Adolescent Depression Screening O C T O B E R 7 , 2 0 1 5 S H R I N E R S H O S P I T A L F O R C H I L D R E N 1 3 1 0 P U N A H O U S T . H O N O L U L U , H I 9 6 8 2 6
/. Disclosures There are no relevant financial or nonfinancial relationships in the tools or services described, reviewed, evaluated or compared in this presentation. Development of this material is supported in part by HMSA and grants administered by the U.S. Department of Health and Human Services, Maternal and Child Health Bureau. This work is licensed under the Creative Commons Attribution‐ NonCommercial‐ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by‐nc‐sa/4.0 10/7/2015
Screening Annual depression screening 12‐21 years of age Validated tool ◦ Reliability (consistent results) ◦ Validated (true results) ◦ Sensitivity (probability of correctly identifying condition)
DSM 5 Major Depressive Episode > 5 Symptoms during same 2 week period that is a change from previous functioning: 1. Depressed mood 2. Markedly diminished interest or pleasure 3. Loss of appetite & weight 4. Insomnia, hypersomnia 5. Fatigue, loss of energy 6. Psychomotor retardation or agitation 7. Low‐self esteem or guilt 8. Diminished ability to think or concentrate 9. Recurrent thoughts of death, suicidal ideation Results in distress or disability Not due to a substance or medical condition
Depression in Children & Adolescents 2009 “The USPSTF recommends screening of adolescents (12‐18 years of age) for major depressive disorder (MDD) when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive‐behavioral or interpersonal), and follow‐up.” Draft revision 2015 ◦ “when adequate systems are in place for diagnosis, treatment, and monitoring.” http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStat ementFinal/depression‐in‐children‐and‐adolescents‐screening
2015 AAP Periodicity Schedule 11 y
Why Screen? Significant adolescent issue Bright Futures & USPSTF Recommendation Affordable Care Act Health Plan Benefit Queen’s Clinically Integrated Physician Network (QCIPN) Year 2 pediatric metric ◦ 1000 screenings by July 1, 2016 Mahie 2020: HMSA Payment Transformation
Validated Screening Tools 1 Center for Epidemilogic Studies Depression Scale ◦ http://cesd‐r.com Mood and Feelings Questionnaire ◦ http://devepi.mc.duke.edu/mfq.html PHQ‐2 ◦ http://www.cqaimh.org/pdf/tool_phq2.pdf PHQ‐A ◦ http://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_ DSM5_Severity‐Measure‐For‐Depression‐Child‐Age‐11‐to‐17.pdf ◦ http://www.ncfhp.org/Data/Sites/1/phq‐a.pdf
Validated Screening Tools 2 PHQ‐9 http://www.integration.samhsa.gov/images/res/PHQ%20‐ %20Questions.pdf http://impact‐uw.org/tools/phq9.html 88% Sensitivity 88% Specificity DSM‐IV
PHQ‐9 Over the last 2 weeks, how often have you been bothered by any of the following problems? 0 = Not At all 1 = Several Days 2 = More Than Half the Days 3 = Nearly Every Day How difficult have those problems made it for you to do your wok, take care of things at home, or get along with other people? Not difficult Somewhat difficult Very difficult Extremely difficult
Scoring PHQ‐9 Questions 1‐9 ◦ > 5 scored in shaded area ◦ 2 = More than Half the Days or ◦ 3 = Nearly Every Day Questions 1 or 2 required Question 9: ◦ 1= several days ◦ or 2 or 3
Scoring PHQ‐9 Question 10 X X X Add total points = Severity Score
PHQ‐9 Severity Score PROVISIONAL DIAGNOSIS ACTION 1‐4 Minimal 1‐9 Support, educate, call if worse, fu 1 month 5‐9 Mild > 10 Psychotherapy and/or 10‐14 Moderate antidepressant 15‐19 Moderately severe 20‐27 Severe
Android & iPhone app
PHQ‐A 10/8/2015
PHQ‐9 or PHQ‐A? PHQ‐9 PHQ‐A 1. Feeling down, depressed, irritable, 1. Little interest or please in doing or hopeless? things 2. Little interest or pleasure in doing 2. Feeling down, depressed or hopeless things? 3. Trouble falling or staying asleep, or 3. Trouble falling asleep, staying asleep sleeping too much or sleeping too much? 4. Feeling tired or having little energy 4. Poor appetite, weight loss or 5. Poor appetite overeating? 6. Feeling bad about yourself‐or that 5. Feeling tired, or having little energy? you are a failure or have let yourself or your family down 6. Feeling bad bout yourself‐or feeling that you are a failure, or that you have let yourself or your family down?
