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  • Measure Summary
  • NQMC:010786
  • Mar 2016

Adult depression in primary care: percentage of patients who reached remission at 12 months (+/- 30 days) after diagnosis or initiating treatment, e.g., had a PHQ-9 score less than 5 at 12 months (+/- 30 days).

Trangle M, Gursky J, Haight R, Hardwig J, Hinnenkamp T, Kessler D, Mack N, Myszkowski M. Adult depression in primary care. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2016 Mar. 131 p. [394 references]

View the original measure documentation External Web Site Policy

This is the current release of the measure.

This measure updates a previous version: Mitchell J, Trangle M, Degnan B, Gabert T, Haight B, Kessler D, Mack N, Mallen E, Novak H, Rossmiller D, Setterlund L, Somers K, Valentino N, Vincent S. Adult depression in primary care. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2013 Sep. 129 p. [334 references]

Primary Measure Domain

Clinical Quality Measures: Outcome

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the percentage of patients age 18 years and older who have reached remission at 12 months (+/- 30 days) after diagnosis or initiating treatment, e.g., had a Patient Health Questionnaire-9 (PHQ-9) score less than 5 at 12 months (+/- 30 days).

Rationale

The priority aim addressed by this measure is to increase the percentage of patients with major depression or persistent depressive disorder who have improvement in outcomes from treatment for major depression or persistent depressive disorder.

At any given time, 9% of the population has a depressive disorder, and 3.4% has major depression (Strine et al., 2008). In a 12-month time period, 6.6% of the United States (U.S.) population will have experienced major depression, and 16.6% of the population will experience depression in their lifetime (Kessler et al., 2005).

Major depression is a treatable cause of pain, suffering, disability and death, yet primary care clinicians detect major depression in only one-third to one-half of their patients with major depression (Williams et al., 2002; Schonfeld et al., 1997). Additionally, more than 80% of patients with depression have a medical comorbidity (Klinkman, 2003). Usual care for depression in the primary care setting has resulted in only about half of depressed adults getting treated (Kessler et al., 2005) and only 20% to 40% showing substantial improvement over 12 months (Unützer et al., 2002; Katon et al., 1999). Approximately 70% to 80% of antidepressants are prescribed in primary care, making it critical that clinicians know how to use them and have a system that supports best practices (Mojtabai & Olfson, 2008).

The goals of treatment for major depression should be to achieve remission, reduce relapse and recurrence, and return to previous level of occupational and psychosocial function. Full remission is defined as a two-month period devoid of major depressive signs and symptoms (American Psychiatric Association, 2013). If using a Patient Health Questionnaire-9 (PHQ-9) tool, remission translates to PHQ-9 score of less than 5 (Kroenke et al., 2001). Response is defined as a 50% or greater reduction in symptoms (as measured on a standardized rating scale) and partial response is defined as a 25% to 50% reduction in symptoms.

Evidence for Rationale

American Psychiatric Association (APA). Diagnostic and statistical manual of mental disorders (DSM-5). Fifth ed. Arlington (VA): American Psychiatric Association (APA); 2013. 991 p.

Katon W, Von Korff M, Lin E, Simon G, Walker E, Unutzer J, Bush T, Russo J, Ludman E. Stepped collaborative care for primary care patients with persistent symptoms of depression: a randomized trial. Arch Gen Psychiatry. 1999 Dec;56(12):1109-15. PubMed External Web Site Policy

Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005 Jun;62(6):617-27. PubMed External Web Site Policy

Klinkman MS. The role of algorithms in the detection and treatment of depression in primary care. J Clin Psychiatry. 2003;64 Suppl 2:19-23. [24 references] PubMed External Web Site Policy

Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001 Sep;16(9):606-13. PubMed External Web Site Policy

Mojtabai R, Olfson M. National patterns in antidepressant treatment by psychiatrists and general medical providers: results from the national comorbidity survey replication. J Clin Psychiatry. 2008 Jul;69(7):1064-74. PubMed External Web Site Policy

