Depression is a problem commonly seen in primary care, often as a comorbidity of chronic conditions, such as diabetes mellitus, coronary heart disease, and chronic obstructive pulmonary disease. Comorbid depression often leads to worse clinical outcomes.^1,2

In 2009, the U.S. Preventive Services Task Force (USPSTF) reaffirmed its support for screening for depression in adults, and expanded on its caveat that screening is effective only if support systems are in place for appropriate treatment of patients with positive screening results. Specifically, the USPSTF “recommends screening adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up.”³

Recognizing the prevalence of depression and its impact on other chronic conditions, MaineHealth, an integrated health care delivery system in southern and central Maine, developed a quality improvement program for depression in primary care.^4,5 The program incorporates four supports for staff-assisted depression care:

• Using a standardized instrument to screen for depression and to monitor response to treatment.

• Using a registry to track patient progress and key aspects of depression care.

• Encouraging self-management by providing education for patients and family members about depression, and providing support for patients to make behavior changes that will enhance their care.

• Providing care management through communication between patients and a staff member to address treatment adherence, self-management activities, and response to treatment.

Screening Tools

There are a number of depression screening tools available, several of which are specifically mentioned in the USPSTF recommendation.³ However, the 2009 recommendation did not update the 2002 review of screening tools and, therefore, did not mention a newer tool that has been validated as a screening, diagnostic, and outcome measure. The Patient Health Questionnaire (PHQ-9) is a nine-item depression assessment tool used in the MaineHealth system.^6–8 The first two questions, known as the PHQ-2, have been validated as a screening tool and are regularly administered to high-risk groups (e.g., those with chronic illnesses, those with a history of depression). These two questions address depressed mood and loss of interest or pleasure in previously enjoyable activities. Patients with positive screening results should complete the PHQ-9. Staff members can assist in identifying patients due for screening, administering the questionnaires, and scoring and reporting results to the physician.

Recommendations for using a standardized assessment tool to monitor treatment response and adjust treatment based on response are becoming more prevalent in the literature.⁹ MaineHealth has developed an algorithm to guide treatment based on changes in PHQ score. It is available at http://www.mainehealth.org/workfiles/depression/PHQdxtxguideline042910.pdf.

Patient Registries

A registry is a tool to track a population of patients and measures of care that are important to that population. MaineHealth created a registry that tracks data about chronic illness and preventive care. Patient data are entered manually by staff or are downloaded automatically from electronic health records. The registry can generate reports about individual patients and populations to inform clinical care and track improvement. Registries are usually electronic, but it is possible to start a simple registry with a box of index cards.

Self-management

Persons with depression, along with their families, have important roles in the management of this illness. Self-management support assists patients with understanding depression and how they can make treatment successful. Many members of the primary care team can participate in depression self-management by helping patients and families access educational materials, linking them to community organizations that support self-management, and helping them set goals and develop action plans to achieve those goals. It is important to emphasize small steps and achievable goals, especially early in the treatment process when some patients get easily discouraged.

Care Management

Care management ties together all of the staff-assisted depression care supports. In the MaineHealth system, care managers are nurses who work with one or more practices to assist in the care of patients with chronic illnesses. Depression care management includes periodic phone calls to patients to assess treatment adherence. Care managers also help troubleshoot barriers to treatment, support self-management, and assess response to treatment by periodically readministering the PHQ-9. If a practice does not have the resources to designate specific care managers, other members of the primary care team can work together to provide basic depression care supports.

Improving Patient Outcomes

MaineHealth has been working on disseminating this approach for several years. We have had the most success in instituting screening for depression, with more than 50 percent of patients with diabetes screened annually. Care management is less widespread, but more than 1,600 patients with depression have received care management in the past year. Data about clinical outcomes are not yet reliable.

By implementing the recommendations of the USPSTF for staff-assisted depression care supports, primary care physicians and their practice teams can help improve the outcomes for patients with depression.