Preventive Care and Screening: Screening for Depression and Follow-Up Plan

Percentage of patients aged 12 years and older screened for depression on the date of the encounter or up to 14 days prior to the date of the encounter using an age-appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the eligible encounter

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Depression is a serious medical illness associated with higher rates of chronic disease, increased health care utilization, and impaired functioning (Katon, 2003; Wells et al., 1989). 2016 U.S. survey data indicate that 12.8 percent of adolescents (3.1 million adolescents) had a major depressive episode (MDE) in the past year, with nine percent of adolescents (2.2 million adolescents) having one MDE with severe impairment. The same data indicate that 6.7 percent of adults aged 18 or older (16.2 million adults) had at least one MDE with 4.3 percent of adults (10.3 million adults) having one MDE with severe impairment in the past year (Substance Abuse and Mental Health Services Administration, 2017). Data indicate that severity of depressive symptoms factor into having difficulty with work, home, or social activities. For example, as the severity of depressive symptoms increased, rates of having difficulty with work, home, or social activities related to depressive symptoms increased. For those twelve and older with mild depressive symptoms, 45.7% reported difficulty with activities and those with severe depressive symptoms, 88.0% reported difficulty (Pratt & Brody, 2014). Children and teens with major depressive disorder (MDD) have been found to have difficulty carrying out their daily activities, relating to others, growing up healthy, and also are at an increased risk of suicide (Siu on behalf of the U.S. Preventive Services Task Force [USPSTF], 2016). Additionally, perinatal depression (considered here as depression arising in the period from conception to the end of the first postnatal year) affects up to 12% of women (Woody, Ferrari, Siskind, Whiteford, & Harris, 2017). Depression and other mood disorders, such as bipolar disorder and anxiety disorders, especially during the perinatal period, can have devastating effects on women, infants, and families (American College of Obstetricians and Gynecologists, 2018). Maternal suicide rates rise over hemorrhage and hypertensive disorders as a cause of maternal mortality (Palladino, Singh, Campbell, Flynn, & Gold, 2011). 

Negative outcomes associated with depression make it crucial to screen in order to identify and treat depression in its early stages. While Primary Care Providers (PCPs) serve as the first line of defense in the detection of depression, studies show that PCPs fail to recognize up to 50% of depressed patients (Borner, Braunstein, St. Victor, & Pollack, 2010). "In nationally representative U.S. surveys, about eight percent of adolescents reported having major depression in the past year. Only 36% to 44% of children and adolescents with depression receive treatment, suggesting that the majority of depressed youth are undiagnosed and untreated" (Siu on behalf of USPSTF, 2016, p. 360 & p. 364). Evidence supports that screening for depression in pregnant and postpartum women is of moderate net benefit and treatment options for positive depression screening should be available for patients twelve and older including pregnant and postpartum women. 

If preventing negative patient outcomes is not enough, the substantial economic burden of depression for individuals and society alike makes a case for screening for depression on a regular basis. Depression imposes economic burden through direct and indirect costs: "In the United States, an estimated $22.8 billion was spent on depression treatment in 2009, and lost productivity cost an additional estimated $23 billion in 2011" (Siu & USPSTF, 2016, p. 383-384). 

This measure seeks to align with clinical guideline recommendations as well as the Healthy People 2020 recommendation for routine screening for mental health problems as a part of primary care for both children and adults (U.S. Department of Health and Human Services, 2014) and makes an important contribution to the quality domain of community and population health.

Adolescent Recommendation (12-18 years):

"The USPSTF recommends screening for MDD in adolescents aged 12 to 18 years. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up (B recommendation)" (Siu on behalf of  USPSTF, 2016, p. 360).

Adult Recommendation (18 years and older):

"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 (B recommendation)" (Siu & USPSTF, 2016, p. 380).

The Institute for Clinical Systems Improvement (ICSI) health care guideline, Adult Depression in Primary Care, provides the following recommendations:
1. "Clinicians should routinely screen all adults for depression using a standardized instrument."
2. "Clinicians should establish and maintain follow-up with patients."
3. "Clinicians should screen and monitor depression in pregnant and post-partum women." (Trangle et al., 2016, p. 8-10).

