Diabetes, Depression, and OASIS-C A GUIDE FOR HOME HEALTHCARE CLINICIANS

Diabetes, Depression, and OASIS-C A GUIDE FOR HOME HEALTHCARE CLINICIANS Depression is significantly higher among elderly adults receiving home healthcare, particularly among adults with Type 2 diabetes. Depression leads to greater medical illness, functional impairment, and chronic pain. Opportunities are often missed to improve mental health and general medical outcomes when mental illness is underrecognized and undertreated. This article discusses the mandate by the Centers for Medicare & Medicaid Services (CMS), Outcome and Assessment Information Set C (OASIS-C) (2009) for the use of the Patient Health Questionnaire (PHQ-2) to screen for depression in home care patients, with special emphasis on the patient with diabetes. Depression is one of the most common mental health disorders and is predicted to be the second leading cause of disability worldwide by 2020 (Pignone et al., 2002). Among persons older than 65 years, one in six suffers from depression (Wang et al., 2005). According to Pickett et al. (2012), depression is significantly higher among elderly adults receiving home healthcare and leads to greater medical illness, functional impairment, and chronic pain. In 2003, Greenberg et al. described the economic burden of depression as substantial and the combined direct and indirect costs at $83.1 billion. Groups that have been identified to be at high risk for depression include minorities, women, patients with low socioeconomic status, and patients with physical disabilities or comorbid conditions (Acee, 2010). Opportunities are often missed to improve mental health and general medical outcomes when mental illness is underrecognized and undertreated (Brown et al., 2007). Beliefs that depression is normal with older age, as well as difficulties present in patients with cognitive deficits, make identification of depression in older adults challenging (Pignone et al., 2002). Depression is treatable, but first must be recognized, treated, and continuously monitored over time like any other chronic condition (Hall, 2012). Targeting depression in home care has been found to decrease hospitalization rates (Pickett et al., 2012). If left undetected or not fully treated, Anna M. Acee, EdD, ANP-BC, PMHNP-BC 362 Home Healthcare Nurse www.homehealthcarenurseonline.com

2.1 HOURS Continuing Education The Centers for Medicare and Medicaid Services, Outcome and Assessment Information Set C has mandated the use of the Patient Health Questionnaire to screen for depression in homecare patients. vol. 32 no. 6 June 2014 Home Healthcare Nurse 363

depression is associated with higher costs, morbidity, risk of suicide, and mortality from other comorbid conditions (Beacham et al., 2008). Challenges in Managing Type 2 Diabetes and Depression A patient diagnosed with diabetes faces multiple self-management tasks each day to effectively manage this chronic illness. A daily regimen of monitoring blood glucose, meal planning, exercise, monitoring skin integrity, annual eye and dental exams, and frequent visits to the primary care provider (PCP) weigh heavily on these patients and serve as a constant reminder of the chronicity of their illness. The research has indicated that depressive disorders are higher among adults with diabetes than in the general population (Markowitz et al., 2011), with the incidence of major depression in patients with diabetes estimated to be 11% to 31% (Egede & Ellis, 2010). The research has indicated that patients with diabetes and depression have increased rates of mortality, cardiac events, hospitalizations, diabetes-related complications, functional impairment, healthcare costs, medical symptoms burden, and a decreased quality of life than patients with diabetes who are not depressed (Gonzalez et al., 2008). According to Katon (2011), comorbid depression is associated with poor adherence to self-care regimens, medical symptom burden, and functional impairment. People with Type 2 diabetes and major depression are at increased risk of microvascular and macrovascular complications (Lin et al., 2010) and up to 80% of patients with comorbid diabetes and depression will experience a relapse of depressive symptoms over a 5-year period (Ell et al., 2005). The risk of deterioration of depression symptoms over time emphasizes the need for ongoing screening for depression symptoms and treatment adherence (Hunt et al., 2012) and adjusting antidepressant therapy as needed over time (Culpepper, 2010). There is a positive relationship between poorer self-care and depressive symptoms (Markowitz et al., 2011) and inversely the higher the self-perception of health, the better the A1c levels (Acee & Fahs, 2012). Home healthcare nurses and other clinicians are well positioned to screen for depression and report the findings to the medical director or PCP. The barriers related to screening for depression include time constraints, difficulty