Depression Screening and Treatment

This member-only article appears in the April issue of Patient Safety Monitor Journal.

Depression is the leading cause of disability worldwide, and 16.2 million Americans experienced a major depressive episode in 2016. It’s also closely tied to suicidal ideation—a major concern of The Joint Commission and CMS. But despite clear guidelines saying providers should screen for depression and provide follow-up and treatment, it’s the fourth least-reported measure on the Medicaid Adult Core Set. And only seven states report depression screening and follow-up data.

In the January edition of The Joint Commission Journal on Quality and Patient Safety, a study named “Not Missing the Opportunity: Improving Depression Screening and Follow-Up in a Multicultural Community” was published by Ann M. Schaeffer, DNP, CNM, and Diana Jolles, PhD, CNM, at the Harrisonburg Community Health Center (HCHC) in Virginia. Set in a diverse city in Virginia, researchers showcased ways to overcome cultural and language barriers to depression treatment. The study looked at methods to improve the Screening, Brief Intervention, and Referral to Treatment (SBIRT) approach for depression. Originally developed for identifying and treating substance abuse disorders, SBIRT has been successfully applied to other chronic health conditions and has demonstrated improved outcomes for depression.

Multicultural Harrisonburg
A big consideration for Schaeffer and Jolles’ study was diversity. HCHC’s main facility and two of its clinic sites are located within Harrisonburg, which is home to a large population of resettled refugees. The health system has 12,000 primary care patients—of whom 47.5% don’t speak English as a first language.
But despite depression being identified as a major health concern for the community in 2016, HCHC only screened and followed up with 9.1% of its patients for the condition.

“Cultural contexts can complicate treating depression in clients with minority, immigrant, or refugee status,” Schaeffer and Jolles wrote. “The quality of the relationship with the provider may affect willingness to accept treatment, and the concept of a ‘warm handoff’ may be confusing. Among various cultural groups, patients may downplay symptoms of depression, which can go unrecognized without careful screening.”

They performed a gap analysis that found many processes needed improvement to adequately address depression. Some of the problems they found were:
A lack of routine training or education on depression
Inconsistent depression screening for new patients
Inconsistent use of screening tools and procedures
A lack of standard guidelines for depression treatment and follow-up
Inconsistent treatment among providers
Cultural barriers or lack of understanding by patients when performing a “warm handoff”—a transfer of care between providers that is conducted in front of the patients and family
Inconsistent documentation
Few written resources

HCHC lacked a standardized depression tool. Research suggests that providers who rely on clinical judgment rather than a tool underdiagnose depression significantly. Language interpreters for the hospital also noted that verbally translating the questions on the Patient Health Questionnaire (PHQ), a widely used screening tool for depression, to and from the patient’s preferred language was “unreliable, cumbersome, and often culturally inappropriate for clients.”

Screening alone isn’t enough to help with depression either, meaning HCHC also needed to revamp its approach to follow-up care.

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