# Presentation: 239301

## Documenting Depression Screening in RPMS

- Depression Screening
- GPRA Clinical Performance Measure

## GPRA

- Government Performance and Results Act
- Federal law
- Performance-based budgeting
- Measurable performance indicators to demonstrate effectiveness in meeting Agency mission

## Depression Screening Targets

- FY 2006 Target:
- During FY 2006, establish a *baseline* rate of annual screening for depression in adults ages 18 and over.
- FY 2006 Result: **15%**
- FY 2007 Target:
- _Maintain_ the rate of annual screening for depression in adults ages 18 and over at the FY 2006 level of **15%.**

## Depression

- About 1 in 20 adults experience major depression in a given year.
- About 1 in 3 people who have survived a heart attack experience depression in a given year.

**Notes:**
Regier DA, Narrow WE, Rae DS, et al. The de facto mental and addictive disorders service system. Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services. Archives of General Psychiatry, 1993; 50(2): 85-94.
Lesperance F, Frasure-Smith N, Talajic M. Major depression before and after myocardial infarction: its nature and consequences. Psychosomatic Medicine, 1996; 58(2): 99-110.

## Effects of Depression

- Depression and anxiety disorders may affect heart rhythms, increase blood pressure, and alter blood clotting.
- Depression can also lead to elevated insulin and cholesterol levels.
- Depression or anxiety may result in chronically elevated levels of stress hormones, such as cortisol and adrenaline. The body's metabolism is diverted away from the type of tissue repair needed in heart disease.

## Major Depressive Disorder

- Major Depressive Disorder (MDD) is the one of the most common mental disorders in primary care settings.
- The prevalence of current MDD in primary care settings has been found to range from 9.2% to 13.5%.
- MDD may occur at any age.

**Notes:**
Source: Veteran’s Administration

## Recurrence

- 50% of Individuals who have had an episode of major depressive disorder will have another episode.
- Of those who have had two episodes, 75% will have a third.

**Notes:**
Source: Veteran’s Administration

## Risk Factors

- Prior episode of depression
- Family history of depressive disorder
- Prior suicide attempt
- Female gender
- Medical conditions
- Lack of social support
- Stressful life events
- Current substance use

**Notes:**
Source: Veteran’s Administration

## Untreated Depression

- Depression is the **2nd** leading cause of disability in industrialized countries
- Depression associated with:
**2x** increased risk of death overall
**26x** increased risk of suicide
- Impaired social functioning

**Notes:**
Source: VA

## Other Consequences

- Depressed patients visit primary care provider **3x** more than non-depressed patients
**2-5x** increase in days absent from work
- Cost of depression in US in 1990 estimated to be **$44 billion**

**Notes:**
Source: VA
The $44 billion in cost for depression is estimated to come from the following sources:
	- $12 billion - direct cost of care
	- $8 billion	- mortality costs
	- $24 billion - absenteeism/lost productivity

## Depressive Disorders

- Major depressive disorder (MDD)
- Minor (subthreshold) depression
- Adjustment disorder with depressed mood
- Dysthymia (chronically depressed mood for at least 2 years, typically with fewer symptoms than major depressive disorder)

**Notes:**
Source: VA

## Diagnostic Criteria (DSM-IV)

- 	Major depression is present when the patient has had at least **5** of the **9** following symptoms for *a minimum of two weeks*.  One of the symptoms must be either:
**Depressed mood, or**
**Loss of interest or pleasure, and...**

**Notes:**
Source: Veteran’s Administration

## Diagnostic Criteria, cont.

**	****3. **Significant change in weight or appetite
**	****4. **Insomnia or hypersomnia
**	****5. **Psychomotor agitation or retardation
**	****6. **Fatigue or loss of energy
**	****7. **Feelings of worthlessness or guilt
**	****8. **Impaired concentration or ability to 		    make decisions
**	****9. **Thoughts of suicide or self-harm

**Notes:**
Source: Veteran’s Administration

## Diagnostic criteria, cont.

- Symptoms must be accompanied by functional impairment in one or more of the following domains:
- work/school
- doing things at home
- relationships with other people

**Notes:**
Source: Veteran’s Administration

## Minor Depression

- Patient has **2 **to** 4** of the 9 symptoms listed above
- Symptoms present for at least two weeks
- One of the symptoms must be either item 1 (depressed mood) or item 2 (loss of interest or pleasure)

**Notes:**
Source: Veteran’s Administration

## Dysthymia

- Depression present more days than not, for 2 years or more
- Well period cannot last more than 2 months during this time

**Notes:**
Source: Veteran’s Administration

## Rule out other causes

- Bipolar disorder
- Anxiety disorders
- Substance abuse
- Medical Conditions
- Bereavement
- Medications
- Note: It is essential to rule out any accompanying episodes of mania, as antidepressants can trigger a manic phase.

