Standardized Follow-up Plan For Depression Through The Implementation Of Provider Note And Nurse Follow-up Phone Call Templates
Keywords:Depression, Follow-up, PHQ-9, Template, Referral
Background: Depression is highly prevalent in primary care settings and depressed patients of all ages are seen by their Primary Care Provider (PCP) for treatment (Datto et al., 2003). In order to adequately treat depression, PCPs must follow the clinical guidelines for follow-up.
Purpose: The purpose of this project was to implement a standardized follow-up plan for patients aged 12 and older with a positive screen for depression using the Patient Health Questionnaire (PHQ-9) screening tool.
Methods: The setting was a rural clinic in Broken Bow, Nebraska. The sample included 89 patients seen between September 1 -November 30, 2020 who met the criteria of a PHQ-9 score of 5 or greater compared with 47 patients seen between September 1 -November 30, 2019. Quantitative data was analyzed using descriptive statistics, frequency and means and compared between before and after implementation of this quality improvement project.
Results: In 2019, 11.3 % of patients reported depression. That more than doubled to 25.6 % in 2020. Of the depressed patients in 2019, 36.2% had mild depression, while the number almost doubled to 60.7% in 2020. The 2020 PHQ-9 results were reviewed from most severe down to mild depression. Of the 35 patients with the highest severity, 89% had at least one measure completed representing an adequate follow-up plan. Referral rates improved from 12.8% in 2019 to 14.6% in 2020. Medication was the most common treatment in both years with 57.4% in 2019 and 27% in 2020. Completed follow-ups improved from 45.5% in 2019 to 73% in 2020; with 1 nurse phone call follow-up and one CSSR-S completed.
Conclusion: It is unknow the affects from the 2020 pandemic. However, and increase in mild depression shows a need to know how to treat sub-threshold depression. The use of the template as a guide led to improvement on all measures. However, some measures were used only sparingly and use may be improved with increased acceptance of the guide.
Agency on Healthcare Quality and Research. (2008). Screening for Depression in Adults. Retrieved from https://www.ahrq.gov/prevention/resources/depression/depsum1.html
Agency for Health Care Policy and Research. (1993). AHCPR Clinical Practice Guidelines. Guideline: Acute Phase Management with Medication and Psychotherapy. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK52224/#A15903
America’s Health Rankings.Org. (2019). Suicide rates per state. Retrieved from https://www.americashealthrankings.org/explore/annual/measure/Suicide/state/NE
American Psychological Association (2019). Clinical Practice Guideline for the Treatment of Depression Across Three Age Cohorts: Guideline Development Panel for the Treatment of Depressive Disorders. Retrieved from https://www.apa.org/depression-guideline/guideline.pdf
Beck, A., Crain, A., & Solberg, L. (2011). Severity of depression and magnitude of productivity loss. Ann Fam Med. (9) pp. 305-11; Institute for Clinical Systems Improvement, 2013.
Butow, P., Price, M. A., Shaw, J. M., Turner, J., Clayton, J. M., Grimison P., Rankin, N., & Kirsten, L. (2015). Clinical pathway for the screening, assessment and management of anxiety and depression in adult cancer patients: Australian guidelines John Wiley & Sons, Inc. doi:10.1002/pon.3920
Census Reporter. (2018). Census Reporter – Broken Bow, Nebraska. Retrieved from https://censusreporter.org/profiles/16000US3106610-broken-bow-ne/
Datto, C. J., Thompson, R., Horowitz, D., Disbot, M., & Oslin, D. W. (2003). The pilot study of a telephone disease management program for depression doi:10.1016/S0163-8343(03)00019-7
Eriksson, M. C. M., Kivi, M., Hange, D., Petersson, E., Ariai, N., Häggblad, P., Agren, H., Spak, F., Linblad, U., Johansson, B., & Björkelund, C. (2017). Long-term effects of internet-delivered cognitive behavioral therapy for depression in primary care – the PRIM-NET controlled trial Taylor & Francis Ltd. doi:10.1080/02813432.2017.1333299
Franx, G., Huyser, J., Koetsenruijter, J., van der Feltz-Cornelis, Christina M., Verhaak, P. F. M., Grol, R. P. T. M., & Wensing, M. (2014). Implementing guidelines for depression on antidepressant prescribing in general practice: A quasi-experimental evaluation BioMed Central. doi:10.1186/1471-2296-15-35
Institute for Clinical Systems Improvement. (2013). Healthcare Guideline: Adult Depression in Primary Care. Retrieved from https://www.icsi.org/guideline/depression/
Jha, M. K., Grannemann, B. D., Trombello, J. M., Clark, E. W., Eidelman, S. L., Lawson, T., Geer, T., Rush, A., &Trivedi, M. H. (2019). A structured approach to detecting and treating depression in primary care: VitalSign6 project Annals of Family Medicine. doi:10.1370/afm.2418
Jibson, M. (n.d). Where to from here? Evidence-Based strategies for treatment of refractory depression. Professor of Psychiatry. University of Michigan.
