Digital Repository Doctoral Projects Fall 2021 Improving Depression Screening Among Women in the Primary Care Gynecological Setting Brenda Toone Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Toone, B. (2021) Improving Depression Screening Among Women in the Primary Care Gynecological Setting Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. Improving Identification of Depression Among Women in the Primary Care Gynecological Setting by Brenda Toone A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah December 21, 2021 Jessica Bartlett, DNP, CNM, RN, IBCLC__(signature) Faculty Advisor/Committee Chair (Jessica Bartlett, DNP, CNM, RN, IBCLC) Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE (signature) Graduate Programs Director Running head: DEPRESSION SCREENING IN WOMEN 1 Improving Depression Screening Among Women in the Primary Care Gynecological Setting Brenda Toone Annie Taylor Dee School of Nursing Weber State University DEPRESSION SCREENING IN WOMEN 2 Acknowledgements Thank you to Dr. Jessica Bartlett, my faculty advisor, for your positivity and guidance; and Shannon Brennan, MSN, FNP and the entire staff at Circle of Life Women’s Center for your partnership in this project. DEPRESSION SCREENING IN WOMEN 3 Dedication Dedicated to my husband Nathan Toone for his unfailing encouragement, persistent confidence in me, and being the embodiment of a grad school spouse extraordinaire; and to Cassidy, Braden, and Connor for being my most enthusiastic cheerleaders. Additional thanks to the women in my life who moved me to find a way to help more women affected by depression. You inspire me. DEPRESSION SCREENING IN WOMEN 4 Abstract Globally, women are particularly susceptible to depression compared to their male counterparts. A long list of risk factors increases its prevalence in the female gender, and the World Health Organization describes current health efforts to address depression in women as inadequate and unacceptable. One in five American women in 2017 reported depression, and at 23%, Utah’s female population experiences a slightly higher rate. Depression causes lower quality of life, social detriment, reduced economic productivity, overuse of health resources, and poor physical health. Many of depression’s physical symptoms are also risk factors for its development. Several psychosocial, cultural, and economic barriers affect female patients’ willingness to discuss their mental health symptoms; thus, depression’s identification and diagnosis in women can prove challenging. Considering these challenges, the American College of Obstetricians and Gynecologists, Healthy People 2020, and the United States Preventive Services Task Force recommend annual preventive screening for depression in women. This quality improvement project introduced the Patient Health Questionnaire (PHQ-9) depression screening tool for annual exams at Circle of Life Women’s Center in Ogden, UT. Education materials, mental health referrals, and treatment were offered to patients who screened positive. Pre- and post-project screening rates were analyzed, and verbal feedback was obtained from participating healthcare providers. One hundred percent of the clinic’s 12 providers participated in the project. Circle of Life’s six-month depression screening rate improved from 2.3% to 23.8%. Of patients screened, 42% of women scored positive, and 23% of those received treatment. Clinicians reported that time and workflow interruption were barriers to screening. This project demonstrated that using a screening tool can improve depression identification in the gynecology setting with minimal intrusion. The findings from this project contribute to better DEPRESSION SCREENING IN WOMEN 5 mental health for women in the greater Ogden area and could be applied in other primary care clinics. With leadership, organizational support, and mitigation of time-related barriers, we can continue to improve depression for women in our community. Keywords: depression screening in women, mental health screening, depression identification, women’s health, PHQ-9 screening tool, primary or ambulatory care, gynecology, well woman or annual or yearly exam DEPRESSION SCREENING IN WOMEN 6 Improving Depression Screening Among Women in the Primary Care Gynecological Setting Introduction Depression is the second leading cause of the global disease burden; however, fewer than half of patients with a depressive disorder are diagnosed in the primary care setting (World Health Organization [WHO], n.d.). The National Institute of Mental Health (NIMH) (2019) estimates that 17.3 million American adults experienced one or more major depressive episodes in 2017. Centers for Disease Control and Prevention (CDC) reports that 8.1% of adults 20 and older in the United States are depressed during a given two-week period (Brody, Pratt, & Hughes, 2018). At 22.5%, Utah adults have a slightly higher level of depression than the 2017 national rate of 19.3%. Along the northern Wasatch Front, the Weber-Morgan and Davis County rate is marginally higher at 23.2% (Utah Department of Health [UDH], 2018). Women in the United States have twice the diagnosed depression rate of men, and nationwide, American adults have not seen significant improvement since 2007 (Brody, Pratt, & Hughes, 2018). Approximating the national average, the age-adjusted rate of depression among Utah women is still double that of men. Among Utah women 18-74 years old, statewide depression rates range from 24.8% to 30.8% (UDH, 2018). This paper describes a quality improvement project whose objective was to improve identification of depression through annual screening at yearly gynecological exams in a medium-sized women’s health clinic. Problem: Improving Depression Screening Depression is more common in women than men. and when left undiagnosed and untreated, it carries consequences of social and relationship effects, reduced economic and job productivity, mental and physical health comorbidities, and increased suicide risk. With no improvement in adult depression rates since 2007 and a rate among Utah women that is slightly DEPRESSION SCREENING IN WOMEN 7 higher than the national average, a gap exists in addressing the condition in the local population (Brody, Pratt, & Hughes, 2018; UDH, 2018). Further underscoring the need are depression rates for Davis and Weber-Morgan counties’ women that surpass both the Utah and United States average rates (UDH, 2018). One hundred percent of patients attending yearly well-woman exams should be screened for depression and receive timely treatment and follow-up when warranted (American College of Obstetrics and Gynecology, 2016a; Siu et al., 2016). Search Strategy This paper describes and discusses a Doctor of Nursing Practice (DNP) evidence-based practice project to improve identification and treatment of depression for women in the primary care setting. A database search for peer reviewed articles was conducted using Medline, PsycINFO, CINAHL Complete, and Cochrane Library. Searches were performed in English. Search terms included depression and primary care or ambulatory or outpatient, depression in women, maternal depression, depression screening or screening tool, depression screening effectiveness, depression intervention or identification, risks of depression, and spirituality or religious or faith and depression. Terms excluded from the search included postpartum or antenatal or pregnant, inpatient, chronic disease, and cancer. The search was initially limited to the last five years, but available literature specific to women was limited. The search was subsequently expanded to ten years to increase yield. Background The 5th edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-V) describes major depression as a mood disorder, typically with loss of pleasure or interest for greater than two weeks. It is attended by at least three of the following: changes to weight or appetite, sleep disturbance, lower energy level, feeling worthless, disrupted concentration or DEPRESSION SCREENING IN WOMEN 8 cognition, and persistent thoughts of death or suicide (American Psychiatric Association [APA], 2019). Healthcare’s efforts to address depression, particularly for women, are “unacceptably low,” and the WHO (n.d.) advocates for health care providers to be better trained at recognition and treatment to improve depression care in the ambulatory setting (p. 18). Risk and Contributing Factors Depression is often not identified early because confounding physical symptoms like insomnia, pain, and fatigue can muddy the waters of diagnosis (Berghöfer, Roll, Bauer, Willich, & Pfennig, 2014; Fujieda et al., 2017; van Eck van der Sluijs et al., 2015). Depression is associated with substance abuse, negative thinking, and poor self-esteem. Its physical symptoms include unintended weight changes, backaches, vague musculoskeletal pain, and physical complaints that lack a clinical explanation (Ng, How, & Ng, 2016; van Eck van der Sluijs et al., 2015). Symptoms of depression are pervasive and disruptive, impairing the individual’s ability to function. With overwhelming feelings of guilt and recurrent harmful, death-related, or suicidal thoughts, depression’s symptoms lead to adverse effects in nearly every aspect of life (Woo & Robinson, 2020). Characteristics that increase a person’s risk for depression include genetic factors, life stressors, abuse, low socioeconomic status, chronic disease, other psychiatric disorders, and gender disparities (Ng, How, & Ng, 2016; Tusa et al., 2019; WHO, n.d.). Globally, differences exist between men and women with depression. Though the worldwide prevalence of depression is the same for women and men, women show a higher likelihood of depression because of their risk for gender-based discrimination, violence, and associated lower education and income (WHO, n.d.). Despite their higher risk, women can be hesitant to disclose mood-related symptoms to a primary care provider until they become severe (Keller, Valdez, Schwei, & Jacobs, 2016). DEPRESSION SCREENING IN WOMEN 9 Literature Review Focus Women represent the majority of depression cases worldwide (WHO, n.d.), and depression’s high prevalence among women is mirrored in both nationwide and Utah-specific statistics. Twenty-nine percent of Utah women have been diagnosed with depression by a physician (UDH, 2018). The WHO (n.d.) suggests that the oppression of women in autonomy, income, reproductive rights, and safety put them at higher risk of poor mental health outcomes and depression. Depression in women appears to be more sensitive to socioeconomic factors, and the prevalence of depression in women below 400% of the federal poverty level is ten times that of men at the same income level (Brody, Pratt, & Hughes, 2018). Its identification in the female population is necessary not only because of gender equity issues but also due to the condition's broad impact on social outcomes and physical health determinants. Though suicide completion rates remain higher in men (WHO, n.d.), epidemiological findings show that most of the recent increase in suicidality was among females, who were 1.52 times more likely to attempt suicide than their male counterparts (Olfson et al., 2017). ACOG (2016) and the USPSTF (Siu, 2016) both recommend well-woman exams that include annual screenings for several physical and psychosocial domains, including mental health and depression. Access to these exams and screenings takes place in the ambulatory setting. Healthy People 2020 aims to increase the level of primary care access beyond the current level of two-thirds of American women who currently have a primary care provider, and the National Prevention Strategy targets an increase from the 2.2% of primary care visits that currently screen adults for depression (United States Health and Human Services, 2020). DEPRESSION SCREENING IN WOMEN 10 Consequences Untreated mental illness takes a toll at individual, family, and community levels. Depression carries consequences of social effects, economic and job productivity, psychological and physical health outcomes, and suicide risk. Difficulty exists in quantifying undiagnosed depression