DEPRESSION SCREENING: NEW GUIDELINES

What are the USPSTF recommendations on Depression Screening?

The USPSTF recommends screening for depression in the general adult population, including pregnant and postpartum women. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. This screening is given a “B” grade rating meaning it is recommended and there is a moderate certainty that the net benefit is moderate to substantial.

Are there any Quality Measures required by DHCS for Depression Screening?

The Comprehensive Depression Follow Up (CDF) is a quality measure that DHCS is asking health plans to report on starting in 2017 that includes both screening and a plan for follow-up of abnormal results. Partnership has chosen to report CDF as an Administrative measure to DHCS for HEDIS 2017.

What Depression Screening tools are available?

The PHQ-9 is the most common screening tool to identify depression. It is available in Spanish as well as in a modified version for adolescents. It is available in multiple languages as this website. Most importantly, the PHQ-9 includes a question designed to screen for danger to self which the shorter PHQ-2 version does not include. Suicide prevention can arguably be regarded as the most important aspect of depression screening.

The Edinburgh Postnatal Depression Scale (EPDS) is highly recommended for screening postpartum women and can be completed in less than 5 minutes. Recommendations are that screening be done both pre-term and postpartum for at least several months or up to a year. The EPDS is available in multiple languages at this website.

NOTE: None of the above screening tools actually DIAGNOSE depression—that is done properly by the PCP or other appropriately licensed health care personnel.

How often should screening for depression take place?

The PHQ-9 recommends that patients newly diagnosed with depression or those in current treatment for depression be screened at baseline and at regular intervals (e.g. every 2 weeks) or at their next scheduled appointment. The PHQ-9 can be filled out at home by the patient and brought to their appointment.

The onset of major or other depression can occur at any time with onset at any level of acuity, unlike other medical conditions where mild indications are monitored so that treatment can be instituted when symptoms reach a critical level of severity. The best practice, adopted by many clinics, is to add depression screening to other routine screening measures, such as blood pressure, weight, or activity level at each appointment (unless completed within the prior 2 weeks). The logistics involve handing the patient a paper copy of the PHQ-9 in their primary language (or email or mail a copy to fill out at home prior to their appointment) and have it scored by office personnel (or use an online version with automated scoring,) and then having the results evaluated by the PCP for appropriate diagnosis, referral or treatment decisions.

What are the recommended effective treatment actions following Depression Screening with the PHQ-9?

  1. If a patient scores anything other than zero on the “suicide ideation” question (#9 on the PHQ-9), immediate referral to an in-house mental health professional or via a warm telephone transfer to a County mental health crisis center is recommended. The county MH systems are mandated by the State to provide services high risk situations.
  2. Total scores greater equal or greater than 10 on the PHQ-9 have an 88% specificity for major depression.
    1. For depression in the minimum to mild range of severity (total score of 0 to 9 on PHQ-9), psychotherapy is the primary recommendation.
    2. For scores in the moderate range (total score of 10-14 on PHQ-9), and even in the moderately severe range (total score of 15-19 on PHQ-9), EITHER psychotherapy or medication are recommended options. A PCP referral to Beacon Health Options (see referral procedures cited at end of this article) can be a good starting point, whether or not medication will be prescribed immediately or will be added later.
    3. For severe major depression (total score of 20-27 on PHQ-9), it is likely that BOTH medication and psychotherapy are needed, most often involving a referral to County Mental Health services because of the severity level.

Are there any caveats in screening for depression in primary care?

Throughout my 40 years as a therapist including 18 years with Kaiser, there were three scenarios that often led to less than positive outcomes when patients were screened for depression in primary care.

  1. Patients who were actually bipolar were diagnosed with major depression and treated with anti-depressant medications (such as SSRIs) that produced a manic “flip” (observed as an almost instantaneous response to the antidepressant with a sudden dramatic increase in the patient’s sense of well-being and energy). This often led to the necessity for psychiatric hospitalization with an increased risk of self-harm. This occurs because bipolar patients rarely present to primary care when in manic states. They present when depressed and thus the manic potential is missed. The Mood Disorder Questionnaire (MDQ) can be used as a further screening when illnesses in the bipolar spectrum are suspected or need to be ruled out.
  1. Patients were on medications, especially opioids, or were abusing or misusing alcohol or other drugs, which were actually contributing to if not producing the depressive symptoms. Screening for alcohol/drug/medication use, even if within prescribed limits, is important for proper referral. Substance abuse problems must be addressed before depression can be treated effectively. The reverse is NOT effective. At present all substance abuse treatment for Partnership members is provided by County Mental Health/Substance Abuse services (County MH telephone numbers).
  1. Patients with mild depression or dysthymia (total PHQ-9 score <10) were immediately placed on anti-depressant medication which was generally not effective for these mild conditions and because the patient was expecting the medication to “work”, they do not seek counseling, which actually could help. The worst case scenario is that dosages are increased or other psychoactive agents added to produce “better results” to the patient’s detriment.

What are some handy hints in diagnosing depression, with or without the use of screening tools?

