Ambulatory Care Pharmacist-Administered Depression Screenings Can Close Gaps in Care

Major depressive disorder (MDD) is a mental condition in which one experiences long-term loss of pleasure or interest in life. It is one of the most prevalent mental disorders in the United States.¹ In 2020, the National Institute of Mental Health estimated that 21 million adults in the United States experienced at least 1 major depressive episode. This represents 8.4% of the entire U.S. population.¹

MDD has an economic burden of $210 billion dollars in medical care and lost productivity annually. This cost was shown to primarily be from comorbid conditions associated with MDD. Previous literature has shown that patients with comorbidities are at an increased risk for depression due to the burden such diseases can place on patients.²

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The US Preventative Service Task Force recommends depression screening of adults in primary care via evidence-based protocols such as the Patient Health Questionnaire (PHQ).³

Unfortunately, only small studies exist showing the benefit of depression screening in primary care. Siniscalchi et al. diagnosed 270 patients with depression out of 481 screened. Fortunately, treatment was started in 236 of those patients,⁴ indicating that depression screening in primary care is a care gap. Some studies, such as Knight et al., have shown up to 48% of patients with diabetes in the primary care setting screening positive for depression.⁵ Additionally, Leon et al. found that the prevalence of mental health disorders is higher in patients with chronic medical conditions, concluding that this specific population could benefit from depression screenings and leading to the development of this quality improvement initiative.⁶

This new study implemented a novel workflow for ambulatory care pharmacists to execute pharmacist-administered PHQ-2 depression screenings and subsequent PHQ-9 depression screenings (Table 1) if a PHQ-2 score was ≥3 in patients with diabetes being seen in primary care clinics. Interpretation of PHQ-9 results can be found in Table 2. A retrospective chart review from September 12, 2022, through January 1, 2023, was conducted to evaluate the implementation of such depression screenings.

The investigators aimed to identify patients with diabetes that needed to be screened for depression and assess how many PHQ-2 screenings pharmacists performed during the study period. The secondary objectives were to evaluate the percentage of diabetes patients positive on a PHQ-9 depression screening, negative on a PHQ-2 depression screening, number of notifications sent to providers for PHQ-9 scores ≥10 (indicating moderate depression), and antidepressant medications started due to PHQ-9 scores greater than or equal to 10.

Patients with a diabetes diagnosis seeing a pharmacist in the primary care clinic during the study period were included in the study. Exclusion criteria included any patients diagnosed with depression, those on an antidepressant medication during the study period (Table 3), patients that had received a PHQ-9 assessment in the previous year, and pharmacy visits taking place via telehealth. Telehealth was considered both virtual visits and telephonic visits completed during the study time period.

There were 975 diabetes pharmacotherapy visits during the study period. There were 946 diabetes pharmacotherapy visits that took place in person and assessed for inclusion. There were 694 patients excluded from the study, 331 patients were on current antidepressant therapy, 298 patients had a preexisting diagnosis of depression, and 65 patients had a PHQ-9 score in the past year. This left 252 patients eligible for the study and due for a PHQ-2 screening (Figure 1).

Although only 252 patients were due for depression screening, the ambulatory pharmacy team administered 286 (113%) PHQ-2 screenings.

Of the screenings administered, 250 (87%) were <3 on PHQ-2 assessments, not indicating the need for PHQ-9 administration. There were 24 PHQ-9 scores ≥10, indicating moderate to severe depression (Table 2), and 19 providers were notified of these scores. No medications were started in included patients after physicians were informed during the study period.

The findings of this study indicate that pharmacists can play a role in filling a gap in care by screening patients with diabetes for depression. Furthermore, after implementing the depression screening workflow, it was later adjusted to help physicians meet their Merit-Based Incentive Payment System (MIPS) measures, increasing physician buy-in.

A future direction for this study is to assess whether providers followed up with patients without starting pharmacologic therapy after being notified of high PHQ-9 scores.

In conclusion, ambulatory care pharmacists have the knowledge and capability to identify patients for further assessment of depression in the primary care setting. Pharmacist-administered PHQ-2 and PHQ-9 screenings can close a gap in patients’ care and highlight patients that could benefit from additional screening, care, and support.

References

1. National Institute of Mental Health. Major depression among adults. Accessed August 14, 2022. https://www.nimh.nih.gov/health/statistics/major-depression

2. Greenberg PE, Fournier AA, Sisitsky T, Pike CT, Kessler RC. The economic burden of adults with major depressive disorder in the United States (2005 and 2010). J Clin Psychiatry. 2015;76:155-162.

3. Siu AL, US Preventive Services Task Force (USPSTF), Bibbins-Domingo K, et al. Screening for depression in adults: US Preventive Services Task Force recommendation statement. JAMA. 2016;315:380-387.

4. Siniscalchi KA, Broome ME, Fish J, et al. Depression Screening and Measurement-Based Care in Primary Care. J Prim Care Community Health. 2020;11:2150132720931261. doi:10.1177/2150132720931261

5. Knight DE, Draeger RW, Heaton PC, Patel NC. Pharmacist screening for depression among patients with diabetes in an urban primary care setting. Am Pharm Assoc. 2008;48:518 – 521. doi:10.1331/JAPhA.2008.07048

6. Leon AC, Olfson M, Broadhead WE, et al. Prevalence of mental disorders in primary care. Implications for screening. Arch Fam Med. 1995;4(10):857-61. doi: 10.1001/archfami.4.10.857.