Jones, L. E., Turvey, C., & Carney-Doebbeling, C. (2006). Inadequate follow-up care for depression and its impact on antidepressant treatment duration among veterans with and without diabetes mellitus in the veterans health administration doi:10.1016/j.genhosppsych.2006.08.002
Kaiser Permanente Medical Care Program. (2012). National Adult Depression Clinical Practice Guideline. Retrieved from http://www.providers.kaiserpermanente.org/info_assets/cpp_cod/cod_depression_guideline_0712.pdf
Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: validity of a brief depression severity measure. Journal of general internal medicine, 16(9), 606–613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x
Kroenke, K., Spitzer, R.L., Williams, J.B. (2003). The Patient Health Questionnaire-2: validity of a two-item depression screener. Medical Care, 41:1284–92.
Kroenke, K., Spitzer, R., Williams, J., & Löwe, B. (2010). The patient health questionnaire somatic, anxiety, and depressive symptom scales: a systematic review. Gen Hosp Psychiatry (32) pp. 345-359; Institute for Clinical Systems Improvement, 2013.
Liu, Z., Yu, Y., Hu, M., Liu, H., Zhou, L., & Xiao, S. (2016). PHQ-9 and PHQ-2 for screening depression in chinese rural elderly Public Library of Science. doi:10.1371/journal.pone.0151042
McDonald KM, Sundaram V, & Bravata DM. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination). Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 Jun. (Technical Reviews, No. 9.7.) 5, Conceptual Frameworks and Their Application to Evaluating Care Coordination Interventions. Available from: https://www.ncbi.nlm.nih.gov/books/NBK44008/
Melham Medical Center. (2019). Community Needs Assessment. Retrieved from https://irp-cdn.multiscreensite.com/a8c802d4/files/uploaded/2019%20Community%20Needs%20Assessment.pdf
Miranda, R., Soffer, A., Polanco-Roman, L., Wheeler, A., & Moore, A. (2015). Mental health treatment barriers among Racial/Ethnic minority versus white young adults 6 months after intake at a college counseling center Taylor & Francis Ltd. doi:10.1080/07448481.2015.1015024
Mullins, C. D., Shaya, F. T., Meng, F., Wang, J., & Bron, M. S. (2006). Comparison of first refill rates among users of sertraline, paroxetine, and citalopram doi:10.1016/j.clinthera.2006.02.006
Mundt, J. C. (2010). Feasibility and validation of a computer-automated columbia-suicide severity rating scale using interactive voice response technology. Oxford:
Na, P. J., Yaramala, S. R., Kim, J. A., Kim, H., Goes, F. S., Zandi, P. P., Vande Voort, J., Sutor, B., Croarkin, P., Bobo, W. V. (2018). The PHQ-9 item 9 based screening for suicide risk: A validation study of the patient health questionnaire (PHQ)-9 item 9 with the columbia suicide severity rating scale (C-SSRS) doi:10.1016/j.jad.2018.02.045
O'Donnell, A. N., Williams, B. C., Eisenberg, D., & Kilbourne, A. M. (2013). Mental health in ACOs: missed opportunities and low-hanging fruit. The American journal of managed care, 19(3), 180–184.
