A Structured Approach to Detecting and Treating Depression in Primary Care

VitalSign6 Project

Manish K. Jha, MD; Bruce D. Grannemann, MA; Joseph M. Trombello, PhD; E. Will Clark, MD; Sara Levinson Eidelman, MPH, MSLOC; Tiffany Lawson, MBA, RN; Tracy L. Greer, PhD; A. John Rush, MD; Madhukar H. Trivedi, MD

Disclosures

Ann Fam Med. 2019;17(4):326-335. 

In This Article

Abstract and Introduction

Abstract

Purpose: This report describes outcomes of an ongoing quality-improvement project (VitalSign6) in a large US metropolitan area to improve recognition, treatment, and outcomes of depressed patients in 16 primary care clinics (6 charity clinics, 6 federally qualified health care centers, 2 private clinics serving low-income populations, and 2 private clinics serving patients with either Medicare or private insurance).

Methods: Inclusion in this retrospective analysis was restricted to the first 25,000 patients (aged ≥12 years) screened with the 2-item Patient Health Questionnaire (PHQ-2) in the aforementioned quality-improvement project. Further evaluations with self-reports and clinician assessments were recorded for those with positive screen (PHQ-2 >2). Data collected from August 2014 though November 2016 were available at 3 levels: (1) initial PHQ-2 (n = 25,000), (2) positive screen (n = 4,325), and (3) clinician-diagnosed depressive disorder with 18 or more weeks of enrollment (n = 2,160).

Results: Overall, 17.3% (4,325/25,000) of patients screened positive for depression. Of positive screens, 56.1% (2,426/4,325) had clinician-diagnosed depressive disorder. Of those enrolled for 18 or more weeks, 64.8% were started on measurement-based pharmacotherapy and 8.9% referred externally. Of the 1,400 patients started on pharmacotherapy, 45.5%, 30.2%, 12.6%, and 11.6% had 0, 1, 2, and 3 or more follow-up visits, respectively. Remission rates were 20.3% (86/423), 31.6% (56/177), and 41.7% (68/163) for those with 1, 2, and 3 or more follow-up visits, respectively. Baseline characteristics associated with higher attrition were: non-white, positive drug-abuse screen, lower depression/anxiety symptom severity, and younger age.

Conclusion: Although remission rates are high in those with 3 or more follow-up visits after routine screening and treatment of depression, attrition from care is a significant issue adversely affecting outcomes.

Introduction

Major Depressive Disorder (MDD) affects 5% to 10% of adults in the United States every year.[1–3] One-half of the patients with MDD seen in medical settings are not recognized as having depression[4,5] and only 1 in 5 receive adequate treatment.[2,6] The growing concern for undetected and untreated depression in medical settings has led to the recommendations for universal screening for depression in general adult populations.[7] In primary care settings, 5% to 10% patients suffer from MDD; 2 to 3 times more suffer from depressive symptoms that do not meet MDD diagnostic criteria.[8] Universal screening of depression and follow-up assessments[9] in medical clinics should ameliorate the problem of under-recognition of depression. Despite gradual improvement in screening rates since 2009, only 3% of patients in a national survey of ambulatory care settings were screened for depression in 2015.[10]

Research over the last 2 decades has reduced the uncertainty regarding where and how to treat patients who screen positive for depression and are diagnosed with a depressive disorder. Primary care clinics are ideal for screening for depression and for managing those who screen positive.[11] Depressed patients treated in primary care clinics have similar outcomes to those in psychiatric settings when identical systematic measurement-based care (MBC) procedures are followed.[12,13] The MBC approach includes (1) standardized assessment of symptoms, side effects, and treatment adherence; (2) point-of-care decision-making for treatment; (3) consistent follow-up visits; and (4) feedback to clinicians to assist decision making. Use of MBC is associated with rates of remission twice as high when compared with standard of care[14] and has now been adopted in treatment guidelines for depression.[15] As clinicians rarely administer serial measurements in their practice,[16–18] the MBC approach relies on patient self-report assessments for both screening and management of depression.

The paradigm of screening plus treatment initiation involves identification of patients who may not be seeking treatment for depression. Hence, the rates of treatment initiation maybe low and those of attrition may be high. Current estimates suggest that even among treatment-seeking depressed outpatients, over one-fourth drop out of care during initial acute-phase antidepressant treatment.[19] Furthermore, adherence to prescribed antidepressant treatment may be an issue among those continuing in care.[20] Finally, the outcome of antidepressant treatment in clinical settings is unknown, but estimates suggest that less than 6% of depressed patients attain remission in community settings.[21]

This report utilizes a sample of convenience to describe clinical outcomes of the first 25,000 patients screened for depression as part of an ongoing quality-improvement project to improve the recognition and treatment of depression in 16 primary care clinics that predominantly serve uninsured or underinsured minority populations. This report describes the screening, diagnostic, and treatment recommendation steps, and the treatment outcomes over the 18 weeks following the screening visit for those who screened positive for depression from an observational cohort of patients seeking care in primary care clinics for nonmental health-related conditions.

This report is novel in describing a quality improvement project that incorporates health information technology advances to implement large-scale screening and treatment of depression. This study aimed to determine the following: (1) the proportion of patients in primary care settings that screen positive for depression, (2) the proportion of those with positive screens that were diagnosed with a depressive disorder, (3) the proportion of those diagnosed with a depressive disorder that initiated MBC treatment, underwent active surveillance, or were referred to an external specialist, (4) the proportion of those who were diagnosed with a depressive disorder that returned for a follow-up visit in the next 18 weeks, and (5) the proportion of those who initiated pharmacological treatment and attained symptomatic improvement with 1 or more follow-up visits during the following 18 weeks.

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