Schonfeld WH, Verboncoeur CJ, Fifer SK, Lipschutz RC, Lubeck DP, Buesching DP. The functioning and well-being of patients with unrecognized anxiety disorders and major depressive disorder. J Affect Disord. 1997 Apr;43(2):105-19. PubMed External Web Site Policy

Strine TW, Mokdad AH, Balluz LS, Gonzalez O, Crider R, Berry JT, Kroenke K. Depression and anxiety in the United States: findings from the 2006 Behavioral Risk Factor Surveillance System. Psychiatr Serv. 2008 Dec;59(12):1383-90. PubMed External Web Site Policy

Trangle M, Gursky J, Haight R, Hardwig J, Hinnenkamp T, Kessler D, Mack N, Myszkowski M. Adult depression in primary care. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2016 Mar. 131 p. [394 references]

Unützer J, Katon W, Callahan CM, Williams JW Jr, Hunkeler E, Harpole L, Hoffing M, Della Penna RD, Noel PH, Lin EH, Arean PA, Hegel MT, Tang L, Belin TR, Oishi S, Langston C. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA. 2002 Dec 11;288(22):2836-45. PubMed External Web Site Policy

Williams JW Jr, Noel PH, Cordes JA, Ramirez G, Pignone M. Is this patient clinically depressed. JAMA. 2002 Mar 6;287(9):1160-70. PubMed External Web Site Policy

Primary Health Components

Major depression; persistent depressive disorder; remission; Patient Health Questionnaire-9 (PHQ-9)

Denominator Description

Number of patients age 18 years and older with major depression or persistent depressive disorder diagnosis and Patient Health Questionnaire-9 (PHQ-9) 12 months from the measurement date (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Number of patients whose Patient Health Questionnaire-9 (PHQ-9) was less than 5 at 12 months (+/- 30 days) after diagnosis or initiating treatment

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A clinical practice guideline or other peer-reviewed synthesis of the clinical research evidence

Additional Information Supporting Need for the Measure

  • Major depression was second only to back and neck pain for having the greatest effect on disability days, at 386.6 million United States (U.S.) days per year (Merikangas et al., 2007).
  • In a World Health Organization (WHO) study of more than 240,000 people across 60 countries, depression was shown to produce the greatest decrease in quality of health compared to several other chronic diseases. Health scores worsened when depression was a comorbid condition, and the most disabling combination was depression and diabetes (Moussavi et al., 2007).
  • A 2011 study showed a relationship between the severity of depression symptoms and work function. Data was analyzed from 771 depressed patients who were currently employed. The data showed that for every 1-point increase in Patient Health Questionnaire-9 (PHQ-9) score, patients experienced an additional mean productivity loss of 1.65%. And, even minor levels of depression symptoms were associated with decrements in work function (Beck et al., 2011).
  • In the U.S., depression costs employers $24 billion in lost productive work time (Stewart et al., 2003).
  • There is evidence that non-majority racial and cultural groups in the U.S. are less likely to be treated for depression than European Americans. In an epidemiological study that compared rates of diagnosing and treating depression in the early 1990s to patterns 10 years later, only 4.9% of minorities were treated with antidepressants compared to 12.4% of non-Hispanic Caucasians (Mojtabai & Olfson, 2008).
  • Depression in the elderly is widespread, often undiagnosed and usually untreated. It is a common misperception that it is a part of normal aging. Losses, social isolation and chronic medical problems that older patients experience can contribute to depression.
  • The rate of depression in adults older than 65 years of age treated in primary care settings ranges from 17% to 37% (Birrer & Vemuri, 2004) and is between 14% and 42% in patients who live in long-term care facilities (Robinson et al., 2014). Comorbidities are more common in the elderly. The highest rates of depression are found in those with strokes (30% to 60%), coronary artery disease (up to 44%), cancer (up to 40%), Parkinson's disease (40%), Alzheimer's disease (20% to 40%), and dementia (17% to 31%) (Birrer & Vemuri, 2004). The recurrence rate is also extremely high at 40% (Birrer & Vemuri, 2004).
  • Between 14% and 23% of pregnant women and 10% to 15% of postpartum women will experience a depressive disorder (Gaynes et al., 2005). A review by Milgrom and Gemmill (2014) cites a point prevalence of 13% at three months after delivery and an average of 9% during each trimester of pregnancy. According to a large-scale epidemiological study by Vesga-López et al. (2008), depression during the postpartum period may be more common than at other times in a woman's life.
  • With growing understanding of the systemic impact of perinatal stressors, there is a new body of research examining paternal depression. A recent meta-analysis shows a 10% to 14% incidence of paternal depression during the perinatal period, with a moderate positive correlation with maternal depression (Paulson & Bazemore, 2010).
  • From 50% to 85% of people who suffer an episode of major depression will have a recurrence, usually within two or three years (American Psychiatric Association, 2010). Patients who have had three or more episodes of major depression are at 90% risk of having another episode.

