Depression Screening with PHQ-9 Round #8. Sherwin Yen Diane Dolan-Soto Annie Whitney March 24, 2010

Transcription

1 Depression Screening with PHQ-9 Round #8 Sherwin Yen Diane Dolan-Soto Annie Whitney March 24, 2010

2 DSM IV: 5 of 9 symptoms present most days nearly every day for at least 2 weeks Includes depressed mood or loss of interest/pleasure S I G E C A P S Change in Sleep Loss of Interest or Pleasure Thoughts of Guilt or worthlessness Loss of Energy Trouble Concentrating Change in Appetite or weight Change in Psychomotor activity Suicidal Ideation

3 PROVIDER/NURSE: Please ask the patient the first two questions. Over the last 2 weeks, how often have you been bothered by any of the following: 1. Little interest or pleasure in doing things? 1. Feeling down, depressed, or hopeless? (0) Not at all (1) Several days (2) More than half the days (3) Nearly every day PATIENT: Please complete the following questions (0) (1) (2) (3) 1. Trouble falling or staying asleep, or sleeping too much? 1. Feeling tired or having little energy? 1. Poor appetite or overeating? 1. Feeling bad about yourself or that you are a failure or have let yourself or your family down? 1. Trouble concentrating on things, such as reading the newspaper or watching television? 1. 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? 1. Thoughts that you would be better off dead or of hurting yourself in some way? Positive PHQ-2 requires PHQ-9. Score>=10 has sensitivity of 88% and specificity of 88% for major depression

4 Depression has been associated with Complications of metabolic disorders Poor glycemic control Non-adherence to medical therapy 1. de Groot M: Association of diabetes complications and depression in type 1 and type 2 diabetes: a meta-analysis (Abstract). Diabetes 49:A63, Lustman PJ Effects of nortriptyline on depression and glucose regulation in diabetes: results of a double-blind, placebo-controlled trial. Psychosom Med 59: , DiMatteo MR Depression is a risk factor for noncomplaince with medical treatment: meta analysis of the effects of anxiety and depression on patient adherence. Arch of Int Med. 2000; 160:

5 Dr. Brill 2/2009: Prevalence of depression in diabetic population. Chart review 52 patients with DM Prevalence of Depression, anxiety or both 23.6% Implementation of PHQ-9, GAD-7 increased prevalence to 35.1% (n=106) Under-diagnosis of depression in our clinics

6 Dr. Cowherd and Dr. Ponder: Review of screening process. 7/2009 Does screening lead to interventions? 76 pts screened (+) for mod/severe depression Random sample of 48 WebCIS charts reviewed for documentation and treatment 31/48 (65%) patients with positive screen addressed and treatment discussed Why? Providers completing prompts?

7 Dr. Vincent: Increasing provider usage of visit planner/depression screening Care assistants not reliably notified for positive PHQ-2 screens Nursing staff directly notified physicians of positive PHQ-2 screens Nursing staff administered PHQ-9 to patients

8 RN administers PHQ-2 Score 3? NO Record on yellow sheet YES RN hands patient PHQ-9 for self-administration MD scores PHQ-9 and records score MD intervenes appropriately

9 Diane Dolan-Soto: Feasibility of pt self administration of PHQ-9 1/ % of patients able to complete PHQ-9 without assistance 77% of patients able to complete PHQ-9 <5minutes Patient self administration can shorten the total screening process

10 Dr. Seib and Dr.Mukherjee: Educating nurses and providers to increase adherence 11/2009 Education and motivation for nursing staff for new screening process Nov 12 staff meeting Education for residents Updated pre-clinic conference for diagnosis and treatment of depression Case presentation

11

12

13 Dr. Haake: Provider participation with new VP Prompt adherence is important Missed prompt = unaddressed issue Interventions are missed Pre-Clinic Conference 3/15-3/19 Review of provider prompt logic Case discussion Sample visit planners Education campaigns may be effective in increasing provider prompt completion

