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 or up to two days after the date of the qualifying 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 (Pratt and Brody, 2014). Results from a 2016 U.S. survey indicated 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 (Substance Abuse and Mental Health Services Administration, 2017). The odds of a diagnosis of depression are believed to be 2.6 times greater for children and adolescents exposed to trauma as compared to those unexposed or less exposed (Vibhakar et al., 2019). 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 are at an increased risk of suicide (Siu on behalf of the U.S. Preventive Services Task Force [USPSTF], 2016). 

The same 2016 study indicated 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). Moreover, it is estimated 22.9 percent of adult patients with chronic pain (2.2 million adults) were diagnosed with comorbid depression from 2011 to 2015, with an upward trend of prevalence among Black Americans, patients aged 65 to 84 years old, Medicare and Medicaid insured patients, and patients from zip code areas with low annual household incomes (Orhurhu et al., 2020). 

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). It's estimated that the global prevalence of antenatal (or perinatal) depression ranges from 15 to 65 percent, with current or previous exposure to abuse and violence, lack of social support, and family history of mental disorders being risk factors. Depressive symptoms measured during pregnancy have been shown to influence the quality of the postpartum mother-infant relationship (Raine et al., 2020). Additionally, the risk of low birth weight and preterm birth is higher among infants born from depressed mothers (Dadi, Miller, Bisetegn, & Mwanri, 2020).

Negative outcomes associated with depression make it crucial to screen in order to identify and treat depression in its early stages. Data indicates that as the severity of depressive symptoms increase, rates of having difficulty with work, home, or social activities related to depressive symptoms increase. For those twelve and older with mild depressive symptoms, 45.7 percent reported difficulty with activities, and for those with severe depressive symptoms, 88 percent reported difficulty (Pratt & Brody, 2014). Depression also imposes significant economic burden through direct and indirect costs, supporting the need for regular depression screening. "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). 

Numerous studies have found significant disparities in depression prevalence and treatment among racial/ethnic minorities. One study revealed that Indigenous adults are at a high risk for posttraumatic stress disorder, depression, suicide, substance use disorder, and concurrent behavioral health disorders secondary to these initial health problems (Ka’apu and Burnette, 2019). Additionally, though rates of depression are lower among Blacks and Hispanics than among whites, depression among Blacks and Hispanics is likely to be more recurrent. Furthermore, 48 percent of whites receive mental health services, compared to just 31 percent of Blacks and Hispanics, and 22 percent of Asians (American Psychiatric Association, 2017). Asian Americans and Black Americans are also significantly more likely to utilize emergency rooms for depression treatment, which contributes to inconsistent follow-up care (Lee et al., 2014). 

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 46 percent of depressed patients (Borner et al, 2010). "In nationally representative U.S. surveys, about eight percent of adolescents reported having major depression in the past year. Only 36 percent to 44 percent 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). Furthermore, 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. 

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 USPSTF recommends that clinicians provide or refer pregnant and postpartum persons who are at increased risk of perinatal depression to counseling interventions. (B recommendation)” (U.S. Preventive Services Task Force, 2019). 

The American College of Obstetricians and Gynecologists (ACOG) provides the following recommendation:
"All obstetrician–gynecologists and other obstetric care providers should complete a full assessment of mood and emotional well-being (including screening for postpartum depression and anxiety with a validated instrument) during the comprehensive postpartum visit for each patient." (American College of Obstetricians and Gynecologists, 2018) 

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

Reference Type: CITATION

Reference Text: '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'

Reference Type: CITATION

Reference Text: 'American Psychiatric Association. (2017). Mental Health Disparities: Diverse Populations. Retrieved from https://www.psychiatry.org/psychiatrists/cultural-competency/education/mental-health-facts'

Reference Type: CITATION

Reference Text: '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'

Reference Type: CITATION

Reference Text: 'Dadi, A. F., Miller, E. R., Bisetegn, T. A., & Mwanri, L. (2020). Global burden of antenatal depression and its association with adverse birth outcomes: an umbrella review. BMC public health, 20(1), 173. https://doi.org/10.1186/s12889-020-8293-9'

Reference Type: CITATION

Reference Text: 'Hazell Raine, K., Nath, S., Howard, L. M., Cockshaw, W., Boyce, P., Sawyer, E., & Thorpe, K. (2020). Associations between prenatal maternal mental health indices and mother-infant relationship quality 6 to 18 months' postpartum: A systematic review. Infant mental health journal, 41(1), 24–39. https://doi.org/10.1002/imhj.21825'