costs, but even when depression is identified, its effects represent a burden to society and the workplace. Job productivity and suicide costs account for two-thirds of total major depression-related expenditures in the United States (Greenberg, Fournier, Sisitsky, Pike, & Kessler, 2015). Improved identification and treatment of depressive disorders would shift the burden from indirect societal and economic impacts to the direct health care cost category, which includes pharmaceutical services, inpatient hospitalizations, outpatient treatment, and emergency visits (Greenberg et al., 2015). Regardless of the distribution of financial indicators, the personal value of greater socioeconomic advantage, improved mental and physical health outcomes, and reduced suicidal behaviors may not be quantifiable to the individual. Social effects. A depression diagnosis carries significant sequelae related to poor social outcomes – of American adults diagnosed with depression, 80% admit at least some disruption to their work, home, or social lives (UDH, 2018). A non-experimental cross-sectional study which observed 553 patients, of which nearly three-fourths were women, demonstrated that loss of interest in relationships and depressed mood correlated with lower scores for social functioning and quality of life on the study’s assessment tool (Guajardo et al., 2011). Depression not only reduces the quality of life for affected individuals but also diminishes the quality of life for their children and family members. Thus, it is of particular concern for pregnant and postpartum women (Siu et al., 2016). A 2016 editorial (Garg, Toy, Yoghos, Cook, & Cordella) lists maternal depression as a predictor of childhood food insecurity DEPRESSION SCREENING IN WOMEN 11 in low-income homes and as a source of early childhood toxic stress in such families. APA (2019) describes this as the "cross-generational impact of depression" (p. 45). Productivity. Socioeconomic disadvantage can be an outcome of untreated depression (Folb et al., 2015), and it is associated with lower income and a higher unemployment rate (Brody, Pratt, & Hughes, 2018; Greenberg et al., 2015; Tusa et al., 2019). Major depression is the primary reason for disability in the U.S. (Woo & Robinson, 2020). Persons with a diagnosis of major depression experience difficulties in both attending and performing at work. They are also less likely to get or keep a job during an economic downturn (Greenberg et al., 2015). Among these individuals, work absenteeism and reduced productivity have grown 22% in the last five years, representing total costs of over $42 million to United States employers during 2010. Conversely, randomization into a primary care depression management program resulted in subjects’ higher productivity, and those treated for depression demonstrated a 22.8% improvement in workplace absenteeism over the usual care group (Rost, Smith, & Dickinson, 2004). Increasing detection and treatment rates for depression may improve work productivity, reduce costs to employers, and improve overall socioeconomic outcomes for successfully treated individuals. Mental and physical health. Depression alters multiple aspects of mental and physical health. A cross-sectional descriptive study found that feelings of depressed mood and loss of interest in activities contributed to significantly reduced quality of life scores among outpatient primary care subjects (Guajardo et al., 2011). Depression’s correlation to high levels of perceived stress and burnout in women demonstrate further impact on their quality of life (Wiegner, Hange, Bjorkelund, & Ahlborg, 2015). Some physical conditions, such as chronic fatigue, fibromyalgia, or irritable bowel syndrome, have a high association with depression or DEPRESSION SCREENING IN WOMEN 12 anxiety; and when those syndromes combine with other, more nebulous physical symptoms, the incidence of mood disorders rises further (van Eck van der Sluijs et al., 2015). Depression shows a relationship to poor physical health indicators, including chronic disease, medication or substance use, and frequent primary care use (clinic visits > 5 per year). Patients more commonly seek help for physical symptoms like appetite changes, fatigue, and sleep disturbance than for changes in mood (Chin, Wan, Dowrick, Arroll, & Lam, 2018; Fujieda et al., 2017; Stromberg et al., 2008; Tusa et al., 2019). While depressed individuals commonly have somatic comorbidities, people with chronic conditions also have higher rates of psychiatric disorders than those without a physical disease (Tusa et al., 2019). Patients with depression also demonstrate a higher rate of substance use and use more medications overall. Depression could explain a patient’s noncompliance in treatment for their chronic disease, particularly in terms of weight management and exercise, which contribute to obesity, hypertension, heart disease, and diabetes (Randle, Spurlock, & Kelley, 2019). Mental health disorders are linked to medically unexplained physical symptoms, which are defined by van Eck van der Sluijs and colleagues (2015) as “one or more physical symptom(s) in the past 12 months for which no adequate organ pathology or pathophysiologic basis was found” (p. 4). In the authors’ observational cohort study (2015) of 6,506 adults in the general population, difficult to treat physical conditions carried a clear association with depression, anxiety, and substance use disorder. Additional correlation emerges between a higher risk of depression and patients who are frequent attenders of primary care clinics (p < .001) (Berghöfer et al., 2014). This finding was independent of any prior mental health diagnosis, indicating that unidentified depression may be present in a percentage of high-frequency primary care utilizers. Tusa and colleagues’ (2019) DEPRESSION SCREENING IN WOMEN 13 cohort study corroborated this finding and found a relationship of depression to worse overall health, less physical activity, larger abdominal circumference, higher weight, heavier smoking, higher rates of diabetes, and greater medication use (analgesic, sedative, cardiovascular, and diabetes prescriptions) compared to controls. Suicide. Low self-esteem is both a risk factor for and a symptom of depression, and a high correlation is present between depression and suicide (ACOG, 2016b; APA, 2019; Samples, Stuart, Saloner, Barry, & Mojtabai, 2020; Siu et al., 2016; WHO, n.d.). The overall percentage of suicide attempts has increased since 2006 in the U.S., with the majority of attempts seen in adult females younger than 50 (Olfson et al., 2017). Attempted suicide was disproportionately higher for adults with a depressive condition, and additionally, the findings showed that attempted suicide related to lower education levels. These data relating suicide and education also align with WHO (n.d.) data correlating depression with less formal education. Further increases to depression incidence and suicide risk have been implicated in relation to the emerging social and economic impacts of the COVID-19 pandemic (Czeisler et al., 2020; McIntyre & Lee, 2020). Barriers Depression’s symptomatic presentation may complicate the identification and correct diagnosis of the condition. Cultural or religious influences can involve an embedded stigma regarding mental health, which consequentially sways individuals’ willingness to disclose depression symptoms or their inclination to participate in treatment. Even after diagnosis, socioeconomic factors can thwart a patient’s compliance with a depression treatment plan. Somatic symptoms. Depression’s physical complaints can include weight changes, fatigue, insomnia, or hypersomnia (APA, 2019). Mental health symptoms have elevated rates of somatization, and it is common for depression-related somatic symptoms to be inadequately DEPRESSION SCREENING IN WOMEN 14 identified and treated (WHO, n.d.). Although a causal relationship was not examined, for nearly two-thirds of patients in a two-stage cross-sectional study, an association existed between depression's presence and at least one chronic disease diagnosis (Berghöfer et al., 2014). Depression’s identification can be challenging. Primary care providers often attempt to rule out physical causes before looking to a mental health explanation for the symptoms (Berghöfer et al., 2014; Leff et al., 2017). A qualitative analysis of primary care family practice physicians uncovered that presenting somatic complaints could be a barrier to depression diagnosis (Leff et al., 2017). Investigation of ailments with a perceived physical origin was a significant problem that delayed the provider's recognition and diagnosis of depression because of the need for differentiation between psychiatric and somatic symptoms. However, once physical exam results proved to be negative, they could be used to convince some patients of the presence of their symptoms' psychiatric origin. None of the physicians interviewed employed a depression screening questionnaire, but they recognized depression earlier when they had contextual psychosocial information that the patient did not disclose during the visit. While finding physical causes for symptoms continues to be necessary, this phenomenon highlights the need for better ways to diagnose depression and differentiate its symptoms more efficiently. Cultural complexity and stigma. Racial and cultural background can deter help-seeking behaviors or acceptance of diagnosis and treatment for varied groups. Women, older adults, and racial minorities are sometimes reluctant to seek help for depression symptoms because of mental health stigma and misperceptions about depression and its treatment possibilities (Colligan, Cross-Barnet, Lloyd, & McNeely, 2020; Lopez, Sanchez, Killian, & Eghaneyan, 2018; Keller et al., 2016; Randle, Spurlock, & Kelley, 2019). For Japanese physicians, questions about insomnia elicited a depression diagnosis more effectively than a direct investigation of DEPRESSION SCREENING IN WOMEN 15 mood (Fujieda et al., 2017). Identification of mental health teaching opportunities in Hispanic women improved the detection of early depression symptoms and shed light on the role stigma plays in their perception of mental health treatment (Lopez et al., 2018). Gaps in mental health education may be a consideration when treating additional ethnic groups. Religion is regarded as protective for depression; however, a correlational study of 267 young adult Latter-day Saints (Mormons) showed that a positive depression sub-scale score was associated with a high degree of scrupulosity and perfectionistic behaviors. The authors suggested these tendencies may increase depression’s incidence among certain religious groups (Allen & Wang, 2014). Clinicians need to account for racial, cultural, and religious risk factors when considering the aspects of diagnosis and effective treatment for these groups. Corresponding adjustments may prove necessary when considering the likelihood of depression and selecting a treatment for specific demographic groups. Economic factors. Though some barriers to appropriate depression diagnosis relate to individual hesitancy in seeking treatment, low income may impact a person’s ability to access primary care resources. A nested longitudinal cohort study cites depression as both the cause and the result of socioeconomic disadvantage (Folb et al., 2015). Poverty and insurance status are both barriers to mental health services access, and Americans’ prospects of accessing mental health treatment are six times more favorable if they are insured (WHO, n.d.). A qualitative study of 247 older adults found rural residence and scarce provider availability to be barriers to diagnosis for the study group (Colligan et al., 2020). Additionally, the Folb et al. (2015) findings showed a relationship between lower incomes and education levels and lower chances of a patient receiving treatment for their depression. The researchers further recommended creating strategies to address socioeconomic determinants that reduce access to care. DEPRESSION SCREENING IN WOMEN 16 Solutions Appropriately identifying depression is critical to prevent