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Practice problem
The rural primary care clinic in this project serves about 6,000 adults, many of whom live more than 40 miles from the nearest mental health provider. Depression screening is done only when a provider suspects depression, and a chart audit of 100 recent adult visits found a documented screen in 12. Patients with depression may therefore go unrecognized until they are severely ill. The clinic and its figures are illustrative.
Significance
The US Preventive Services Task Force (2023) recommends screening for depression in the adult population, including pregnant and postpartum persons and older adults (a B recommendation). It concluded with moderate certainty that screening has a moderate net benefit. It found the evidence insufficient to assess screening for suicide risk in adults (an I statement), so the project focuses on depression screening while making sure positive screens include a clinical assessment of safety.
The screening tool
The Patient Health Questionnaire-9 (PHQ-9) scores the nine DSM-IV criteria for major depression from 0 to 3. In its validation study of 6,000 primary care and obstetrics–gynecology patients, a score of 10 or more had 88% sensitivity and 88% specificity for major depression, and scores of 5, 10, 15 and 20 represented mild, moderate, moderately severe and severe depression (Kroenke et al., 2001). It is brief, free to use and also tracks response to treatment.
PICOT question
In adult patients at a rural primary care clinic (P), does implementing universal PHQ-9 screening at annual and chronic care visits with a standardized follow-up pathway (I), compared with screening at provider discretion (C), increase the percentage of eligible visits with a documented screen and the percentage of positive screens with documented follow-up (O) over 12 weeks (T)?
Project aims
- Increase documented depression screening at eligible adult visits from 12% to at least 75% by week 12.
- Ensure that at least 90% of patients scoring 10 or more have a documented follow-up plan, such as a diagnostic assessment, treatment discussion, referral or follow-up visit, within 2 weeks.
- Ensure that 100% of patients with a positive response to the PHQ-9 item on thoughts of self-harm receive a same-day safety assessment.
Proposed intervention
| Component | Detail |
|---|---|
| Workflow | Medical assistants give the PHQ-9 on a tablet at check-in for eligible visits |
| EHR support | Scores file into a structured field and display to the provider |
| Follow-up pathway | Score-based steps, with a same-day safety assessment for any positive item 9 |
| Referral resources | Telehealth behavioral health partner; the 988 Suicide & Crisis Lifeline information on discharge paperwork |
| Training | A 45-minute session for medical assistants, nurses and providers |
Framework and evaluation
The project will use the Model for Improvement with weekly audits displayed on run charts. Balancing measures include visit length and staff-reported workload.
Anticipated barriers
Limited mental health referral options are the main risk, because screening without access to treatment can leave positive screens unaddressed. The project therefore pairs screening with a telehealth partnership and provider education in first-line treatment.
References
Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (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
US Preventive Services Task Force. (2023). Screening for depression and suicide risk in adults: US Preventive Services Task Force recommendation statement. JAMA, 329(23), 2057–2067. https://doi.org/10.1001/jama.2023.9297