Evidence for Additional Information Supporting Need for the Measure

American Psychiatric Association (APA). Practice guideline for the treatment of patients with panic disorder, 2nd edition. Arlington (VA): American Psychiatric Association (APA); 2010. various p.

Beck A, Crain AL, Solberg LI, Unutzer J, Glasgow RE, Maciosek MV, Whitebird R. Severity of depression and magnitude of productivity loss. Ann Fam Med. 2011 Jul-Aug;9(4):305-11. PubMed External Web Site Policy

Birrer RB, Vemuri SP. Depression in later life: a diagnostic and therapeutic challenge. Am Fam Physician. 2004 May 15;69(10):2375-82. [25 references] PubMed External Web Site Policy

Gaynes BN, Gavin N, Meltzer-Brody S, Lohr KN, Swinson T, Gartlehner G, Brody S, Miller WC. Perinatal depression: prevalence, screening accuracy, and screening outcomes. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2005 Feb.  (Evidence report/technology assessment; no. 119).  [77 references]

Merikangas KR, Ames M, Cui L, Stang PE, Ustun TB, Von Korff M, Kessler RC. The impact of comorbidity of mental and physical conditions on role disability in the US adult household population. Arch Gen Psychiatry. 2007 Oct;64(10):1180-8. PubMed External Web Site Policy

Milgrom J, Gemmill AW. Screening for perinatal depression. Best Pract Res Clin Obstet Gynaecol. 2014 Jan;28(1):13-23. PubMed External Web Site Policy

Mojtabai R, Olfson M. National patterns in antidepressant treatment by psychiatrists and general medical providers: results from the national comorbidity survey replication. J Clin Psychiatry. 2008 Jul;69(7):1064-74. PubMed External Web Site Policy

Moussavi S, Chatterji S, Verdes E, Tandon A, Patel V, Ustun B. Depression, chronic diseases, and decrements in health: results from the World Health Surveys. Lancet. 2007 Sep 8;370(9590):851-8. PubMed External Web Site Policy

Paulson JF, Bazemore SD. Prenatal and postpartum depression in fathers and its association with maternal depression: a meta-analysis. JAMA. 2010 May 19;303(19):1961-9. PubMed External Web Site Policy

Robinson M, Oakes TM, Raskin J, Liu P, Shoemaker S, Nelson JC. Acute and long-term treatment of late-life major depressive disorder: duloxetine versus placebo. Am J Geriatr Psychiatry. 2014 Jan;22(1):34-45. PubMed External Web Site Policy

Stewart WF, Ricci JA, Chee E, Hahn SR, Morganstein D. Cost of lost productive work time among US workers with depression. JAMA. 2003 Jun 18;289(23):3135-44. PubMed External Web Site Policy

Trangle M, Gursky J, Haight R, Hardwig J, Hinnenkamp T, Kessler D, Mack N, Myszkowski M. Adult depression in primary care. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2016 Mar. 131 p. [394 references]

