Esperanza Health Center PACHC Conference October 2014 Presented by Les Book, MA, LCSW Director of Behavioral Health

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1 Esperanza Health Center PACHC Conference October 2014 Presented by Les Book, MA, LCSW Director of Behavioral Health

2 Why? Depression is a common problem that causes much morbidity and mortality Many patients treated for depression receive all their treatment in the primary care setting Many patients treated for both anxiety and depression in community behavioral health (our population) are only being medicated for anxiety. There is solid evidence that a model of depression care consistent with the Planned Care Model leads to better outcomes for people with depression.

3 .a short story Began BHC in 2008 Some resistence among our medical providers at first but not anymore! Confidence Flow/timing Noted a BIG change when we began to use the PHQ9 Why use a screen? Like blood work Confidence of pcps went up Validated instrument Guide for medication monitoring Tool to teach patients, identify patterns

4 The PHQ-9 What is the PHQ-9? The PHQ-9 is the nine item depression scale of the Patient Health Questionnaire*. It can be a powerful tool to assist clinicians with diagnosing depression and monitoring treatment response. The nine items of the PHQ-9 are based directly on the nine diagnostic criteria for major depressive disorder in the DSM5 and ICD9/10 ( This can help track a patients overall depression severity as well as the specific symptoms that are improving or not with treatment. Is a validated tool to screen for and diagnose depression. Has also been validated as a tool for measuring response to treatment. Is easy to use and has been found to be helpful by both primary care medical and behavioral health clinicians

5 The PHQ-9 Depression Screener is provided at in a variety of languages, including Arabic, Assamese, Chinese (Cantonese, Mandarin), Czech, Dutch, Danish, English, Finnish, French, French Canadian, German, Greek, Gujarati, Hindi, Hebrew, Hungarian, Italian, Malay, Malayalam, Norwegian, Oriya, Polish, Portuguese, Russian, Spanish, Swedish and Telugu.

6 How? Generally we administer it sometimes the MA gives the PHQ9 when the medical provider asks them to and they inform a BHC when there is a positive score. Often we go through the form with the patient False positives sometimes when a patient cannot understand the form or its language Leads to more info as one can stop in the middle after the sleep; question to ask sleep hygiene questions, or ask clarifying questions

7 PHQ9- sample Over the last 2 weeks, how often have you been bothered by any of the following problems? 1. Little interest or pleasure in doing things Please mark your answer with an X Not at all Several days More than half the days 2. Feeling down, depressed or hopeless Almost daily 3. Trouble falling or staying asleep, or sleeping too much Feeling tired or lacking energy none / 5-9 mild / moderate/15-19 moderately severe / severe 5. 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. 8. Moving or speaking so slowly that other people notice- or being so fidgety or restless that you are moving around more than normal Thoughts that you would be better off dead or of hurting yourself in some way. PHQ9 Total 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

8 MacArthur Depression Toolkit arthurtoolkit.pdf Toolkit to guide treatment of depression, especially designed for primary care providers

9 Guideline for Using the PHQ-9 for Initial Management Score/ Symptom Level 0-4 No depression 5-9 Minimal Mild Moderate Severe Consider other diagnoses Treatment Consider other diagnoses If diagnosis is depression, watchful waiting is appropriate initial management Consider watchful waiting If active treatment is needed, medication or psychotherapy is equally effective Active treatment with medication or psychotherapy is recommended Medication or psychotherapy is equally effective Medication treatment is recommended For many people, psychotherapy is useful as an additional treatment People with severe symptoms often benefit from consultation with a psychiatrist

10 What is Watchful Waiting? It is estimated that a third of people with mild symptoms will recover without treatment. Watchful waiting means you are seeing the patient about once a month and monitoring their PHQ-9 score, but not starting active treatment. Self-care activities such as exercise or relaxation are usually a component of watchful waiting. If the patient s symptoms have not resolved after 2-3 months, active treatment ought to be considered.

11 PHQ-9 - Change from last score, measured monthly Drop of 5 or more points each month Treatment Response Good Treatment Plan Antidepressant &/or Psychotherapy No treatment change needed. Follow-up in 4 weeks. Drop of 2-4 points each month Fair Antidepressant: May warrant an increase in dose. Drop of 1 point, no change or increase each month Interpreting Follow Up Scores Poor Psychotherapy: Probably no treatment change needed. Share PHQ-9 with psychotherapist. Antidepressant: Increase dose or augment or switch; informal or formal psychiatric consult; add psychotherapy. Psychotherapy: 1. If depression-specific psychotherapy discuss with supervising psychiatrist, consider adding antidepressant. 2. For patients satisfied in other psychotherapy consider adding antidepressant. 3. For patients dissatisfied in other psychotherapy, review treatment options and preferences.

12 Screening Who and How US Preventive Services Task Force, 2003 statement supporting screening for depression: (We) recommend screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow-up.

13 Screening for Depression: Who do you screen? HRSA is beginning to work with FQHC s to establish what percentage of 12-older are screened. High risk groups every year History of depression Family history of depression or bipolar Chronic illnesses such as diabetes, heart disease, pain problems High utilization of services People with complaints that suggest depression such as insomnia or fatigue

14 Screening for Depression: The first two questions of the PHQ-9 have been validated as a sensitive way to screen for depression and referred to as the PHQ-2 96% of people with depression will say yes to one of those two questions Answer of 2 or 3 on either of those questions is a positive screen Administer the full PHQ-9 to those who screen positive In many clinics these are asked by the Medical Assistants, some initial history forms include them as well. Some e-h-r s have them embedded in software here are some examples from a robust practice in Maine

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16 PHQ-9 Depression Assessment Tool The PHQ-9-9 is used in two different ways. Initially to assess patients for depression and subsequently to monitor treatment progress should a formal DX of depression be made. When assessing patients the score of the first two questions will determine whether or not you would need to go forward with the remaining questions. For example if the first two questions score as two or less you will be notified that the patient has screened negative for depression. For patient with a diagnosis of depression all other questions should be answered regardless of score in the first two question.

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18 Things to Consider in Initiating Use of the PHQ-9 in your daily work How will you identify those patients who should fill out a PHQ? Who will give the patient the PHQ? Who will score the PHQ? Who will enter the results into the registry? When will that be done? How often should the PHQ be done?

19 How often should the PHQ be done? Once a month until the patient reaches remission (score 0-4) or for the first 6 months of treatment Every 3 months after that while the patient is on active treatment Once a year for people with a history of depression who are no longer on active treatment

20 Other screeners for depression PHQ-A for adolescents Geriatric Depression Screen for elderly whose depression symptoms are more behavioral. Columbia Depression Screen for 8-12 (write to get permission)

21 Institute of Medicine Quality Chasm Report for Mental Health Clinicians should: Increase their use of valid and reliable patient questionnaires that are feasible for routine use to assess the progress and outcomes of treatment systematically and reliably.

22 References Improving the Quality of Health Care for Mental and Substance-Use Conditions, Institute of Medicine, Accessed at 6/2/06 An Employer s Guide to Behavioral Health Services, National Business Group on Health, Accessed at %20Health%20Services:%20Tools%20and%20Solutions%20- %20&, 6/2/06 Spitzer, Kroenke et al, JAMA, 1999, V.282, pp Lowe, Unutzer et al, Medical Care, 2004, V.42, pp Li, MM, Friedman, B, Conwell, Y, Fiscella, K. Validity of the Patient Health Questionnaire 2 (PGQ-2) in Identifying Major Depression in Older People. Journal of the American Geriatric Society. 2007; 55:

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