Higher score indicates better quality

American College of Obstetricians and Gynecologists, Committee on Obstetric Practice. (2018). ACOG Committee Opinion Number 757: Screening for perinatal depression. Obstetrics and Gynecology, 132(5), e208-e212. doi: 10.1097/AOG.0000000000002927

Borner, I., Braunstein, J. W., St. Victor, R., & Pollack, J. (2010). Evaluation of a 2-question screening tool for detecting depression in adolescents in primary care. Clinical Pediatrics, 49(10), 947-995. doi:10.1177/0009922810370203

Katon, W. J. (2003). Clinical and health services relationships between major depression, depressive symptoms, and general medical illness. Biological Psychiatry, 54(3), 216-226. doi: 10.1016/s0006-3223(03)00273-7

Palladino, C. L., Singh, V., Campbell, J., Flynn, H., & Gold, K. (2011). Homicide and suicide during the perinatal period: Findings from the National Violent Death Reporting System. Obstetrics and Gynecology, 118(5), 1056-1063. doi:10.1097/AOG.0b013e31823294da

Pratt, L. A., & Brody, D. J. (2014). Depression in the U.S. household population, 2009-2012. NCHS Data Brief No. 172. Hyattsville, MD: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. Retrieved from https://www.cdc.gov/nchs/data/databriefs/db172.pdf

Siu, A. L., on behalf of USPSTF. (2016). Screening for depression in children and adolescents: U.S. Preventive Services Task Force recommendation statement. Annals of Internal Medicine, 164(5), 360-366. doi:10.7326/M15-2957

Siu, A. L., & USPSTF. (2016). Screening for depression in adults: U.S. Preventive Services Task Force recommendation statement. Journal of the American Medical Association, 315(4), 380-387. doi:10.1001/jama.2015.18392.

Substance Abuse and Mental Health Services Administration. (2017). Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health. Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2016/NSDUH-FFR1-2016.htm

Trangle, M., Gursky, J., Haight, R., Hardwig, J., Hinnenkamp, T., Kessler, D.,… Myszkowski, M. (2016). Adult depression in primary care. Bloomington, MN: Institute for Clinical Systems Improvement. Retrieved from https://www.icsi.org/guideline/depression/

U.S. Department of Health and Human Services. (2014). Healthy People 2020: Mental health and mental disorders.  Washington, DC: U.S. Department of Health and Human Services. Retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=28

Wells, K. B., Stewart, A., Hays, R. D., Burnam, M. A., Rogers, W., Daniels, M., … Ware, J. (1989). The functioning and well-being of depressed patients. Results from the Medical Outcomes Study. Journal of the American Medical Association, 262(7), 914-919. Abstract retrieved from https://www.ncbi.nlm.nih.gov/pubmed/2754791

Woody, C. A., Ferrari, A. J., Siskind, D. J., Whiteford, H. A., & Harris, M. G. (2017). A systematic review and meta-regression of the prevalence and incidence of perinatal depression. Journal of Affective Disorders, 219, 88-92. doi:10.1016/j.jad.2017.05.003

Screening:
Completion of a clinical or diagnostic tool used to identify people at risk of developing or having a certain disease or condition, even in the absence of symptoms.  

Standardized Depression Screening Tool: A normalized and validated depression screening tool developed for the patient population in which it is being utilized.

Examples of standardized depression screening tools include but are not limited to: 
*  Adolescent Screening Tools (12-17 years) 
   *  Patient Health Questionnaire for Adolescents (PHQ-A)
   *  Beck Depression Inventory-Primary Care Version (BDI-PC)
   *  Mood Feeling Questionnaire (MFQ)
   *  Center for Epidemiologic Studies Depression Scale (CES-D)
   *  Patient Health Questionnaire (PHQ-9)
   *  Pediatric Symptom Checklist (PSC-17)
   *  PRIME MD-PHQ2 
*  Adult Screening Tools (18 years and older) 
   *  Patient Health Questionnaire (PHQ9)
   *  Beck Depression Inventory (BDI or BDI-II)
   *  Center for Epidemiologic Studies Depression Scale (CES-D)
   *  Depression Scale (DEPS)
   *  Duke Anxiety-Depression Scale (DADS)
   *  Geriatric Depression Scale (GDS)
   *  Cornell Scale for Depression in Dementia (CSDD)
   *  PRIME MD-PHQ2 
   *  Hamilton Rating Scale for Depression (HAM-D)
   *  Quick Inventory of Depressive Symptomatology Self-Report (QID-SR)
   *  Computerized Adaptive Testing Depression Inventory (CAT-DI)
   *  Computerized Adaptive Diagnostic Screener (CAD-MDD)
* Perinatal Screening Tools
   *  Edinburgh Postnatal Depression Scale
   *  Postpartum Depression Screening Scale
   *  Patient Health Questionnaire 9 (PHQ-9)
   *  Beck Depression Inventory
   *  Beck Depression Inventory-II
   *  Center for Epidemiologic Studies Depression Scale
   *  Zung Self-rating Depression Scale
   
