A Structured Approach to Detecting and Treating Depression in Primary Care: VitalSign6 Project

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 lowincome 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 followup visits after routine screening and treatment of depression, attrition from care is a significant issue adversely affecting outcomes.

Association of anger attacks with suicidal ideation in adults with major depressive disorder: Findings from the EMBARC study

“…Screening for anger attacks in depressed patients may identify those at risk of persistently elevated SI. Thus, these findings further argue for systematic assessment of anger attacks and its related constructs in clinical practice (Jha, Grannemann, et al, 2019; Jha, Minhajuddin, et al, 2019; Trivedi et al, 2019). While patients with anger attacks typically experience improvement with antidepressants, previous reports have found new‐onset anger attacks in a small minority of patients (Fava et al, 1993, 1997).…”

Depression Screening and Measurement-Based Care in Primary Care

“…The ultimate outcome of depression care is patient remission. 20,52,60 Studies report a depression remission rate of <6% for patients treated in primary care, 52,61 Results of this quality improvement study showed patient remission rates improved from 0% to 23.1% post-intervention. We contribute this finding to the combination of screening, diagnosing, and treating patients using principles of measurement-based care with evidence-based CDS tools interoperable with the EHR.…”

“…31 Measurement-based care (MBC) is a comprehensive guideline offering validated screening tools, standard symptom measurements, treatment effects and adherence monitoring, and evidence-based decision tools to support primary care physicians with diagnosis, treatment, follow-up, and referrals. 20,28,37,[49][50][51][52][53][54] Future efforts must optimize technology innovation to equip primary care providers with tools to seamlessly integrate screening and MBC with existing workflow. The University of Texas Southwestern Medical Center for Depression Research and Clinical Care (CDRCC) developed an MBC program called VitalSign6 and built an application programming interface enabling interoperability with the electronic health record (EHR).…”

A projection for psychiatry in the post-COVID-19 era: potential trends, challenges, and directions

“…The changes in psychiatric practice following the pandemic may also stimulate improvements in these models. For example, high attrition rates and inadequate clinician/staff time are some of the major limitations to the PCP-First model [ 20 , 25 ]. The undergoing transformation in telemedicine may accelerate the development of smart-phone apps or web-based surveys that would allow remote (and wider) screening and help patients interact with clinicians before and between scheduled visits.…”

“…The undergoing transformation in telemedicine may accelerate the development of smart-phone apps or web-based surveys that would allow remote (and wider) screening and help patients interact with clinicians before and between scheduled visits. These developments may help overcome the major obstacles to the widespread adoption of these models [ 20 , 25 ].…”