Differences in What Happens After You Screen Positive for Depression Versus Hazardous Alcohol Use

MILITARY MEDICINE, 178, 10:1071, 2013 Differences in What Happens After You Screen Positive for Depression Versus Hazardous Alcohol Use Jennifer S. Funderburk, PhD* ; Kyle Possemato, PhD* ; Stephen A. Maisto, PhD* ABSTRACT The success of any secondary prevention effort in identifying those in need for further services depends on the primary care team following all positive screening results with additional assessment or intervention. Initial research suggests possible differences in primary care responses to positive screens for hazardous alcohol use compared to depression. Therefore, the purpose of this study was to examine current practices of Veterans Affairs healthcare providers following a positive screen for hazardous alcohol use or depression. Chart reviews were conducted for a random sample of 98 Veterans who screened positive for hazardous alcohol use using the Alcohol Use Disorder Identification Test Consumption (AUDIT-C) questions and a separate sample of 99 Veterans who screened positive for depression using the 2-item Patient Health Questionnaire (PHQ-2) over a 1-year period. Findings suggest multiple discrepancies in screening practices between the AUDIT-C and the PHQ-2. These include a higher likelihood of further depression assessment or referral after a positive PHQ-2 screen. Scores on the AUDIT-C that indicate heavier alcohol consumption were more likely to result in assessment or intervention than did lower but still positive AUDIT-C scores. Overall, these data suggest that many opportunities are missed, especially in regards to hazardous alcohol use, for prevention and intervention. *VA Center for Integrated Healthcare, Syracuse VA Medical Center, 800 Irving Avenue (116C), Syracuse, NY 13210. Department of Psychology, Syracuse University, 430 Huntington Hall, Syracuse, NY 13244. Department of Psychiatry, University of Rochester, 300 Crittenden Boulevard, Rochester, NY 14642. Portion of results previously presented in poster form: Funderburk JS, Bateman R, Maisto SA. Characteristics of veterans screening positive on the AUDIT-C and PHQ-2 during a primary care visit. Poster session presented at: 4th annual meeting of the VHA Mental Health Conference; Jul 27 29, 2010; Baltimore, MD. The views expressed in this article are those of the authors and do not reflect the official policy of the Veterans Affairs department, Department of Defense, or other departments of the U.S. Government. doi: 10.7205/MILMED-D-13-00165 INTRODUCTION Alcohol use and depression are the two most common behavioral health problems presenting in primary care, occurring in as many as 30% of Veterans presenting for treatment in Veterans Health Administration (VHA) primary care clinics. 1 3 Because of the physical and emotional correlates of these disorders 4 6 as well as increased healthcare use, 7,8 the impetus to implement secondary prevention efforts, such as screening for hazardous alcohol use and depression within primary care, continues to be high. Following national recommendations, 9 11 the VHA mandates that all Veterans be screened annually for hazardous alcohol use and depression using the Alcohol Use Disorder Identification Test Consumption (AUDIT-C) questions 12 and 2-item Patient Health Questionnaire 13 (PHQ-2), respectively, in all VHA primary care settings. Both measures have good sensitivity and specificity, 13 15 indicating that they are extremely useful at identifying those Veterans in need of additional assessment. However, research has shown that screening alone does not necessarily advance secondary prevention, because positive screens are not typically followed by further assessment or intervention. In this regard, as few as 25% of patients who screen positive for depression or alcohol receive appropriate follow-up care. 16,17 Therefore, improving follow-through after a positive screen is essential. One way to do that is to use the advanced capabilities of the electronic medical record (EMR), including electronic alerts and guided menus that can help VHA primary care providers (PCPs) through the screening, intervention, and referral process. 18 For instance, a VHA provider is alerted when a screen needs to be conducted and when a screen is positive if it was administered by a nonprovider (e.g., a licensed practical nurse). In addition, the EMR helps track clinical outcomes following a positive screen by providing a menu of options checked by PCPs when they respond to the alert. These options include: (1) giving the provider access to additional measures to help determine whether the Veteran is reporting clinically significant symptoms of depression with the 9-item Patient Health Questionnaire 19 (PHQ-9) or hazardous alcohol use with the full AUDIT 20 ; (2) giving the provider access to the electronic consult menu within the EMR that is the primary method of referral to specialty clinics; (3) providing a place to document the recommendations made by the provider (e.g., advise the patient to drink at low-risk limits); and (4) providing a way to document that the patient does not report clinically significant symptoms or is not interested in treatment. This process was implemented to ensure that VHA providers address pressing mental health/ substance use problems as part of routine patient care. 21 It has also been a component of provider pay for performance. 