Follow-Up Plan: 
Documented follow-up for a positive depression screening must include one or more of the following:
 *  Referral to a practitioner who is qualified to diagnose and treat depression
 *  Pharmacological interventions
 *  Other interventions or follow-up for the diagnosis or treatment of depression

A depression screen is completed on the date of the encounter or up to 14 days prior to the date of the encounter using an age-appropriate standardized depression screening tool AND if positive, a follow-up plan must be documented on the date of the encounter, such as referral to a practitioner who is qualified to treat depression, pharmacological interventions or other interventions for the treatment of depression.

This eCQM is a patient-based measure. Depression screening is required once per measurement period, not at all encounters.

The intent of the measure is to screen for depression in patients who have never had a diagnosis of depression or bipolar disorder prior to the eligible encounter used to evaluate the numerator. Patients who have ever been diagnosed with depression or bipolar disorder will be excluded from the measure.

Screening Tools:
 *  An age-appropriate, standardized, and validated depression screening tool must be used for numerator compliance.
 *  The name of the age-appropriate standardized depression screening tool utilized must be documented in the medical record.
 *  The depression screening must be reviewed and addressed in the office of the provider, filing the code, on the date of the encounter. Positive pre-screening results indicating a patient is at high risk for self-harm should receive more urgent intervention as determined by the provider practice.
 *  The screening should occur during a qualifying encounter or up to 14 days prior to the date of the qualifying encounter.
 *  The measure assesses the most recent depression screening completed either during the eligible encounter or within the 14 days prior to that encounter. Therefore, a clinician would not be able to complete another screening at the time of the encounter to count towards a follow-up, because that would serve as the most recent screening. In order to satisfy the follow-up requirement for a patient screening positively, the eligible clinician would need to provide one of the aforementioned follow-up actions, which does not include use of a standardized depression screening tool.

Follow-Up Plan:

The follow-up plan must be related to a positive depression screening, for example: "Patient referred for psychiatric evaluation due to positive depression screening."

Examples of a follow-up plan include but are not limited to: 
 *  Referral to a practitioner or program for further evaluation for depression, for example, referral to a psychiatrist, psychologist, social worker, mental health counselor, or other mental health service such as family or group therapy, support group, depression management program, or other service for treatment of depression
 *  Other interventions designed to treat depression such as behavioral health evaluation, psychotherapy, pharmacological interventions, or additional treatment options

Should a patient screen positive for depression, a clinician should opt to complete a suicide risk assessment when appropriate and based on individual patient characteristics. However, for the purposes of this measure, a suicide risk assessment or additional screening using a standardized tool will not qualify as a follow-up plan.

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

TBD

All patients aged 12 years and older at the beginning of the measurement period with at least one eligible encounter during the measurement period

Equals Initial Population

Patients who have been diagnosed with depression or with bipolar disorder

Patients screened for depression on the date of the encounter or up to 14 days prior to the date of the encounter using an age-appropriate standardized tool AND if positive, a follow-up plan is documented on the date of the eligible encounter

Not Applicable

Patient Reason(s)
Patient refuses to participate 
OR
Medical Reason(s)	
Documentation of medical reason for not screening patient for depression (e.g., cognitive, functional, or motivational limitations that may impact accuracy of results; patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient's health status)

For every patient evaluated by this measure also identify payer, race, ethnicity and sex