The National College Depression Project: The Journey Thus Far Eleanor W Davidson MD Susan Kimmel MD May 20 2014
Dec 23, 2015
The National College Depression Project:The Journey Thus Far
Eleanor W Davidson MDSusan Kimmel MDMay 20 2014
Background: What’s the rationale for this project?
Depressive disorders are highly prevalent, enormously costly, and a leading cause of disability and reduced quality of life*
Depressed adolescents are at increased risk for impaired academic performance and attainment**
Among college students stress-related symptoms are major impediments to academic performance***
*Langlieb, et al: JOEM 2005;47:1099-1109**Asarnow, et al: J Adolesc Health 2005;37(6):477-83***ACHA data
American College Health Association - National College Health Assessment (ACHA-NCHA) Web Summary. Updated April 2006. http://www.acha.org/projects_programs/ncha_sampledata.cfm. 2006.
ACHA data
JED Foundation Report 2006
Approx 90% of those who die by suicide at any age:
have a diagnosable mental illness,
most often depression,
Hence identification & treatment of students with emotional disorders is critical to suicide prevention efforts.
ACHA, ACPA, AUCCCD, NASPA
JED report 2006
Counseling service directors report # of students seeking help for serious emotional problems has been rising, but…
The majority of students who die by suicide
have never been to their counseling center!
National data
The vast majority of individuals who suicide have never seen a behavioral health professional.
Have they been to primary care?
AFSP website
Visit to primary care % of suicides
Within 3 months of death 45%
Within 12 months of death 77%**
College Breakthrough Series-Depression: 2006-07
NYU, Princeton, Cornell, CUNY (Hunter & Baruch), CWRU, St Lawrence
Gap Strategy
Under-detection of students with depression & suicidal ideation
Maximize existing medical & mental health resources to identify and treat depression
All studies show that follow up after initiation of treatment (in any setting) is a critical factor for successful outcomes
Create a safety net for identified depressed students including systematic planned follow up, treatment monitoring & coordinated referrals to community links.
Quality Improvement in NCDP
“Trying harder will not work. Changing systems
of care will.”
Don Berwick MD
Institute for Healthcare Improvement
Phase I: challenges
● How would students react to depression screening in the health service?
● Could the health service achieve an 80% rate of screening all patients once during a school year?
● How would clinicians react to screening for depression in primary care?
-Use of Plan-Do-Study-Act cycles
-Start small and grow.
Some of us imagined that our biggest challenge was identification of depressed students who would then be referred to the counseling service for treatment.
Next step: implement depression screening
Changing our systems of care
Which patients will be screened for depression?
What tool will be used for screening?
How will the screening be done?
• When?
• By whom?
• Where will results of screen be recorded?What will be the plan for follow-up of patients after depression screening?
PHQ-2
During the past two weeks, have you been bothered by:
Little interest or pleasure in doing things? □ No □ Yes
Feeling down, depressed or hopeless? □ No □ Yes
Change process : start small and grow
1. Paper PHQ2
10 students tried it
No resistance
2. Screen 1/2 day of my patients.
3. Add more of my patients.
4. Bring on another provider to screen
5. Screen in allergy clinic
Medical assistants: “Just as we screen you for high blood pressure, we also screen for depression.”
Evaluate each change: PDSA cycles
PHQ-9
If you checked off any problems, how difficult have these problems made it for you to do your work, study, go to class or get along with other people? __ Not difficult at all (0) __ Somewhat difficult (1) __ Very difficult (2) __ Extremely difficult (3)
Over the last 2 weeks, how often have you been bothered by the following problems?