22 Although there is a fair amount of literature examining PCPs screening practices, 23 25 little is known about how PCPs typically respond when meeting with a patient who screened MILITARY MEDICINE, Vol. 178, October 2013 1071

positive, especially within the context of the support system provided by the VHA s EMR. Initial research suggests that PCPs may respond differently to patients screening positive for depression than hazardous alcohol use, even with the EMR support. 26 Specifically, Maust et al 26 used quantitative data pulled directly from the EMR and found that PCPs are more likely to make referrals to additional clinical services for positive depression screens than following a positive alcohol screen. They speculated that the lower rate of alcohol referrals could have reflected the PCPs desire to counsel patients with alcohol problems themselves. However, they were unable to investigate it more thoroughly as the study was retrospective and did not involve an actual chart review. The findings of Conigliaro et al 27 provide some initial support for the hypothesis that PCPs like to counsel patients with alcohol problems themselves, as Veterans screening positive on an AUDIT-C remembered their PCP advising them to limit their alcohol use, but indicated referrals to specialty care were provided less often than advice. However, this research was based on patients reported experiences. Furthermore, other research has found that PCPs reported that they did not feel comfortable addressing hazardous alcohol use themselves and preferred referring to other providers. 1 Therefore, it is still unknown whether these differential responses between the PHQ-2 and AUDIT-C are resulting in missed opportunities to help patients with hazardous alcohol use or whether the discrepancy is due to PCPs giving the necessary advice to the patient, but the data were missed due to the method used to collect data from the EMR. If there are differential responses within the context of the EMR support, then it would seem useful to explore the patient, provider, and system-level barriers that may be impeding the necessary interventions that are inherent to the secondary prevention effort involved with conducting hazardous alcohol use screening. This study intends to help clarify these discrepancies by using chart review to describe the current practices of PCPs following a positive screen for depression or hazardous alcohol use. It was hypothesized that we would continue to find a discrepancy, such that the chart review would continue to find a lower percentage of Veterans who screened positive on the AUDIT-C receiving follow-up assessment/intervention in comparison to the rates among Veterans who screened positive on the PHQ-2. The second aim of the study was to examine the relationship between patient characteristics, such as current involvement in mental health treatment and presence of the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) diagnoses associated with the screens (e.g., major depressive disorder, alcohol abuse/ dependence, post-traumatic stress disorder [PTSD]), and the PCP s practices. We hypothesized that these characteristics may help to explain providers tendency to ignore a positive screen, as the information may not be perceived as clinically relevant or contribute to a provider s inadvertent failure to attend to a positive screen within an appointment. METHODS Setting The EMR system provides automatic notifications for medical staff to administer the PHQ-2 and AUDIT-C annually. Once a screen is completed, the Veteran s PCP receives an automatic electronic notification of the screening results when he/she opens the patient s chart. Procedure Using the recommendation of reviewing at least 10 charts per outcome variable (8 variables), 28 we identified a random sample of 98 Veterans who screened positive on the AUDIT-C and another 99 Veterans who screened positive on the PHQ-2 during a primary care visit in VHA clinics within upstate New York (VISN 2) between January 2008 and September 2008 for the chart review. Participants were randomly selected from a list of patients seen by the PCP during this time period who screened positive for alcohol use disorders (AUDs) using the AUDIT-C (n = 10,646), or for depression using the PHQ-2 (n = 2,905). An information specialist pulled