Behavioral Health - Key Activity 9A

KEY ACTIVITY #9A:

Screen Adults for Depression, Including Suicidality

 

This key activity involves the following elements of person-centered population-based care: operationalize clinical guidelines; behavioral health integration.

Overview

This activity provides guidance on screening for depression for adults (those greater than 18 years, though this age cut-off may be site-determined).

Major depressive disorder (MDD), a common mental disorder in the U.S., can have a substantial impact on the lives of affected individuals and their families. If left untreated, MDD often interferes with daily functioning and is associated with an increased risk of cardiovascular events, exacerbation of comorbid conditions, or increased mortality. In 2021, 8.3% (21 million) of adults in the U.S. experienced at least one major depressive episode and 5.73% (14.5 million) experienced a major depressive episode with severe impairment.[1] Depression can be a chronic condition characterized by periods of remission and recurrence, often beginning in adolescence or early adulthood. However, full recovery may occur.

Depression is common in postpartum and pregnant people and affects both the parent and infant. Depression during pregnancy increases the risk of preterm birth, low birth weight and small for gestational age (SGA).[2] Postpartum depression may interfere with parent-infant bonding. See the PHMI Children Guide for specifics about screening for postpartum depression in a pediatric setting.

Psychiatric disorders and previous suicide attempts increase the risk of suicide. Depression screening must include plans for responding to patient statements regarding suicidal ideation. See Key Activity 9B. Implement Suicide Risk Assessment and Response Protocol.

There is overwhelming evidence of racial and ethnic inequities in depression treatment and outcomes. Racism and structural policies have contributed to wealth inequities in the U.S., which affect mental health services in underserved communities. Black and Hispanic or Latino/a white patients.[3][4] A cohort study of more than 50,000 primary care patients in California showed that the implementation of a standardized depression screening process may reduce inequities in screening and improve recognition and appropriate treatment of depression for all patients.[5] Implementation of systematic depression screening for all patients is one approach to more equitable delivery of depression treatment in primary care.

Research suggests that, for those reporting unmet social need, there is an association with higher rates of depression.[6][7] Consequently, depression should be considered a comorbidity when social needs are screened for, and both areas of potential need and support should be considered when designing appropriate interventions. See Key Activity 10: Develop a Social Needs Screening Process that Informs Patient Treatment Plans for more.

Technology can support screening for behavioral health conditions by delivering structured guidelines, protocols, and clinical decision support to care team members responsible for carrying out assessments. It can also help by incorporating standardized screening tools into EHRs and care management and care coordination applications. These screening tools can also be made available directly to patients through patient outreach and screening technologies.

Understanding the prevalence of behavioral health conditions assists in program and resource development to track their impact on health outcomes and to incorporate behavioral health conditions into risk stratification. Health information technologies used to track referrals are also important in care management.

Action steps and roles

Many brief tools have been developed that screen for depression and are appropriate for use in primary care. All positive screening results should lead to additional assessments to confirm the diagnosis, determine symptom severity, and identify comorbid psychological problems.

The use of PHQ-2 and PHQ-9 is recommended and recognized as the most commonly used tools for assessing adults for depression. In addition to being a clinically validated tool for use in person, over the phone, and via self-administration on a tablet or computer, these questionnaires been translated into multiple languages other than English (e.g., translations of PHQ and General Anxiety Disorder 7 (GAD-7) screeners are provided at PHQScreeners.com). As your skills evolve, there are considerations for using tools that are more specific to particular populations. Commonly used population-specific depression screening instruments include the Patient Health Questionnaire (PHQ) in various forms in adults and adolescents, the Geriatric Depression Scale (GDS) in older adults, and the Edinburgh Postnatal Depression Scale (EPDS) in postpartum. You can also start by reviewing current U.S. Preventive Services Task Force (USPSTF) Recommendations for Depression and Suicide Risk in Adults: Screening.

The following action steps are relevant, regardless of the screening tool chosen. Given that screening workflows may vary based on the clinic setting, teams are encouraged to modify and adapt this process as needed, depending on if the process starts when a patient presents at registration or when a patient is roomed (in-person or virtually).

 

1. Patient presents for medical care.

Suggested team member(s) responsible: Care coordinator or MA.

Staff identifies prior to the visit that the patient is due for routine depression screening. Routinely screen for depression at every medical visit.

 

2. Care team member administers the depression screening to the patient and identifies the next step in following the intended process for responding to positive screening results.

Suggested team member(s) responsible: Rooming staff.

Teams should decide upon the appropriate cut-off (e.g., greater than zero) that would result in a referral or next level of care or treatment.

  • If the result is negative, return to the routine screening interval.
  • If the score is positive, then rooming staff hands off information to the medical or behavioral health staff.

Many teams approach universal depression screening by utilizing a two- to four-question tool (e.g., the PHQ-2). If the PHQ-2 is positive (e.g., in response to either question the patient has a positive response), there is a workflow or standardized process that directs staff to administer the PHQ-9.

