Note: This measure should only be used by grantees who either, are participating in the BPHC Depression Collaborative (HDC), or who have a similar mental health program with a registry or EHR/EMR. This measure is the same as the HDC’s required measure #1.

If grantee is participating in the HDC, then this measure is the same as the Collaborative’s required measure #1:

• On the last workday of the month, search the registry and count the number of patients with CSD and 50% or greater reduction in PHQ (comparing last New Episode PHQ to the most recent Current PHQ; e.g., from 14 to 7 or less). The Current PHQ must be dated later than the New Episode PHQ.
• Query registry for value as of December 31, 2005, December 31, 2004 and December 31, 2003, etc. to obtain measurement with trend.

If grantee being reviewed is not participating in the HDC, then of persons who are in denominator (or random sample of denominator):

• If most recent severity score is at least 50% lower than the index score, then code = “yes”
  (e.g., if using PHQ, then if index score was 14 then most recent score must be < 7.)
• If person had no recorded follow-up encounter after index score, then code as “no.”
• If person had a follow-up encounter after index score, but no score recorded, then code as “no.”
• If person had a follow-up, but all recorded scores represent less than 50% improvement (e.g., from a 10 to a 6 or 14 to 8 on PHQ-9) then code as “no.”
• Repeat for each annual cohort of then prevalent patients (e.g., as of December 31, 2005; as of December 31, 2004; as of December 31, 2003, etc.).

If grantee being reviewed is participating in the HDC then:

• This is the same as the Collaborative’s required measure #1.
• Denominator = all CSD patients (CSD=clinically significant depression, equivalent to any ICD9 diagnosis of depression AND PHQ-9 > 10 in the New Episode Field of the registry.)
• Query registry for value of measure #1 as of December 31, 2005 (for example).
• Then repeat using December 31, 2004 and December 31, 2003, etc. to obtain measurement with trend.

If grantee being reviewed is not participating in HDC, then:

• Must have a depression registry, or EHR/EMR, that allows query for all patients (all users, not just current year), ever diagnosed with depression.
• Must also be able to query system to determine most recent prior acute (new or recurrent) episode of major depression as determined by a diagnostic abnormal value from a validated structured depression instrument. For example > 10 on the PHQ-9. Most recent acute episode may be from any year.
• All patients who have ever been diagnosed with major depression make up the denominator, with their most recent prior severity score consistent with major depression being the index score.
• Note that this denominator represents prevalence of major depression in patient population; it is cumulative over years and not limited to so-called active users.
• May exclude patients for whom there is a documented referral for treatment for depression outside the grantee’s system of care (i.e., then do not include in the sample frame for the denominator).
• May not drop from denominator just because patient “disappeared” from follow-up.
• Repeat for each annual cohort of then prevalent patients (e.g., as of December 31, 2005; as of December 31, 2004; as of December 31, 2003).

• >40% is the target goal from HDC.
• Experience from HDC suggests early efforts achieving 20% with improvement upwards to 40% and even higher.
• 44% to 74% have been reported as achievable in other studies.1,2
• See http://www.healthdisparities.net/hdc/html/collaboratives.topics.depression.aspx
  

• Grantees participating in the HDC may just use their registry and the collaborative’s required measure #1.
  See http://www.healthdisparities.net/hdc/html/collaboratives.topics.depression.aspx
• Health Centers not in the collaborative wishing to use this measure may use their own depression registry, or EMR/EHR.
• One goal for this measure has been to make it the same as the HDC required measure #1, but to also allow health centers not in the Collaborative (or not using the PHQ-9) to use the measure if they wish to.
  

• Major depression is “ ranked second only to ischemic heart disease in magnitude of disease burden in established market economies” and “is the leading cause of disability (measured by the number of years lived with a disabling condition) worldwide among persons age 5 and older.” Murray CJL, Lopez AD, eds. The Global Burden Of Disease And Injury Series, Volume 1: A Comprehensive Assessment Of Mortality And Disability From Diseases, Injuries, And Risk Factors In 1990 And Projected To 2020. Cambridge, MA: Published by the Harvard School of Public Health on behalf of the World Health Organization and the World Bank, Harvard University Press, 1996; see: http://www.nimh.nih.gov/publicat/burden.cfm
  
• Research studies have shown that depression is under-detected in primary care settings. Untreated depression is associated with diminished quality of life, impaired work productivity, and decreased social functioning. Screening for depression in primary care settings has been shown to improve detection rates, but has not been shown to improve outcomes unless coupled with initiatives to improve treatment and follow-up. Close to 6 percent of the adult U.S. population use the general medical sector for mental health care, with an average of about four mental health visits per year—far lower than the average of 14 visits per year found in the specialty medical sector. The general medical sector has long been identified as the initial point of contact for many adults with mental disorders; for some, these providers may be their only source of mental health services. This attention to mental state in primary care can promote early detection and intervention for mental health problems.
  
• One example of a health center appropriate model for treating depression in primary care is the HDC. This measure is derived from the #1 Required measure from that collaborative, allowing for Health Centers that may wish to use the measure but are not necessarily in the collaborative with a registry or using the PHQ as their tool of choice. As noted by the collaborative, a 50% reduction in symptom score (“response”) has for years been an accepted measurement of clinical improvement in randomized trials evaluating treatment for depression. Studies have found that collaborative care can increase the percentage that have a 50% reduction in symptoms – for example, 74% vs. 44% in one study1 and 45% vs. 19% in another study2.
  1. Katon W, et al. Collaborative management to achieve treatment guidelines. Impact on depression in primary care. JAMA 1995; 273:1026-31.
  2. Unutzer J, et al. IMPACT investigators. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA 2002; 288:2836-45.

For more tools & resources for treating depression in general primary care, see:

• http://www.healthdisparities.net/hdc/html/collaboratives.topics.depression.aspx
• http://www.healthdisparities.net/hdc/html/library.aspx?folderId=2-24-2005.Clinical%20Resources.7842&folderOpen=yes
• http://www.depression-primarycare.org/
• http://www.icsi.org/knowledge/detail.asp?catID=29&itemID=180

*Validated structured severity measurement tools for depression:

• Patient Health Questionnaire (PHQ-9): Probably the most widely used tool in the primary care setting in the U.S, including by the BPHC Depression Collaborative. See: http://www.depression-primarycare.org/clinicians/toolkits/materials/forms/phq9/.
• Other validated structured depression tools include, but are not limited to:
  Beck Depression Inventory (BDI): http://www.uea.ac.uk/~wp316/depression.pdf
  CES-D: http://chipts.ucla.edu/assessment/Assessment_Instruments/Assessment_files_new/assess_cesd.htm
  DEPS: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=7572242
  Duke Anxiety-Depression Scale (DADS): http://healthmeasures.mc.duke.edu/
  Geriatric Depression Scale (GDS): http://www.stanford.edu/~yesavage/GDS.english.long.html
  GDS - Short Version: http://www.stanford.edu/~yesavage/GDS.english.short.score.html
  Hopkins Symptom Checklist (HSCL-25 & 90): http://www.hprt-cambridge.org/Layer3.asp?page_id=10
  Symptom Driven Diagnostic System-Primary Care: http://www.psychiatrictimes.com/p950839.html
  The Zung Self-Rating Depression Scale (SDS): http://www.wellbutrin-sr.com/hcp/depression/zung.html
  Hamilton Rating Scale for Depression: http://healthnet.umassmed.edu/mhealth/HAMD.pdf
  See also list maintained at: http://www.neurotransmitter.net/depressionscales.html