clinicians are listed on this slide. Um They're there for you to read and they're there in the guidelines, but we're really gonna concentrate on engaging the patient and making sure that they know what options are open. No, one of the key things we say is uh for clinicians and we emphasize with patients are what are the basic management principles around uh organizing and delivering depression treatment. And here's a pretty picture, a circle of all the things that uh have to be done. But for today, I'm going to just concentrate where the two blue stars are. Number one, we're gonna be talking about uh the kind of education and self management advice that patients need to have. And number two, the other star is just emphasizing that it's really helpful to use measurement based care. How can we deliver better patient education? Well, what we did is when we first created depression guidelines uh recently, uh not on not the 2023 version, but the uh uh preceding version, we were also encouraged to get patients involved. So what we did is we undertook a different project where we had seven people with lived experience of depression who were also skilled writers, go through our treatment guidelines for clinicians and modify it and adapt it and add extra tips, not treatments, just extra tips for patients on how to approach depression. This is your handy guide to educating patients making them informed about various treatments and by exploring this with them, you're engaging in collaborative decision making. It's available on the website. It's available on uh it's free. It's about the size of a, a magazine. It's about 3040 pages, bright colors, big print, easy to read, uh lots of tables and I'm gonna just walk you through it now. So here's the overall um table of contents for this. It starts with a general introduction which is actually pretty important because it tells people things like, well, how do you prepare for your first appointment with a clinician and so on. It goes through the standard thing, psychological treatment, medication treatments, neurostimulation treatments. But we also have sections that pertain to what patients often ask us about. So complementary and alternative treatments, exercise herbs, uh things like that, light therapy. Uh But we also have a number of helpful uh small sections about common abbreviations that we use in the mental health field. Um What's the difference between a psychiatrist and a psychologist and a social worker and a nurse clinician and all that? Um and some various other resources. And finally, there's a section for family members or friends on how to support someone with depression. So here's a, an example, one of the pages which is actually the quick summary page uh from this guide. So um you can see we just cherry picked a few of the questions that we answer in this patient and family guide to depression. How do I know if I'm depressed? Um What else can I do the psychotherapy work? Uh Why would I consider medications? And I'm gonna walk you through more of the individual tables. So here's the introduction. And again, uh you can see that there are a number of topics there, but I'm gonna draw your attention to the fact that it it answers and number of questions that we wish patients would know. Uh but we often don't have the chance to fully explain them. So, you know, will you always have depression? Uh how can technology be used to treat depression? Uh the first step of treatment, meeting with your healthcare provider and so on. So there's some advice there for them. So here is an example of what our patient writers told us and which we put in this uh guide. And they said, you know, here are some things, bring your symptom checklist. So there's a symptom checklist in the introduction. So patients can fill out the symptom checklist, which is not a rating scale, but it's just a guide for the patient to be able to capture the frequency and intensity and type of symptoms. Write down your current medications, make sure you have a list of all your other medical conditions and ask your relatives about family history. So again, you come prepared to this clinical interview. Here's an example of how we talk about the different forms of psychotherapy. This is not the only thing. This is just one table. There are several pages devoted to answering questions about what are different types of psychotherapy and what happens and how, how does the patient engage in the psychotherapy? But the first uh table that summarizes the best recommendations and, and corresponding to the Kanmet uh first line treatments for depression. There were three first line psychotherapy treatments, CBT I PT and behavioral activation. So we explained them briefly here. There's a little bit more detail in the balance of the uh document here is an example of where you can really engage in informed treatment. We have a number of tables like this and I'm gonna show you a couple where we say the pros and the cons and here this table sets up the pros and the cons of psychological treatments. Everything has, has cons psychological treatments have side effects. And I emphasize that with my patients, here's an example of some of the pros and cons about psychotherapy, it talks about the advantages in terms of, well, you don't have medication side effects, but then it takes longer