  1. I would say that the majority of the literally thousands of patients to whom I gave a depression diagnosis did NOT cite depressed mood as a primary symptom. In my experience, the most significant symptoms for major depression, in order of prominence, were:
    1. Increased irritability (often more obvious to family members)
    2. Anhedonia (an inability to enjoy formerly enjoyable activities)
    3. Anergia (drop dead tiredness)
    4. Insomnia (especially mid or terminal insomnia).
    5. Crying easily and social isolation
  1. Remembering that most commonly prescribed anti-depressant medications take a few weeks to kick in, it is always appropriate to refer for psychotherapy at the outset. In fact, patients are more motivated for counseling because they have not yet experienced symptom relief. This is also recommended if the level of severity is in question. Beacon is experienced in making step-up referrals to the county MHPs.

How can a PCP refer to Beacon Health Options for patients diagnosed with depression or any other psychiatric disorder presenting in the mild to moderate range of severity?

The newly revised Beacon PCP Referral Form can be accessed in fillable form online at: https://www.beaconhealthoptions.com/material/phpc-pcp-referral-form/

In completing the form, follow these suggested steps:

  1. Fill in identifying information and check Medi-Cal Eligibility
  2. [NEW] Check your preferred method of contact (email or FAX) to receive CONFIRMATION that your referral has been received and INFORMATION of the referral outcome. This will be referral information only, not clinical treatment information. But will let you know that your referral has been processed and the outcome of the Member contact concerning that referral.
  3. Check which service you are requesting for this Member:
    1. PCP Decision Support: A phone consult with a Beacon psychiatrist for diagnostic and prescribing support
    2. Out Patient Behavioral Health Services: Member referred to Beacon network provider for therapy and/or medication management (including coordination with county MH services).
    3. Referral for Local Care Management: Beacon case managers co-located with PHC will provide health care coordination services to engage and link Members who may have difficulty making their own appointments.
  4. Check all request reasons at bottom of form and submit (FAX to 866-422-3413 or email to medi-cal.referral@beaconhealthoptions.com

 NOTE: A follow-up blog will be coming soon, aimed at depression screening and maternal health including perinatal depression screening.

submitted by Karen Stephens, PhD, Mental Health Clinical Director, Partnership HealthPlan

 

SHARED DECISION MAKING – WHAT IT IS AND WHY IT MATTERS

“Nothing about me without me”…. Picker Institute

Every day as a busy clinician you make countless decisions regarding patient care. This includes decisions about diagnostic options, treatments, dispositions of patients, follow up and management of your patients.  Some decisions have clear and compelling evidence, and few alternative paths. For example, a fractured hip needs to be repaired or acute bacterial meningitis needs antibiotics.  Therapeutic action supersedes rigorous patient discussion (but does not completely replace it). However, for many medical decisions, the evidence is not compelling or there are multiple similar options. In this case, truly patient centered care asks for thorough discussion and consideration of patient’s preferences and values in making the decision. For instance, which option to choose for early stage breast cancer has quite different effect on the patient’s appearance, survival potential, and cost? This is what is called by the Dartmouth Atlas, “preference sensitive care”. In these cases, engagement with the patient in making the decision in order to fully understand and take into account their preferences and values is of paramount importance. A Cochrane Review of shared decision making found that in 86 trials that were examined, there was a consistent improvement in patient knowledge, more accurate risk perceptions, greater number of decisions that were consistent with the patient’s values, reduced level of internal decisional conflict, and fewer patients remaining undecided or passive.

The Agency for Healthcare Research and Quality (AHRQ) has developed an approach to assist physicians and other caregivers in taking a systematic approach to Shared Decision Making. This approach called SHARE 1 provides a five step process that includes:

 

Step 1: Seek your patient’s participation. Communicate that a choice exists and invite your patient to be involved in decisions

Step 2: Help your patient explore and compare treatment options. Discuss the benefits and harms of each option

Step 3: Assess your patient’s values and preferences. Ask open and non-judgmental questions.

Step 4: Reach a decision with your patient. Decide on best option and arrange follow up

Step 5: Evaluate your patient’s decision. Revisit the decision and monitor its implementation.

 

AHRQ provides shared decision making tools for both clinicians and for patients.  These include:

 

 

 

 

Beside AHRQ, a number of other organizations offer patient decision aids for shared decision making which include:

A full inventory of resources of patient decision aids is available at:

https://decisionaid.ohri.ca/AZinvent.php

 

In coming blogs, we will dive more deeply into the steps outlined above, and explore communication with patients and overcoming health literacy barriers, and heightening cultural awareness in your practice.

Partnership HealthPlan of California is eager to assist network practices and clinicians at becoming more skillful in shared decision making, and will be offering onsite training. Stay tuned!

 

(www.ahrq.gov/professionals/education/curriculum-tools/shareddecisionmaking/index.html

Submitted by Scott Endsley MD, Associate Medical Director, Quality

Trauma Informed Care – What You Can Do In Your Practice

PHC has had intensive care management programs in many of our FQHCs since 2012.  These care management programs will be evolving into our health homes programs in 2017.  Health Homes is an evolution of the patient centered medical home with an increased focus on substance abuse, integration of mental and behavioral health with medical care and a more intense effort to work with homeless members.