the quantitative data (e.g., patient s name, date of screen, score of screen) directly from the EMR. One research assistant trained and supervised by the first author (JF) then reviewed each patient s EMR. Demographics were obtained from the patient information tab in the EMR. The number of previous positive screens was calculated by using the search for text option within the EMR to identify and sum all notes that documented a unique result of the PHQ-2 and AUDIT-C before the screen date. The current participation in mental health treatment was obtained by the research assistant reviewing recent behavioral health progress notes to ascertain the Veteran s current treatment status at the time of the screen. The prior diagnoses were obtained by reviewing the medical problem list for the existence of a diagnosis of alcohol abuse/dependence, PTSD, or a depression diagnosis (i.e., major depressive disorder, depressive disorder not otherwise specified, or dysthymia) at the time of the screen. The progress notes, including those created by the EMR when a provider completes the electronic alert following a positive screen, and medication orders were reviewed on the date and within the week of the screen to identify the PCP actions in response to the screen. These actions included whether the PCP conducted further assessment/counseling on the topic or provided a referral or prescription for a medication. Resolved positive screens were defined as screens that were acknowledged, further assessed/counseled, and/or referred to other providers. Measures Alcohol Use The AUDIT-C 12 is a 3-item version of the 10-item AUDIT. The AUDIT-C assesses an individual s frequency and quantity of drinking in the past year, and frequency of heavy 1072 MILITARY MEDICINE, Vol. 178, October 2013

episodic drinking. Each question is scored on a 0 to 4 scale, with higher scores reflecting greater consumption. Scores range from 0 to 12. The AUDIT-C is reliable and has been validated as a screening instrument for hazardous alcohol use, including risky (for the occurrence of alcohol-related problems) drinking and AUDs. A positive screen for hazardous alcohol use in VHA patients is a score of 4 or more for males and 3 or more for females 12 and indicates that further assessment of alcohol use and related problems is warranted. Depression The PHQ-2 13 is a 2-item version of the 10-item PHQ that assesses the frequency of depressed mood and anhedonia (i.e., loss in interest in activities) over the prior 2 weeks. Each question is scored on a 0 (not at all) to 3 (nearly every day) scale, with possible total scores ranging from 0 to 6. This scale has been validated for use as a screen for depression in primary care, 13 with scores of 3 or more considered positive. Analyses Demographic information is presented with summary statistics. Because alcohol and depression charts were taken from two samples of Veterans (i.e., individuals who screened positive for alcohol or depression, but not both), we were unable to directly compare positive screen follow-up patterns across diagnoses in the same patients. Therefore, cross-diagnosis comparisons will be purely descriptive in nature. The relationship between patient characteristics and screen resolution status was investigated using t-tests and c 2 -tests. All analyses were performed using SPSS version 16.0 (IBM, New York, New York). TABLE I. Demographics for Total Samples (N = 197) AUDIT-C (n = 98) PHQ-2 (n = 99) %(N) % (N) Male 98 (96) 94 (93) Race Caucasian 75 (73) 80 (79) Black 6 (6) 8 (8) Other 0 (0) 1 (1) Missing 19 (19) 11 (11) Marital Status Married 45 (44) 43 (43) Divorced/Separated 22 (22) 36 (36) Single 20 (20) 8 (8) Other 12 (12) 12 (12) M (SD) M (SD) Age 62.9 (16.45) 62.1 (14.78) TABLE II. Comparison of Demographic and Clinical Characteristics for Resolved and Positive AUDIT-C Screens Resolved (N = 37) (N = 61) Sig. M (SD) M (SD) t Age 61.49 (15.67) 64.10 (16.89) 0.664 Total Score 6.92 (2.13) 4.65 (1.33) 6.40*** %(N) % (N) c 2 Previous Treatment 13.5 (5) 14.8 (9) 0.10 Previous AUD Diagnosis 21.6 (8) 4.9 (3) 6.45** Previous PTSD Diagnosis 5.4 (2) 9.8 (6) 0.60 AUDIT-C, Alcohol Use Disorder Identification Test Consumption; AUD, alcohol use disorder; PTSD, post-traumatic stress disorder; Sig., significant difference. **<.01, ***<.001. RESULTS A total of 197 Veteran charts were reviewed for this study, 98 who scored positive on the AUDIT-C and 99 who scored positive on the PHQ-2. Demographic information for both samples is summarized in Table I. The two samples did not differ in their demographic characteristics. The overwhelming majority of Veterans were male and Caucasian, and the mean age of Veterans was approximately 60 years. Overall, each sample is representative of the regional veteran population of the primary care clinics from which the patient charts were pulled. 