Not At All
(0)
Several days
(1)
More than half the
days(2)
Nearly every day
(3)
1. Little interest or pleasure in doing things □ □ □ □
2. Feeling down, depressed, or hopeless □ □ □ □
3. Trouble falling or staying asleep, or sleeping too much □ □ □ □
4. Feeling tired or having little energy □ □ □ □
5. Poor appetite or overeating □ □ □ □
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
□ □ □ □
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
□ □ □ □
9. Thoughts that you would be better off dead, or of hurting yourself in some way
□ □ □ □
Subtotals (add columns)
Total Score
Design multiple options for administering PHQ9
1. Clinician can do the PHQ9 right then (or bring the patient back for the PHQ9)
2. Nurse care manager can do PHQ9
3. Clinician can refer for a PHQ9 (Women’s Health Advocate)
4. Nurse could refer directly to counseling
You can individualize the model to suit your own circumstances; you have to have the elements but not a single solution.
You’re creating the “prepared practice.”
Additional benefits of the PHQ9
Turned out to be a great teaching tool:
for patients (what is depression)
for clinicians
Leads clinicians from the easier questions (typical for a primary care setting) into the more difficult ones—gives them a script to follow.
Next step: score the PHQ9
Minimal depression 0-4
Mild depression 5-9
Moderate depression 10-14
Moderately severe 15-19
Severe 20-27
Positive # 9 always needs to be addressed (written emergency information provided & documented).
1. Discuss results with student.
2. High score does not equal depression.
3. Other primary disorders ruled out.
4. Initiate evidence-based treatment for depression (counseling, medication, self-management).
Other elements
Design clinical information system (registry):
Track more highly affected students using enhanced care management.
Use registry to plan next visits & achieve process measures (check PHQ9 scores for evidence of improvement). Change treatment if no improvement.
Assign care manager who reaches out to students who haven’t followed up
Monitor progress in screening
Weekly lists of students screened
Finding when we missed an opportunity to screen.
Figure out why & redesign system.
Depression Screening in Primary Care
- A stretch goal of 80% for primary care screening was set for the 6 sites that committed to implement standardized depression screening
- The collaborative achieved an aggregate screening rate of 65% by the end of 2007.
Aggregate CBS-D Depression Screening Totals for 2007
(N = 58,759 as December 31, 2007)
4,492
9,759
15,146
42,504
48,903
20,489
24,920
35,70532,012
28,643
58,759 55,489
-
10,000
20,000
30,000
40,000
50,000
60,000
70,000
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Depression Registry
Growth in the CBS-D Depression Registry Size (N = 801 as of December 31, 2007)
161
240
304371
412
471
545 561
623
710768
801
0
100
200
300
400
500
600
700
800
900
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
CWRU experience
We could achieve 80-90% screening throughout the Health Service (we excelled at using it through all visit types).
Screening was well-received by students.
CWRU experience
The team embraced the PHQ9:
- routine measurement
- routine documentation in EHR
- communication tool between services
CWRU experience
Certain populations disproportionately accessed care in the Health Service:
1. Non majority students
2. Men
So we did appear to be expanding access to care.
A Pyati PhD
Next phases of NCDP
• More partners, more diversity of schools
• Connections to Healthy Minds (Daniel Eisenberg PhD)
• Other measures (anxiety, alcohol, mental health flourishing)
• Expanded self-management focus
The information presented herein may not be distributed without express permission from New York University as coordinating center of the National College Depression Partnership.
