Improving Depression Detection

Wednesday, June 13, 2018

As a primary care physician in Easley, South Carolina, Dr. Julie Dangler treats a range of medical conditions. So it didn’t surprise her when a 35-year old woman visited her last year complaining of chronic back pain.

But this time, instead of just conducting a physical exam, Dr. Dangler asked the woman several questions about her mental state.

“Over the past two weeks, how often have you had little interest or pleasure in doing things?” she asked. “And over the past two weeks, how often have you felt down, depressed or hopeless?”

The woman’s response: “Nearly every day.”

The questions are part of Bon Secours Health System’s new depression screening initiative, designed to improve depression detection, ensure patients have access to quality behavioral health services, and dispel the stigma surrounding mental illness.

“One in five Americans lives with a mental illness,” said Jeff Oak, senior vice president, whose role includes leading mental health strategy for Bon Secours Health System. “That’s roughly 43 million Americans. From a population health perspective, that’s significant.”

Among all those experiencing mental illness, only half receive treatment and only a third receive treatment that’s deemed effective by the Institute of Medicine, he said. And the number one barrier to treatment of mental illness is the associated stigma.

“When we think about population health, which is so important to us as a health care ministry, we can’t do population health well unless and until we do mental health well,” Oak said.

With the use of patient questionnaires, the system began depression screenings in spring 2016 as part of the Medicare Annual Wellness Visits for patients 65 and older, an initiative where Bon Secours is a nationwide leader. Medicare Annual Wellness Visits across Bon Secours increased from 26% in September 2014 to nearly 67% as of August 21, 2017; as compared to 20% of Medicare Part B beneficiaries completing AWVs nationwide.   

“It’s not a way to pry,” Dr. Dangler said. “It’s a way to really show that we care and let people know that it’s something that really does impact their health, and that’s why we’re stressing it.”

In 2017, Bon Secours primary and specialty care providers began expanding the screenings, evaluating patients ages 12 and older during every visit.

Early signs show the initiative is working. Between January and August 2016, Bon Secours Health System screened 19.92 percent of patients over the age of 12 for depression. The health system set a goal to increase screenings to 29.92 percent between January and August 2017. It surpassed this goal, with 56.21 percent of patients receiving depression screenings.

Bon Secours Health System was also the top performer for depression screenings in the Premier Population Health Collaborative – a cohort of 22 Accountable Care Organizations (ACOs) across country working to improve population health.

“It’s getting the message out there once again and really stressing that we need to make sure we ask every person over 12, every time they come in,” Dr. Dangler said. “It’s important because the first time you leave it out, you might have missed someone who was depressed and needed your help.”

Someone like her back pain patient, who shared she had been “blue” for quite a while, Dr. Dangler said.

“It never really occurred to her that it might be depression,” she said. “We treated her for it, prescribing medication and recommending counseling.”

But the efforts don’t end there. By August 2018, the health system hopes to screen more than 62 percent of patients over age 12 for depression. And by the spring, the health system expects to launch a pilot collaborative care model in Greenville, South Carolina that embeds behavioral health care managers like social workers into the primary care setting, says W. Carson Felkel II, M.D., a psychiatrist and head of behavioral health program services in Greenville.

Under the model, patients who receive a positive depression screening are connected with a care manager. The care manager then reaches out to patients every two to four weeks and rescreens them to see if they’re improving.

“For the patients who are not getting better, the team around them will change the type of therapy, change their medicines, refer to them to specialists if needed,” Dr. Felkel said. “Or, a psychiatrist reviewing the patients weekly will perform a one-time consult.”

If all goes well, Bon Secours will implement the model system wide, he said.

The Health System Office’s mental health team is also creating clinical guidelines for screening, treatment and follow up, which will include guidelines for identifying other mental health conditions, such as anxiety, bipolar disorder, alcohol and substance use disorders, Dr. Felkel said.

“We are in this for the long haul” Oak said. “If I do nothing else in this leadership role, I want to help remove the embarrassment and shame around mental illness. To remove avoidance and fear. To remove ignorance and stereotypes. No matter what your role, you can make a difference in battling stigma by treating those with mental illness with the dignity they deserve.”