As stated above, screens are not a replacement for assessment.

 

3. If PHQ9 results are greater than zero or the agreed upon cutoff for initiating the next level of care, talk with the patient about appropriate timing of the best next steps for follow-up.

Suggested team member(s) responsible: Medical provider with possible handoff to the BH team.

Next steps might include:

  • Watchful waiting;
  • BH referral; and/or
  • Medication management, including a combination of the above.

 

4. If suicide risk is identified, immediate follow-up is initiated based on the acuity of symptoms established by the healthcare team (see suicide protocol).

Suggested team member(s) responsible: Medical and/or BH provider.

 

5. Plan for regular follow-up, such as annual repeat screening.

Suggested team member(s) responsible: Medical and/or BH provider.

Teams collectively should decide upon appropriate intervals for screening for depression and follow-up activities. Suggested intervals are:

  • Adults who screen negative will be screened annually.
  • Adults who have minimal symptoms and opt for watchful waiting will be readministered the PHQ-9 in three to six months.
  • Adults who have significant depression and move to assessment will be readministered the PHQ-9 in three months.

For those who are not being screened annually, such as those with depression who may be screened more frequently, determine the mechanism by which this alternative to the schedule will be followed and whether rooming staff or behavioral health staff will do the assessment. For example, this may include alterations to the care gap module in the EHR or utilization of another reminder system.

Note that, for those previously diagnosed with depression, teams annually monitor symptoms and the possibility of remission with the PHQ-9 as a means of monitoring ongoing care and treatment. Though the same tool is used for screening and monitoring, note that it is being used for a different purpose and the decision to administer it arises from different clinical workflows.

Consider narrowing intervals for repeating the PHQ-9 for those with a previous positive screen, diagnosis of depression or living with chronic conditions, such as every six months.

Implementation tips

  • Care teams may administer depression screening in various ways: Verbally by rooming staff, by paper screener at check-in, virtually through tablets at check-in, or as part of a pre-visit screening packet sent via text or email. Regardless of the method, care teams must have a process for reviewing the results in a timely fashion on the day of the visit and initiating the next step in the workflow.
  • An example workflow for depression screening is provided in Depression Screening and Case-Finding: Training Tools for Primary Care Teams from the Advancing Integrated Mental Health Solutions (AIMS) Center at the University of Washington.
  • Consider alternatives and modifications to the workflow for those patients whose primary language is not English.
  • Outside of those rooming and providing medical care/management, consider who else should be involved in the patient’s depression care. This might include community health workers, community-based organizations, support groups, and peers. Community health workers can be incorporated into care team planning and huddles and must be made aware of positive screens so that they can align needed supports.

Endnotes

  1. National Institute of Mental Health. Major Depression [Internet]. National Institute of Mental Health. 2023. Available from: https://www.nimh.nih.gov/health/statistics/major-depression  
  2. Jahan N, Went TR, Sultan W, Sapkota A, Khurshid H, Qureshi IA, et al. Untreated depression during pregnancy and its effect on pregnancy outcomes: A systematic review. Cureus [Internet]. 2021 Aug 17;13(8). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8448270/ 
  3. Enslow, M. R., Galfalvy, H. C., Sajid, S., Pember, R. S., Mann, J. J., & Grunebaum, M. F. (2023). Racial and ethnic disparities in time to first antidepressant medication or psychotherapy. Psychiatry research, 326, 115324. https://doi.org/10.1016/j.psychres.2023.115324 
  4. Simpson, S. M., Krishnan, L. L., Kunik, M. E., & Ruiz, P. (2007). Racial disparities in diagnosis and treatment of depression: a literature review. The Psychiatric quarterly, 78(1), 3–14. https://doi.org/10.1007/s11126-006-9022-y 
  5. Garcia ME, Hinton L, Neuhaus J, Feldman M, Livaudais-Toman J, Karliner LS. Equitability of Depression Screening After Implementation of General Adult Screening in Primary Care. JAMA Netw Open. 2022;5(8):e2227658. doi:10.1001/jamanetworkopen.2022.27658 
  6. Califf, R. M., Wong, C., Doraiswamy, P. M., Hong, D. S., Miller, D. P., Mega, J. L., & Baseline Study Group (2022). Importance of Social Determinants in Screening for Depression. Journal of general internal medicine, 37(11), 2736–2743. https://doi.org/10.1007/s11606-021-06957-5 
  7. Chavez, L. J., Tyson, D. P., Davenport, M. A., Kelleher, K. J., & Chisolm, D. J. (2023). Social Needs as a Risk Factor for Positive Postpartum Depression Screens in Pediatric Primary Care. Academic pediatrics, S1876-2859(23)00095-5. Advance online publication. https://doi.org/10.1016/j.acap.2023.03.007