Patti Olusola, M.D. Kathryn Wortz, Ph.D. Robert B. Tompkins, M.D. The Effect of Implementing PHQ-9 Screening in Two Primary Care Clinics University of Texas Health Sciences Center at Tyler Patti Olusola, M.D. patti.olusola@uthct.edu Kathryn Wortz, Ph.D. Robert B. Tompkins, M.D. Kiona Coleman, M.D. Yury Ragoza, D.O.

Background Depression and other mental health disorders have a significant impact on patients and society Depression affects 5-10% of individuals in primary care settings; however it is recognized in only 50% of cases1 Individuals with behavioral health disorders often have comorbid physical health conditions. Patients with depression seek medical care more frequently and utilize more healthcare resources than non-depressed patients1 The USPSTF recommends routine screening for depression in adults and adolescents Despite this recommendation, two-thirds of primary care physicians report not being able to access outpatient behavioral health for their patients. 3 Focus areas of Healthy People 2020 include increasing depression screening by primary care providers and increasing the proportion of primary care facilities that provide mental health treatment onsite which are also incentivized through the Affordable Care Act and CMS through the DSRIP waiver programs 4 Research indicates that better integration of behavioral health care services into the primary care settings can have a positive impact on quality, costs and outcomes;5 yet, achieving actual integration can be difficult. Even in organizations where there is buy-in, changing practice habits and professional culture is challenging.

*Patient Health Questionnaire-8 severity score of ≥10. Prevalence of current depression* among adults aged ≥18 years, by state quartile *Patient Health Questionnaire-8 severity score of ≥10. Source: Centers for Disease Control and Prevention. MMWR 2011;60(Suppl).

Mental Health Costs in the US Mark TL, Levit KR, Buck JA, Coffey RM, Vandivort-Warren R. Mental health treatment expenditure trends, 1986--2003. Psychiatr Serv 2007;58:1041--8

Project Description The PHQ-9 depression screening questionnaire was administered to all adult patients in the Family Medicine and Internal Medicine clinics. Residents were offered didactics on depression and its effects on physical illness. They were also trained in the use of the PHQ-9. Resident and staff physicians were initially resistant the screenings; however, the resistance evaporated when behavioral health support, in the form of “warm handoffs,” were available to the physicians at all times during clinic hours. The patients were offered the PHQ-9 during check-in at each clinic visit. The questionnaires were scored, documented in the EMR and given to the physicians before entering the patient’s room.

PHQ-9

Outcomes Following implementation, we retrospectively reviewed data to determine the success of both using the PHQ-9 as a screening tool in our primary care clinics and collaboration with behavioral health specialists. Implementing the PHQ-9 screening increased our diagnoses of depression as well as other mental health disorders. There was improved collaboration with behavioral health specialists with an increase in psychology referrals. We found a progressive improvement of integrated health care during primary care visits through “warm hand-offs” with behavioral health specialists.

Patient Visits in FPC and IMC with Diagnosis of Depression

Patient Visits in FPC and IMC with Other Mental Health Diagnoses Bipolar Disorder Anxiety Disorder

Psychology Referrals

Warm-Handoffs to Psychology

Discussion It was intriguing to discover that introducing a screening tool for depression became the catalyst first for practice change by improving the diagnosis of mental health disorders and then for cultural change through collaborative care in the clinic. Resistance to the implementation of the tool created awareness of the need for greater behavioral science support. Once this support was in place, physicians were willing to utilize the PHQ-9 to assist in the diagnosis and treatment of their patients and physicians took the opportunity to collaborate with psychology and provide integrated care to their patients Physicians were not resistant to behavioral health integration efforts, but rather to increasing demands on their time. Integrated psychology within the primary care clinic removed barriers to patient diagnosis and treatment for depression and other mental health disorders within our primary care clinics. For residents , it has allowed for continued growth and education regarding mental health disorders and psychology techniques.

Future Directions Now that there is established routine depression screening, improved diagnosis, and integrated behavioral health care within our primary care clinics: We would like to review, analyze and report whether we have seen improvement in the treatment of our patients with depression and other mental health disorders through objective PHQ-9 scores and subjective patient questionnaires We would like to investigate the family medicine residents’ perception of integrated behavioral health care during their training and the impact it has had on their current and future care of patients with mental health disorders.

References Gilbody, Simon, David Richards, Stephen Brealey, and Catherine Hewitt. "Screening for Depression in Medical Settings with the Patient Health Questionnaire (PHQ): A Diagnostic Meta-Analysis." J Gen Intern Med 2007; 22(11):1596-1602 Final Update Summary: Depression in Adults: Screening. U.S. Preventive Services Task Force. July 2015. Accessed Nov 5, 2015. http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/depression-in-adults-screening?ds=1&s=depression Cunningham PJ. “Beyond parity: Primary care physicians' perspectives on access to mental health care.” Health Aff. 2009; 28(3):490–501. Healthy People 2020. Accessed Nov 5, 2015. http://www.healthypeople.gov/2020/topics-objectives/topic/mental-health-and-mental-disorders/objectives#4807 TRENDWATCH. “Bringing Behavioral Health into the Care Continuum: Opportunities to Improve Quality, Costs and Outcomes.” American Hospital Association. January 2012. http://www.aha.org/research/reports/tw/12jan-tw-behavhealth.pdf

Special thanks to Bryan Harvey and Zeding Li for helping gather data for this project