1. Depression Screening and Management
Elizabeth Klein, MD FAAFP
Jennifer Herber, MD
Providence Family Medicine Residency
Milwaukie Oregon

3. Goals and Objectives
Discuss the importance of Depression and Depression Screening in Family Medicine
Review PHQ-9, Mood Disorder, CAGE and Suicide Risk forms in Logician
Discuss treatment options, adding meds - when and how - through case discussion and use of the electronic health record

4. What are your goals?
How to better document depression and depression treatment?
How to make depression screening and treatment happen in your clinic?
How to better treat depression to remission?
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5. Questions for you
How common is depression in the general population? 5,10 or 20%?
How common is depression in primary care clinics? 10, 15 or 30%?
T/F - Lost years of healthy life due to depression is 2nd only to ischemic heart disease.
T/F - Suicide is in the top 10 causes of death in USA.

6. Major Depression: DSM-IV Criteria
>5 of the following symptoms QD x 2+ weeks
Essential symptoms (must have at least 1)
depressed mood
anhedonia
Physical symptoms
changes in sleep
change in appetite or weight
fatigue
change in psychomotor activity
Psychological symptoms
feelings of guilt or worthlessness
difficulty in thinking, concentrating or making decisions
recurrent thoughts of death and/or suicidal plans or attempts

7. Other Mood Disorders Dysthymia Minor depression Bipolar disorder
Common co-existing behavioral health disorders
anxiety
substance abuse
ADD

8. Major Depression – The Facts Common, Chronic, Costly
>10% of the general population has major depression (women > men)
15-35% of nursing home patients
20-30% of primary care patients
24-46% of hospitalized medically ill patients
% lifetime prevalence
Common comorbidity of other medical diseases

9. Major Depression –Chronic
untreated disease often lasts months-years
even with treatment, recurrent episodes are common

10. Major Depression – Costly
Costly: untreated > treated disease
 direct and indirect costs
$44 billion annually in US
> healthcare utilization and costs
> disability and time lost from work
worsens medical outcomes
post CVA and MI DM
cancer
lost yrs of healthy life 2nd only to ischemic heart dz
suicide among top 10 causes of death in the US
US Preventive Services Task Force

11. Depression in Primary Care
Majority of patients present to PCPs
Only 50-70% recognition in primary care
high volume of patients
time limitations in visits w/ competing issues
lack of resources to assist w/ dx, tx, and f/u
inadequate reimbursement/carve-outs
concern for overdiagnosis
“rationalized” depression
stigma of depression

12. Depression in Primary Care
Underrecognition (continued)
may present differently in 1o care
chief complaint of depression is rare
complicated by multiple somatic complaints
suspect high utilizers
self-described lack of expertise
“subjective” nature of diagnosis
Underrecognition  undertreatment

13. Lack of Adequate Treatment
Despite prevalence and impact on pt lives, major depression is undertreated
50% screened
25% receive initial treatment
12.5% receive adequate treatment
5% continue for >6 months National Institute of Mental Health
Patients with depression have 20X risk of suicide compared to normal

14. Importance of Screening
Recommendation to screen adults for depression to enhance detection
need systems to ensure accurate diagnosis, effective treatment and follow-up
insufficient evidence to recommend for/ against routine screening of children and adolescents
USPSTF

15. Importance of Screening
Screening also provides objective information
assists with diagnosis – DSM-IV criteria
assignment of severity
improves documentation
higher level of coding/billing
code: V79.0 (depression screening)
can guide treatment decisions
beneficial in follow-up
level of response
dose titration
achievement of remission

16. Our Choice… PHQ-9
Primary Care Evaluation of Mental Disorders (PRIME-MD) Patient Health Questionnaire - Depression Subscale 9
patient self-administered, 9 item survey
assesses DSM-IV criteria & evaluates severity
scored continuously to monitor response
81% sensitivity, 92% specificity, 85% overall accuracy, 55% PPV after 2-question screen
validated across many primary and tertiary care populations
Journal of Family Practice 2003;52:118-26
JAMA 2002;287:
Journal of General Internal Medicine 2007; 22:

17. Who Should Be Screened? Risk factors:
economic hardships/unemployment
stressful events, loss
chronic illness
h/o abuse or trauma
1st degree relative w/ mood disorder
female
caretaking responsibilities
Risk factors alone are not predictive

18. Approaches for Patient Identification
All new pts and with preventative visits
Chronically ill
Post-MI or CVA
Pts w/ HTN, asthma, COPD, DM
Pts w/ somatic complaints
High utilizers
Pts w/ dysthymia or minor depression

19. Logician Encounter Form
PHQ-9
Related screening tools
Patient History
Suicide Risk
CAGE Questions
Grief Reaction
Mood disorders questionnaire
Scoring instructions
Common ICD-9 codes

20. Special Features Self-calculating scores
Links to problem and med lists
Direct flow into patient’s flowsheet

21. Depression Screening

22. Training Document

28. Logistics Initial screening questions (y/n)
“Over the last 2 weeks, have you been bothered by...
1) Little interest or pleasure in doing things?”
2) Feeling down, depressed or hopeless?”
If one or both positive, then give PHQ-9
MA can hand out and enter results into EMR

29. Groups

30. Case-Based Learning Judith, Case #1
49 yo female, PHQ 17
What are the issues?
What do you advise? Do you switch or add medication?
Do you use the depression self-care handout?
Discuss f/u. By phone and in clinic?

31. Judith at 2 week follow-up
“I love Lexapro.”
PHQ went from 17 to 4
What are the treatment options?
What are your treatment recommendations?
When do you recommend follow-up?

32. Debra, Case #2 39 yo with worsening depression and anxiety on Prozac
PHQ 21, Mood Disorder 11
What are the issues?
What are the options for treatment?
What do you recommend and why?
When do you schedule follow-up?

33. Debra at 2 week follow-up
PHQ 14, down from 21
What are your treatment options?
What do you recommend?
Do you use the Depression Self-Care Action Plan handout?
How do you communicate with counselors?
When do you recommend follow-up?

34. Lisa, Case #3 Anxiety and tummy pain, disliked Zoloft PHQ 14
What are the issues?
What are the treatment options?
Remember non-medicinal options for treatment of anxiety and depression.
When do you advise follow-up?

35. Lisa at 3 week follow-up PHQ went from 14 to 3
What are the treatment options?
Why do you see this patient back in 2-3 weeks?
How long should she be treated with medication?

36. Larry, Case #4 56 yo with hx of meth abuse, s/p anoxic brain injury.
Tried bupropion, fluoxetine, duloxetine – no remission
PHQ 18
What are the issues?
What are the options for treatment?
What do you recommend and why?

37. Larry at 3 week follow-up
PHQ went from 18 to 15, overall feeling more functional.
What are the treatment options?
When do you see this patient for f/u?
How long should he be treated with medication?

39. Use Your Resources PHQ-9, Mood Disorder, Suicide Risk
Use the handouts on the EMR
Use RN support
Collaborate with counselors
Check in with your patients regarding counseling and self-care

40. Depression Screening and Management
Depression screening on vitals form
Nurse follow up of PHQ >18 or after medication initiation
Depression phone follow-up at 3 days and 2 weeks
Close follow-up and med management
Depression self-care and counseling

42. Future Depression screening is best in an integrated program
Depression screening on our Diabetic Registry
Depression Registry
Better access to mental health providers
Better medications with fewer side effects
We have only just begun . . .