further decline in personal social effects, economic productivity, mental and physical health outcomes, and suicide risk. Proper identification of depression can occur through screening, evaluation for other psychosocial problems, and assessment for potential related medical conditions (ACOG, 2016b; Siu et al., 2016). The standard of care includes a medical evaluation with laboratory testing to rule out potential physical causes of depression's presentation. The appropriate treatment for depression involves medication, psychotherapy, and non-pharmacological solutions such as exercise. A validated screening instrument can provide further evidence that informs a correct diagnosis of depression (Woo & Robinson, 2020). The need for screening. Because patients more often seek help for unrelated conditions or the somatic symptoms of depression, undiagnosed depression is more likely to be identified in the primary care setting (Lopez et al., 2018). Despite this, depression screening may account for as low as 3% of primary care visits (Samples et al., 2020). A correlational study of 155 women visiting a general practitioner demonstrated that one-third did not initially disclose their mental symptoms, instead waiting until a subsequent visit to discuss them (Stromberg et al., 2008). High-frequency attendees of primary care may also be a population that can benefit from routine depression screening, mainly because some from this group have a higher correlation of acute suicidality (p < .001) than typical health care users (Berghöfer et al., 2014; Tusa et al., 2019). Screening in ambulatory settings. Depression screening tools were created to aid accurate identification. These tools counter the capricious nature of depression’s presentation, inconsistency in primary care providers’ mental health training, and clinicians’ lack of confidence to diagnose the condition (Samples et al., 2020). Frequently used in primary care, DEPRESSION SCREENING IN WOMEN 17 such instruments minimize clinician bias and utilize DSM-V major depression diagnostic criteria (Nabbe et al., 2017). These validated, written tools are Likert scale questionnaires that use self-reported data. They can be completed by the patient, with assistance from the provider, or administered by trained support staff (Chin et al., 2018; Colligan et al., 2020; Nabbe et al., 2017; O'Connor et al., 2009). Examples include versions of the Patient Health Questionnaire (PHQ), Geriatric Depression Scale (GDS), or Edinburgh Postnatal Depression Scale (EDPS) (Siu et al., 2016). They are used to quantitatively screen for, assess, and monitor depression (Chin et al., 2017). The Patient Health Questionnaire-9 (PHQ-9) is an easy to use, self-administered patient survey that assesses depression severity. A clear benefit of this tool over some other widely used screeners is its short completion time. Developed initially from the clinician-administered PRIME-MD tool, the PHQ-9 was based on DSM-IV depression diagnostic criteria. It is considered reliable and valid to screen and assess for depression. Its scores can track changes in patient depression levels over time (Kroenke, Spitzer, & Williams, 2001). The PHQ-9 is widely used in primary care and research settings (Chin et al., 2018; Nabbe et al., 2017) and is recommended by the USPSTF (Siu et al., 2016). It is endorsed by ACOG (2015). ACOG (2016b) guidelines for well-woman exams mandate education and assessment for a variety of annual screenings for physical and psychosocial conditions, conception and contraceptive services, primary and secondary prevention risk factors, and immunizations. Due to the challenge of covering such a comprehensive list, in the absence of a patient’s disclosure, mental health might understandably be overlooked. These considerations underscore the need for a depression screening instrument in women’s health settings. DEPRESSION SCREENING IN WOMEN 18 Impact. Screening for depression can expand detection, improve treatment, and reduce health care costs. A ten-year cross-sectional analysis of National Ambulatory Medical Care Survey data showed that screening was more likely to result in depression diagnosis and treatment. In the absence of screening, depressive symptoms are less likely to be ascertained by primary care providers (Samples et al., 2020). A qualitative study of 34 women attending a primary care visit found that patients postpone a discussion of depression signs until the symptoms become severe and threatening to their well-being (Keller et al., 2016). The authors identified several barriers to women's willingness to broach the topic at a primary care visit. These barriers include misperception that primary care providers are only concerned with physical health, fear of not having a choice in treatment, and the perceived likelihood of getting help if they endure the emotional cost of retelling their symptoms. Standardized screening may hasten and enable such discussions. Improving treatment and lowering health care costs go hand in hand and could be achieved through screening for depression. A randomized clinical trial demonstrated the effectiveness of an Agency for Healthcare Research and Quality [AHRQ] protocol for improving depression severity scores among indigent primary care patients (Jarjoura et al., 2004). Results provided strong support for screening, plus an evidence-based treatment strategy. Such an intervention highlights the opportunity for improvement in mental health outcomes for patients with socioeconomic disadvantage and could lead to quality of life improvements for patients, cost savings for health care (Jarjoura et al., 2004), a reduction to the primary care utilization burden (Tusa et al., 2019), and more cost-effective care (Jiao, Rosen, Bellanger, Belkin, & Muennig, 2017). A quasi-experimental study of primary care patients exhibited a jump in depression recognition from 0 to 41% after the adoption of the Patient Health Questionnaire-9 DEPRESSION SCREENING IN WOMEN 19 (PHQ-9) depression screening tool (Randle, Spurlock, & Kelley, 2019). Thirty-nine percent (n=75) of the patients with a positive PHQ-9 screening score received treatment, which demonstrated the tool’s potential to improve alignment with the USPSTF’s goals of early diagnosis, treatment, and better health outcomes. As health care aims to advance the recognition, diagnosis, and treatment of depression in primary care, particularly for the at-risk female population, improving screening for the condition must play a role in the strategy. Treatment. The USPSTF stresses the critical nature of having “adequate systems…and effective treatment” in place as an adjunct to screening for depression (Siu et al., 2016, p. 381). In support of this, a systematic review of depression screening in the adult primary care setting provided strong evidence for the combination of screening with a staff-administered depression care support program (O’Connor, Whitlock, Beil, & Gaynes, 2009). The review reports that the most salient barrier for depression relief is inadequate treatment. A recently updated guideline from the American Psychiatric Association (APA) (2019) serves as a comprehensive resource to the psychological treatment of depressive disorders. The guideline recommends psychotherapy or antidepressant medications -- or a combination of the two -- as equally efficacious. It acknowledges that in comparison to psychiatric drugs, cognitive behavioral therapy has superior long-term effects that endure after discontinuation (APA, 2019). Adherence to planned treatment interventions such as medication or therapy can reflect the level of access to care or patient socioeconomic disparities (Thompson et al., 2019). Accurate identification is the first step to successful depression care, but education level and income can be barriers to treatment adherence once a patient is diagnosed. Cultural factors influence the likelihood of being diagnosed with depression, but they also add challenges to selecting a treatment. Unexpectedly, when some Hispanic women with higher education scored lower on DEPRESSION SCREENING IN WOMEN 20 mental health knowledge assessments, they persisted in negative attitudes toward antidepressant use (Lopez et al., 2018). Accordingly, members of some cultures may require additional teaching or to be offered a range of options to achieve compliance with depression treatment. Independent of cultural factors that present challenges, low socioeconomic status creates a barrier to accessing clinics, medications, and therapy to adhere to antidepressant therapy (Folb et al., 2015). The vagaries of cultural and socioeconomic factors require awareness from providers as they consider a depression diagnosis in the context of the patient’s possibilities for receiving and continuing adequate treatment. The importance of identifying depression among undiagnosed or undertreated women cannot be overstated. Depressed women carry increased risk for gender inequity, poor physical outcomes, adverse socioeconomic effects, and suicide, which justify the USPSTF and ACOG recommendations for annual depression screening. Regular screening in the gynecological primary care setting can improve and increase depression’s diagnosis among affected women. The use of a validated screening tool can save time and increase diagnostic accuracy for clinicians who should be performing these screenings. Depression diagnosis supported by screening tool use enables shared decision making between health care providers and patients. They can then select appropriate evidence-based treatment and connect these affected women to additional mental health resources and support. Practice Change Goals and Expected Outcomes This evidence-based practice project intended to improve the identification and treatment of depression at COLWC. The project aimed to increase screening and assessment for DEPRESSION SCREENING IN WOMEN 21 depression at annual exams, educate patients about depression, and provide patient resources for mental health support. One hundred percent of patients presenting for an annual exam should be screened for depression, but during the initial phase of the practice change, 80% was selected as the initial benchmark. Theoretical Framework A practice change for quality improvement can be supported by using a theoretical framework to guide its implementation. Lewin’s Theory of Planned Change is a simple, people-centered model that focuses on three elements that leaders use to approach the change process: unfreezing, moving or transitioning, and refreezing (Finkelman, 2018; Shirey, 2013). During the unfreezing stage, the team gathers knowledge and information about the problem, then identifies catalysts and barriers to the change (Finkelman, 2018). The moving stage is seen as a transition process rather than as a discrete event, which requires engaging stakeholders in a detailed plan for change implementation (Shirey, 2013). The final stage is refreezing. The new idea is cemented as a part of the organizational culture, resulting in stability after finding a balance between enabling and restraining forces (Finkelman, 2018; Shirey, 2013). The three steps of the theory focus on discovery, engagement, and readjustment of driving and restraining forces. Careful change planning to address these forces during the process will aid a more effective organizational transition through the cycle (Finkelman, 2018). The model is regarded as more effective when a change is initiated from the top-down. Thus, Lewin's Theory was appropriate for a program that involved improving depression screening by clinicians in a primary care setting: clinic leadership, doctors, or nurse practitioners supported the change as senior members of the organization (Shirey, 2013). For this quality improvement project, the unfreezing stage included identifying the need to improve depression DEPRESSION SCREENING IN WOMEN 22 screening, disseminating information to increase awareness of the problem, and talking with stakeholders to identify driving or restraining forces specific to the proposed change. Stakeholders included clinic leadership, department managers, individual clinicians, nursing and