Depression Screening in Primary Care

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1 Depression Screening in Primary Care Toni Johnson, MD Kristen Palcisco, BA, MSN, APRN MetroHealth System

2 Our Vision Make Greater Cleveland a healthier place to live and a better place to do business. 2

3 Welcome! Who are we? Nurses Providers Social workers Others Coaches Quality Officers Healthcare Professionals 3

4 Depression: The Problem There are times when I have to hurt through a situation, and when this happens the choice is not whether to hurt or not to hurt, but what to do with the pain. -Anonymous 4

5 Session Objectives 1. To review the rationale for depression care in primary care 2. To discuss the education gap that exists in medical education, which can impact knowledge, skills and attitude of primary care providers 3. To discuss the history and evidence to support PHQ-2 and PHQ-9 as tools for screening and tracking depression treatment 4. To discuss one educational model to increase primary care provider competence for screening and treating depression 5. To discuss EMR/EPIC opportunities in depression screening.

6 Why Screen for Depression in primary care?

7 Primary Care Provider Education Who are we educating? Why do we need to educate providers on depression screening and management? How can we educate?

8 Provider Education Overall Goal: To improve the likelihood of successful depression screening, treatment and ongoing management by clinicians in primary care clinics

9 Your Practice? Has your institution/ system of care bought into the importance of depression screening in primary care?

10 Depression Facts Epidemiology Lifetime prevalence of 10-24% in women and 5-12% in men 19 million Americans diagnosed each year 151 million people affected worldwide 2 nd leading cause of disability by 2020 Epidemiology Depressive disorders are 2- fold more prevalent in patients with diabetes, CAD, HIV, and stroke Depression associated with 2x increase in risk of type 2 diabetes Depression associated with 64% increase in risk of CAD Untreated symptoms of depression exacerbate chronic illness

11 Depression Screening: Tool The Patient Health Questionnaire: PHQ-2 and PHQ-9 The PHQ-9 is a screening tool used to screen for Major Depression Contains 9 items, with scores ranging from 0-3 Includes item #10, to measure the impact severity of symptoms on work, home life, and relationships *From the Behavioral Health Toolkit 1.0, June 201, BHGC

12 Patient Health Questionnaire 9 (PHQ-9) Over the last 2 weeks, how often have you been bothered by any of the following problems? Not at all, Several days, More than half the days, Nearly every day: 1. Little interest or pleasure in doing things 2. Feeling down, depressed, or hopeless 3. Trouble falling or staying asleep, or sleeping too much 4. Feeling tired or having little energy 5. Poor appetite or overeating 6. Feeling bad about yourself or that you are a failure or have let yourself or your family down 7. Trouble concentrating on things, such as reading the newspaper or watching television distribute. 8. Moving or speaking so slowly that other people could have noticed? Or the opposite being so fidgety or restless that you have been moving around a lot more than usual. 9. Thoughts that you would be better off dead or of hurting yourself in some way. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all, Somewhat difficult, Very difficult, Extremely difficult Scoring: 1-4 = Minimal, 5-9 Mild, Moderate, Moderately Severe, Severe Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues =Total Score:

13

14 Your Practice? 1. Are you currently screening for depression in your organization or practice? 2. Do you utilize the PHQ-2/ PHQ-9 in your primary care clinic(s)?

15 What do you think? 1. How is the PHQ-9 related to diagnosis of depression? 2. What concerns, if any, present in primary care when screening for depression and suicidal thinking? (Question #9)

16 Major Depressive Disorder (commonly referred to as Major Depression or Depression) DSM IV Criteria Depressed mood or anhedonia every day, all day for at least 2 weeks At least 4 additional symptoms: Sleep changes Fatigue Appetite or weight changes Psychomotor agitation or retardation Helplessness Hopelessness (excessive guilt) Difficulty concentrating or making decisions Recurrent thoughts of death or suicide Significant functional impairment

17 What do you think? HOW might provider education on depression address some of these concerns?

18 Provider Education

19 Outline: Teaching Series Depression Facts Epidemiology Co-morbidity with other chronic illness Screening USPSTF and BHGC PHQ-2 and PHQ-9 Diagnosis DSM IV Criteria Ruling out: medical, psychiatric conditions (including personality disorders), substance abuse Phases of illness (remission, recurrence, recovery)

20 Outline: Teaching Series Suicide Assessment Risk factors / Protective factors Emergency plan Application for Emergency Admission (Pink Slip) Community resources (Suicide Hotline Cuyahoga Co.) Treatment STAR*D landmark study Antidepressant medication classes Neurotransmitters and specific depression symptoms Duration of treatment Switching medications Drug-drug interactions Referral to Specialty Care

21 PHQ-9 Sample Workflow

22 Depression Screening: Workflow Processes Screening workflow: One and Two stages (PHQ-2 and 9) Screening workflow: Paper Screening workflow: EMR/Epic MetroHealth, CareAlliance, NFP, Cambridge Health Alliance (Cambridge, MA Harvard Teaching Affiliate) Benefits and Challenges

23 SUMMARY: Challenges for Depression Screening in Primary Care Provider time Provider knowledge about depression Responding to score on screening tool Diagnosis Appropriate treatment (antidepressant) Provider concern about suicide risk and liability Provider concern about ability to refer to Psychiatry or to receive timely direction (curbside consultation)

24 Summary: Provider Education Topics Depression identification and management. Suicide identification and management. Provider fears. Pharmacological management: Onset of therapy, duration, antidepressants, neurotransmitters, medication classes, side effects/complications of drug therapy.

25 Thank You! Questions or Comments? Toni Johnson, MD Kristen Palcisco, BA, MSN, APRN 25

26 Toolkit Availability A hardcopy of our Behavioral Health Toolkit is available for any Better Health Greater Cleveland member practice at no charge. E-copies also are available. Please contact Bonnie at or

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