A large-scale, systematic depression screening of adults with cardiovascular disease (CVD) conducted by Kaiser Permanente in Southern California produced some unexpected result. Even those with negative depression screens benefitted.
Gabrielle Beaubrun, MD, assistant chief of psychiatry at the health maintenance organization’s South Bay Medical Center, said her study examined the effects of depression screening on general healthcare utilization.
"Many studies have shown a strong association between various cardiovascular conditions and major depression and have found that treating depression in the cardiovascular disease patient improves mood and improves perceived quality of life. But demonstrating physical CVD improvement achieved by depression treatment has always proven rather illusive," she said.
In 2002, the US Preventative Services Task Force (USPSTF) recommended screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment and follow-up. An update of that recommendation adds some specificity by stipulating that staff-assisted depression care supports need to be in place. If such supports are not in place, the USPSTF does not recommend routine screening of adults.
The USPSTF’s recommendation provokes some controversy, Beaubrun said. Critics contend that widespread depression screening can be logistically challenging, can result in mislabeling of patients and can often be difficult to justify in terms of costs.
Nonetheless, in 2005, Kaiser decided to launch a collaborative depression care program somewhat modified from the Improving Mood–Promoting Access to Collaborative Treatment (IMPACT) program developed by Untzer and colleagues,1 according to Beaubrun.
"For patients who have some medical chronic disease and are thought to be at risk for depression, we mail out a letter. The letter explains that depression is more than just the blues, can affect their physical illness and invites them to complete a questionnaire," Beaubrun said.
The PHQ-9 questionnaire asks about mood, sleep, attention and appetite disturbances and thoughts about being better off dead or hurting oneself, among other symptoms.
When the collaborative care program first began, the letter was sent to any patient with a cardiovascular condition, Beaubrun said. Now it is sent to those with type 2 diabetes, chronic obstructive pulmonary disease, obesity and other chronic diseases.
If a patient returns a positive screen, they get a telephone call from a depression specialist who serves as a case manager. The case manager invites the patient to be engaged in the depression care program. Patients with PHQ-9 scores between 10 and 14 receive the behavioral activation intervention, an explanation of why they should be more engaged in the world around them. Patients with PHQ-9 scores between 15 and 19 are encouraged to consider medication and receive problem-solving therapy. Those with PHQ-9 scores of 20 and higher are referred to the psychiatry department. Scores of less than 10 on the PHQ-9 are considered negative.
"The case manager visits can be face-to-face or by telephone," Beaubrun said. "There is no copay for these visits. The case manager also supports medication adherence and measures the progress of the patient every month with the PHQ-9. Each program is attached to a psychiatry champion who reviews the patients’ charts, may offer suggestions and advises on medication changes when appropriate."
Most of the patients remain in the primary care setting with medications prescribed by their primary care doctor. Primary care doctors are also free to utilize the service for patients they identify as possibly depressed during patient visit.
The program, according to Beaubrun, has expanded every year at the 12 Kaiser Permanente medical centers in Southern California, and last year more than 71,000 depression screenings were done.
Looking at efficacy of care, Beaubrun said that 2007-2008 data showed that within the program, 43.7% of those patients reached for rescreening are in remission, 29% are improved, 25.2% are about the same, and the remaining are worse.
We are pleased with results, she said, because they are highly comparable to other depression treatments.
Overall healthcare utilization
To look at the effects of depression screening on overall healthcare utilization, Beaubrun and her team conducted a retrospective analysis for the period of 2007 to 2008. The research task was made easier since Kaiser Permanente is a network HMO with a fully integrated electronic record system linking data from primary care, all specialties, pharmacies, emergency rooms and other services.
Out of 1.5 million Southern California members at the time, some 309,000 Kaiser members were offered the screening, with 41,000 completing the questionnaire.
The number of medical visits one year prior to depression screening was compared with one year after the screening for the 41,000 screened for depression and for a like period for the 268,000 members who did not complete the questionnaire.
Unscreened members had more medical visits than they had the year before. In contrast, a statistically significant reduction in the total number of medical encounters per patient was demonstrated in the year following depression screening when compared with data from the same patient one year earlier.
What was more surprising was that the effect was actually most prominent among the group who screened negative for depression, which constituted about 80% of the screens, she said. During the year before screening, the average number of clinic or hospital visits was about 2.8 for the nondepressed patients, versus 2.7 afterward (P<0.05).
"It made no sense, because those patients had no treatment intervention," she said. "They got only a little bit of information about depression in the letter accompanying the questionnaire…Perhaps that was enough of an intervention."
One could argue, she explained, that the patients might conclude they are okay and are not as bad off as they thought they were or that they felt their doctor cared enough to send them a screen.
The research team is now examining a second cohort to see if the finding is replicated. If it is, it may support the cost-effectiveness of increased widespread depression screening, according to Beaubrun. Reduced unnecessary medical visits could translate into real dollars saved and improved access.
Part two of the study, still underway, looks at CVD outcome. The impact of actual depression treatment is examined on selected cardiovascular parameters, such as blood lipids and blood pressure, cardiac events and mortality.
Challenges associated with the screening, depression treatment and research included a less than 30% return rate of mailed screens, a resistance by some primary care physicians to do screens in-office and a low engagement of patients in depression treatment.
Our findings and challenges are of great practical importance, Beaubrun added. Real world patients are very different from research patients.
1. Unützer J, Katon W, Callahan CM, et al.; IMPACT Investigators. Improving Mood-Promoting Access to Collaborative Treatment. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA. 2002;288:2836-2845.