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Measure Summary
Title
Major depression in adults in primary care: percentage of patients with major depression whose primary care records show documentation of any communication between the primary care physician and the mental health care clinician.
Source(s)
Trangle M, Dieperink B, Gabert T, Haight B, Lindvall B, Mitchell J, Novak H, Rich D, Rossmiller D, Setterlund L, Somers K. Major depression in adults in primary care. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2012 May. 119 p. [320 references]

Measure Domain

Primary Measure Domain
Clinical Quality Measures: Process
Secondary Measure Domain
Does not apply to this measure

Brief Abstract

Description

This measure is used to assess the percentage of patients 18 years and older with a new or existing major depression diagnosis whose primary care records show documentation of any communication between the primary care physician and the mental health care clinician.

Rationale

The priority aim addressed by this measure is to improve communication between the primary care physician and the mental health care clinician (if patient is co-managed).

At any given time, 9% of the population has a depressive disorder, and 3.4% has major depression. In a 12-month time period, 6.6% of the United States population will have experienced major depression, and 16.6% of the population will experience depression in their lifetime.

Major depression is a treatable cause of pain, suffering, disability and death, yet primary care clinicians detect major depression in only one-third to one-half of their patients with major depression. Additionally, more than 80% of patients with depression have a medical comorbidity. Usual care for depression in the primary care setting has resulted in only about half of depressed adults getting treated and only 20% to 40% showing substantial improvement over 12 months. Approximately 70% to 80% of antidepressants are prescribed in primary care, making it critical that clinicians know how to use them and have a system that supports best practices.

The design of a team-based collaborative care approach involves communication between primary care team and psychiatry to consult frequently and regularly regarding the patient under clinical supervision, as well as direct patient visits as needed.

Evidence for Rationale
Katon W, Von Korff M, Lin E, Simon G, Walker E, Unutzer J, Bush T, Russo J, Ludman E. Stepped collaborative care for primary care patients with persistent symptoms of depression: a randomized trial. Arch Gen Psychiatry. 1999 Dec;56(12):1109-15. PubMed External Web Site Policy

Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005 Jun;62(6):617-27. PubMed External Web Site Policy

Klinkman MS. The role of algorithms in the detection and treatment of depression in primary care. J Clin Psychiatry. 2003;64 Suppl 2:19-23. [24 references] PubMed External Web Site Policy

Mojtabai R, Olfson M. National patterns in antidepressant treatment by psychiatrists and general medical providers: results from the national comorbidity survey replication. J Clin Psychiatry. 2008 Jul;69(7):1064-74. PubMed External Web Site Policy

Schonfeld WH, Verboncoeur CJ, Fifer SK, Lipschutz RC, Lubeck DP, Buesching DP. The functioning and well-being of patients with unrecognized anxiety disorders and major depressive disorder. J Affect Disord. 1997 Apr;43(2):105-19. PubMed External Web Site Policy

Strine TW, Mokdad AH, Balluz LS, Gonzalez O, Crider R, Berry JT, Kroenke K. Depression and anxiety in the United States: findings from the 2006 Behavioral Risk Factor Surveillance System. Psychiatr Serv. 2008 Dec;59(12):1383-90. PubMed External Web Site Policy

Trangle M, Dieperink B, Gabert T, Haight B, Lindvall B, Mitchell J, Novak H, Rich D, Rossmiller D, Setterlund L, Somers K. Major depression in adults in primary care. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2012 May. 119 p. [320 references]

Unutzer J, Katon W, Callahan CM, Williams JW Jr, Hunkeler E, Harpole L, Hoffing M, Della Penna RD, Noel PH, Lin EH, Arean PA, Hegel MT, Tang L, Belin TR, Oishi S, Langston C. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA. 2002 Dec 11;288(22):2836-45. PubMed External Web Site Policy

Williams JW Jr, Noel PH, Cordes JA, Ramirez G, Pignone M. Is this patient clinically depressed. JAMA. 2002 Mar 6;287(9):1160-70. PubMed External Web Site Policy
Primary Health Components

Major depression; care coordination communication

Denominator Description

Number of patients age 18 years with new or existing diagnosis of major depression (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Number of patients with documentation of communication between primary care clinician and mental health clinician