assessing The Patient Health Questionnaire is a validated instrument that is widely used in primary care and is available in 48 languages. depressive symptoms with comorbid diabetes, clinician s lack of clinical expertise in assessing for mental health issues, patient s cultural taboos and fear of labeling, and cultural beliefs. Adding to this challenge, diagnosing depression in patients with diabetes is challenging due to the similarity of physical (e.g., weight loss and fatigue) or cognitive (e.g., trouble concentrating) symptoms. Assessing for Depression Centers for Medicare and Medicaid Services (CMS), Outcome and Assessment Information Set-C (OASIS-C) (2009) has mandated the use of the Patient Health Questionnaire (PHQ-2) to screen for depression in home care patients. The PHQ-2 assesses for two very significant signs of depression (including little interest or pleasure in doing things and experiencing a depressed mood) one of which is required to assess significant clinical depression. A score of 3 or higher is the recommended indicator for additional assessment. The PHQ-2 has been validated and showed wide variability in sensitivity (Gilbody et al., 2007). PHQ-9, the Next Step After a Positive PHQ-2 Any scores equal to or greater than 3 on the PHQ-2 should be referred to an advanced practice clinician (e.g., nurse practitioner, psychologist, physician) by the home healthcare team for diagnoses. CMS has recommended the use of the Patient Health Questionnaire-9 (PHQ-9) to further evaluate depressive symptoms during an initial visit and over time to monitor depressive symptoms and medication effectiveness in home care patients. The PHQ-9 is a nine-item screening 364 Home Healthcare Nurse www.homehealthcarenurseonline.com

Table 1. Patient Health Questionnaire (PHQ-9) Over the last 2 weeks, how often have you been bothered by any of the following problems? (use ü to indicate your answer) Not at all Several Days More Than Half the Days Nearly Every Day 1. Little interest or pleasure in doing things 0 1 2 3 2. Feeling down, depressed, or hopeless 0 1 2 3 3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3 4. Feeling tired or having little energy 0 1 2 3 5. Poor appetite or overeating 0 1 2 3 6. Feeling bad about yourself or that you are a failure or have let yourself or your family down 7. Trouble concentrating on things, such as reading the newspaper or watching television watching television 0 1 2 3 0 1 2 3 8. Moving or speaking so slowly that other people could have noticed. Or the opposite being so fidgety or restless that you have been moving around a lot more than usual 0 1 2 3 9. Thoughts that you would be better off dead, or of hurting yourself in some way 0 1 2 3 ADD COLUMNS 0 1 2 3 TOTAL 0 1 2 3 (Health care professional: For interpretation of TOTAL please refer to scoring card below.) 10. If you checked off any problems, how difficult have these Not difficult at all Somewhat difficult problems made it for you to do your work, take care of things at home, or get along with other people? Very difficult Extremely difficult PHQ-9 QUICK DEPRESSION ASSESSMENT For initial diagnosis: 1. Patient completes PHQ-9 Quick Depression Assessment. 2. Add score to determine severity. 3. Consider Major Depressive Disorder if there are at least 5./S in the shaded section (1 of which corresponds to Question #1 or #2). Consider Other Depressive Disorder if there are 2-4.Is in the shaded section (1 of which corresponds to Questions #1 or #2). Note. As the questionnaire relies on patient self-report, all responses should be verified by the clinician. A definitive diagnosis is made on clinical grounds, taking into account how well the patient understood the questionnaire and other relevant information from the patient. Diagnoses of major depressive disorder or other depressive disorder also require impairment of social, occupational, or other important areas of functioning (Question # 10) and ruling out normal bereavement, a history of a manic episode (bipolar disorder), and a physical disorder, medication, or other drug as the biological causes of the depressive symptoms. To monitor severity over time for newly diagnosed patients or patients in current treatment for depression: 1. Patients may complete questionnaires at baseline and at regular intervals [e.q., every 2 weeks) at home and bring them in at their next appointment for scoring, or they may complete the questionnaire during each scheduled appointment. 2. Add up.ü s by column. For every ü s: Several days = 1; More than half the days = 2; Nearly every day = 3. 3. Add together column scores to get a total score. 4. Refer to the PHQ-9 Scoring Card to interpret the total score. 5. Results may be included in patients files to assist you in setting up a treatment goal and determining degree of response, as well as guiding treatment intervention. PHQ-9 SCORING CARD FOR SEVERITY DETERMINATION for health professional use only Scoring - add up all checked boxes on PHQ-9 For every Not at all = 0; Several days = 1; More Than Half the Days = 2; Nearly Every Day = 3. Interpretation of Total Score Total Score Depression Severity 1 4 None 5 9 Mild depression 10 14 Moderate depression 15 19 Moderately severe depression 20 27 Severe depression This PHQ-9 questionnaire is also available at www.depression-primarycare.org/clinicians/toolkits/materials/forms/phq9/ Copyright Pfizer Inc. All rights reserved. Developed by On. Robert l. Spitzer, Janet B. Williams/ and Kurt Kroenke vol. 32 no. 6 June 2014 Home Healthcare Nurse 365