29 Positive AUDIT-C Only 37 (37.7%) of the 98 sampled screens of Veterans with a positive AUDIT-C were resolved. Table II shows the demographic and clinical characteristics for resolved and unresolved screens. The 61 Veterans with unresolved screens had significantly lower mean AUDIT-C scores than the resolved cases (unresolved M = 4.67, SD = 1.35, resolved M = 6.92, SD = 2.13). In addition, a greater number of those Veterans with resolved screens had a diagnosis of an AUD (e.g., DSM-IV Alcohol Abuse or Alcohol Dependence) than those Veterans with unresolved screens (c 2 = 6.45, p < 0.05). No other significant differences were found. Fewer than 20% (n = 15/98) of these Veterans screened in the severe range of alcohol use (AUDIT-C ³ 8). 30 Of these, 3 were left unresolved and involved Veterans who did not have a previous diagnosis of an AUD nor were actively involved in substance use treatment. More than half (n = 55) of these patients had between one and four previous positive screens, and about 14% (n = 14) had been in mental health treatment at some point before the positive screen. Resolved AUDIT-C Screens Almost 70% (n = 24/37) of resolved screens had at least one and as many as seven previous positive screens. None of them had been in substance use treatment at some point before the screen, although nine had been in mental health treatment before. Fifteen Veterans were assessed by the PCP to be already drinking below the recommended limit. Table III provides an overview of the outcomes following the positive AUDIT-C screen. None of the 37 Veterans was given the AUDIT to assess his/her current level of alcohol use. Of the 37 Veterans, 36 received further counseling from MILITARY MEDICINE, Vol. 178, October 2013 1073

TABLE III. Referral Outcomes for Veterans Who Scored Positive on AUDIT-C or PHQ-2 for Whom the Screen Was Resolved AUDIT-C (n = 37) %(N) PHQ-2 (n = 82) %(N) Received PCP Counseling 97 (36) 100 (82) Assessed Symptoms Using 0 (0) 70 (60) PHQ-9/AUDIT Consult to BHS in Primary 3 (1) 6 (5) Care on Day of Screen Provider-Recommended MH/SUD Treatment 22 (8) 40 (33) PCP, primary care provider; BHS, behavioral health specialist; MH/ SUD, mental health/substance use disorder. These are not mutually exclusive categories. their PCP; however, none of them was prescribed a medication to treat alcohol use, such as naltrexone. Despite behavioral health specialists (BHSs) being located in all VHA primary care clinics, only 1 patient was referred to a BHS for further assessment or intervention. Approximately 20% (n = 8) of those who received provider counseling were referred to specialty care (either mental health or substance use), but all declined. Among the unresolved cases, half (n = 31/61) had screened positive for alcohol at least once before the screen date and only six were currently engaged in either mental health or substance use treatment at the time of the screen. Approximately 15% (n = 9/61) had never been in substance use or mental health treatment in the past and 5% (n = 3) had a past AUD diagnosis. Positive PHQ-2 Of the 99 positive PHQ-2 screens, 82 (82.8%) were resolved by the PCP. Table IV presents the demographic and clinical characteristics of resolved and unresolved cases. Those Veterans with an unresolved PHQ-2 screen were more likely TABLE IV. Comparison of Demographic and Clinical Characteristics for Resolved and Positive PHQ-2 Screens Resolved (N = 82) (N = 17) Sig. M (SD) M (SD) M (SD) Age 60.72 (14.70) 63.59 (15.40) 0.726 Total Score 4.96 (1.24) 4.56 (1.15) 0.972 %(N) % (N) c 2 Prior Treatment 40.2 (33) 47.1 (8) 0.05 Prior MDD Diagnosis 42.7 (35) 35.3 (6) 0.32 Prior PTSD Diagnosis 13.4 (11) 35.3 (6) 5.42* PHQ-2, Personal Health Questionaire-2 items; MDD, major depressive disorder; PTSD, post-traumatic stress disorder; Sig., significant difference. *<0.05. to have a diagnosis of PTSD at the time of the screen than those Veterans with resolved PHQ-2 screens. No other significant differences were found. Fifty-two percent of the Veterans (n = 52) scored the maximum score of 6 on the PHQ-2 reporting depressed mood and lack of interest or pleasure in activities nearly every day over the past week. Of these, 12% (n = 6) were left unresolved and involved three Veterans who were not currently engaged in treatment. About half (n = 45) of these Veterans had between one and four previous positive screens, and about 41% (n = 41) had been in mental health treatment at some point before the positive screen. Resolved Approximately 52% (n = 43/82) of resolved screens had at least one previous positive screen. Fourteen of them had been in treatment specifically for depression at some point before the screen. As shown in Table III, PCPs addressed positive screens with further counseling 100% of the time. Specifically, about 70% (n = 60) administered a full PHQ-9 to assess depressive symptoms in more detail. On average, those who were assessed with