Part 1: Depression Screening in Primary Care
Toni Johnson, MD
Kristen Palcisco, BA, MSN, APRN
Objectives
Part 1:
Improve ability to screen and diagnose Depression in
Primary Care
Increase ability to use PHQ-2 and PHQ-9 tools in
Why screen for depression in primary
care?
Depression Facts -- Epidemiology
Lifetime prevalence of 10-24% in women and 5-12% in men 19 million Americans diagnosed each year
151 million people affected worldwide 2nd leading cause of disability by 2020
Depressive disorders are 2-fold more prevalent in patients
with diabetes, CAD, HIV, and stroke
Depression associated with 2x increase in risk of type 2
diabetes
Depression associated with 64% increase in risk of CAD Untreated symptoms of depression exacerbate chronic
Depression in Primary Care
<5% of clinical instruction for 20-33% of primary care
practice
Only 30-50% of patients with depression are recognized
by PCPs
Only 50% of patients with depression receive treatment
Challenges for Depression Screening in Primary Care
Provider time
Provider knowledge about depression
Responding to score on screening tool
Appropriate treatment (antidepressant)
Provider concern about suicide risk and liability
Provider concern about ability to refer to
Psychiatry or to receive timely direction
(curbside consultation)
Better Health
Greater
Cleveland
Recommendations
Every adult with diabetes, heart failure or hypertension at
least once a year for depression using the Patient Health Questionnaire (PHQ-2/PHQ-9).
All patients who screen positive for depression will be
provided with appropriate diagnosis, treatment, and follow-up.
Eligible patients with an established diagnosis of
depression should have follow-up monitoring using the PHQ-9 at least annually.
Depression Screening: Tool
The Patient Health Questionnaire: PHQ-2 and PHQ-9
The PHQ-9 is a screening tool studied in the primary care setting
(3000 primary care patients and 3000 OB/GYN patients)
Used to screen and monitor treatment for Major Depression Contains 9 items, with scores ranging from 0-3 (depending on
frequency of symptoms which reflects severity)
#9 asks about death/ suicide thinking
Includes item #10, to measure the impact severity of symptoms
on work, home life, and relationships
• http://www.phqscreeners.com/pdfs/02_PHQ-9/English.pdf
PHQ-2 (Patient Health Questionnaire-2)
It is the first 2 questions of the PHQ-9 asked as yes/ no Inquires about the frequency of depressed mood and
anhedonia (lack of interest or pleasure) over the preceding 2 weeks
The PHQ-2 is a first step in screening and is not for
diagnosis or monitoring
Patients who screen “positive”(i.e. answer “yes” to either
question) should be evaluated further with a PHQ-9 to determine whether they meet criteria for a depressive disorder diagnosis
(PHQ-9)Patient Health Questionnaire – 9
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Not at all, Several days, More than half the days, Nearly every day:
1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much 4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself — or that you are a failure or have let yourself
or your family down
7. Trouble concentrating on things, such as reading the newspaper or
watching television
8. Moving or speaking so slowly that other people could have noticed? Or
the opposite — being so fidgety or restless that you have been moving around a lot more than usual.
9. Thoughts that you would be better off dead or of hurting yourself in
some way.
=Total Score: ______
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
Not difficult at all (score = 0) Somewhat difficult (score = 1) Very difficult (score = 2) Extremely difficult (score = 3) Scoring Totals: 1-4 = Minimal 5-9 = Mild 10-14 = Moderate 15-19 = Moderately Severe 20-27 =Severe
Screening for suicidality in primary care
The PHQ-9 (question #9) asks about suicidal thoughts Screening tools (PHQ-9) do not predict which patients
with suicidal thoughts will actually attempt suicide
Positive response should proceed to questions about
Best Practice Alert in Epic
Major Depressive Disorder
(commonly referred to as Major Depression or Depression)
DSM IV Criteria
Depressed mood or anhedonia (loss of interest/ pleasure) every
day, all day for at least 2 weeks
At least 4 additional symptoms:
Sleep changes Fatigue
Appetite or weight changes
Psychomotor agitation or retardation Helplessness
Hopelessness (excessive guilt)
Difficulty concentrating or making decisions Recurrent thoughts of death or suicide
Significant functional impairment (in occupational, educational,
social/ relationship areas of life)
Recurrence of Depression
Recurrence of episode of depression is 50-85% after 1st
episode.
Risk of recurrence increases with each successive depressive episode.
Untreated episodes are associated with treatment
resistant recurrence.
Depressive episode of Bipolar Disorder?
Bipolar disorder has either manic or hypo-manic
episodes in addition to major depressive episodes.
Patients with bipolar disorder may present in the
depressive phase with symptoms that appear to be
major depression.
Bipolar depression requires different treatment than
major depression.
The Mood Disorder Questionnaire (MDQ) can provide
“clues” to bipolar disorder but is not a diagnostic tool.
DSM-IV Criteria for Mania
Abnormally and persistently elevated, expansive or irritable mood
for at least 1 week.
At least 3 symptoms listed (4 symptoms if mood is only irritable):
Distractibility
Irresponsibility: Involvement in pleasurable activities with high
potential for painful consequences
Grandiosity or inflated self-esteem
Flight of ideas or reports “racing thoughts”
Increase in activity level (goal-directed) or psychomotor agitation Decreased need for sleep
Talkative: pressured to keep talking
Significant functional impairment (occupational, social, relationships,
educational, recreational)
Screening for Mania or Hypomania
Has there ever been a period of 4 days or more when you were feeling so good, “high,” excited, or hyper that you: …..did not need to sleep (for long)?
…..made illogical (impulsive) decisions you later regretted? …..did things you normally would not do
(spending, sexual, high risk)? …..got into trouble (legal or social)?
…..had family or friends worried, irritated with you?
…..had a doctor tell you that you were manic or bipolar?
Some Medical Mimics or Causes of Exacerbation of
Mood Disorders (Depression and Bipolar)
Endocrinopathies (hypo- or hyperthyroidism)
Substance use/abuse/dependence
Medications (opiates, corticosteroids, hormonal therapies, interferon/ chemotherapy, stimulants, antidepressants)
Chronic viral infections (HIV, Hep C)
Liver disease
Neurological diseases (Parkinson’s, Multiple Sclerosis, seizure disorders, dementias)
Thank You!
Questions or Comments?
Toni Johnson, MD
Kristen Palcisco, BA, MSN, APRN