**Notes:**
Source: Veteran’s Administration

## Evaluating for Depression

- Do not ask patient: “Are you Depressed?”, INSTEAD, Ask: “How has your mood been?”
- Ask about Anhedonia: “What are you doing for fun?” OR: “Does your (pain, anxiety, grief, whatever symptoms patient mentions) keep you from doing all the things you enjoy?”

**Notes:**
Source: Veteran’s Administration

## Why use open-ended questions?

- Asking the patient directly if s/he is depressed is not recommended for three reasons:
- A yes/no answer limits the amount of information you can obtain from the patient.
- It requires the patient to make his/her own definition of depression to answer the question.  Their definition may be very different from your definition.
- Depression often carries a stigma and is associated with personal weakness; many patients may be reluctant to answer truthfully.

**Notes:**
Source: Veteran’s Administration

## Assessment of Suicide Risk

- 80% of seriously depressed patients think of suicide
- Assess risk factors:
- PRIOR ATTEMPTS
- Family history of suicide
- Hopelessness
- Demographics
- Clinical
- Substance abuse, psychosis, potentially terminal illness

**Notes:**
Source: Veteran’s Administration

## Suicide Risk Assessment

- Use a gradual, sensitive approach to raise the subject:
- How does the future look to you?
- Living with (pain/anxiety/patients’ symptoms) can be very difficult. Do you sometimes wish your life was over?
- Have you had thoughts that you would be better off dead?
- Have you had thoughts of hurting yourself?
- Have you thought about how you might hurt yourself?

**Notes:**
Source: Veteran’s Administration

## Suicide Risk Assessment

- There is no evidence that talking about suicide will introduce a new idea or provoke the patient to take action.
- Patients with specific plans are at greater risk for suicide than those who only think about it or express concerns

**Notes:**
Source: Veteran’s Administration

## When to Refer to Behavioral Health

- Suicidal ideation
- Psychotic symptoms
- Manic symptoms
- Current substance abuse
- Severe psychosocial problems

**Notes:**
Source: Veteran’s Administration

## Treatment

- Depression is one of the most treatable mental illnesses
- 70% - 75% of all depressed people respond to treatment
- almost all who receive treatment experience some relief in symptoms
- Medication (including prescription antidepressant medications, particularly the selective serotonin reuptake inhibitors)
- Psychotherapy (“talk” therapy)
- Electroconvulsive Therapy
- Watchful waiting

## Barriers to Treatment

- Practical Barriers
- Ethnic/Cultural barriers (includes certain groups being reluctant to discuss emotional issues with providers - especially common in Native Americans)
- Patient doesn’t agree with diagnosis or plan
- Patient doesn’t understand treatment plan
- Patient is afraid of becoming addicted to antidepressants

**Notes:**
Source: Veteran’s Administration

## Screening and Diagnosis

- Depression is difficult to diagnose in primary care and often goes undetected:
- depressed mood typically not presenting complaint
- competing demands (acute and chronic illnesses)
- limited resources and time
- Screening improves detection

**Notes:**
Source: VA

## USPSTF Recommendation

- Adult patients 18 years of age and older should be screened for depression *at least annually.*

**Notes:**
Source: United States Preventive Services  Task Force 

## Clinical Reporting System (CRS) GPRA Logic

- Denominator: Active Clinical patients ages 18 and older, broken down by gender.
- Numerator: Patients screened for depression or diagnosed with mood disorder at any time during the Report Period, including documented refusals in past year.

## Documenting Screening in RPMS

- The preferred method of documenting depression screening is via the RPMS Exam Code #36
- WHY are Exam Codes preferred?
- V codes (such as v79.0 Screening for Depression) *cannot *capture the screening *result*
- Exam Code #36 provides best evidence of intentional screening
- Currently, CRS will accept diagnosis and patient education codes as evidence of screening, but this may change in future

**Notes:**
Exam Codes are typically found on the “Wellness Tab” (along with Patient Education, Health Factors, etc.) in the RPMS Electronic Health Record and the Behavioral Health component in Patient Chart.