P?s?relu, C. R., Andersson, G., Bergman Nordgren, L., & Dobrean, A. (2017). Internet-delivered transdiagnostic and tailored cognitive behavioral therapy for anxiety and depression: A systematic review and meta-analysis of randomized controlled trials Routledge. doi:10.1080/16506073.2016.1231219
Patten, S. B., Burton, J. M., Fiest, K. M., Wiebe, S., Bulloch, A. G. M., Koch, M., Dobson, K., Metz, L., Maxwell, C., & Jetté, N. (2015). Validity of four screening scales for major depression in MS doi:10.1177/1352458514559297
Pignone, M., Gaynes, B., Rushton, J., Burchell, C., Orleans, T., Mulrow, C., & Lohr, K. (2013). Screening for depression in adults. Agency for Health Research and Quality. Retrieved from: https://www.ahrq.gov/prevention/resources/depression/depsum1.html
Poluzzi, E., Piccinni, C., Sangiorgi, E., Clo, M., Tarricone, I., Menchetti, M., & De Ponti, F. (2013). Trend in SSRI-SNRI antidepressants prescription over a 6-year period and predictors of poor adherence doi:10.1007/s00228-013-1567-8
Posner, K; Brown, G.K., Stanley, B; Brent, D.A., Yershova, K.V., Oquendo, M.A., Currier, G.W., Melvin, G.A., Greenhill, L., Shen, S., Mann, J.J. (2011). "The Columbia-Suicide Severity Rating Scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults". The American Journal of Psychiatry. 168 (12): 1266–77. doi:10.1176/appi.ajp.2011.10111704. PMC 3893686. PMID 22193671.
Ross, E. L., Vijan, S., Miller, E. M., Valenstein, M., & Zivin, K. (2019). The cost-effectiveness of cognitive behavioral therapy versus second-generation antidepressants for initial treatment of major depressive disorder in the united states: A decision analytic model doi:10.7326/M18-1480
Sadock, E., Perrin, P. B., Grinnell, R. M., Rybarczyk, B., & Auerbach, S. M. (2017). Initial and follow-up evaluations of integrated psychological services for anxiety and depression in a safety net primary care clinic John Wiley & Sons, Inc. doi:10.1002/jclp.22459
Simon, G., Ralston, J., Savarino, J., Pabiniak, C., Wentzel, C., Operskalski, B., Gregory, S., Ralston, J., & Operskalski, B. H. (2011). Randomized trial of depression follow-up care by online messaging doi:10.1007/s11606-011-1679-8
United States Preventive Services Task Force. (2016). Screening for Depression in Adults. US Preventive Services Task Force Recommendation Statement. JAMA. Retrieved from https://uspreventiveservicestaskforce.org/home/getfilebytoken/BnHj53HwgSBNXMvnyavxfS
Vries, Y., Jonge, P., Kalverdijk, L., Bos, J., Schuiling-Veninga, C., & Hak, E. (2016). Poor guideline adherence in the initiation of antidepressant treatment in children and adolescents in the netherlands: Choice of antidepressant and dose Springer Nature. doi:10.1007/s00787-016-0836-3
WebMD. (2020). Guide to Psychiatry and Counseling. Retrieved from: https://www.webmd.com/mental-health/guide-to-psychiatry-and-counseling#2
Weir, K. (2019). Worrying trends in U.S. suicide rates. American Psychological Association. Retrieved from https://www.apa.org/monitor/2019/03/trends-suicide
Weobong, B., Weiss, H. A., McDaid, D., Singla, D. R., Hollon, S. D., Nadkarni, A., Park, A.-L., Bhat, B., Katti, B., Anand, A., Dimidjian, S., Araya, R., King, M., Vijayakumar, L., Wilson, G. T., Velleman, R., Kirkwood, B. R., Fairburn, C. G., & Patel, V. (2017). Sustained effectiveness and cost-effectiveness of the Healthy Activity Programme, a brief psychological treatment for depression delivered by lay counsellors in primary care: 12-month follow-up of a randomised controlled trial. PLoS Medicine, 14(9), 1–21. https://doi-org.cuhsl.creighton.edu/10.1371/journal.pmed.1002385
Wittkampf, K., Naeije, L., & Schene, A. (2007). Diagnostic accuracy of the mood module of the patient health questionnaire: a systematic review. Gen Hosp Psychiatry. (29) pp. 388-95; Institute for Clinical Systems Improvement, 2013.
World Health Organization. (2020). Depression. Retrieved from https://www.who.int/news-room/fact-sheets/detail/depression
How to Cite
Copyright (c) 2021 Journal Of Nursing Practice
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.