Evidence Supporting the Measure

Type of Evidence Supporting the Criterion of Quality for the Measure
  • A clinical practice guideline or other peer-reviewed synthesis of the clinical research evidence
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal
Additional Information Supporting Need for the Measure
  • Major depression was second only to back and neck pain for having the greatest effect on disability days, at 386.6 million United States (U.S.) days per year.
  • In a World Health Organization (WHO) study of more than 240,000 people across 60 countries, depression was shown to produce the greatest decrease in quality of health compared to several other chronic diseases. Health scores worsened when depression was a comorbid condition, and the most disabling combination was depression and diabetes.
  • A recent study showed a relationship between the severity of depression symptoms and work function. Data was analyzed from 771 depressed patients who were currently employed. The data showed that for every 1-point increase in Patient Health Questionnaire (PHQ-9) score, patients experienced an additional mean productivity loss of 1.65%. And, even minor levels of depression symptoms were associated with decrements in work function.
  • In the U.S., depression costs employers $24 billion in lost productive work time.
  • There is evidence that non-majority racial and cultural groups in the U.S. are less likely to be treated for depression than European Americans. In an epidemiological study that compared rates of diagnosing and treating depression in the early 1990s to patterns 10 years later, only 4.9% of minorities were treated with antidepressants compared to 12.4% of non-Hispanic Caucasians.
  • African Americans are more likely than Caucasians to believe that mental health professionals can be helpful but also are more likely to believe mental illness will improve on its own. They may tend to seek service late, and therefore face poorer outcomes.
  • In comparison to the general U.S. population, Latinos show no difference in the prevalence of major depression, but often show psychological distress differently. Assessment for depressive symptoms alone may not adequately capture the contextual factors of psychological distress the Latino experiences.
  • In a study of 12 provinces in Canada, Caucasians were more likely to have used mental health services than immigrants from Asia, including Chinese, South Asians and Southeast Asians. Among the Asian participants, the Chinese were less likely to have used mental health services than other Asian groups.
  • Ten percent to 75% of patients are non-compliant with medication use, and rates are higher in intercultural settings because of cultural expectations and communication problems.
  • Depression in the elderly is widespread, often undiagnosed and usually untreated. It is a common misperception that it is a part of normal aging. Losses, social isolation and chronic medical problems that older patients experience can contribute to depression.
  • The rate of depression in adults older than 65 years of age ranges from 7% to 36% in medical outpatient clinics and increases to 40% in the hospitalized elderly. Comorbidities are more common in the elderly. The highest rates of depression are found in those with strokes (30% to 60%), coronary artery disease (up to 44%), cancer (up to 40%), Parkinson's disease (40%), and Alzheimer's disease (20% to 40%). The recurrence rate is also extremely high at 40%.
  • Between 14% and 23% of pregnant women and 10% to 15% of postpartum women will experience a depressive disorder.
  • From 50% to 85% of people who suffer an episode of major depression will have a recurrence, usually within two or three years. Patients who have had three or more episodes of major depression are at 90% risk of having another episode. 
Evidence for Additional Information Supporting Need for the Measure
Anglin DM, Alberti PM, Link BG, Phelan JC. Racial differences in beliefs about the effectiveness and necessity of mental health treatment. Am J Community Psychol. 2008 Sep;42(1-2):17-24. PubMed External Web Site Policy

Beck A, Crain AL, Solberg LI, Unutzer J, Glasgow RE, Maciosek MV, Whitebird R. Severity of depression and magnitude of productivity loss. Ann Fam Med. 2011 Jul-Aug;9(4):305-11. PubMed External Web Site Policy

Birrer RB, Vemuri SP. Depression in later life: a diagnostic and therapeutic challenge. Am Fam Physician. 2004 May 15;69(10):2375-82. [25 references] PubMed External Web Site Policy

Gaynes BN, Gavin N, Meltzer-Brody S, Lohr KN, Swinson T, Gartlehner G, Brody S, Miller WC. Perinatal depression: prevalence, screening accuracy, and screening outcomes. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2005 Feb.  (Evidence report/technology assessment; no. 119).  [77 references]

Kirmayer LJ. Cultural variations in the clinical presentation of depression and anxiety: implications for diagnosis and treatment. J Clin Psychiatry. 2001;62 Suppl 1:22-8; discussion 29-30. [77 references] PubMed External Web Site Policy

Menselson T, Rehkopf DH, Kubzansky LD. Depression among Latinos in the United States: a meta-analytic review. J Consult Clin Psychol. 2008 Jun;76(3):355-66. [72 references] PubMed External Web Site Policy

Merikangas KR, Ames M, Cui L, Stang PE, Ustun TB, Von Korff M, Kessler RC. The impact of comorbidity of mental and physical conditions on role disability in the US adult household population. Arch Gen Psychiatry. 2007 Oct;64(10):1180-8. PubMed External Web Site Policy