the PHQ-9 scored in the moderately depressed range (M = 13.61, SD = 6.56). The most popular referral option was to specialty mental health services. Forty percent of PCPs (n = 33) made a mental health referral, though almost half (45.5%, n = 15) of these patients declined. Only a handful of PCPs (n = 5) made a referral to the BHS in primary care. Five patients were prescribed an antidepressant by the PCP. Out of the 49 patients who were not referred to specialty mental health services, 22% (n = 11) were already receiving some sort of depression treatment (psychotherapy or pharmacology) either in or outside the VHA. Seventeen positive PHQ-2 screens were left unresolved. For these Veterans, the mean PHQ-2 score was 4.65 (SD = 1.12) out of a possible 6. Examining the characteristics of the unresolved group shows that 12 Veterans had a previous positive PHQ-2 screen. Six Veterans had an existing diagnosis of depression in their EMR. Eight had received psychological or pharmacological treatment before the screen date. DISCUSSION These data further support existing research by Maust et al 26 that there are different clinical practices when PCPs are presented with a Veteran screening positive for hazardous alcohol use, using the AUDIT-C, versus a Veteran screening positive for symptoms of depression, using the PHQ-2. It also builds upon that study by examining these practices in greater depth, including how certain patient characteristics impact practices by using chart review. 1074 MILITARY MEDICINE, Vol. 178, October 2013

Similar to the results found by Maust et al 26, one of the most striking discrepancies observed was the higher number of positive AUDIT-C screens unresolved (62.3%) compared with unresolved PHQ-2 screens (17.2%), despite the VHA s similar levels of support that exist within the EMR system for both screens. It may be that the electronic support given is not sufficient and some specific system, provider, or patient barriers have not yet been identified impeding the delivery of assessment/intervention following a positive AUDIT-C screen. Another possibility for these discrepancies is that PCPs ignore positive AUDIT-C screens if they know that a Veteran is already engaged in mental health treatment. Only 15% of those who screened positive on the AUDIT-C and were unresolved were already receiving treatment in the form of medications or psychotherapy; the counterpart statistic for those who screened positive on the PHQ-2 was 47%. Therefore, this possibility may explain why some positive PHQ-2 screens are left unresolved, but it is not the likely explanation for the unresolved AUDIT-C screens. Interestingly, those Veterans whose AUDIT-C positive screens were resolved in the EMR tended to have higher scores on the AUDIT-C, indicating a greater likelihood of experiencing alcohol abuse/dependence, than those Veterans whose AUDIT-C screens were left unresolved. No relationship between scores and resolution status was found for PHQ-2 screens. These findings are consistent with those of previous research on the AUDIT-C showing that providers are more likely to provide counseling to those reporting more severe problems. 31 Research on PCP attitudes suggests that practitioners are more willing to intervene when they believe that a patient s health is directly influenced by his/her alcohol consumption. 32 In contrast, those Veterans scoring lower on the AUDIT-C screen while drinking at a level of hazardous use may not have any currently discernible medical symptoms, 33 and would therefore have a lower likelihood of the positive screen coming to the PCP s attention. However, this finding contradicts other research that examined the usefulness of the VHA s electronic AUDIT-C-guided menus, which found no difference in severity between those Veterans for whom providers did or did not complete the reminder. 18 Research should continue to examine this question, as it may be an indication of one of the provider barriers to implementation of brief alcohol interventions: that PCPs may not perceive positive, yet lower scores as a valid indicator of future health problems. Our interests in the presence of a depression, AUD, or PTSD diagnosis and its association with providers reactions to positive screens may also support the hypothesis that more attention is given to Veterans with more severe symptoms on the AUDIT-C. Veterans with a resolved AUDIT-C were more likely to have an existing AUD than those with an unresolved AUDIT-C (22% vs. 5%). However among Veterans screening positive on the PHQ-2, resolution status was unrelated to an existing depressive diagnosis, but was related to an existing PTSD diagnosis. Veterans with a resolved PHQ-2 were less likely to have an existing PTSD diagnosis than those with an unresolved PHQ-2 (13% vs. 35%). These findings indicate a pattern in which Veterans with AUDs get more PCP services while those with PTSD diagnosis get less. Further exploration should be conducted to better understand why this discrepancy may have occurred. Overall, these data suggest that there are missed opportunities for prevention and/or intervention, even after the initiation of screening and electronic support within an EMR system. Any hazardous alcohol use is predictive of subsequent AUDs 34 as well as higher levels of overall impairment. 