14

15 2/15/10: PHQ-9 moved to the back of the visit planner, suicidality assessments placed in exam rooms. TEST providers for DM patients. 2/22/10: ALL providers receive new visit planner for DM patients 2/25/10: Nurses trained on depression screening changes, review of PHQ-2 and PHQ-9 administration 3/1/10: Roll out of new screening process for TEST providers for ALL patients, pre-clinic conference 3/15/10: Screening began for ALL clinic patients, not just DM pts (starting population - IVD and h/o depression)

16 PHQ-9 Score (all 9 questions) Indicate actions taken

17 Is the nursing staff completing PHQ-2? Are patients completing PHQ-9 if indicated? Are providers acknowledging scores? Are providers completing the algorithm? Are providers addressing depression in patients with PHQ-9 >=10 Are interventions being missed?

18 Determine the level of adherence by nursing staff and providers in the depression screening process Determine if positive PHQ-9 screens result in provider interventions

19 Reviewed all VP from 2/15-3/19 n=836 Identify all VP with PHQ-2 n=247 Review prompts for nurses and providers to evaluate adherence/correctness Webcis chart review patients with PHQ-2>=3 n=42 Determine if medication added or changed, if patient was referred for counseling, or if patient already on antidepressant. Suicidal ideation? Documented?

20 Nurse Roles PHQ-2 if prompted Pt completes PHQ-9 if score >=3 Follow-up on missed PHQ-9s by phone Provider Roles Review results and complete prompts Calculate PHQ-9 score Complete treatment algorithm Document in Webcis

21 Prompted for Screen (247) 30% PHQ-2 done by nurse (235) 95% PHQ-2 negative (193) 82% (score < 3) PHQ-2 (score > 3) (42) 18% PHQ-9 administered (40) 95% Assessment not indicated (6) 15% No to mild depression (score <9) Assessment indicated (34) 85% Moderate depression (score 10 14) Severe depression (score > 15)

22 Assessment indicated (34) 85% Moderate depression (score10 14) Severe depression (score > 15) PHQ-9 Score: PHQ-9 Score: > 15 35% (n=12) 65% (n=22) Suicidal thoughts Pos response to question 9 38% (n=13)

23 February Screening when prompted (92/97): 95% Contacting CA for PHQ-9 (16/17): 94% 8/2009 1/2010: PHQ-9 rates were 33 81% March 1-19 Screening when prompted (143/150): 95% Asking pt to complete or asking PHQ-9 (24/25): 96%

24 February PHQ-2 (n=92) March 1-19 PHQ-2(n=143) Review of PHQ-2 results on front of VP 47% (43/92) 49% (70/143) Calculation of total score for PHQ-9 56% (9/16) 63% (15/24) Algorithm complete following PHQ % (6/15) 37% (7/19) Document in Webcis if PHQ % (12/15) 79% (15/19) New Rx, med change, on medication or referral for PHQ % (12/15) 89% (17/19) Suicidal patients, positive #9 47% (7/15) 32% (6/19) Suicidality addressed in Webcis 14% (1/7) 50% (3/6)

25 #9. Thoughts that you would be better off dead or hurting yourself in some way? 4/13 patients suicidality mentioned in Webcis Patient 1: Safety contract made with pt Patient 2: Passive suicidal ideation Patient 3: Not actively suicidal Patient 4: Safety contract made with pt

26

27 Headed by Diane Dolan-Soto, LCSW Will review and track positive PHQ-9s in a registry Will call patients 2 wks after positive screen to follow-up Will provide psychotherapy/counseling to patients Patients can be seen same day as other IMC appts Problem-Solving Therapy (similar to CBT) Template open, appointments start in April

28 Nursing staff doing excellent job Though provider participation in completing prompts is low, majority are documenting in Webcis and intervening Suicidality by patients not adequately addressed in Webcis.

29 Provider adherence to screening prompts through further education Un-prompted depression screening in SDC/continuity Pre-Clinic conference on suicidality Treatment algorithm for depression/suicidality Depression program referral How to document in Webcis When to send to the ED Develop training module for providers to review new process and protocols, including a test of knowledge

30 The Team Diane Dolan-Soto Anne Whitney Kim Young-Wright