Mojtabai R, Olfson M. National patterns in antidepressant treatment by psychiatrists and general medical providers: results from the national comorbidity survey replication. J Clin Psychiatry. 2008 Jul;69(7):1064-74. PubMed External Web Site Policy

Moussavi S, Chatterji S, Verdes E, Tandon A, Patel V, Ustun B. Depression, chronic diseases, and decrements in health: results from the World Health Surveys. Lancet. 2007 Sep 8;370(9590):851-8. PubMed External Web Site Policy

Simon GE, Von Korff M, Ludman EJ, Katon WJ, Rutter C, Unutzer J, Lin EH, Bush T, Walker E. Cost-effectiveness of a program to prevent depression relapse in primary care. Med Care. 2002 Oct;40(10):941-50. PubMed External Web Site Policy

Stewart WF, Ricci JA, Chee E, Hahn SR, Morganstein D. Cost of lost productive work time among US workers with depression. JAMA. 2003 Jun 18;289(23):3135-44. PubMed External Web Site Policy

Tiwari SK, Wang J. Ethnic differences in mental health service use among White, Chinese, South Asian and South East Asian populations living in Canada. Soc Psychiatry Psychiatr Epidemiol. 2008 Nov;43(11):866-71. PubMed External Web Site Policy

Trangle M, Dieperink B, Gabert T, Haight B, Lindvall B, Mitchell J, Novak H, Rich D, Rossmiller D, Setterlund L, Somers K. Major depression in adults in primary care. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2012 May. 119 p. [320 references]
Extent of Measure Testing

Unspecified

State of Use of the Measure

State of Use
Current routine use
Current Use
Internal quality improvement

Application of the Measure in its Current Use

Measurement Setting
Ambulatory/Office-based Care
Professionals Involved in Delivery of Health Services
Advanced Practice Nurses
Nurses
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Least Aggregated Level of Services Delivery Addressed
Clinical Practice or Public Health Sites
Statement of Acceptable Minimum Sample Size
Unspecified
Target Population Age

Age greater than or equal to 18 years

Target Population Gender
Either male or female

National Strategy for Quality Improvement in Health Care

National Quality Strategy Aim
Better Care
National Quality Strategy Priority
Prevention and Treatment of Leading Causes of Mortality

Institute of Medicine (IOM) National Health Care Quality Report Categories

IOM Care Need
Living with Illness
IOM Domain
Effectiveness

Data Collection for the Measure

Case Finding Period

The time frame pertaining to the data collection is quarterly.

Denominator Sampling Frame
Patients associated with provider
Denominator (Index) Event or Characteristic
Clinical Condition
Patient/Individual (Consumer) Characteristic
Denominator Time Window
Does not apply to this measure
Denominator Inclusions/Exclusions

Inclusions
Number of patients age 18 years with new or existing diagnosis of major depression

Note: Major depression includes International Classification of Diseases, Ninth Revision (ICD-9) codes 296.2x and 296.3x.

Exclusions
Unspecified

Exclusions/Exceptions
Unspecified
Numerator Inclusions/Exclusions

Inclusions
Number of patients with documentation of communication between primary care clinician and mental health clinician

Exclusions
Unspecified

Numerator Search Strategy
Fixed time period or point in time
Data Source
Administrative clinical data
Paper medical record
Type of Health State
Does not apply to this measure
Instruments Used and/or Associated with the Measure

Unspecified

Computation of the Measure

Measure Specifies Disaggregation
Does not apply to this measure
Scoring
Rate/Proportion
Interpretation of Score
Desired value is a higher score
Allowance for Patient or Population Factors
Unspecified
Standard of Comparison
Internal time comparison

Identifying Information

Original Title

Percentage of patients with major depression whose primary care records show documentation of any communication between the primary care physician and the mental health care clinician.

Submitter
Institute for Clinical Systems Improvement - Nonprofit Organization
Developer
Institute for Clinical Systems Improvement - Nonprofit Organization
Funding Source(s)

The Institute for Clinical Systems Improvement's (ICSI's) work is funded by the annual dues of the member medical groups and five sponsoring health plans in Minnesota and Wisconsin.