medical assisting staff, and patients. The moving stage was a detailed process that engages stakeholders to identify desired outcomes (Finkelman, 2018) and launch the new plan (Shirey, 2013). In this phase, project leadership identified desired outcomes of improved screening rates while continuing to provide adequate treatment and referrals upon diagnosis (Finkelman, 2018; Siu et al., 2016). Achievement of refreezing occurred when the change became integrated into the clinic's workflow, policy, and culture (Shirey, 2013). With refreezing, the clinic's healthcare team members no longer reverted to the old way of doing things, as the driving and restraining forces became rebalanced (Finkelman, 2018). Ongoing efforts to maintain the new process for higher rates of depression screening were then the clinic's ‘new normal’. Setting COLWC is a medium-sized suburban clinic in Weber County, Utah. It provides ambulatory health services for adolescent and adult women seeking obstetrical and gynecological care. Patients present for yearly well-woman exams once they reach the age of 18 and may continue throughout the lifespan. In 2019, the clinic provided 7,777 annual exams, with a mean of 648 patient visits per month among all 12 providers. As three of the clinicians have part-time schedules, the 2019 monthly mean of yearly consultation appointments ranged from 31 to 86 visits per provider. Prior to the project, the clinic's patient-completed health history paperwork for annual exams contained questions about a personal or family history of depression. However, there was no opportunity to disclose current mental health concerns on the form (COLWC, 2020). The DEPRESSION SCREENING IN WOMEN 23 USPSTF and ACOG recommend annual depression screening (ACOG, 2016b; Siu et al., 2016), but there was no consistent depression screening at the clinic's yearly well-woman exams. Population Twelve providers practiced at COLWC, and comprising six medical doctors (MDs), three certified nurse-midwives (CNMs), and three nurse practitioners (NPs). Five of the MDs and two CNMs provided both obstetrical and gynecological services. The remaining MD, one CNM, and all three nurse practitioners served gynecology patients exclusively. All 12 providers offered yearly well-woman exams. Just three (one MD and two NPs) regularly documented the use of a validated depression screening tool when patients presented with depression-related complaints. One Ob-Gyn doctor used the Edinburgh Postnatal Depression Scale for all patients at the postpartum visit. Two nurse practitioners periodically used the Patient Health Questionnaire-9 and Hamilton Anxiety scale at yearly exams, but only when a patient complained of mood disturbance. These two NPs were not using the questionnaires for general screening purposes. Need and Gaps The providers at the clinic acknowledged the need for depression screening and treatment, but they required support to efficiently integrate it into the annual exam process. One barrier to the change involved providers' perception of having limited time to adequately address depression concerns during time allotted for the yearly visit. Other applicable barriers were identified in the literature. Confounding physical symptoms often complicate the identification of depression by the provider who completes the physical exam (APA, 2019; Berghöfer et al., 2014; Leff et al., 2017). Further challenges include patients' reluctance to disclose mental health-related symptoms for a variety of reasons that include cultural background, stigma, and views on treatment (Colligan et al., 2020; Lopez et al., DEPRESSION SCREENING IN WOMEN 24 2018; Keller et al., 2016; Randle, Spurlock, & Kelley, 2019). Socioeconomic factors and mental health education levels can persist after diagnosis as barriers to recovery (Colligan et al., 2020; Folb et al., 2015; Lopez et al., 2018). A variety of factors and organizational stakeholders contributed to the project, including health professionals and clinic operational support personnel. Ideally, the electronic health record (EHR) yearly exam template should have been updated to include an entry field for a depression screening score, which would save time for providers and staff. However, the organization had just hired a new information technology manager who was orienting and training. The early period of role adjustment for the lone technology specialist at the clinic necessitated the postponement of this modification to a later phase of the project. This capability would enhance the initiative's sustainability, but the team needed to carefully time this EHR update. Facilitators. Provider and department head champions at Circle of Life Women’s Center (COLWC) were essential to spread enthusiasm and support for the adoption of the change. They had an ongoing role in sustainability. Another enabling factor was that the change was relatively simple and did not require significant employee time or operating costs to implement. Printable resources were downloaded for free from the National Institute of Mental Health (NIMH, 2020). Therefore, the principal cost of patient education materials was the cost of photocopies. The doctor of nursing practice (DNP) leader's role involved identifying, promoting, and facilitating organizational change through the application of practice change theory (DeNisco, 2021). The DNP candidate led and communicated with the site's collaborative project team, provided cost and risk analyses, developed the detailed plan for execution, collected data and evaluated the implementation outcomes, addressed barriers with stakeholders, and enabled adjustments that were needed for sustainability (DeNisco, 2021; Reavy, 2016). DEPRESSION SCREENING IN WOMEN 25 Project Issues The role of ethics in depression treatment cannot be ignored, but the harms of screening were judged by the USPSTF to be minimal to none (Siu et al., 2016). Confidentiality was maintained to protect patient privacy, and the project team demonstrated compliance with COLWC's Health Insurance Portability and Accountability Act policy. The project was evaluated by Weber State University's Institutional Review Board (IRB) and received a quality improvement exemption. Implementation This evidence-based practice project for depression screening and treatment was executed over a one-month pilot period and a five-month full implementation period. The project leader interviewed the providers, medical assistants, nursing managers, and administrative staff to assess barriers and facilitators to the proposal. During and after both the pilot and implementation periods, the participating providers, medical assistants, and nurses were asked for project feedback using brief, informal survey questions (see Appendix D). Standardizing the use of a validated depression screening tool, providing patient education on depression, and creating support materials for collaborative mental health care coordination aimed to improve the clinic’s identification and treatment of depression (APA, 2019; Siu et al., 2016). The project promoted depression screening by implementing the PHQ-9 at the clinic's well-woman visits. With a completion time of under five minutes, the PHQ-9 was well-suited for the annual visit where a variety of screenings and concerns may need to be addressed (ACOG, 2015; ACOG, 2016b). The project’s DNP leader recommended that patients fill out the PHQ-9 survey in the exam room, with the clinician then using it to guide treatment decisions as appropriate. DEPRESSION SCREENING IN WOMEN 26 After IRB approval, patients of a four-provider pilot group were screened for depression with the PHQ-9 when they presented for an annual exam. The one-month pilot study consisted of two MDs and two NPs who agreed to join the pilot. Following the pilot period, feedback was obtained from the participating providers and clinic staff. No project plan adjustments were identified from this feedback. The remaining eight clinic providers then received education about the rationale and protocol for the initiative and were given the opportunity to opt-in. All twelve clinicians agreed to join the project. Chart reviews were conducted for a one-month period during the prior year to determine the clinic’s baseline yearly exam depression screening rate. Treatment plans and interventions remained at the discretion of the clinician. Copies of the PHQ-9 were available in both English and Spanish at each patient care station or in selected exam rooms, based on provider and medical assistant preference. They were given to patients on a clipboard by the medical assistant for completion either during vital sign collection or in the exam room before the visit began. The clinician then scored the tool during the appointment and discussed the results with the patient (Loeb et al., 2015). After being marked with a patient identification sticker from the charge sheet, completed tools were collected in a folder at the station. They were later scanned and indexed into the EHR by the project leader, nursing staff, or front desk employees. The medical assistant and nursing personnel were educated on the importance of mental health screening, oriented to their roles in the protocol procedures, and made familiar with the screening tool and data collection methods (see Appendix A). With the intent of saving time and streamlining the process of initiating treatment, the DNP project leader created a written patient packet to support clinicians following a patient's diagnosis. Materials for patient education and treatment coordination were included in the DEPRESSION SCREENING IN WOMEN 27 printed packet. The education materials paired a customized follow-up instruction sheet (see Appendix B, Appendix C) with the NIMH (2020) Depression in Women: 5 Things you Should Know brochure. A treatment follow-up handout accompanied the brochure, along with a list of options to build a mental health care team if required. The handout included information on the treatment plan: when to return for any follow up primary care appointments, how to select a mental health professional or therapist, how to access community support, how COLWC would assist with needed referrals, and how to obtain suicide crisis treatment (Stone et al., 2017). The project leader interviewed participating providers regarding their preferences for the patient handout components. This packet was available in either English or Spanish and placed in a folder at each station or in a folder in the exam room according to provider preference. Use of the packets was not exclusively limited to yearly exam patients. They were available for any patients attending any type of appointment who screened positive or were identified by the clinician as needing ongoing support for depression. Copies of the depression education packets were also available in the nurses' office. Underpinned by the patient care coordination already provided by clinic nursing staff, these education and support materials ensured compliance with the USPSTF recommendation that screening take place in the context of appropriate treatment and follow up (Siu et al., 2016). The education packet also equipped clinicians with easy to use, evidence-based patient resources to promote sustainable change. Evaluation and Data Analysis Data Collection DEPRESSION SCREENING IN WOMEN 28 Data was collected and analyzed with descriptive statistics to evaluate the project outcomes. The DNP leader examined chart review data to determine pre- and post-implementation depression screening rates. The project tracked the PHQ-9 screening severity, treatment plan continuation or changes (including whether providers made mental health referrals), and positive responses to the PHQ-9’s question 9 about suicidality and self-harm (Appendix E). Though the education packets were not exclusively used for yearly exam patients, the project leader planned to count the total number of packets distributed by the end of the implementation period to evaluate overall materials utilization. Quantitative data was organized and analyzed with Microsoft Excel Version 16.5. The completed PHQ-9 forms were saved in a designated folder at each