to work. Um And uh you know, psychotherapy is a much safer in pregnancy, of course. Um but on the cons, it requires a lot of effort and so on, there are these kinds of considerations. Um even before the pandemic, people used to wonder whether psychotherapy by phone or video work. So we, we address this and we address the issue of what comes first. Should we start with psychotherapy then add meds or uh do they work well together? Those are other kinds of discussions that we have and we, we have brief answers to these questions, but we also usually have a little bit more discussion later in the document. So here is the um uh pro and con list about using antidepressant. So there are a number of pros and we're used to as clinicians advocating for the, the distinct uh good aspects of medications and beyond just side effects, there are other cons and we list them here uh including things like um you know, the interactions with other medicines. Uh And unfortunately, the, the honesty that you know, the first one you try doesn't always work and so on. Well, if there are two major treatments, psychotherapy and medication doctor, how am I supposed to choose? That's a common question that our patients pose. Here's a, an attempt at an answer. How do I choose between antidepressant medication and psychotherapy? And we have the two dark blue boxes here, uh where one says antidepressant medication is likely the best type, type of treatment if and a couple of the answers are well, if it's more severe, probably start with medicines or psychotherapy is simply not uh available. Uh Those are a couple of the examples. Psychotherapy is uh better and we're very clear in our clinical guideline that if you have mild depression, it's probably better to start off with psychotherapy rather than pharmacotherapy. Uh And there are, you know, certainly other situations where psychotherapy is more appropriate. Now, patients want to be able to use comprehensive approaches. They don't just want psychotherapy and medication and they also want things that they can do and the things that are the most commonly cited by people around the world. What's the role of exercise? What about yoga? What about acupuncture? What about light therapy? Again, we have a brief description of what the table. Uh sorry what the treatment is like in this table, but we also have the recommendation there and the recommendation is a, it's a bit like what we did for clinicians, you know, first line, second line, third line, we said strong medium or weak recommendations. And again, that's, you know, using it in patient friendly language. This is a strong recommendation and we do explain at the bottom of the table which you can't see here what we mean by a strong recommendation and what we mean by a weak one and so on. And basically, it's a uh juxtaposition of evidence and appropriateness and uh again, side effects cost uh and things like that. So we have these here as well. People like to use herbs and uh I certainly like to use herbs when I cook. But for depression, so many patients like to use herbs. And here's a list of some herbs as well as some supplements. And you can see here that we have the recommendations upfront. So we don't explain what these are in this table. We have a little bit of explanation elsewhere, but we thought it was really important because some people get carried away with. Uh oh, well, you know, the Omega threes are going to work or uh crypt Ahan, which used to be a fan favorite uh will work. But we think it's really important to think about evidence. And part of the reason we thought this was different than the other complementary treatment like exercise is we think that there's real harm that can be done by these by clinging to things that may have weak recommendations and delay more effective treatment. I don't think anyone will uh suffer much harm from exercising. Um but they may suffer some harm if they delay treatment by uh taking, you know, inositol for instance, or even uh folate and so on. And we also clarify whether the evidence and the recommendation is whether these things should be added on to treatment or could be uh a, a monotherapy. Well, we've covered the basics of patient education, just a word or two about measurement based care. And here's where digital health care could be of some uh key value. Now, what do we mean by measurement based care? We mean that you actually have some numbers that you can use to follow how the patient is doing. We're all familiar with using BP and saying, OK, your hypertension is worse or or not. Yeah, I've given you a treatment, let's measure the BP again and see how you're doing. Um It's been well established through research that if we do the same with depression rating scales, whether they're patient rating scales or they're, they're clinician scales that having that signal, oh, the patient's stuck or they're getting better or they're not getting better. That's really helpful in tailoring treatment. Some of us have electronic health records and integrated systems where this happens or can happen automatically. Others uh are, you know, in different practice settings where they don't have that. So here we thought that for people who don't have automatic access to measurement based care. Maybe you can work with the patient through a digital health intervention. Now, the