42 Partnering Institutions Since 2006
• Rio Hondo College• Rutgers University• Sarah Lawrence College• School of the Art Institute of
Chicago• St. Lawrence University• Skidmore College• Texas A&M University• Texas Christian University• Tufts University• University of Arizona• University of California, Los
Angeles• University of Central Florida• University of Louisville• University of Maryland• University of Missouri - Columbia• University of Nevada, Las Vegas• University of Pennsylvania• University of Vermont• University of Wisconsin -
Madison• Wagner College• West Valley College
• Baruch College• Boston University• Bowling Green State University• Case Western Reserve University• Colorado State University• Columbia University• Cornell University• Evergreen State College• Finger Lakes Community College• Hunter College/CUNY• Lewis-Clark State College• Louisiana State University• McMaster University• Michigan State University • Montana State University• The New School• Northeastern University• New York University• Penn State – Altoona• Princeton University• Rensselaer Polytechnic Institute
Population perspective: Healthy minds study
Permission to use next set of slides from
Daniel Eisenberg PhD
Director, Healthy Minds Network
Healthymindsnetwork.org
Data from the Healthy Minds Network: Prevalence and Treatment of
Depression among College Students
Daniel Eisenberg, Ph.D. Director, Healthy Minds Network
University of Michigan School of Public Health
Presentation for NCDP, September 16, 2013
Healthy Minds Study
Began in 2005 Fielded at approximately 100 campuses ~100,000 survey respondents
Main measures Mental health (depression, anxiety, self-injury, suicidality, disordered
eating, positive mental health) Lifestyle and health behaviors (substance use, exercise, sleep, etc.) Attitudes and awareness about services Service utilization Academic and social environment
29
HMN Survey Research
Healthy Minds Study (nearly 100 schools, 2005-present); Healthy Bodies Study (beginning 2013)
28
Main Findings from Healthy Minds
“Treatment gap” of >50% in college populations
Stigma low and knowledge high for many untreated students Help-seeking interventions require new approaches
Mental health predicts academic success GPA & retention Economic case for mental health services/programs
31
9.8%
Data source: HMS, 2007-2013
17.9%
9.9%7.2%
15.7%
34%
0
10
20
30
40
50
Major dep. (PHQ-9)
Any dep. (PHQ-9)
Anxiety (PHQ)
SuicidalIdeation
Self-injury Any
Prevalence of MH problems
Past-year Treatment for MH problems(Medication or counseling/therapy)
45%
Data source: HMS, 2007-2013
38%
53% 52%
41%
39%
100
90
80
70
60
50
40
30
20
10
0
Major dep. (PHQ-9)
Any dep. (PHQ-9)
Anxiety (PHQ)
Self-injury AnySuicidalIdeation
Past-year Treatment,among students with past-year PHQ-2 score ≥3
19%
Data source: HMS, 2009-2013
32%30
37%
10
0
20
40
50
Antidepressant Counseling/therapy Either modality
Duration of Antidepressant Use,among students with antidepressant use and PHQ-2
score ≥3
9%
Data source: HMS, 2009-2013
12%
79%
100
90
80
70
60
50
40
30
20
10
0
<1 month 1-2 months >2 months
Prescriber Types,among students with antidepressant use and PHQ-2
score ≥3
49%
Data source: HMS, 2007-2013
54%
3% 0.4% 3.5%
100
90
80
70
60
50
40
30
20
10
0
General Practitioner
Psychiatrist Other Don't know Took w/o RX
Number of Counseling/Therapy Visits,among students w/ counseling/therapy use and PHQ-2
score ≥3
30%
Data source: HMS, 2007-2013
23%
16%
31%
0
10
20
30
40
50
1 to 3
4 to 6 7 to 9 10 or more
Problem and Opportunity
PROBLEM:
“Minimally adequate depression care” (Wang et al, 2005 Arch Gen Psych): 8+ psychotherapy visits, or 2+ months of antidepressant use with 4+ discussions with provider
Only 20% of students with past-year depression (Healthy
Minds 2009-2013)
OPPORTUNITY:
80% of students report visiting a health professional at least once in the past year
Extrapolating Numbers to Typical Campus of 10,000 Students
2,630 students with past-year depression 530 with minimally
adequate care 2,100 without minimally adequate care
525 at least some mental health care
1,120 no mental health care, but contact with health care
435 no contact at all with health care
Gap between perceived need
and use of mental health services
60%
25%
100%
28%
77%
35%
77%
43%
0102030405060708090
100
Asian Black Latino White
Perceived Need
Service Use
Perc
en
tag
e
Among students with depression based on current positive PHQ-9 screen [n = 971].