4,35 Therefore, the success of the AUDIT-C screen in identifying those with hazardous alcohol use and circumventing more severe negative consequences depends on the primary care team s conducting further assessment and initiating intervention or treatment if necessary. Another interesting discrepancy in provider practices when encountering Veterans with positive screens is the more frequent use of the PHQ-9 compared with the use of the full AUDIT to further assess symptoms. The questionnaires are 9 and 10 items, respectively, have a large evidence base, 36 39 and are easily available within the EMR system as part of the resolution menus. It is unknown why PCPs tend to be considerably more likely to use the PHQ-9 for further assessment and not use the AUDIT. Because these self-report questionnaires can be useful in conducting the necessary additional assessment following a positive screen, future research should explore the reasons that may be contributing to this discrepancy, such as PCP concerns that patients may react more poorly to alcohol use assessment and lack of familiarity with the AUDIT. Another area that warrants further exploration is the infrequent use of prescribed medications. In our data, we found no Veterans receiving a prescription for naltrexone and only 6% receiving an antidepressant following a positive screen. It is difficult to ascertain the severity of symptoms reported by these Veterans, because many of them did not receive the full AUDIT. Therefore, it is possible that some of the Veterans who screened positive on the AUDIT-C or the PHQ-2 may have endorsed a significant level of symptoms to suggest the use of medications to help; however, past research has shown that physician factors such as lack of exposure to efficacy information on such medications negatively affect prescribing practices even when their use is indicated. 40,41 The data show that there are also some similarities between the PCP practices when responding to a positive AUDIT-C or PHQ-2 screen. When PCPs do resolve the screens within EMR, they often indicate that they conduct further counseling with the Veteran and refer for additional treatment. Unfortunately, the data also show that a large proportion of Veterans refuse referrals for additional treatment, whether it is to address depressive symptoms (46%) or hazardous alcohol use (100%). Similar observations reflecting patients lack of interest in specialty mental health treatment have been found at a national level, indicating both MILITARY MEDICINE, Vol. 178, October 2013 1075

a reluctance to initiate treatment and high dropout rates. 42,43 Increased use of BHSs embedded in the primary care setting may help overcome patient barriers to receiving specialty mental health or addiction treatment. 44 There are limitations to this study that should be considered. First, all of the data were collected through chart review, and it is possible only to evaluate what occurred based on the information included in the EMR. For instance, a PCP may have direct knowledge of a Veteran s status in non Veterans Affairs mental health treatment or the Veteran may have had serious acute medical issue that took precedent over the preventative screening, yet a chart review would not be able to easily quantify these issues. In addition, it is possible that other assessment and/or counseling by PCPs may have taken place but were not documented in the EMR within the text of progress notes. This shows the importance of continuing this line of research. Second, the data are based only on those Veterans seen within VHA primary clinics in upstate New York and may not be representative of the primary care practices at other locations. Third, no direct comparisons between Veterans with AUDIT-C positive screens and those with PHQ-2 positive screens can be made, as different samples were included in the chart review. However, this study provides a foundation for additional research that can be used to examine how to further improve this screening process. Overall, these data suggest that the electronic support given via the EMR may not be sufficient to help support PCPs as they attempt to provide preventive services. Future research needs to examine the system, provider, and patient barriers that impact this process. ACKNOWLEDGMENTS This article is based on work supported by the VA Center for Integrated Healthcare. REFERENCES 1. 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