patient care station and collected weekly or biweekly during the data collection period. The project leader was responsible for collecting the completed PHQ-9 forms, then scanning and indexing them into the patient's chart in the electronic health record (EHR). The informal questions to stakeholders were asked during the collection of the PHQ-9 forms and at other convenient opportunities to meet with the various providers and staff members. Qualitative responses to the informal interview questions (Appendix D) were recorded using Ginger Labs note management software Notability Version 10.4. Goal achievement was determined by evaluating the number of providers who participated in the protocol and by the overall number and percentage of PHQ-9 tools completed at yearly exams during the data collection period. An executive summary (Appendix F) reviewed the data for the clinic's physician owners and administration. Post-implementation feedback from the provider, nursing, and medical assistant staff was incorporated to allow for adjustments that would support the ongoing uptake of the depression screening tool. DEPRESSION SCREENING IN WOMEN 29 Analysis The clinic-wide total of completed PHQ-9 tools and the total number of completed yearly visits were tallied for each month. These data were used to calculate the monthly percentage of patients screened for depression at the yearly exam and the mean percentage of patients screened during the implementation period. These percentages determined the attainment of the project's monthly benchmark goal of 80% screening for yearly exam patients. Data were also collected to determine the level of depression identified by the PHQ-9 for each of the tool's severity categories (Appendix E). The total number of patients with a score in each of five categories (ranging from minimal to severe) was counted and then divided by the total number of PHQ-9 screened yearly exam patients during the six-month study period. Severity data provided the overall percentage of patients who scored positive for minimal, mild, moderate, moderately severe, or severe depression. The number of patients who responded with a score greater than 0 to PHQ-9's Question 9, which evaluates for suicidal ideation, was also totaled for each of the three severity categories over the entire six-month data period. The prevalence of this data point was low, so monthly percentages were not calculated for this metric. Documentation of depression treatment was also analyzed. A stratified approach analyzed treatment plan data according to PHQ-9 depression score severity. Treatment plans were classified as either initiated, continued, or changed. Treatment initiation included discussing lifestyle changes, starting medication, recommending therapy, referring to psychiatry, or obtaining lab work. Continuation of treatment included any documentation of maintaining the status quo of medication, therapy, or ongoing care by other mental health providers. Changed treatment was defined as patients who were already receiving depression treatment and received medication change or dosage adjustment, the addition of therapy, or referral to other mental DEPRESSION SCREENING IN WOMEN 30 health team members at the time of their yearly visit. The treatment plan details were obtained from notes handwritten on the PHQ-9 forms by the provider or from chart review data in the EHR yearly visit documentation. Responses to the project’s brief verbal survey questions were not formally analyzed using qualitative techniques. However, this feedback from provider subjects, nursing, medical, and administrative staff was incorporated to allow for nimble changes during the quality improvement process and enable project longevity. In addition, because the use of the depression packets was not limited to yearly exam patients, the number of distributed education materials was not tracked. Findings Findings included comparisons between pre-implementation and post-implementation data along with qualitative verbal feedback from stakeholders. Pre-intervention data were obtained for four providers who agreed to participate in the project's pilot study. Charts were reviewed for these two MDs and two NPs for the yearly exams documented in February 2020. In one month, of the 217 yearly exams completed by these clinicians, three patients were excluded for age below the criteria (18 years). Among the remaining 214 exams, 62 visits (28.9%) contained documentation of a conversation about mood, depression, anxiety, or mental health. A PHQ-9 score was documented six times by one NP for an individual rate of 12.5% depression screening using a validated tool (n = 48 total exams). This NP was the only provider who documented a screening tool score for patients, resulting in an overall PHQ-9 tool utilization rate of 9.6% for this single clinician. Because chart notes for the patients with PHQ-9 scores also contained mental health or depression evaluation documentation, the combined rate of screening discussions and PHQ-9 tool scores across all annual exam patients (n=214) did not change. It DEPRESSION SCREENING IN WOMEN 31 was apparent that the NP who used the PHQ-9 did so as an adjunct to patient interviews that uncovered the need for further diagnostic information or additional intervention. Across all four pilot participants, the overall pre-intervention depression screening rate using a validated tool was 2.3%. Implementation period data showed significant improvement over the baseline screening rate for all months of data collection. The mean screening rate for the six-month implementation period was 23.8%. The project demonstrated the highest monthly percentage during the first month of implementation in October 2020, with 34.1% of patients screened. The lowest screening rate was in the third month, at 8.8%. No months of the implementation period met the project’s 80% screening goal (Table G1). During the study period, one of the clinic’s physicians resigned and left the practice — however, the newly hired physician who replaced them opted-in and agreed to participate. Therefore, the project maintained a 100% provider participation rate despite staff turnover. A total of 41.5% of women screened scored > 5 on the PHQ-9, indicating a severity level of at least mild depression or worse. Of the patients with a score for mild depression, 23.5% were positive (Appendix F). Seventeen percent of respondents had scores indicative of moderate to severe depression (see Table G2). In addition, of 960 patients screened over six months, 42 women answered with a score of 1, 2, or 3 to Question 9, “Thoughts that you would be better off dead, or of hurting yourself” (Appendix F). Thus, over one-third of patients at well-woman visits screened positive for depression, with a 4.4% suicidal ideation rate among those same annual exam patients (Table G2 and G4). Twenty-three percent of screened patients received a recommendation to initiate, continue, or change depression treatment at their yearly exam. A majority with a mild depression DEPRESSION SCREENING IN WOMEN 32 score received no intervention, lifestyle recommendations, or lab work. The remainder continued or changed an ongoing depression treatment plan (19%), and 10% of those with a mild depression score received newly initiated treatment. Not surprisingly, those with moderate depression scores received some form of depression treatment greater than two-thirds of the time. Women with a moderately severe or severe depression score received treatment at a rate of 85%. It is important to note that 31% of women with moderately severe depression and 50% of those with severe depression were not already diagnosed, and they received a new recommendation during their annual exam appointment (Table G3). A prominent theme elicited from informal verbal survey questions identified the barriers of some providers and their medical assistants feeling like there was not enough time to address or complete the PHQ-9. This led to concerns about workflow timing for the PHQ-9 administration. Other themes included the need to screen for depression to follow best practices, clinicians feeling a dislike for or lack of confidence in treating depression, or disagreement on the level of importance for depression treatment. Another significant concern included balancing the depression screening project with other time-sensitive Covid-19 pandemic-related demands to the clinic’s operations. Feedback from clinicians was positive toward the helpfulness of the education packet. Though they were asked for suggestions about recommended changes to the packet, the consensus was that no updates were needed. The project leader attempted to calculate the overall number of packets distributed during the implementation period, but accurate assessment was difficult because three of the packet folders went missing during the six-month observation period. Verbal feedback from the four providers who used the PHQ-9 most often indicated they remembered to use the handouts “sometimes” or “occasionally.” Discussion, Recommendations, and Conclusions DEPRESSION SCREENING IN WOMEN 33 Discussion Population outcomes. Using the overall 23% treatment rate as a proxy for a depression diagnosis shows that COLWC’s population has a similar depression rate to Utah's adult state average (UDH, 2018). The treatment rates identified during this project’s data analysis underscore the importance of screening. Screening is essential in the context of women in the moderately severe to severe categories who received new treatment at such high rates (31% and 50%, respectively). These patients may represent persons whose clinician might not otherwise have identified their depression. Although 100% of clinicians opted into the project, significant differences emerged between practitioners. When comparing the rate of monthly screening that resulted in a quarter of patients completing the PHQ-9, only 25% of provider-medical assistant dyads were consistent with the screening efforts. The remaining dyads found that time-related workflow barriers stood in the way of regular PHQ-9 completion or were not committed to screening despite opting in. All clinicians were willing to review the patient's completed PHQ-9 if it was finished before the provider entered the exam room. However, if that did not happen in time, they did not remember that it had been forgotten or were unwilling to interrupt the visit and wait for the patient to fill out the screening tool. Therefore, it was apparent to the project leader that the commitment to and buy-in of the medical assistants was of significantly greater importance than considered initially. If the medical assistant did not offer the tool when the patient was roomed, the provider rarely came back out to reinforce their desire to have it completed. Paradoxically, some providers who were generally more efficient or always running on time had a lower PHQ-9 completion rate. Even if the patient received the tool, she did not have enough time to fill it out before the DEPRESSION SCREENING IN WOMEN 34 provider entered the room to begin the visit. In fact, on some busy days, there were a few providers who would explicitly advise their assistants not to administer the PHQ-9 that day because of the anticipated slowdown. The preparation of a depression handout packet seemed to promote openness to change during the initial project proposal to the clinic providers. Providers who were more likely to use the PHQ-9 were also most likely to use the packets. However, the availability of the education and follow-up materials did not appear to affect the likelihood of PHQ-9 use among all providers. However, this is difficult to corroborate because a post-implementation packet tally was unavailable due to loss of some folders from the patient care stations. Setting and organization outcomes. With an average screening rate of 23%, this project fell far short of its initial 80% depression screening goal. Multiple factors contributed to this result. Significantly, the clinic experienced a catastrophic server crash setback that resulted in a two-week data loss of all calendared appointments, chart