Composition of the Group that Developed the Measure

Work Group Members: Michael Trangle, MD (Work Group Leader) (HealthPartners/Medical Group and Regions Hospital) (Psychiatry); David Rossmiller, MD (Family HealthServices Minnesota) (Family Medicine); Bob Haight, PharmD, BCPP (Fairview Health Services) (Pharmacy); Deb Rich, PhD (Fairview Health Services) (Psychology); Benita Dieperink, MD (Hennepin County Medical Center) (Psychiatry); Tom Gabert (Marshfield Clinic) (Family Medicine); Jay Mitchell, MD (Mayo Clinic) (Family Medicine); Kristin Somers, MD (Mayo Clinic) (Psychiatry); Heidi Novak, WHNP (North Point Health & Wellness Center) (Women's Health OB/GYN); Linda Setterlund, MA, CPHQ (Institute for Clinical Systems Improvement) (Clinical Systems Improvement Facilitator); Britta Lindvall, MHA (Institute for Clinical Systems Improvement) (Project Manager)

Financial Disclosures/Other Potential Conflicts of Interest

Benita Dieperink, MD, Work Group Member
Job Title(s), Department, Affiliated Organization: Psychiatry, HCMC, Hennepin Women's Mental Health Clinic
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: University of Minnesota lecturer, $300; Stock holdings with Pfizer and Schering-Plough both <$1,500

Thomas Gabert, MD, MPH, Work Group Member
Job Title(s), Department, Affiliated Organization: Regional Medical Director, QI Care Management, Internal Medicine, Marshfield Clinic
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Bob Haight, PharmD, BCPP, Work Group Member
Job Title(s), Department, Affiliated Organization: Psychiatric Clinical Specialist, Pharmacy, Fairview Health Services
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Jay Mitchell, MD, Work Group Member
Job Title(s), Department, Affiliated Organization: Consultant, Family Medicine, Mayo Clinic
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Heidi Novak, WHNP, Work Group Member
Job Title(s), Department, Affiliated Organization: Women's Health Nurse Practitioner, Women's Health OB/GYN, Minnesota Association of Community Health Centers
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Deborah Rich, PhD, Work Group Member
Job Title(s), Department, Affiliated Organization: Coordinator, Fairview Perinatal Loss Services and Perinatal Mood Disorders, Psychology, Fairview Health Services
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

David Rossmiller, MD, Work Group Member
Job Title(s), Department, Affiliated Organization: Family Medicine, Family Health Services Minnesota
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Kristin Somers, MD, Work Group Member
Job Title(s), Department, Affiliated Organization: Consultant in Psychiatry, Psychiatry, Mayo Clinic
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: Honorarium paid to Mayo for speaking at IPMA conference

Michael Trangle, MD, Work Group Leader
Job Title(s), Department, Affiliated Organization: Associate Medical Director, Psychiatry, HealthPartners Medical Group and Regions Hospital
National, Regional, Local Committee Affiliations: Board of Governors for DHS State Operated Services, Board of Directors for Mental Health Resources, Board of Directors for the Mental Health Association of MN
Guideline-Related Activities: DIAMOND committee, RARE Mental Health Committee
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC
2012 May
Measure Maintenance

Scientific documents are revised every 12 to 24 months as indicated by changes in clinical practice and literature.

Date of Next Anticipated Revision

The next scheduled revision will occur within 24 months.

Measure Status

Please note: This measure has been updated. The National Quality Measures Clearinghouse is working to update this summary.

Source(s)
Trangle M, Dieperink B, Gabert T, Haight B, Lindvall B, Mitchell J, Novak H, Rich D, Rossmiller D, Setterlund L, Somers K. Major depression in adults in primary care. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2012 May. 119 p. [320 references]
Measure Availability

The individual measure, "Percentage of Patients with Major Depression Whose Primary Care Records Show Documentation of Any Communication between the Primary Care Physician and the Mental Health Care Clinician," is published in "Health Care Guideline: Major Depression in Adults in Primary Care." An update of this document is available from the Institute for Clinical Systems Improvement (ICSI) Web site External Web Site Policy.

For more information, contact ICSI at 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; phone: 952-814-7060; fax: 952-858-9675; Web site: www.icsi.org External Web Site Policy; e-mail: icsi.info@icsi.org.

NQMC Status

This NQMC summary was completed by ECRI Institute on November 28, 2012.

Copyright Statement

This NQMC summary (abstracted Institute for Clinical Systems Improvement [ICSI] Measure) is based on the original measure, which is subject to the measure developer's copyright restrictions.

The abstracted ICSI Measures contained in this Web site may be downloaded by any individual or organization. If the abstracted ICSI Measures are downloaded by an individual, the individual may not distribute copies to third parties.

If the abstracted ICSI Measures are downloaded by an organization, copies may be distributed to the organization's employees but may not be distributed outside of the organization without the prior written consent of the Institute for Clinical Systems Improvement, Inc.

All other copyright rights in the abstracted ICSI Measures are reserved by the Institute for Clinical Systems Improvement, Inc. The Institute for Clinical Systems Improvement, Inc. assumes no liability for any adaptations or revisions or modifications made to the abstracts of the ICSI Measures.

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