Table 2. Using Patient Health Questionnaire (PHQ-9) Diagnostic Assessment and Initiating Treatment PHQ-9 Symptoms and Impairment 1 to 4 symptoms, functional impairment PHQ-9 Severity Provisional Diagnosis < 10 Mild or minimal depressive symptoms Treatment Recommendations Reassurance and/or supportive counseling Patient self-management Recommend physical activity Educate patient to call if his or her condition deteriorates 2 to 4 symptoms, including Questions 1 and/or 2, plus functional impairment 5 symptoms, including Questions 1 and/or 2, plus functional impairment 5 symptoms, including Questions 1 and/or 2, plus functional impairment 10 14 Moderate depressive symptoms (minor depression)** 15 19 Moderately severe symptoms, major depression 20 Severe symptoms, major depression Watchful waiting Supportive counseling If no improvement after one or more months, use antidepressant or brief psychological counseling Patient preference for antidepressants and/or psychological counseling Antidepressants alone or in combination with psychological counseling Refer patient to psychiatrist or psychiatric nurse practitioner * Count the total number of symptoms in shaded sections of PHQ-9 from Table 2. **If symptoms present for > 2 years, chronic depression, or functional impairment is severe, remission with watchful waiting is unlikely, and immediate active treatment is indicated for moderate depressive symptoms (minor depression). Adapted with permission from Oxman, T. for 3CM, LLC, and the MacArthur Initiative on Depression and Primary Care, 2006. Source: Oxman T. Re-Engineering Systems for Primary Core Treatment of Depression: The Respect Depression Core Process. The Depression Initiative & Primary Care. Dartmouth Medical School. 2006: Version 9.11: 18. tool based on the diagnostic criteria for depression (Sheeran et al., 2010) (Table 1), with a scoring system based on duration/severity of particular symptoms (Kroenke et al., 2001). Depression is diagnosed when symptoms impact normal activities and persist for more than 2 weeks (Table 1). In 2002, the American Psychiatric Association outlined the diagnostic criteria for depression to include a positive response to at least one of the first two questions on the PHQ-9, indicating cardinal symptoms of persistent and pervasive low mood and loss of pleasure in usual activities. The PHQ-9 is a validated instrument that is widely used in primary care and is available in 48 languages (Multicultural Mental Health Resource Center, 2012). Patients with comorbidities (e.g., depression and diabetes) can be more thoroughly screened using the PHQ-9, because unlike the PHQ-2, it includes physical symptoms of depression. This tool is very user friendly, in that it can be administered and findings reviewed during the home visit. Home care staff may need to be trained to assess for any history or treatment of depression, or other mental health illness, substance abuse, or alcohol use. Evaluation of the findings from the PHQ-9 screen should then be interpreted by a physician, psychiatrist, psychologist, or advanced practice psychiatric nurse. The addition of this standardized tool will require agency approval and education for clinicians to assure reliability of results. Although the role of the home care nurse does not include diagnosis and treatment of depression, a review of the PHQ-9 is provided as a basic overview for better understanding of the signs and symptoms of depression. In order to make a diagnosis of major depression, a patient has had five or more depressive symptoms present for more than half the days over at least 2 weeks, with at least one of the symptoms being either depressed mood or inability to experience pleasure with activities that were at one time pleasurable (Kroenke et al., 2001). From the list of nine depressive symptoms, a patient indicates whether each symptom has bothered them during the last 2 weeks. The PHQ-9 can be used as both a diagnostic tool and a measurement of depression severity over time, to evaluate medication effectiveness and mental status (Spitzer et al., 1999). Based on a structured interview, the PHQ-9 has a high sensitivity (73%) and specificity (98%) (Kroenke et al., 2001). The PHQ-9 identifies clinical depression as a score of 10 or higher or a positive response to Item # 9: Thoughts of death or harming themselves (Bruce et al., 2011). A positive response to Item # 366 Home Healthcare Nurse www.homehealthcarenurseonline.com