notes, and records and test results from the EHR. All clinic staff members were involved in data retrieval and chart re-documentation, which overwhelmed employees and halted the early momentum of the project. It proved challenging to reignite enthusiasm for the depression screening project following the stress of that unforeseen incident. December 2020 was the third month of implementation and showed a nearly threefold reduction in the screening rate. Deviations explained this marked drop at the busiest patient care station, which houses six of the twelve clinicians. The medical assistants at that station reported training a new hire and adding some extra workflow tasks during that month. Due to these factors, the screenings were forgotten and omitted for most of December. Additionally, support from the administration for a semi-permanent clinic-wide adoption of the depression screening DEPRESSION SCREENING IN WOMEN 35 was difficult to achieve because of the significant strain of the Covid-19 pandemic on time and resources for the entire clinic operation and the individual providers. Though 80% compliance with depression screening did not occur, this project moved the clinic from a functional depression tool screening rate of zero to a monthly average of 23%. If the identified barriers are successfully addressed in the second phase of implementation, the DNP project leader anticipates ongoing gains and eventual compliance with the ACOG depression screening recommendation. Recognized changes to practice. This quality improvement project enhanced healthcare by promoting evidence-based practice and ongoing advocacy for improving patient mental health. By the end of the implementation period, one-third of providers used the PHQ-9 during most yearly exams. This represents a significant increase, as just one of twelve was using a screening tool before the project. The front desk staff has also assumed partial responsibility for indexing the PHQ-9 forms into the EHR chart, which will promote longevity once the project leader is no longer actively involved in the process. In addition, after the Phase 1 implementation, conversations between all clinic providers and the clinic manager resulted in a decision to move the PHQ-9 screening away from the patient care area and into the pre-registration waiting room. This recommendation intended to prevent delays in the exam rooms. If the time-related barriers to PHQ-9 completion are moved earlier in the workflow, the hope is that screening rates will increase compared to the first phase of project implementation. Recommendations The outcomes from this project underpin the need for organization-wide support to enable the completion of depression screening at yearly exams. Time is a significant barrier to screening completion and incorporating screening into a system-wide process is needed to DEPRESSION SCREENING IN WOMEN 36 surmount this barrier for the individual clinician. As seen during this project, the willingness of physicians, nurse practitioners, and certified nurse midwives to screen for depression at yearly exams was not enough to solidify it into the workflow process. Future recommendations that would benefit this organization would be incorporating the PHQ-2 or PHQ-9 into the Yearly Exam Registration packet and concomitant addition of the responses to those depression screening questions into the yearly exam EHR template. If the PHQ-2 is chosen, the PHQ-9 could be given only to those who screen positive (Jha et al., 2019). This was proposed in the early phases of the project, but clinic leadership was reluctant to make any changes to its documents or EHR that were not certain to be permanently desired by the providers. Moreover, future projects would benefit from concerted efforts to gain support from all staff members, not just clinicians. The physician or nurse practitioner is the natural choice to lead out in evidence-based practice, but the provider’s time management and workflow can be influenced by the activities and attitudes of their support staff. Such changes would surmount the barriers seen by both providers and their medical assistants concerning time management and remembering to use the screening tool. This recommendation was included in an executive summary proposal for Phase 2, presented at the end of the six-month implementation phase (Appendix F). Findings from this project could be generalized beyond the gynecological setting into other specialties or primary care offices. Conclusions Depression is a significant problem among women in the United States. With even slightly higher than national average rates in northern Utah, proper identification and treatment are vital for our local population. The social and economic impacts of COVID-19 on mental health are still unfolding. Emerging evidence on mental health and the COVID-19 pandemic DEPRESSION SCREENING IN WOMEN 37 substantiate its additive effects on depression's impact on society and an increased need for vigilance in suicide prevention (Czeisler et al., 2020; McIntyre & Lee, 2020). Several factors, including stigma, cultural complexity, chronic disease, and somatic symptoms, may muddy the waters of depression identification and diagnosis. Existing literature and practice guidelines support annual screening for adults in the presence of an adequate support system to ensure appropriate treatment. A validated screening tool should be adopted for use at yearly gynecological exams, as long as feasible implementation occurs in the context of staff training and sustainability at the site, with mental health referral and appropriate follow-up for patients. In line with the USPSTF recommendations, ACOG recommends annual depression screening at well-woman exams. Such screening was either being inadequately implemented or inconsistently documented at COLWC. The adoption of the PHQ-9 improved compliance with ACOG recommendations, enhanced COLWC providers' depression identification and ongoing treatment for their patients and has the potential to improve the mental health of women affected by the condition. The DNP leader enabled this project during every step of its lifecycle, including planning, implementation, and evaluation. The leader facilitated communication between team members, organized project details for implementation, identified and addressed barriers, adapted the project to the organization’s needs, and completed data analysis and evaluation for the clinic leadership. This project’s results contribute to advanced nursing practice by demonstrating the need for organizational support and identifying time-related barriers to screening for mental health during well visits in primary care and gynecological settings. Running head: DEPRESSION SCREENING IN WOMEN 38 References Allen, G. E. K., & Wang, K. T. (2014). Examining religious commitment, perfectionism, scrupulosity, and well-being among LDS individuals. Psychology of Religion and Spirituality, 6(3), 257-264. doi:http://dx.doi.org.hal.weber.edu:2200/10.1037/a0035197 American College of Obstetricians and Gynecologists. (2015). ACOG committee opinion: Screening for perinatal depression. Obstetrics & Gynecology, 132(5), e208-e212. Retrieved from https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/11/screening-for-perinatal-depression American College of Obstetricians and Gynecologists. (2016a). ACOG Statement on Depression Screening. [Press release]. https://m.acog.org/About-ACOG/News-Room/Statements/2016/ACOG-Statement-on-Depression-Screening American College of Obstetricians and Gynecologists. (2016b). Women’s Preventive Services Initiative. Recommendations for preventive services for women: Final report to the U.S. Department of Health and Human Services, Health Resources & Services Administration. [pdf]. Retrieved from https://www.womenspreventivehealth.org/recommendations/final-report/ American Psychiatric Association. (2019). Clinical practice guideline for the treatment of depression across three age cohorts. [pdf]. Retrieved from https://www.apa.org/depression-guideline/guideline.pdf Berghöfer, A., Roll, S., Bauer, M., Willich, S. N., & Pfennig, A. (2014). Screening for depression and high utilization of health care resources among patients in primary care. Community Mental Health Journal, 50(7), 753–758. https://doi-org.hal.weber.edu/10.1007/s10597-014-9700-4 DEPRESSION SCREENING IN WOMEN 39 Brody, D. J., Pratt, L. A., & Hughes, J. (2018). Prevalence of depression among adults aged 20 and over: United States, 2013–2016. NCHS Data Brief, 303, 1-8. Hyattsville, MD: National Center for Health Statistics. Chin, W., Wan, E. Y. F., Dowrick, C., Arroll, B., & Lam, C. L. K. (2018). Tree analysis modeling of the associations between PHQ-9 depressive symptoms and doctor diagnosis of depression in primary care. Psychological Medicine, 49, 449-457. https://doi.org/10.1017/S0033291718001058 Circle of Life Women’s Center. (2020, February 4). Patient gynecology packet. [pdf]. Retrieved from http://colwc.com/documents/Gynecology%20Packet.pdf Colligan, E. M., Cross-Barnet, C., Lloyd, J. T., & McNeely, J. (2020). Barriers and facilitators to depression screening in older adults: A qualitative study. Aging & Mental Health, 24(2), 341–348. https://doi-org.hal.weber.edu/10.1080/13607863.2018.1531376 Czeisler, M. É., Lane, R. I., Petrosky, E., Wiley, J. F., Christensen, A., Njai, R., . . . Rajaratnam, S. M. W. (2020). Mental health, substance use, and suicidal ideation during the COVID-19 pandemic — United States, June 24–30, 2020. Morbidity and Mortality Weekly Report (MMWR), 69(32), 1049–1057. doi: http://dx.doi.org/10.15585/mmwr.mm6932a1external icon DeNisco, S. (2021). Advanced practice nursing: Essential knowledge for the profession. (4th ed.). Jones & Bartlett Learning: Burlington, MA. Finkelman, A. (2018) Quality improvement: A guide for integration in nursing. Jones & Bartlett Learning; Burlington, MA. Folb, N., Lund, C., Fairall, L. R., Timmerman, V., Levitt, N. S., Steyn, K., . . . Bachmann, M. O. (2015). Socioeconomic predictors and consequences of depression among primary care DEPRESSION SCREENING IN WOMEN 40 attenders with non-communicable diseases in the Western Cape, South Africa: Cohort study within a randomised trial. BMC Public Health, 15(1194), 1-12. doi:10.1186/s12889-015-2509-4 Fujieda, M., Uchida, K., Ikebe, S., Kimura, A., Kimura, M., Watanabe, T., . . . Uchimura, N. (2017). Inquiring about insomnia may facilitate diagnosis of depression in the primary care setting. Psychiatry and Clinical Neurosciences, 71(6), 383–394. https://doi-org.hal.weber.edu/10.1111/pcn.12507 Garg, A., Toy, S., Yoghos, T., Cook, J., & Cordella, N. (2016). Ameliorating maternal depression and its harmful consequences for low-income families: Primary care to the rescue? Academic Pediatrics, 16(8), 714-715. doi: 10.1016/j.acap.2016.08.003 Greenberg, P. E., Fournier, A., Sisitsky, T., Pike, C. T., & Kessler, R. C. (2015). The economic burden of adults with major depressive disorder in the United States (2005 and 2010). The Journal of Clinical Psychiatry, 76(2), 155. doi:10.4088/JCP.14m09298 Guajardo, V. D., Souza, B. P. F., Henriques, S. G., Lucia, M. C. S., Menezes, P. R., Martins, M. A., . . . Fráguas, R. (2011). Loss of interest, depressed mood and impact on the quality of life: Cross-sectional survey. BMC Public Health, 11(826), 1-7. doi:10.1186/1471-2458-11-826 Jarjoura, D., Polen, A., Baum, E., Kropp, D., Hetrick, S., & Rutecki, G. (2004). Effectiveness of screening and treatment for depression in ambulatory indigent patients. Journal of General Internal Medicine, 19(1), 78–84. https://doi.org/10.1111/j.1525-1497.2004.21249.x Jha, M. K, Grannemann, B. D., Trombello, J. M., Clark, E. W., Eidelman, S. L., Lawson, T. . . . & Trivedi, M. H. (2019). A structured approach to detecting and treating depression in DEPRESSION SCREENING IN WOMEN 41 primary care: VitalSign6 project. Annals of Family Medicine, 17(4), 326-335. https://doi.org/10.1370/afm.2418 Jiao, B., Rosen, Z., Bellanger, M., Belkin, G., & Muennig, P. (2017). The cost-effectiveness of PHQ screening and collaborative care for depression in New York City. PloS One, 12(8), e0184210. https://doi-org.hal.weber.edu/10.1371/journal.pone.0184210 