PHQ‐9 or PHQ‐A? PHQ‐9 PHQ‐A 7. Trouble concentrating on things, 7. Trouble concentrating on things such as reading the newspaper like school work, reading or or watching television watching TV? 8. Moving or speaking so slowly 8. Moving or speaking so slowly that other people could have that other people could have noticed? Or the opposite‐being noticed? Or the opposite‐being so fidgety or restless that you so fidgety or restless that you have been moving around a lot were moving around a lot more more than usual than usual? 9. Thoughts that you would be 9. Thoughts that you would be better off dead or hurting better off dead, or of hurting yourself in some way yourself in some way?
PHQ‐9 or PHQ‐A? PHQ‐9 PHQ‐A In the past year have you felt depressed If you checked off any problems, or sad most days, even if you felt okay how difficult have these problems sometimes? made it for you to do your work, If you are experience any of these take care of things at home, or get problems on this form, , how difficult have these problems made it for you to along with other people? do your work, take care of things at home or get along with other people? Have there been a time in the past month when you have had serious thoughts about ending your life? Have you EVER , in your whole life, tried to kill yourself or made a suicide attempt?
Introduction to the screen Many middle‐schoolers and high schoolers report being under stress. Sometimes stress may affect how you feel. Please fill out this form that will help us understand how you are dealing with the stresses you face.
Tracking / Billing Screening for Depression ◦ ICD‐9: V79.0 Screening for other condition ◦ ICD‐10 : Z13.89 CPT: 96127
99401 – 99404: Not depression screening codes Counseling risk factor reduction and Behavioral change intervention services for the purpose of promoting health and preventing illness Provided at a separate encounter where the patient came in only for this preventive counseling and has no health issues. ◦ E.g. Family problems, diet, exercise 99401 = 15” 99402 = 30” 99403 = 45” 99404 = 60”
99420: Not depression screening code Administration and interpretation of Health Risk Assessment instruments ◦ Lead Risk assessment ◦ Tb exposure assessment ◦ Edinburgh Postnatal Depression Scale when reported under baby’s claim
Screen is +: ICD‐10 F32.0 ‐ Major depressive disorder, single episode, mild F32.1 ‐ Major depressive disorder, single episode, moderate F32.2 ‐ Major depressive disorder, single episode, severe without psychotic features F32.3 ‐ Major depressive disorder, single episode, severe with psychotic features
Screen is +: ICD‐10 F32.8 ‐ Other depressive episodes F32.9 ‐ Major depressive disorder, single episode, unspecified F43.21(Adjustment disorder with depressed mood) F06.31 ‐ Mood disorder due to known physiological condition with depressive features F06.32 ‐ Mood disorder due to known physiological condition with major depressive‐like episode
Is this youth positive or negative for the screen? Why or Why not?
PHQ‐9 Severity Score PROVISIONAL DIAGNOSIS ACTION 1‐4 Minimal 1‐9 Support, educate, call if worse, fu 1 month 5‐9 Mild > 10 Psychotherapy and/or 10‐14 Moderate antidepressant 15‐19 Moderately severe 20‐27 Severe
What is this youthʻs severity score? Is the youth positive or negative for major depressive episode? Why or Why not?
PHQ‐9 Severity Score PROVISIONAL DIAGNOSIS ACTION 1‐4 Minimal 1‐9 Support, educate, call if worse, fu 1 month 5‐9 Mild > 10 Psychotherapy and/or 10‐14 Moderate antidepressant 15‐19 Moderately severe 20‐27 Severe
What is this youthʻs severity score? Is the youth positive or negative for major depressive episode? Why or Why not?
PHQ‐9 Severity Score PROVISIONAL DIAGNOSIS ACTION 1‐4 Minimal 1‐9 Support, educate, call if worse, fu 1 month 5‐9 Mild > 10 Psychotherapy and/or 10‐14 Moderate antidepressant 15‐19 Moderately severe 20‐27 Severe
Now What Do I Do? SCREENING IS POSITIVE, NOW WHAT?
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