9 should be followed by questions to determine the level of risk and other influencing factors. When using the PHQ-9 for the first time to assess a patient s mood, the clinician must know that each item of the PHQ-9 ranges in severity from 0 to 3. The possible range of total scores is 0 to 27, with the higher score indicating more severe depression (Kroenke et al., 2001) (Table 2). The provider totals the checked boxes on the PHQ-9 based on the following: not at all = 0; several days = 1; more than half the days = 2; nearly every day = 3 (see Table 3 for the interpretation of total scores). The PHQ-9 assessment findings can help in determining first-line treatment options (e.g., watchful waiting, psychotherapy, or pharmacotherapy) (Table 3). Once diagnosed care will include ongoing monitoring, patient education, and selfmanagement support, which includes medication adherence, physical activity, and spending time in a nurturing environment (New York City Department of Health and Mental Hygiene, 2008). With mild depression (scores 5 9), the care provider can initiate supportive counseling and patient self-management, encourage physical activity, and educate the patient to report if his condition deteriorates (Table 3). With moderate depressive symptoms (scores 10 14), the patient will be monitored closely and provided with supportive counseling; if no improvement is observed in 1 month, an antidepressant may be indicated. For moderately severe depression (score 15 19), the care provider should determine the patient s preference for an antidepressant and/or psychotherapy. In the case of severe depression (major depression; score > 20), an antidepressant alone or in combination with psychotherapy is recommended; a referral to a psychiatric nurse practitioner or a psychiatrist is highly warranted (Spitzer et al., 1999). To determine the most appropriate treatment for a patient, the care provider should consider the severity of the patient s symptoms, psychosocial stressors, comorbid conditions, and patient s willingness to engage in increased physical activity. Additional factors that should be considered include the following: Table 3. Initial Response After 4 6 Weeks of an Adequate Dose of an Antidepressant PHQ-9 Treatment Response Treatment Plan Drop of 5 points from baseline Adequate No treatment change needed; follow-up in 4 weeks Drop in 2 4 points from baseline Possibly Inadequate May warrant an increase in antidepressant dose Drop of 1 point or no change or increase Inadequate Increase dose, augment, or switch; consider informal or formal psychiatric consultation, adding psychological counseling Initial Response to Psychological Counseling After 3 Sessions Over 4 6 Weeks PHQ-9 Treatment Response Treatment Plan Drop of > 5 points from baseline Adequate No treatment change needed; follow-up in 4 weeks Drop in 2 4 points from baseline Possibly Inadequate Probably no treatment change needed; share PHQ-9 score with psychotherapist Drop of 1 point or no change or increase Inadequate With depression-specific psychological counseling (CBT, PST, IPT*), discuss with therapist, consider adding antidepressant For patients satisfied in other type of psychological counseling, consider starting antidepressant For patients dissatisfied with psychological counseling, review treatment options and preferences The goal of acute phase treatment is remission of symptoms so that patients will have a reduction of the PHQ-9 to a score < 5. Patients who achieve this goal enter into the continuation phase in treatment. Patients who do not achieve this goal remain in acute phase treatment and require some alteration (dose increase, augmentation/switch/combination treatment). Patients who do not achieve remission after two adequate trials of antidepressant and/or psychological counseling by 20 to 30 weeks should have a psychiatric consultation for diagnostic and management suggestions. Note. CBT = Cognitive-Behavioral Therapy; IPT = Interpersonal Therapy; PHQ-9 = Patient Health Questionnaire; PST = Problem Solving Treatment. Adapted with permission from Oxman, T., for 3CM, LLC and the MacArthur Initiative on Depression and Primary Care, 2006. Source: Oxman T. Re-Engineering Systems for Primary Care Treatment of Depression: The Respect Depression Care Process. The Depression Initiative & Primary Care. Dartmouth Medical School. 2006: Version 9.11:48. vol. 32 no. 6 June 2014 Home Healthcare Nurse 367