Keller, A. O., Valdez, C. R., Schwei, R. J., & Jacobs, E. A. (2016). Disclosure of depression in primary care: A qualitative study of women’s perceptions. Women’s Health Issues, 26(5), 529–536. https://doi-org.hal.weber.edu/10.1016/j.whi.2016.07.002 Kroenke, K., Spitzer, R. L., & Williams, J. B. (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 Leff, M. S., Vrubļevska, J., Lūse, A., & Rancāns, E. (2017). Latvian family physicians’ experience diagnosing depression in somatically presenting depression patients: A qualitative study. The European Journal of General Practice, 23(1), 91–97. https://doi-org.hal.weber.edu/10.1080/13814788.2017.1291626 Loeb, D., Sieja, A., Corral, J., Zehnder, N. G., Guiton, G., & Nease, D. E. (2015). Evaluation of the role of training in the implementation of a depression screening and treatment protocol in 2 academic outpatient internal medicine clinics utilizing the electronic medical record. American Journal of Medical Quality: The Official Journal of the American College of Medical Quality, 30(4), 359–366. https://doi.org/10.1177/1062860614532681 DEPRESSION SCREENING IN WOMEN 42 Lopez, V., Sanchez, K., Killian, M. O., & Eghaneyan, B. H. (2018). Depression screening and education: An examination of mental health literacy and stigma in a sample of Hispanic women. BMC Public Health, 18(1), 1-8. https://doi.org/10.1186/s12889-018-5516-4 McIntyre, R. S., & Lee, Y. (2020). Preventing suicide in the context of the COVID-19 pandemic. World Psychiatry, 19(2), 250-251. doi: 10.1002/wps.20767 Nabbe, P., Le Reste, J. Y., Guillou-Landreat, M., Munoz Perez, M. A., Argyriadou, S., Claveria, A., . . . Van Royen, P. (2017). Which DSM validated tools for diagnosing depression are usable in primary care research? A systematic literature review. European Psychiatry, 39, 99-105. http://dx.doi.org/10.1016/j.eurpsy.2016.08.004 National Institute of Mental Health. (2019). Major depression. Retrieved from https://www.nimh.nih.gov/health/statistics/major-depression.shtml National Institute of Mental Health. (2020). Depression in women: 5 things you should know. [pdf]. Retrieved from https://www.nimh.nih.gov/health/publications/depression-in-women/index.shtml Ng, C. W., How, C. H., & Ng, Y. P. (2016). Major depression in primary care: Making the diagnosis. Singapore Medical Journal, 57(11), 591–597. https://doi.org/10.11622/smedj.2016174 O’Connor, E. A., Whitlock, E. P., Beil, T. L., & Gaynes, B. N. (2009). Screening for depression in adult patients in primary care settings: A systematic evidence review. Annals of Internal Medicine, 151(11), 793–803. https://doi-org.hal.weber.edu/10.1059/0003-4819-151-11-200912010-00007 DEPRESSION SCREENING IN WOMEN 43 Olfson, M., Blanco, C., Wall, M., Liu, S. M., Saha, T. D., Pickering, R. P., & Grant, B. F. (2017). National trends in suicide attempts among adults in the United States. JAMA Psychiatry, 74(11), 1095–1103. doi:10.1001/jamapsychiatry.2017.2582 Randle, A. C., Spurlock, A. L., & Kelley, S. (2019). Depression screening among African American adults in the primary care setting. Journal of Psychosocial Nursing and Mental Health Services, 57(10), 18–23. https://doi-org.hal.weber.edu/10.3928/02793695-20190610-0 Reavy, K. (2016). Inquiry and leadership: A resource for the DNP project. F.A. Davis: Philadelphia: PA. Rost, K., Smith, J. L., & Dickinson, M. (2004). The effect of improving primary care depression management on employee absenteeism and productivity: A randomized controlled trial. Medical Care, 42(12), 1202-1210. https://doi.org/10.1097/00005650-200412000-00007 Samples, H., Stuart, E. A., Saloner, B., Barry, C. L., & Mojtabai, R. (2020). The role of screening in depression diagnosis and treatment in a representative sample of U.S. primary care visits. Journal of General Internal Medicine, 35(1), 12–20. https://doi-org.hal.weber.edu/10.1007/s11606-019-05192-3 Shirey, M. R. (2013). Lewin’s theory of planned change as a strategic resource. JONA: The Journal of Nursing Administration, 43(2), 69–72. doi: 10.1097/NNA.0b013e31827f20a9 Siu, A. L., Bibbins-Domingo, K., Grossman, D. C., Baumann, L. C., Davidson, K. W., Ebell, M., . . . Pignone, M. P. (2016). Screening for depression in adults: U.S. Preventive Services Task Force recommendation statement. JAMA, 315(4), 380–387. doi:10.1001/jama.2015.18392 DEPRESSION SCREENING IN WOMEN 44 Stone, D., Holland, K., Bartholomew, B., Crosby, A., Davis, S., & Wilkins, N. (2017). Preventing suicide: A technical package of policy, programs, and practices. [pdf]. Retrieved from https://www.cdc.gov/violenceprevention/pdf/suicideTechnicalPackage.pdf Stromberg, R., Wernering, E., Aberg-Wistedt, A., Furhoff, A. K., Johansson, S. E., & Backlund, L. G. (2008). Screening and diagnosing depression in women visiting GPs’ drop in clinic in primary health care. BMC Family Practice, 9(34), 1-10. https://doi-org.hal.weber.edu/10.1186/1471-2296-9-34 Thompson, H., Faig, W., Gupta, N., Lahey, R., Golden, R., Pollack, & Karnik, N. (2019). Collaborative care for depression of adults and adolescents: Measuring the effectiveness of screening and treatment uptake. Psychiatric Services, 70(7), 604-607. doi: 10.1176/appi.ps.201800257 Tusa, N., Koponen, H., Kautiainen, H., Korniloff, K., Raatikainen, I., Elfving, P., . . . Mäntyselkä, P. (2019). The profiles of health care utilization among a non-depressed population and patients with depressive symptoms with and without clinical depression. Scandinavian Journal of Primary Health Care, 37(3), 312–318. https://doi-org.hal.weber.edu/10.1080/02813432.2019.1639904 United States Health and Human Services. (2020). Leading health indicators: Access to health services. Retrieved from https://www.healthypeople.gov/2020/leading-health-indicators/2020-lhi-topics/Access-to-Health-Services/data#primary-care Utah Department of Health. (2018). Complete health indicator report of depression: Adult prevalence. [pdf]. Retrieved from ibis.health.utah.gov DEPRESSION SCREENING IN WOMEN 45 van Eck van der Sluijs, J., ten Have, M., Rijnders, C., van Marwijk, H., de Graaf, R., & van der Feltz-Cornelis, C. (2015). Medically unexplained and explained physical symptoms in the general population: Association with prevalent and incident mental disorders. PLoS ONE, 10(4). Retrieved from https://link-gale-com.hal.weber.edu/apps/doc/A429374410/OVIC?u=ogde72764&sid=OVIC&xid=21daa1c4 Wiegner, L., Hange, D., Bjorkelund, C., & Ahlborg, G. (2015). Prevalence of perceived stress and associations to symptoms of exhaustion, depression and anxiety in a working age population seeking primary care - An observational study. BMC Family Practice, 16(38), 1-8. doi: 10.1186/s12875-015-0252-7 Woo, T. M., & Robinson, M. V. (2020). Pharmacotherapeutics for advanced practice nurse prescribers. (5th ed.). F. A. Davis: Philadelphia, PA. World Health Organization. (n.d.). Gender disparities in mental health. [pdf]. Retrieved from https:--www.who.int-mental_health-media-en-242.pdf?ua=1 Running head: DEPRESSION SCREENING IN WOMEN 46 Yearly Exam Depression Screening Project - Staff Instruction Sheet • Give PHQ-9 screening form (with clipboard and pen) to every Yearly Exam patient when entering exam room. Please put a patient ID sticker on the bottom of the form. o PHQ-9 Spanish Form is available if patient prefers (back of folder) • Politely ask patient to fill out the form while she waits • If the patient declines to complete the screening tool: o Write “Patient Declined” on the form. o Still place it in the “Completed” folder. • Provider will score the form and discuss with patient. • Please return completed forms to Blue “Completed PHQ-9” Folder at each station. o I will collect them weekly and scan them into the patient’s chart. • If the patient screens positive: o Patient Education packets are available for the providers in each exam room in a colored folder marked “Depression Packets” o The first page of the packet has instructions for the provider to complete about how the patient should follow up. o If you run out of PHQ-9 screening or Depression Education forms, there are extra copies in the Nurses office at the 5th desk. o I am tracking how many Education packets we give out. If you make your own copies, please put a sticky note on the front of the folder that says how many you added. ☺ • If you have any questions, talk with your provider or Brenda in the Nurses office. o My usual workdays are Mon/Thurs but if you need anything you can Email me at brenda@toonetown.com or Text to 801-698-0806. Thank you for working together as a team to improve our patients’ mental health!!! 1525 E. 6000 S. Suite A South Ogden, UT 84405 Phone: 801-337-5800 www.colwc.com “This helps us get more information about how you are doing with your mental health and how we can help you during your visit today.” “It is routine standard of care to have a mental health screening every year.” Appendix A Running head: DEPRESSION SCREENING IN WOMEN 47 Please schedule a follow up appointment in __________ (weeks / months) Yes / No Schedule follow up at Circle of Life before leaving? My next appointment is with: ______________________ on ___________ at _______ My treatment plan: ________ Begin prescribed medication ________ Counselor or Therapist ________ Support group ________ Psychologist or Psychiatrist Call the Circle of Life Nurses at (801) 337-5800 Option 1 if you have questions • About your referral to a mental health provider, treatment plan, or medication Treatment works best when you have a good relationship with your mental health provider. Find a psychologist, psychiatrist, counselor, or therapist Building a mental health team can be a process that requires patience! You may need to meet with more than one provider before finding the right one. • First, find 5 names from your insurance plan’s list of contracted providers • Then review provider bios at one of these sites to make your choice: o https://psidirectory.com -or- https://psychologytoday.com • For Utah Medicaid/Medicare plans: ▪ Weber Human Services https://www.weberhs.net • 237 26th Street, Ogden, UT • Ph: (801) 625-3700 (daytime only) ▪ Davis Behavioral Health https://www.dbhutah.org • 4 Davis County locations • Ph: 801-773-7060 (daytime only) If you aren’t comfortable or are feeling like the treatment is not helping, talk with your provider, or consider finding a different provider or another type of treatment. Do not stop current treatment without talking to your doctor or nurse practitioner. 