Extent of Measure Testing

Unspecified

National Guideline Clearinghouse Link

Adult depression in primary care. External Web Site Policy

State of Use

Current routine use

Current Use

Internal quality improvement

Measurement Setting

Ambulatory/Office-based Care

Professionals Involved in Delivery of Health Services

Advanced Practice Nurses

Nurses

Physician Assistants

Physicians

Least Aggregated Level of Services Delivery Addressed

Clinical Practice or Public Health Sites

Statement of Acceptable Minimum Sample Size

Unspecified

Target Population Age

Age greater than or equal to 18 years

Target Population Gender

Either male or female

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Getting Better

Living with Illness

IOM Domain

Effectiveness

Case Finding Period

The time frame pertaining to the data collection is monthly.

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Clinical Condition

Diagnostic Evaluation

Patient/Individual (Consumer) Characteristic

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
Number of patients age 18 years and older with major depression or persistent depressive disorder diagnosis* and Patient Health Questionnaire-9 (PHQ-9) 12 months from the measurement date

Population Definition: Major depression or persistent depressive disorder International Classification of Diseases, Tenth Revision (ICD-10) codes include F32.x, F33.x and F34.1.

*Diagnosis may be either new or existing.

Exclusions
Unspecified

Exclusions/Exceptions

Unspecified

Numerator Inclusions/Exclusions

Inclusions
Number of patients whose Patient Health Questionnaire-9 (PHQ-9) was less than 5 at 12 months (+/- 30 days) after diagnosis or initiating treatment

Exclusions
Unspecified

Numerator Search Strategy

Fixed time period or point in time

Data Source

Administrative clinical data

Electronic health/medical record

Type of Health State

Physiologic Health State (Intermediate Outcome)

Instruments Used and/or Associated with the Measure

Patient Health Questionnaire-9 (PHQ-9)

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a higher score

Allowance for Patient or Population Factors

Unspecified

Standard of Comparison

Internal time comparison

Original Title

Percentage of patients who have reached remission at 12 months (+/- 30 days) after initiating treatment, e.g., had a PHQ-9 score less than 5 at 12 months (+/- 30 days).

Measure Collection Name

Adult Depression in Primary Care

Submitter

Institute for Clinical Systems Improvement - Nonprofit Organization

Developer

Institute for Clinical Systems Improvement - Nonprofit Organization

Funding Source(s)

The Institute for Clinical Systems Improvement's (ICSI's) work is funded by the annual dues of the member medical groups and three sponsoring health plans in Minnesota.

Composition of the Group that Developed the Measure

Work Group Members: Michael Trangle, MD (Work Group Leader) (HealthPartners Medical Group and Regions Hospital) (Psychiatry); Daniel Kessler, LP (Allina Medical Clinic) (Psychology); Jeffrey Hardwig, MD (Essentia Health) (Psychiatry); Todd Hinnenkamp, RN (Essentia Health) (Internal Medicine); Robert Haight, PharmD, BCPP (Fairview Health Services) (Pharmacy); Tom Gabert (Howard Young Medical Center) (Family Medicine); Mioki Myszkowski, MD (Mayo Clinic) (Family Medicine); Nicky Mack, RN (North Memorial Health Care) (Family Medicine); Jeffrey Gursky, MD (Olmstead Medical Center) (Psychiatry); Jodie Dvorkin (Institute for Clinical Systems Improvement [ICSI]) (Project Manager/Health Care Consultant); Senka Hadzic (ICSI) (Clinical Systems Improvement Facilitator)

Financial Disclosures/Other Potential Conflicts of Interest

The Institute for Clinical Systems Improvement (ICSI) has long had a policy of transparency in declaring potential conflicting and competing interests of all individuals who participate in the development, revision and approval of ICSI guidelines and protocols.

In 2010, the ICSI Conflict of Interest Review Committee was established by the Board of Directors to review all disclosures and make recommendations to the board when steps should be taken to mitigate potential conflicts of interest, including recommendations regarding removal of work group members. This committee has adopted the Institute of Medicine Conflict of Interest standards as outlined in the report Clinical Practice Guidelines We Can Trust (2011).