Reference Type: CITATION

Reference Text: 'Ka'apu, K., & Burnette, C. E. (2019). A Culturally Informed Systematic Review of Mental Health Disparities Among Adult Indigenous Men and Women of the USA: What is known?. British journal of social work, 49(4), 880–898. https://doi.org/10.1093/bjsw/bcz009'

Reference Type: CITATION

Reference Text: 'Lee, S. Y., Xue, Q. L., Spira, A. P., & Lee, H. B. (2014). Racial and ethnic differences in depressive subtypes and access to mental health care in the United States. Journal of affective disorders, 155, 130–137. https://doi.org/10.1016/j.jad.2013.10.037'

Reference Type: CITATION

Reference Text: 'Orhurhu, V., Olusunmade, M., Akinola, Y., Urits, I., Orhurhu, M. S., Viswanath, O., … Gill, J. S. (2019). Depression Trends in Patients with Chronic Pain: An Analysis of the Nationwide Inpatient Sample. Pain physician, 22(5), E487–E494.'

Reference Type: CITATION

Reference Text: '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'

Reference Type: CITATION

Reference Text: '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.'

Reference Type: CITATION

Reference Text: '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'

Reference Type: CITATION

Reference Text: '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'

Reference Type: CITATION

Reference Text: '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/'

Reference Type: CITATION

Reference Text: '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'

Reference Type: CITATION

Reference Text: 'U.S. Preventive Services Task Force. (2019). Interventions to Prevent Perinatal Depression: US Preventive Services Task Force Recommendation Statement. JAMA, 321(6):580–587. doi:10.1001/jama.2019.0007'

Reference Type: CITATION

Reference Text: 'Vibhakar, V., Allen, L. R., Gee, B., & Meiser-Stedman, R. (2019). A systematic review and meta-analysis on the prevalence of depression in children and adolescents after exposure to trauma. Journal of affective disorders, 255, 77–89. https://doi.org/10.1016/j.jad.2019.05.005'

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 provider for additional evaluation and assessment to formulate a follow-up plan for a positive depression screen
   *  Pharmacological interventions
   *  Other interventions or follow-up for the diagnosis or treatment of depression

The intent of the measure is to screen for new cases of depression in patients who have never had a diagnosis of depression or bipolar disorder. Patients who have ever been diagnosed with depression or bipolar disorder prior to the qualifying encounter used to evaluate the numerator will be excluded from the measure regardless of whether the diagnosis is active or not.

A depression screen is completed on the date of the encounter or up to 14 calendar 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 or up to two calendar days after the date of the encounter, such as referral to a provider for additional evaluation, pharmacological interventions, or other interventions for the treatment of depression. An example to illustrate the follow-up plan documentation timing: if the encounter is on a Monday from 3-4 pm (day 0) and the patient screens positive, the clinician has through anytime on Wednesday (day 2) to complete follow-up plan documentation.

This measure does not require documentation of a specific score, just whether results of the normalized and validated depression screening tool used are considered positive or negative. Each standardized screening tool provides guidance on whether a particular score is considered positive for depression.  

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

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 by 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 calendar days prior to the date of the qualifying encounter.
 *  The measure assesses the most recent depression screening completed either during the qualifying encounter or within the 14 calendar 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 still be provided for and discussed with the patient during the qualifying encounter used to evaluate the numerator. However, documentation of the follow-up plan can occur up to two calendar days after the qualifying encounter, in accordance with the policies of an eligible clinician or provider’s practice or health system. All services should be documented during, or as soon as practicable, after the qualifying encounter in order to maintain an accurate medical record.

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 provider or program for further evaluation for depression, for example, referral to a psychiatrist, psychiatric nurse practitioner, psychologist, clinical 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:
*  Only order pharmacological intervention when appropriate and after sufficient diagnostic evaluation. However, for the purposes of this measure, additional screening and assessment during the qualifying encounter will not qualify as a follow-up plan.
*  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 5.6. 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 qualifying encounter during the measurement period

Equals Initial Population

Patients who have ever been diagnosed with depression or with bipolar disorder at any time prior to the qualifying encounter

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 or up to two days after the date of the qualifying 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

Preventive Care and Screening