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.

2. 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).

3. 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

2. 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