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 using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen.

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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, Brody 2014). 2014 U.S. survey data indicate that 2.8 million (11.4 percent) adolescents aged 12 to 17 had a major depressive episode (MDE) in the past year and that 15.7 million (6.6 percent) adults aged 18 or older had at least one MDE in the past year, with 10.2 million adults (4.3 percent) having one MDE with severe impairment in the past year (Center for Behavioral Health Statistics and Quality, 2015). 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) has been found to have difficulty carrying out their daily activities, relating to others, and growing up healthy with an increased risk of suicide (Siu and USPSTF, 2016). Additionally, among pregnant women, especially during the perinatal period, depression and other mood disorders, such as bipolar disorder and anxiety disorders, can have devastating effects on women, infants, and families. Maternal suicide rates rise over hemorrhage and hypertensive disorders as a cause of maternal mortality (American College of Obstetricians and Gynecologists, 2015). 

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, 2010, p. 948). "Coyle et al. (2003), suggested that the picture is more grim for adolescents, and that more than 70% of children and adolescents suffering from serious mood disorders go unrecognized or inadequately treated" (Borner, 2010, p. 948). "In nationally representative U.S. surveys, about 8% 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" (Sui, A. and USPSTF, 2016). 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" (Sui, A. and USPSTF, 2016).

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)" (Sui, A. and USPSTF, 2016, p. 360).

"Clinicians and health care systems should try to consistently screen adolescents, ages 12-18,  for major depressive disorder, but only when systems are in place to ensure accurate diagnosis, careful selection of treatment, and close follow-up" (ICSI, 2013, p. 16).

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)" (Sui, A. and 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, 2016 p.p. 9 - 10)

Higher score indicates better quality

American College of Obstetricians and Gynecologists (2015). Screening for perinatal depression. Committee Opinion No. 630. Obstet Gynecol 2015;125:1268-71. Retrieved from http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Screening-for-Perinatal-Depression

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

Center for Behavioral Health Statistics and Quality. (2015). Behavioral health trends in the United States: Results from the 2014 National Survey on Drug Use and Health (HHS Publication No. SMA 15-4927, NSDUH Series H-50). Retrieved from http://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf

Coyle J T, Pine D.S, Charney D S, Lewis L, Nemeroff C B, Carlson G A, Joshi P T (2003). Depression and bipolar support alliance consensus development panel. Depression and bipolar support alliance consensus statement on the unmet needs in diagnosis and treatment of mood disorders in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 42, 1494-1503.

Pratt L.A, Brody DJ (2014). Depression in the U.S. Household Population, 2009-2012. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention National Center for Health Statistics. NCHS Data Brief No. 172, 1-8.

Siu AL, on behalf of the U.S. Preventive Services Task Force. Screening for Depression in Children and Adolescents: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2016; 164:360-366. http://annals.org/article.aspx?articleid=2490528

Siu AL, and the US Preventive Services Task Force (USPSTF). Screening for Depression in Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2016; 315(4):380-387. doi:10.1001/jama.2015.18392. http://jama.jamanetwork.com/article.aspx?articleid=2484345

Steinman LE, Frederick JT, Prohaska T, Satariano WA, Dornberg-Lee S, Fisher R, ...Snowden M (2007). Recommendations for treating depression in community-based older adults. American Journal of Preventive Medicine, 33(3), 175-81. Retrieved from:  www.ajpm-online.net/article/S0749-3797%2807%2900330-3/abstract

Trangle M, Gursky J, Haight R, Hardwig J, Hinnenkamp T, Kessler D, Mack N, Myszkowski M. Institute for Clinical Systems Improvement. Adult Depression in Primary Care. Updated March 2016.

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

Wilkinson J, Bass C, Diem S, Gravley A, Harvey L, Maciosek M, McKeon K, Milteer L, Owens J, Rothe P, Snellman L, Solberg L, Vincent P. Institute for Clinical Systems Improvement. Preventive Services for Children and Adolescents. Updated September 2013.

Zalsman G, Brent DA & Weersing VR (2006). Depressive disorders in childhood and adolescence: an overview: epidemiology, clinical manifestation and risk factors. Child and Adolescent Psychiatric Clinics of North America. 2006;15:827-841

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 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:
 *  Additional evaluation or assessment for depression 
 *  Suicide Risk Assessment
 *  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 using an age appropriate standardized depression screening tool AND if positive, either additional evaluation for depression, suicide risk assessment, referral to a practitioner who is qualified to diagnose and treat depression, pharmacological interventions, or other interventions or follow-up for the diagnosis or treatment of depression is documented on the date of the positive screen. 

Depression screening is required once per measurement period, not at all encounters; this is patient based and not an encounter based measure. 

Screening Tools:
 *  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
 *  The screening should occur during a qualified encounter 
 *  Standardized  depression screening tools should be normalized and validated for the age appropriate patient population in which they are used 

Follow-Up Plan:

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

Examples of a follow-up plan include but are not limited to: 

* Additional evaluation or assessment for depression such as psychiatric interview, psychiatric evaluation, or assessment for bipolar disorder
* Completion of any Suicide Risk Assessment such as Beck Depression Inventory or Beck Hopelessness Scale
* 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 psychotherapy, pharmacological interventions, or additional treatment options
* Pharmacologic treatment for depression is often indicated during pregnancy and/or lactation. Review and discussion of the risks of untreated versus treated depression is advised. Consideration of each patient's prior disease and treatment history, along with the risk profiles for individual pharmacologic agents, is important when selecting pharmacologic therapy with the greatest likelihood of treatment effect.

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 with an active diagnosis for depression or a diagnosis of bipolar disorder

Patients screened for depression on 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 positive screen

Not Applicable

Patient Reason(s)
Patient refuses to participate 
OR
Medical Reason(s)	
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 
OR
Situations where the patient's functional capacity or motivation to improve may impact the accuracy of results of standardized depression assessment tools.  For example: certain court appointed cases or cases of delirium

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

Preventive Care and Screening