whole theme of digital health interventions is fairly complicated. Our treatment guideline for depression has very detailed review of this. But what I'm going to be talking about here, um yeah, are uh mainly digital tools that can help you with ratings. Now, I show this table just to uh indicate to you that the the clinician guideline goes through the different kinds of digital interventions and does rank them first line, second line and third line. So we talked about patient education, we talked about patient engagement. One of the easy things to do in the old days before the internet, we might say use a self help book these days, everyone, you know Googles this or goes to some other helpful website. Here are the few, a few of the websites we recommend the uh Depression Center Toolkit is one I'm biased. It's uh one that I edit here at the University of Michigan, but we have 300,000 unique users annually from around the world. So it's a pretty popular site and it just provides basic education and some tips on depression. Some of the other sites that are listed there also give actual CBT that is cognitive behavior therapy in a kind of self help format. So what if you just want to measure the person's symptoms? Well, one of the easiest and simplest and cheapest ways is to go to a website known as Mood FX. So Mood FX is based at a university. Uh it's developed by um a distinguished psychiatrist, Ray Lamb out of uh Vancouver Canada. And uh here's what it does. It's available uh in English and in French and you can go to it and you don't have to register if you just wanna plug in and score some uh questions and then get a result. So the uh uh for depression and anxiety, the patient self report scales P HQ nine and G AD seven are there. If you are, you have the patient in front of you or the patients in your waiting room, you can just say go to mood FX. You've of course, told them what it is first and so on and fill out your numbers, fill out, you know, answer the questions and then we'll just look at your scores. That's one way to do it. There's some other scales there that are also useful. If you actually want the patient, they can register for it for free and then it'll keep their data and you can actually look at, oh I did it once a week for six weeks and here's my scores over six weeks. And the patient can also uh set it up with reminders to, you know, do the scale again. So that's mood FX a second one. And this is uh you know, I'm, I'm sharing ones that I use So this is not the, the world's best one or the only one. But here is an app, it's called E Moods. It's a commercial app, but it has a free version. And in a similar way, it allows you to um to answer a, a series of questions. It actually has a lot of questions about symptoms. But I just tell my patients just answer a couple of questions like the questions on your mood and on your sleep and so on. And you can easily get numbers or a graph of their findings. If you're gonna use digital tools, there are some key uh aspects to consider. First of all, when can I use a digital tool? Well, the person should have a disorder for which digital tools have already been developed and widely used. And that's usually for mood and anxiety conditions. Digital tools work best with people with milder illness. Although if you're using it only for monitoring, you could use it with severe depression because you're just using it for monitoring and not any kind of adjunct treatment. Um The clinician using these, especially if they're using a CBT self-help tool. Uh They're using it to augment care, they're not using it instead of their own care. And if you really want patients to be engaged with it, you need to document it, it's use, but you need to discuss its use in the session. So what I do is if I mention it, I usually go to the site if the person's here, uh, in, in live, I will go on my computer to the home page of the website application that I'm recommending and say here it is. And actually, uh, I often print the home page and give it to them. Kind of like a old fashion paper prescription as a kind of reminder. I want you to go to the site and in subsequent visits, I make sure and ask, did you go to the site? And what did you get out of it if they are learning something from it? And if it's just a score, I say, let's, you know, find out about your score. So to summarize, um you know, if you wanna treat depression effectively, it's really a process of care. And the first and most important element of that process is having an attitude and an a a, an approach that fosters collaboration with the, with the patient that allows for the patient to be aware of how they're doing self assessment through rating scales and allows them to be making really informed choices about treatment. So they should be educated about what are the various options of depression and so on. Uh We would suggest that the choice, the patient and family guide to depression treatments, which is the full name of our patient and family guide to depression treatments. From C A me, we, we would propose that this is an ideal vehicle for patient education and shared decision making. And again, if you don't have access to measurement based care through your electronic health record, consider using a couple of uh digital tools like the ones I mentioned. Thank you.