## RPMS Depression ScreeningExam Code

- Allowable Results:
- Negative
- Positive - further evaluation indicated
- Refused - patient declined exam/screen
- Unable to screen
- Comment
- Not required

## Documenting Depression Screening in EHR 

***Documenting Depression Screening in EHR ***

**Notes:**
Exams are typically found on the Wellness Tab in the EHR. Click on Add and choose the Depression Screening exam code from the drop down list. 

## Documenting Depression Screening in BH GUI (IHS Patient Chart)

***Documenting Depression Screening in ******BH GUI (IHS Patient Chart)***

**Notes:**
The Screening Exam codes are found on the Wellness Tab in the BH GUI. The Wellness Tab can be accessed on the following Visit Types: Reguar, Intake and A/SA. 

## Health Maintenance Reminder

- Title:  Depression Screening
- Logic:  Mimics the GPRA Depression Screening measure logic
- Default Parameters*
- Annually starting at age 18
- Males and Females
- *HMR Parameters can be changed to reflect local policy and procedures regarding screening

## Health Maintenance Reminder

- Displays on Health Maintenance Reminder (HMR) component of Health Summary
- HMR has to be added to each type of HS
- HS Display
- Title of Screen *and the notation:*
- “May be Due Now” *or*
- Date Last Done
- Screening Result
- Initials of Provider who screened

## Recommended Screening Tool

- PHQ-2 Scaled Version
- Patient Health Questionnaire
- Possible results:
- Negative
- Positive
- A positive result means further evaluation is indicated; it *does not*
-    constitute a diagnosis of depression

## PHQ-2 Scaled Version

- Over the last two weeks, how often have you been bothered by
- any of the following problems?
- Little interest or pleasure in doing things
- Not at all				Value:	0
- Several days			Value:	1
- More than half the days		Value:	2
- Nearly every day 			Value:	3
- Feeling down, depressed or hopeless
- Not at all				Value:	0
- Several days			Value:	1
- More than half the days		Value:	2
- Nearly every day 			Value:	3
- Total PHQ-2 score possible:		Range: 0-6

## PHQ-2 Scaled Version Scores

- 0 – 2  = Negative
- Depression Screening Exam Code Result:  NEGATIVE
- 3 – 6 = Positive; further evaluation is indicated
- Depression Screening Exam Code Result:  POSITIVE
- The patient may decline the screen or refuse to answer
- Depression Screening Exam Code Result:  REFUSED
- Some patients cannot be screened due to disability or other reasons
- Depression Screening Exam Code Result:  UNABLE TO SCREEN

## Documenting PHQ-2 Screening

- Indicate result of screen
- Positive, Negative, Refused, or Unable to Screen
- Recommended to document name of tool used (PHQ-2)
- Can capture this in COMMENT section of Exam Code
- PCC documentation should include actions taken (PHQ-9 results, treatment, referral, etc.) in response to a Positive PHQ-2 screen

## What to do if PHQ-2 is Positive

- Evaluate further in the primary care setting
- Consider using PHQ-9 tool (next slide)
- If further evaluation is positive for depression...
- Discuss treatment options with the patient including:
- Counseling
- Medication
- Combination of counseling and medication
- Refer to Behavioral Health as needed
- Medication consultation
- Counseling

## PHQ-9

- Self-administered version of the PRIME-MD diagnostic instrument for common mental disorders
- PHQ-9 is the depression module
- Criteria-based diagnoses of depressive disorder
- Scores each of the 9 DSM-IV criteria for depressive disorders
- 0 (not at all) to 3 (nearly every day)
- Half the length of other depression measures with comparable sensitivity and specificity
- Can establish diagnosis and grade depressive symptom severity

## IHS GPRA Measure Contacts

- Wilbur Woodis, HQ (Measure Lead) Wilbur.Woodis@ihs.gov
- Francis Frazier, HQ (GPRA Lead) Francis.Frazier@ihs.gov
- Theresa Cullen, OIT Theresa.Cullen@ihs.gov
- Amy Patterson, CAO Amy.Patterson@ihs.gov