Dr. Anna M. Acee, EdD, ANP-BC, PMHNP-BC Long Island University, Heilbrunn School of Nursing

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1 Dr. Anna M. Acee, EdD, ANP-BC, PMHNP-BC Long Island University, Heilbrunn School of Nursing

2 Overview Depression is significantly higher among elderly adults receiving home healthcare, particularly among adult with Type 2 diabetes. Depression leads to greater medical illness, functional impairment and chronic illness. Opportunities often missed to improve mental health & general medical outcomes when mental illness is under recognized & undertreated. Mandate by Centers for Medicare & Medicaid Services, Outcome & Assessment Information Set-C (OASIS-C) for the use of the PHQ-2 to screen for depression in all home care patients with an emphasis on patients with diabetes. PHQ-9 provides deeper depth in assessing for depression. Depression is treatable, but first must be recognized, treated, and monitored over time like any other chronic illness.

3 Overview Depression is one of the most common mental health disorders & the second leading cause of disability worldwide by Among persons older than 65 years, one in six suffers from depression. Depression is significantly higher among elderly adults receiving homecare and leads to greater medical illness, functional impairment, and chronic pain. The economic burden of depression is $83 billion in direct and indirect costs. Groups at high risk: minorities, women, pts w/low socioeconomic status & patients with physical disabilities or co-morbid conditions.

4 Overview Opportunities are often missed to improve mental health and general medical outcomes when mental illness is underrecognized and undertreated. Beliefs that depression is normal with older age as well as difficulties present in patients with cognitive deficits, make identification of depression in older adults challenging. Depression is treatable, but first must be recognized, treated, and continuously monitored over time like any other chronic condition.

5 Overview Targeting depression in homecare has been found decrease hospitalization rates. If left undetected or not fully treated depression is associated with higher costs, morbidity, risk of suicide, and mortality from other comorbid conditions.

6 Challenges in Managing Type 2 Diabetes & Depression: Diabetics face multiple self-management tasks each day; monitoring blood glucose, meal planning, exercise, monitoring skin integrity, annual eye and dental exams and frequent visits to the primary care provider. Routine weighs heavily on pt & constant reminder of their chronicity of their illness Incidence of depression higher among adults with diabetes than the general population, estimated to be 11% to 31%.

7 Research Background Patients with co-morbid diabetes & depression have increased rates of mortality, cardiac events, hospitalizations, diabetes-related complications, functional impairment, healthcare costs, medical symptoms burden and decreased quality of life than patients who are not depressed. Co-morbid depression associated with poor adherence to self-care regimens, medical symptom burden, and functional impairment. Increased risk of microvascular & macrovascular complications. Up to 80% of pts. with comorbid diabetes & depression will

8 Depression Risk of deterioration of depressive symptoms over time emphasizes the need for ongoing screening for depression symptoms and treatment adherence and adjusting antidepressant therapy as needed. Often started on a medication and its not adjusted. There is a positive relationship between poorer self-care and depressive symptoms and inversely the higher the selfperception of health, the better the A1c levels. Nurses are well positioned to screen for depression and report the findings to their PCP.

9 Barriers to Screening for Depression Risk of deterioration of depressive symptoms over time emphasizes the need for ongoing screening for depression symptoms and treatment adherence and adjusting antidepressant therapy as needed. Often started on a medication and its not adjusted. There is a positive relationship between poorer selfcare and depressive symptoms and inversely the higher the self-perception of health, the better the A1c levels. Nurses are well positioned to screen for depression and report the findings to their PCP.

10 Assessing for Depression Centers for Medicare and Medicaid Services (CMS), OASIS-C has mandated the use of the Patient Health Questionnaire (PHQ-2) to screen for depression in home care patients. PHQ-2 assesses for two significant signs of depression (including little interest or pleasure in doing things and experiencing a depressed mood) one of which is required to assess significant clinical depression. Score of 3 or > indicator for additional assessment.

11 PHQ-9 Next Step After a Positive PHQ-9 Any scores = to or > than 3 on the PHQ-2 should be referred to an advanced practice clinician (Psychiatric Nurse Practitioner, Psychologist or Physician) by the home healthcare team for diagnosis. CMS has recommended the use of the PHQ-9 (Patient Health Questionaire-9) to further evaluate depressive symptoms during an initial visit and over time to monitor depressive symptoms and medication effectiveness (VERY IMPORTANT-chronic disorder) in homecare patients.

12 PHQ-9 Nine-item screening tool based on diagnostic criteria for depression, with scoring based on duration/severity of particular symptoms. Depression is diagnosed when symptoms impact normal activity and persist for more than 2 weeks. Diagnostic criteria include for depression to include a positive response to at least one of the first two questions on the PHQ-9, including cardinal symptoms of persistent and pervasive low mood and loss of pleasure in usual activities.

