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  • Measure Summary
  • NQMC:010777
  • Mar 2016

Adult depression in primary care: percentage of patients with type 2 diabetes with documentation of screening for major depression or persistent depressive disorder using either PHQ-2 or PHQ-9.

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: Process

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 with type 2 diabetes with documentation of screening for major depression or persistent depressive disorder using either Patient Health Questionnaire-2 (PHQ-2) or PHQ-9.

Rationale

The priority aim addressed by this measure is to increase the screening for major depression or persistent depressive disorder of primary care patients presenting with additional high-risk conditions such as diabetes, cardiovascular disease, post-stroke, chronic pain and all perinatal women.

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 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 importance of the interplay between depression and many medical comorbidities cannot be overstated. A long list of medical conditions has been associated with increased risk for depression; these include chronic pain, diabetes, cancer, HIV, Parkinson's disease, cardiovascular and cerebrovascular disease, and multiple sclerosis (Kozhimannil, Pereira, & Harlow, 2009; Egede, 2005; Katon et al., "Cardiac," 2004).

Major depression is associated with an increased number of known cardiac risk factors in patients with diabetes and a higher incidence of coronary heart disease; therefore, screening and treatment of depression in this patient group should be emphasized (Petrak et al., 2013; Katon et al., "Cardiac," 2004).

Individuals with diabetes have two- to threefold higher odds of depression than those without diabetes (Jeeva et al., 2013). Additionally, depression earlier in life increases the risk of developing diabetes (Katon et al., "Behavioural," 2004). Depressive symptom severity is associated with poor self care and medication compliance in addition to higher health care-related costs (van Dijk et al., 2013). Patient physical and mental quality of life is also decreased (Petrak et al., 2013).

High levels of symptoms associated with diabetes that do not correlate with physical or laboratory assessments should prompt the physician to assess for depression (Ludman et al., 2004).

Either the Patient Health Questionnaire-2 (PHQ-2) or the PHQ-9 can be used to screen for depression. There is stronger evidence supporting the use of the PHQ-9 in patients with chronic disease. The PHQ two-question tool (PHQ-2) should be used in routine screening settings (Gilbody et al., 2006). If the patient answers "yes" to either of the two questions, the full PHQ-9 depression instrument should be administered (Kroenke et al., 2010).

Evidence for Rationale

Egede LE. Effect of comorbid chronic diseases on prevalence and odds of depression in adults with diabetes. Psychosom Med. 2005 Jan-Feb;67(1):46-51. PubMed External Web Site Policy

Gilbody S, Bower P, Fletcher J, Richards D, Sutton AJ. Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes. Arch Intern Med. 2006 Nov 27;166(21):2314-21. [72 references] PubMed External Web Site Policy

Jeeva F, Dickens C, Coventry P, Bundy C, Davies L. Is treatment of depression cost-effective in people with diabetes? A systematic review of the economic evidence. Int J Technol Assess Health Care. 2013 Oct;29(4):384-91. PubMed External Web Site Policy

Katon W, von Korff M, Ciechanowski P, Russo J, Lin E, Simon G, Ludman E, Walker E, Bush T, Young B. Behavioral and clinical factors associated with depression among individuals with diabetes. Diabetes Care. 2004 Apr;27(4):914-20. PubMed External Web Site Policy

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

Katon WJ, Lin EH, Russo J, Von Korff M, Ciechanowski P, Simon G, Ludman E, Bush T, Young B. Cardiac risk factors in patients with diabetes mellitus and major depression. J Gen Intern Med. 2004 Dec;19(12):1192-9. 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

Kozhimannil KB, Pereira MA, Harlow BL. Association between diabetes and perinatal depression among low-income mothers. JAMA. 2009 Feb 25;301(8):842-7. PubMed External Web Site Policy

Kroenke K, Spitzer RL, Williams JB, Lowe B. The Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales: a systematic review. Gen Hosp Psychiatry. 2010 Jul-Aug;32(4):345-59. PubMed External Web Site Policy

Ludman EJ, Katon W, Russo J, Von Korff M, Simon G, Ciechanowski P, Lin E, Bush T, Walker E, Young B. Depression and diabetes symptom burden. Gen Hosp Psychiatry. 2004 Nov-Dec;26(6):430-6. 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

Petrak F, Herpertz S, Albus C, Hermanns N, Hiemke C, Hiller W, Kronfeld K, Kruse J, Kulzer B, Ruckes C, Muller MJ. Study protocol of the Diabetes and Depression Study (DAD): a multi-center randomized controlled trial to compare the efficacy of a diabetes-specific cognitive behavioral group therapy versus sertraline in patients with major depression and poorly controlled diabetes mellitus. BMC Psychiatry. 2013;13:206.

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

van Dijk SE, Pols AD, Adriaanse MC, Bosmans JE, Elders PJ, van Marwijk HWJ, van Tulder MW. Cost-effectiveness of a stepped-care intervention to prevent major depression in patients with type 2 diabetes mellitus and/or coronary heart disease and subthreshold depression: Design of a cluster-randomized controlled trial. BMC Psychiatry. 7 May 2013;13:128. 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; diabetes; screening; Patient Health Questionnaire-2 (PHQ-2); PHQ-9

Denominator Description

Number of patients age 18 years and older with type 2 diabetes who had at least one contact with a clinician in primary care in the last 12 months from the measurement date (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Number of patients screened for depression symptoms with Patient Health Questionnaire-2 (PHQ-2) or PHQ-9 (see the related "Numerator Inclusions/Exclusions" field)

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

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

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

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]

Vesga-López O, Blanco C, Keyes K, Olfson M, Grant BF, Hasin DS. Psychiatric disorders in pregnant and postpartum women in the United States. Arch Gen Psychiatry. 2008 Jul;65(7):805-15. PubMed External Web Site Policy

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

Health and Well-being of Communities
Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Living with Illness

Staying Healthy

IOM Domain

Effectiveness

Case Finding Period

The time frame pertaining to data collection is quarterly.

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Clinical Condition

Encounter

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 type 2 diabetes* who had at least one contact with a clinician in primary care in the last 12 months from the measurement date

*Diagnosis may be either new or existing.

Exclusions
Unspecified

Exclusions/Exceptions

Unspecified

Numerator Inclusions/Exclusions

Inclusions
Number of patients screened for depression symptoms with Patient Health Questionnaire-2 (PHQ-2) or PHQ-9

Data Collection: Count only one screen.

Exclusions
Unspecified

Numerator Search Strategy

Fixed time period or point in time

Data Source

Electronic health/medical record

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

  • Patient Health Questionnaire-2 (PHQ-2)
  • 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 with type 2 diabetes with documentation of screening for major depression or persistent depressive disorder using either PHQ-2 or PHQ-9.

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 on August 18, 2004.

This NQMC summary was updated by ECRI Institute on July 11, 2006, August 13, 2007, June 30, 2008, December 7, 2009, January 4, 2011, November 28, 2012, March 5, 2014, and again on July 12, 2016.

Copyright Statement

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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.

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