Conduct assessment Using PHQ-2/M1730 PHQ-2 score: 0 2 PHQ-2 score: 3 or higher Repeat PHQ-2 weekly for fwo weeks; if 0 2 no further action; rescren for depression if symptoms arise during care or otherwise clincally indicated Conduct full PHQ-9 PHQ-9 score: <10 & no suicide ideation PHQ-9 score: 10 Suicidal ideation PHQ iteam 9 ( 1) Instruct patients with Depression Eduction Toolkit. Report PHQ-9 weekly for 2 wks; Follow Depression Care Management When PHQ-9 is positive ( 10) or if sucidal ideation emerges. Depression Care Management (DCM) Follow agency Suicide Risk Protocol when indicated Figure 1. Depression Screening Protocol. Reproduced from Bruce, M. L., Raue, P. J., Sheeran, T., Reilly, C., Pomerantz, J. C., Meyers, B. S.,..., Zukowski, D. (2011). Depression Care for Patients at Home (Depression CAREPATH): Home care depression care management protocol, part 2. Home Healthcare Nurse, 29(8), 480 489. prior suicide attempt; significant comorbid anxiety, psychotic symptoms, or active substance abuse; access to firearms; living alone or with poor social supports; older adult male; recent loss or separation; hopelessness; preparatory acts (procuring means, putting affairs in order, warning statement, giving away personal belongings, suicidal notes); and family history of affective disorder, suicide, alcoholism (Intermountain Healthcare, 2008). If a patient expresses suicidal ideation or intent they should be immediately referred to their PCP for further evaluation. If the PCP is not available, the home care provider should consult with a psychiatrist or psychiatric nurse practitioner to determine which safety measures and treatment are needed (Intermountain Healthcare, 2008). If a patient requires ongoing mental evaluation and monitoring for depression, the patient should be referred to a home care mental health program where qualified mental health clinicians can oversee the patient s mental healthcare. It is important for the members of a home healthcare team to understand the role of the mental health team when managing a patient with comorbid depression. It has been recommended that the PHQ-9 be readministered 12 weeks after the beginning of treatment for depression (New York City Department of Health and Mental Hygiene, 2008). The patient s response to treatment (psychotherapy and/or medication) can be monitored primarily by the mental health home care provider (Table 3) in collaboration with the home healthcare team. Implications for Practice Depression is a very treatable condition, with research indicating that up to 70% to 80% of patients respond positively when adequate care is 368 Home Healthcare Nurse www.homehealthcarenurseonline.com

provided (New York City Department of Health and Mental Hygiene, 2008). There is strong evidence that training a home care provider to detect depression symptoms will increase appropriate mental health referrals (Brown et al., 2007). Medicare s revised OASIS-C (2009) was implemented into practice in January 2010 and has streamlined many assessments and enhanced the section on depression. OASIS-C, recommends using the PHQ-2 assessment with all patients. Home healthcare providers need to be skilled at administering the PHQ-2 and referring patients who score positive on the PHQ-2 and would benefit from further evaluation using the PHQ-9 (Figure 1). For depression screening to be effective in patients with comorbidities, a collaborative framework needs to be in place between home care mental health services and home healthcare providers in order to satisfactorily diagnose, treat, and follow up home care patients. Anna M. Acee, EdD, ANP-BC, PMHNP-BC, is an Associate Professor, School of Nursing, Brooklyn Campus, Long Island University, Brooklyn, New York. The author and planners have disclosed no potential conflicts of interest, financial or otherwise. Address for correspondence: Anna M. Acee, EdD, ANP-BC, PMHNP-BC, 1 University Plaza, Brooklyn, NY 11201-5372 (anna.acee@liu.edu). DOI:10.1097/NHH.0000000000000091 REFERENCES Acee, A. M. (2010). Detecting and managing depression in Type II diabetes: PHQ-9 is the answer! MEDSURG Nursing, 19(1), 32-38. Acee, A. M., & Fahs, M. C. (2012). Can treating depression improve diabetic management? Nurse Practitioner, 37(1), 46-52. American Psychiatric Association. (2002). Diagnostic and Statistical Manual IV-TR (pp. 328-338). Washington, DC: APA. Beacham, T., Williams, P. R., Askew, R., Walker, J., Schenk, L., & May, M. (2008). Insulin management: A guide for the home health nurse. Home Homecare Nurse, 26(7), 421-428. Brown, E., Kaiser, R., & Gellis, Z. (2007). 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F., Raue, P. J., Weinberger, M. I., Pomerantz, J., & Bruce, M. L. (2010). The PHQ-2 on OASIS-C: A new resource for identifying geriatric depression among home health patients. Home Healthcare Nurse, 28(2), 92-104. Spitzer, R. L., Kroenke, K., & Williams, J. B. (1999). Validation and utility of a self-report version of PRIME-MD: The PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. Journal of the American Medical Association, 282(18), 1737-1744. Wang, P. S., Schneeweiss, S., Brookhart, M. A., Glynn, R. J., Mogun, H., Patrick, A. R., & Avorn, J. (2005). Suboptimal antidepressant use in the elderly. Journal of Clinical Psychopharmacology, 25(2), 118-126. For 193 additional continuing nursing education activities related to home healthcare, go to nursingcenter.com/ce. vol. 32 no. 6 June 2014 Home Healthcare Nurse 369