13 TEACHABLE MOMENT!!!

14 PATIENT HEALTH QUESTIONNAIRE (PHQ-9) Over the last 2 weeks, how often have you been bothered by any of the following problems? (Use to indicate your answer) Not at all Several More than half Nearly every days the days day 1. Little interest or pleasure in doing things Feeling down, depressed, or hopeless Trouble falling or staying asleep, or sleeping too much 4. Feeling tired or having little energy Poor appetite or overeating 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 watching television 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 (Health care professional: For interpretation of TOTAL please refer to scoring card below.) add columns: TOTAL: 10. 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 Very difficult Somewhat difficult Extremely difficult

15 PHQ-9 Scoring Card for Severity Determination Add up all the checked boxes on PHQ-9 For every Not at all = 0; Several days = 1; More than half of the days = 2; Nearly every day = 3. Interpretation of Total Score: Total Score Depressive Severity 1-4 None 5-9 Mild depression Moderate depression Moderately severe depression Severe depression

16 Dx Assessment & Initiating Tx PHQ-9 Symptoms and Impairment PHQ-9 Severity Provisional Diagnosis Treatment Recommendations 1 to 4 symptoms, functional impairment < 10 Mild or minimal depressive symptoms Reassurance and /or supportive counseling Patient selfmanagement Recommend physical activity Educate patient to call if his or her condition deteriorates 2 to 4 symptoms, including questions #1 and/or #2, plus functional impairment Moderate depressive symptoms (minor depression) * * Watchful waiting Supportive counseling If no improvement after one or more months, use antidepressant or brief psychological counseling 5 symptoms, including questions #1 and/or #2, plus functional impairment Moderately severe symptoms Major depression Patient preference for antidepressants and/or psychological counseling

17 PHQ-9: Instrument Validation Widely used in primary care and is available in 48 languages. More effective than the PHQ-2 when assessing pts with co-morbidities that include physical symptoms of depression. User friendly; can be administered during a home visit & findings reviewed during a visit. Staff may need additional training to assess for any hx or tx of depression or other mental illness, SA or alcohol use.

18 PHQ-9 Findings Evaluation of the findings from the PHQ-9 screen should be interpreted by a nurse practitioner, psychologist or psychiatrist. The role of the homecare nurse does not include diagnosis & treatment, a review of the PHQ-9 is provided as a basic overview for better understanding of the signs and symptoms of depression. The additional of this standardized tool will require agency approval and education for clinicians to assure reliability of results.

19 PHQ-9 instrument High sensitivity (73%) and Specificity (98%). Clinical depression as a score of 10 or more, or a positive response to Item # 9: Thoughts of death or harming themselves. When assessing the pt. for the first time the clinician needs to know that each item ranges in severity from 0 to 3. The possible range of total scores is 0 to 27, with the higher score indicating more severe depression. The findings help determine first line treatment (e.g. watchful waiting, psychotherapy or pharmacotherapy.

20 Depression Dx On diagnosed care will include ongoing monitoring, patient education, and self-management support, which includes medication adherence, physical activity, and spending time in positive and nurturing environment.

21 Diagnosis of Major Depression Five or more depressive symptoms present for more than half the days over at least two weeks, with at least one of the symptoms being either depressed mood or inability to experience pleasure with activities that were at one time pleasurable. From the list of nine depressive symptoms, a pt. indicates whether each symptoms has bothered them during the last two weeks. The PHQ-9 can e used as both a dx tool and a measurement of depressive severity over time, to evaluate medication effectiveness & mental status.

22 PHQ-9 instrument: Once diagnosed, care will include ongoing monitoring, pt. education, and self-management support, which includes medication adherence, physical activity, and spending time in a nurturing environment. To determine most appropriate treatment, consider the severity of symptoms, psychosocial stressors, comorbid conditions, willingness to increase physical activity.

23 Additional factors to consider: Prior suicide attempt Significant comorbid anxiety, psychotic symptoms, or active SA; Access to firearms; Living alone or with poor social supports; Older adult male; Recent loss or separation; Hopelessness; Preparatory acts (putting affairs in order, giving away belongings); Family hx of affective disorder, suicide, alcoholism.

24 Additional factors to consider: Nurses need to instructed that if a pt. expresses suicidal ideations or intent they should be immediately referred to their PCP for further evaluation. If the PCP is not available, the homecare nurse should consult with a psychiatrist or psychiatric nurse practitioner.

25 Ongoing Treatment If ongoing mental evaluation and monitoring of depression is required, the pt should be referred to a home care mental health program where MH clinicians can oversee the pt's care.

26 Implications for Practice Depression is a treatable condition. Up to 70-80% of patients respond positively when adequate care is provided. There is strong evidence that training home care providers to detect depression symptoms will increase appropriate mental health referrals. OASIS-C, recommends using the PHQ-2 for all patients. Homecare providers need to be skilled in administering the PHQ-2 and referring patients who score positive and would benefit from further evaluation with the PHQ-9.

27 Conclusion For depression screening to be effective in patients with comorbidities, a collaborative framework needs to be in place between home care mental health services and home healthcare providers in order to satisfactorily diagnosis, treat, and follow up home care patients.

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