One of the new components in patient assessments will be a look at how trauma has affected the lives of our patients.  How serious is this problem?  Here are a few statistics:

  • Over half of women (55 to 99%) in substance abuse treatment report trauma
  • Nearly all women in the public mental health system (85 to 95%) have had trauma
  • Nearly all homeless veterans suffer PTSD
  • Trauma exposed youth have arrest rates 8 times that of same age peers
  • The economic costs of untreated trauma-related alcohol and drug abuse are estimated to have been $161 billion in 2000.

The Substance Abuse and Mental Health Services Administration (SAMHSA) concept of the trauma informed approach defines a trauma informed system of care:

  • Realize the widespread impact of trauma and understand paths to recovery
  • Recognize the signs and symptoms of trauma
  • Respond by integrating policies and procedures in your practices
  • Resist re-traumatizing patients

The goal is recognizing the effects of trauma on our patients is to provide an emotionally and physically safe environment for our patients.

How can you know if trauma is playing in a role in your patient’s behavior or choices?  You might start by asking about his or her childhood or how things are going at home.  Once you get a feel for whether trauma has affected your patient you may be able to be more direct in your questioning. The Life Events Checklist has 17 specific traumatic events, but you can consider a shorter list that we will be implementing into our PHC health risk assessments.

Have you been involved in or exposed to:

  • A natural disaster such as a flood, fire or earthquake?
  • Combat or a warzone?
  • Physical or emotional abuse?
  • Sexual abuse or assault?
  • Sudden violent death or unexpected death in someone close to you?
  • Any serious harm, injury or death caused by you?

Trauma is treatable. There are many evidence-based models and practices to help heal our patients and improve the behavioral manifestations of trauma.  A history of trauma is often hidden or denied and we don’t often ask about trauma in our patients with problematic behaviors.

How will this play out in your practices?  The next time someone acts out in your practice, consider asking “Can you tell me what happened to you?” instead of “What’s wrong with you?” You may be surprised at the answer.

And Now for Something Completely Different….

While most people associate “magic mushrooms” and “X” with illicit drug use some recent research indicates these substances may have a role with some of the most difficult-to-treat psychiatric patients.

Two studies published in the December edition of the Journal of Psychopharmacology used psilocybin and similar study designs to treat cancer patient’s depression and anxiety. Previous studies have (unsurprisingly) shown high rates of both conditions in cancer patients with life-threatening diagnoses along with difficulty in adequately treating these same conditions leading to a variety of poor outcomes. (e.g. decreased survival rates, increase in suicides, decreased function, among others)

Utilizing a crossover study and high or moderate dose of psilocybin versus placebo or very low dose psilocybin both studies found not only a marked improvement in both depression and anxiety scores but also improving measureable factors such as spiritual wellbeing, general life satisfaction, and quality of life, life meaning, and optimism, while decreasing cancer-related demoralization and hopelessness, and death anxiety. Even more remarkable the effect on depression and anxiety (with reduction rates as high as 80%) persisted for 6-8 months with only a single dose of psilocybin!!  Both studies even used a Mystical Experience Questionnaire (MEQ30) which “is a self-report questionnaire that evaluates discrete mystical experiences induced by serotoninergic psychedelics and is sensitive to detecting psilocybin-induced mystical experiences.” As an additional benefit, no subjects in either study suffered from any serious side effects.

 

Along this same vein the FDA announced this week that based on the success of small drug trials it is allowing large-scale Phase 3 clinical trials to study the use of MDMA, or Ecstasy, for patients with severe PTSD. The Multidisciplinary Association for Psychedelic Studies (MAPS), a non-profit group that advocates for the medical use of banned drugs, sponsored six Phase 2 studies that led to the FDA’s decision.

In 2 of the trials they studied combat veterans, sexual assault victims, firefighters and police officers that suffered from PTSD and had not responded to previous treatments. The average duration of symptoms was 17 years! Subjects were given 3 doses of MDMA a few weeks apart under supervision of a psychiatrist along with psychotherapy. This was also a crossover study.

One study showed a 56% decline in severity and by the study conclusion 2/3 no longer met the criteria for PTSD. In addition improvements persisted for over a year. The researchers have applied for “breakthrough therapy status” with the FDA which could allow approval by 2021. Other researchers urge caution, using the opioid crisis as an example of how the drug could be abused.

As a historical aside, MDMA was first patented in 1914 but in 1978 it was resynthesized by chemist Dr. Alexander Shulgin. (Dr. Shulgin was my toxicology professor during my MPH studies at UC Berkeley – an interesting man to say the least!) He gave it to friends in the psychiatric field to use for augmenting psychotherapy but when it spread to more general recreational use the FDA classified it a Schedule 1 drug and initial research was halted.

The results so far are promising but likely a long way off for routine clinical use.