Where there are work group members with identified potential conflicts, these are disclosed and discussed at the initial work group meeting. These members are expected to recuse themselves from related discussions or authorship of related recommendations, as directed by the Conflict of Interest committee or requested by the work group.

The complete ICSI policy regarding Conflicts of Interest is available at the ICSI Web site External Web Site Policy.

Disclosure of Potential Conflicts of Interest

Jeffrey Gursky, MD (Work Group Member)
Department Chair of Psychiatry and Psychology, Olmsted Medical Center
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Robert Haight, Pharm D, BCPP (Work Group Member)
Clinical Pharmacy Specialist, Psychiatry, Fairview Health Services
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: Paid expert testimony for the State of Minnesota. On request case, consulting for specific patient cases involving psychiatric medications to be reviewed by various departments.

Jeffrey Hardwig, MD (Work Group Member)
Psychiatrist, Essentia Health
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Todd Hinnenkamp, RN, NC (Work Group Member)
Nurse Clinician, Internal Medicine, Essentia Health
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Daniel Kessler, LP (Work Group Member)
Lead Psychologist, Allina Medical Clinic – Part of Allina Health
National, Regional, Local Committee Affiliations: Minnesota Psychological Association
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Nicki Mack, RN (Work Group Member)
Care Navigator, North Memorial Health Care
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Mioki Myszkowski, MD (Work Group Member)
Mayo Clinic
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Michael Trangle, MD (Work Group Leader)
Senior Medical Director for Behavioral Health Services, Psychiatry, HealthPartners Medical Group and Regions Hospital
National, Regional, Local Committee Affiliations: None
Guideline Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2016 Mar

Measure Maintenance

Scientific documents are revised as indicated by changes in clinical practice and literature. Institute for Clinical Systems Improvement (ICSI) staff monitors major peer-reviewed journals for any pertinent evidence that would affect a particular guideline and recommendation.

Date of Next Anticipated Revision

The next revision will be no later than March 2021.

Measure Status

This is the current release of the measure.

This measure updates a previous version: Mitchell J, Trangle M, Degnan B, Gabert T, Haight B, Kessler D, Mack N, Mallen E, Novak H, Rossmiller D, Setterlund L, Somers K, Valentino N, Vincent S. Adult depression in primary care. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2013 Sep. 129 p. [334 references]

Source(s)

Trangle M, Gursky J, Haight R, Hardwig J, Hinnenkamp T, Kessler D, Mack N, Myszkowski M. Adult depression in primary care. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2016 Mar. 131 p. [394 references]

Measure Availability

Source available for purchase from the Institute for Clinical Systems Improvement (ICSI) Web site External Web Site Policy. Also available to ICSI members for free at the ICSI Web site External Web Site Policy and to Minnesota health care organizations free by request at the ICSI Web site External Web Site Policy.

For more information, contact ICSI at 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; Phone: 952-814-7060; Fax: 952-858-9675; Web site: www.icsi.org External Web Site Policy; E-mail: icsi.info@icsi.org.

NQMC Status

This NQMC summary was completed by ECRI Institute on November 28, 2012.

This NQMC summary was updated by ECRI Institute on March 5, 2014 and again on July 12, 2016.

Copyright Statement

This NQMC summary (abstracted Institute for Clinical Systems Improvement [ICSI] Measure) is based on the original measure, which is subject to the measure developer's copyright restrictions.

The abstracted ICSI Measures contained in this Web site may be downloaded by any individual or organization. If the abstracted ICSI Measures are downloaded by an individual, the individual may not distribute copies to third parties.

If the abstracted ICSI Measures are downloaded by an organization, copies may be distributed to the organization's employees but may not be distributed outside of the organization without the prior written consent of the Institute for Clinical Systems Improvement, Inc.

All other copyright rights in the abstracted ICSI Measures are reserved by the Institute for Clinical Systems Improvement, Inc. The Institute for Clinical Systems Improvement, Inc. assumes no liability for any adaptations or revisions or modifications made to the abstracts of the ICSI Measures.

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