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, 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 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 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 # 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 self-management 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:
- 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;
- 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 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.
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