Healthy Minds Study, 2007
Models of care : each has challenges
Some with integrated health & counseling:
Stanford, Cornell, Princeton, Wash U, NYU, Penn State Altoona
Some with mostly counseling:
SAIC, Baruch
Some with both elements, parallel reporting:
Shared EHR
Non shared records (both electronic & paper)
CWRU model: assets & challenges
• Vast majority of students entered into depression registry from Health Service (early adopters more on Health Service side).
• Robust, open access counseling service on campus, no charge for visits
• We originally thought our task was to identify depressed students and refer to UCS for care
• We found that most students wanted to return to the place they originally came for help.
Identification was the easy part.
Our challenge was what to do when students did not want either counseling or medication
Self-management tools
Phase II and III of NCDP markedly increased the role of self-management skills
Tamara Lazenby MD, NYU (psychiatry)
Evette Ludman PhD Group Health Research Institute
What Is Self-Management?
Self-management - Goal directed patient behaviors that enhance clinical & functional outcomes:
– Medication management and adherence– Self-monitoring of symptoms, treatment status
– Managing effects of illness on social role function– Reducing health risks (alcohol misuse, smoking)
– Preventive maintenance (e.g., exercise,
screening check-ups)– Working with health care professionals
NCDP Operational Definition
The engagement of patients in a collaborative partnership with clinicians to achieve goal-directed behavioral change and patient activation.
Why self-management?
• It’s evidence-based• It’s fairly simple
• Focuses on student-activation• We know these work well to improve outcomes for
both medical and mental health conditions• It was something we had access to (all of Student
Affairs has self-management tools for students)
Developmental parallels
Many of the tasks of being a student center around self management skills:
1. Activities of daily living (how much to sleep, eat, study, play video games, etc)
2. How much caffeine to take in, how many energy drinks, supplements, etc
3. How much alcohol or other substances to use
4. How much to sleep
Options
Mindfulness tools
Meditation
Exercise
Diet/nutrition/sleep hygiene
Harm reduction
Positive social supports
DBT skills
More recent changes
We add data from:
Emergency transports (Case EMS & Security)
Students of Concerns committee
Risk assessment discussions
We routinely add these into our records
FERPA not HIPAA
Lessons & Challenges
1. Screening for depression in primary care has helped all clinicians see sooner and with more clarity the underlying reasons for visit.
2. The entire staff understands a collaborative, systems approach to quality care and why teams are more effective than individuals working alone.
3. Each school must tailor implementation of depression screening to fit its own assets and student needs.
Putting the mind & body “back together”
It seems to be a challenge (for students & clinicians):
- continuity of care
- mind-body connection
- not coming to mental health issues only after every other avenue has been explored—bring these considerations up early/often & in a straightforward, transparent manner
- teach the importance of knowing about all medication taken and who’s prescribing.
Communicate
Your primary care clinician is interested in you as a whole person—all of these elements are significant in your care.
Expect us to check in with you as to how these things are going.
Teach students what they can expect in the future from healthcare that values them as whole people.
The journey: our current recommendations
Depression screening in a university health service is feasible, well received by students, and accepted by staff.
Everyone should be able to screen using the PHQ2, no matter what the resources available.
We recommend screening all students (not just elective visits for primary care).
Using a follow up PHQ9 is helpful for both diagnosis and measuring response to treatment.
Questions?
Comments?
Thanks for listening.
© New York UniversityCBS-D
From January 1, 2007 – December 31,2007
© New York UniversityCBS-D
From January 1, 2007 – December 31,2007
© New York UniversityCBS-D
Sites that reported exceeding designated goals on all three process
measures reported rates of functional improvement at 12 weeks more than double than those sites who did not surpass all three goals (66.5% vs. 31.7%).
Rates of Functional Improvement Grouped by Site Process Measure Success
66.5%
31.7%
0%
10%
20%
30%
40%
50%
60%
70%
80%
All Process Goals Met (n = 260) Not All Process Goals Met (n = 224)
All Process Goals Met(n = 260)Not All Process GoalsMet (n = 224)