1525 E. 6000 S. Suite A South Ogden, UT 84405 Phone: 801-337-5800 www.colwc.com Appendix B DEPRESSION SCREENING IN WOMEN 48 Deciding if a Provider is Right for You Once you find a potential provider it can be helpful to prepare a list of questions to help decide if they are a good fit for you. Examples of questions you might want to ask a potential provider: • What experience do you have treating someone with my issue? • How do you usually treat someone with my issue? • How long do you expect treatment to last? • Do you accept my insurance? • What are your fees? Other Helpful Tips for talking with your healthcare provider: • Taking Control of Your Mental Health: Tips for Talking with Your Health Care Provider o https://www.nimh.nih.gov/health/publications/tips-for-talking-with-your-health-care-provider/index.shtml Mental Health Support Groups • Find a local group at PsychologyToday.com o Many insurances accepted • NAMIut.org Online Support Group services (Free) o https://namiut.org/our-programs o Connection Support Group o Peer-to-Peer (8-week program, one on one) Local Crisis Resources • Behavioral Health Access Center - at McKay-Dee Hospital o Ph: 801-387-5543 o Open 24 hours o Patient walk-in entrance located next to the Emergency Department on the southwest side of McKay-Dee Hospital 4401 Harrison Blvd, Ogden, UT o Insurance is not required, all plans accepted • Weber Human Services (Medicaid) o Accepts walk-ins Mon-Fri 8:00 am – 5:00 pm at 237 26th Street, Ogden o Ph: (801) 625-3700 (daytime only) • ORMC Behavioral Services o Ph: 801-479-2250 Intake Line o call Intake Line first or go to ORMC ER • SafeUT Crisis Chat App: in App Store or Google Play o Learn more at https://healthcare.utah.edu/uni/safe-ut/ • Utah’s Crisis Hotline: 24-hour Emergency Services o For immediate mental health help, (800) 273-8255. o A licensed professional will listen, send emergency help if needed, and give referrals for follow-up services. DEPRESSION SCREENING IN WOMEN 49 Programe una cita de seguimiento en __________ (semanas / meses) Si / No ¿Programar seguimiento en Circle of Life antes de partir? Mi próxima cita es con: ______________________ el ___________ a las _______ Mi plan de tratamiento: ________ Comenzar con la medicación recetada ________ Consejero o Terapeuta ________ Grupo de apoyo ________ Psicólogo o Psiquiatra Llame a las enfermeras de Circle of Life al (801) 337-5800 Opción 1 si tiene preguntas • Sobre su derivación a un proveedor de salud mental, plan de tratamiento o medicación El tratamiento funciona mejor cuando tiene una buena relación con su proveedor de salud mental. Encuentra un Psicólogo, Psiquiatra, Consejero o Terapeuta ¡Formar un equipo de salud mental puede ser un proceso que requiere paciencia! Es posible que deba reunirse con más de un proveedor antes de encontrar el adecuado. • Primero, busque 5 nombres de la lista de proveedores contratados de su plan de seguro • Luego, revise las biografías de los proveedores en uno de estos sitios para hacer su elección: o https://psidirectory.com -o- https://psychologytoday.com • Para planes de Utah Medicaid / Medicare: ▪ Weber Human Services https://www.weberhs.net • 237 26th Street, Ogden, UT • Tel: (801) 625-3700 (solo durante el día) ▪ Davis Behavioral Health https://www.dbhutah.org • 4 ubicaciones en Davis County • Tel: 801-773-7060 (solo durante el día) Si no se siente cómodo o siente que el tratamiento no está ayudando, hable con su proveedor o considere buscar un proveedor diferente u otro tipo de tratamiento. No interrumpa el tratamiento actual sin hablar con su médico o enfermera especializada. 1525 E. 6000 S. Suite A South Ogden, UT 84405 Phone: 801-337-5800 www.colwc.com Appendix C DEPRESSION SCREENING IN WOMEN 50 Decidir si un Proveedor es Adecuado para Usted Una vez que encuentre un proveedor potencial, puede ser útil preparar una lista de preguntas para ayudar a decidir si son adecuados para usted. Ejemplos de preguntas que podría querer hacerle a un proveedor potencial: • ¿Qué experiencia tiene tratando a alguien con mi problema? • ¿Cómo suele tratar a alguien con mi problema? • ¿Cuánto tiempo espera que dure el tratamiento? • ¿Acepta mi seguro? • ¿Cuáles son sus tarifas? Otros consejos útiles para hablar con su proveedor de atención médica: • Tome control de su salud mental: Consejos para hablar con su proveedor de atención médica o https://www.nimh.nih.gov/health/publications/espanol/consejos-para-hablar-con-su-proveedor/index.shtml Grupos de apoyo de salud mental • Encuentre un grupo local en PsychologyToday.com o Se aceptan muchos seguros • NAMIut.org Servicios de Grupo de Soporte en línea (Fratis) o https://namiut.org/our-programs/ o Grupo de Soporte de Conexión o Peer-to-Peer (programa de 8 semanas, uno a uno) Recursos de Crisis Locales • Behavioral Health Access Center - en McKay-Dee Hospital o Tel: 801-387-5543 o Abierto las 24 horas o Entrada sin cita para pacientes ubicada junto al Departamento de Emergencias en el lado suroeste del Hospital McKay-Dee 4401 Harrison Blvd, Ogden, UT o No se requiere seguro, se aceptan todos los planes • Weber Human Services (Medicaid) o Acepta visitas sin cita de lunes a viernes de 8:00 am a 5:00 pm en 237 26th Street, Ogden o Tel: (801) 625-3700 (solo durante el día) • ORMC Behavioral Services o Tel: 801-479-2250 Línea de admisión o Llame a la línea de admisión primero o vaya a ORMC ER • SafeUT Aplicación Crisis Chat: en App Store o Google Play o Para aprender más en https://healthcare.utah.edu/uni/safe-ut/ • Línea directa de crisis de Utah: Servicios de emergencia las 24 horas o Para ayuda de salud mental inmediata, (800) 273-8255. Un profesional con licencia escuchará, enviará ayuda de emergencia si es necesario y dará referencias para servicios de seguimiento. DEPRESSION SCREENING IN WOMEN 51 Appendix D Depression Screening Project Brief Verbal Survey Questions 1. How is it going with the depression screening project? 2. Do you have any concerns? 3. What barriers are keeping you from getting the PHQ-9 filled out with each yearly patient? 4. What suggestions do you have that would be better for your workflow and enable each YC patient to complete the PHQ-9? 5. What suggestions do you have to improve or adjust the patient education packet? DEPRESSION SCREENING IN WOMEN 52 Appendix E DEPRESSION SCREENING IN WOMEN 53 DEPRESSION SCREENING IN WOMEN 54 Appendix F Executive Summary: Depression Identification in the Ambulatory Gynecological Setting Women over the age of 18 should be screened annually for depression in the primary care setting. • Gynecology as a familiar primary care resource: a touchpoint for mental health outreach • Annual depression screening is mandated by the American College of Obstetricians and Gynecologists ([ACOG], 2016) o Patient Health Questionnaire-9 (PHQ-9) screening tool meets ACOG’s mental health screening recommendations. Background Information Population: • Worldwide, women are at greater risk for depression than men. • The World Health Organization (n.d.) calls current efforts to address depression for women ‘unacceptable.’ • National population prevalence is 19%. Utah depression rate exceeds the national average by 3%. • Adult depression prevalence in Weber-Morgan and Davis Health districts is 23.2% (UDH, 2018). Setting: Circle of Life Women’s Center (COLWC) • The February 2019 depression screening rate with a validated screening tool was 2.8% among four pilot group providers. o Current depression screening is either inconsistently done or inadequately documented: a mental health conversation occurred in 28.9% of chart reviews for the same pilot group. o These rates would be lower if clinic-wide 2019 data had been examined for all twelve providers. Purpose of Project • Bring COLWC in line with ACOG standards for yearly exams: o adopt the PHQ-9 tool and a customized Depression Packet resource o integrate the PHQ-9 to make screening quicker and easier: shorten the conversation when it occurs o assist clinicians in earlier, more effective depression identification and support o standardized screening to benefit patients’ overall mental health, add a personal touch, and show patients we care about the whole person • Benefit: some insurances reimburse for Depression Screening Tool use ($4-8 per PHQ-9) Project Methodology Plan and Implementation. • Phase 1 SMART Goal: o By the end of a Phase 1 trial period, the PHQ-9 will be completed by more than 80% of yearly well woman exam patients. ▪ Five-minute completion while waiting in the exam room, scored during the visit, and addressed according to provider judgment ▪ Depression Packet resource: depression education with follow-up instructions ▪ Packet includes individualized treatment plan details, directions for finding a mental health team (such as psychiatrist or therapist), and crisis resources. • Phase 2 SMART Goal: o The long-term goal is 100% completion to meet ACOG standards o Add PHQ-9 to yearly patient packet to prevent workflow slowing in exam area DEPRESSION SCREENING IN WOMEN 55 o EMR update to facilitate documentation during registration, and provider ease and time-savings: add a PHQ-9 section and ‘Education materials provided’ checkbox. Short-term interventions Oct. 2020: Pilot test - 4 providers, 1 month Nov. 2020-Spring 2021: Phase 1: 3-6 months - 12 providers Spring 2021: Stakeholder feedback for packet Long-term interventions Spring 2021: Incorporate packet feedback, add Spanish translation to packet Summer 2021: Add PHQ-9 to Registration and Yearly exam paperwork Summer 2021: Add PHQ-9 and Depression packet fields to EMR Evaluation. • Phase 1 analysis: o percentage of clinic providers who opted-in to the project Phase 1 o pre-implementation / post-implementation screening rate comparison o percentage of PHQ-9 scores positive for mild, moderate, or severe depression o percentage of PHQ-9 screens positive for suicidal or self-harm ideation o percentage of positive PHQ-9 screened in which treatment was documented o number of Depression Packets distributed (resources provided) Recommendations and Dissemination of Findings • COLWC should standardize the use of the PHQ-9 screening tool for annual well woman exam patients to promote quality, patient-centered care that meets ACOG (2016) standards. Phase 1 Evaluation data will be shared at the clinic’s upcoming provider meeting along with recommendations for further process integration in Phase 2. Evidence Highlights Gender, depression, and suicide: • 29% of Utah women have been diagnosed with depression (UDH, 2018). • women have higher risks for discrimination, interpersonal violence, and lower educational opportunities, which lead to a greater prevalence of depression (WHO, n.d.). • Depression prevalence has quadrupled, and suicidal ideation has doubled during the Covid-19 pandemic (Czeisler et al., 2020), and women are 50% more likely to attempt suicide than men (Olfson et al., 2017). Social determinants of health and economic consequences: • Depression worsens relationships and lowers quality of life, lower incomes and job productivity, higher unemployment, primary reason for disability in the U.S. (Greenberg et al., 2015, Guajardo et al., 2011, Tusa et al., 2019; Woo & Robinson, 2020) • Depression is both the cause and the result of economic disadvantage, which impede depression diagnosis and treatment, and lowers treatment adherence (Folb et al., 2015; Thompson et al., 2019). • Racial minorities: increased prevalence of depression, stigma presents barriers to treatment-seeking (Lopez, Sanchez, Killian, & Eghaneyan, 2018; Randle, Spurlock, & Kelley, 2019). Physical effects: • physical symptoms mimic physical illness, time wasted on ruling out possible causes (Samples, Stuart, Saloner, Barry, & Mojtabai, 2020). • noncompliance in chronic disease treatment, associated with poor weight control, lack of exercise, and substance use (Tusa et al., 2019). Primary care considerations: • Depression is more likely to be identified in the primary care setting. • Clinicians recognize depression earlier when they know the patient's psychosocial context (Lopez et al., 2018). DEPRESSION SCREENING IN WOMEN 56 Appendix G Table 1 Monthly PHQ-9 Screening at Yearly Exams 1-month period PHQ-9 completed Total YC visits in month % YC patients screened February 2020 a N/A N/A 2.8% October 2020 241 706 34.1% November 2020 159 571 27.8% December 2020 b 60 675 8.8% January 2021 179 710 25.2% February 2021 143 637 22.4% March 2021 182 747 24.4% a February 2020 is used as a baseline and accounts for chart reviews for only four of the clinic’s twelve providers. b Deviation from trend: Station 5 comprised 53% of yearly exams during December. The medical assistants reported training a new employee and adding new workflow tasks during this period, so the screenings were forgotten and not done for most of this month. Table 2 Depression Severity at Yearly Exams (Oct 2020-Mar 2021) PHQ-9 score Number screened Percent of total screened Minimal (0-4) 571 59.5% Mild (5-9) 226 23.5% Moderate (10-14) 97 10.1% Moderately Severe (15-19) 49 5.1% Severe (20-27) 18 1.8% Total patients screened 960 100.0% Table 3 Depression Treatment at Yearly Exams (Oct 2020-Mar 2021) Score severity Total scored Treatment Plan Initiated Continued Changed Total Minimal (0-4) 571 2 8 0 10 (2%) Mild (5-9) 226 24 48 18 90 (39%) Moderate (10-14) 97 23 28 13 64 (66%) Moderately Severe (15-19) 49 12 16 11 39 (80%) Severe (20-27) 18 8 4 4 16 (89%) Total patients 960 69 104 46 219 (23%) Note: Actual treatment rate may be higher in all categories due to data lost in the October 2020 server crash. DEPRESSION SCREENING IN WOMEN 57 Table 4 Positive responses to Question 9: Thoughts that you would be better off dead, or of hurting yourself (Oct 2020-Mar 2021) Score severity Patients screened positive 1. Several days 28 2. More than half the days 12 3. Nearly every day 2 Total positive responses 42 patients 4.4% of Total screened