27 Mar Discuss your proposal change project with your classmates, including brief information about the process, the results obtained, and your experience comp

N-710

Enhancing Healthcare Professional’s Role in Assessing and Monitoring Depression Levels Using PHQ 9 Depression Screening Tool

Facilitator:

Module # 5: Assignment # 1: Final Proposal

Student:

Date: March 11th, 2025

A prevalent and crippling mental illness that affects millions of people globally is depression (Moitra et al., 2023). Its sneaky nature frequently goes unrecognized until its terrible consequences become apparent, affecting the victims, their families, communities, and larger social systems. It is becoming more and more important to provide early detection, continuing monitoring, and management as the prevalence of depression rises. How important it is to train medical staff to recognize, diagnose, and track depression in various healthcare settings is a recognized priority (Ford et al., 2020).

To improve healthcare practitioners' comprehension and application of the Patient Health Questionnaire (PHQ-9) for clinical practice depression screening, this project intends to conduct an educational activity. Through highlighting the significance of prompt identification and treatment of depression, the initiative seeks to enhance patient outcomes.

Significance of the Practice Problem

Depression affects people of all ages, genders, socioeconomic statuses, and cultural origins; it has no borders. The World Health Organization (WHO) estimates that 264 million people worldwide suffer from depression, making it one of the main causes of disability worldwide (Goodwin et al., 2022). Even more, it is anticipated that the prevalence of depression will rise globally due to a number of variables, including socioeconomic inequality, the stigma associated with mental illness, and the long-lasting effects of the COVID-19 pandemic.

Crucial tactics for reducing the negative impacts of depression are early detection and intervention. Early diagnosis and treatment significantly enhance recovery rates, diminish symptom severity, and improve the overall quality of life for individuals grappling with depression (Blackstone et al., 2022).

Healthcare experts play a key role in the management of depression. They are frontline responders with the knowledge and power to evaluate, identify, and treat depression in a variety of healthcare settings, from general practice offices to inpatient mental health centers. Providing evidence-based interventions, identifying depression, and facilitating patient-centered care all depend on healthcare providers having the right information, abilities, and resources (Blackstone et al., 2022).

In the toolkit of healthcare providers, the Patient Health Questionnaire (PHQ-9) shows promise as a screening instrument for depression detection. The PHQ-9 is a short, self-administered questionnaire designed to evaluate the frequency and intensity of depressive symptoms, allowing medical professionals to determine whether or not a patient is depressed rapidly (Levis et al., 2019). Its ease of use, dependability, and validity make it a priceless tool for identifying those in danger and enabling prompt treatments.

Even with the importance of diagnosing and treating depression, medical practitioners still face several obstacles in their work. Inadequate mental health education and training, time restraints, stigma, and resource scarcity frequently make it difficult for them to treat depression in clinical practice successfully. Furthermore, because depression has many facets, treating it requires an integrated, multidisciplinary strategy that includes social, pharmaceutical, and psychological interventions (Cuijpers et al., 2020).

To address the growing demand for improved depression screening and treatment, a comprehensive training program aimed at medical professionals is suggested. This program aims to give medical professionals the necessary understanding, abilities, and self-assurance to evaluate, treat, and track depression levels in a variety of healthcare environments. The main screening instrument in this proposal is the Patient Health Questionnaire (PHQ-9), which is complemented by evidence-based therapies and continuous monitoring procedures.

PICOT Question

For healthcare providers (P), does an education program on the Patient Health Questionnaire 9 (PHQ9) (I), compared with no education program (C), increase knowledge on screening depression (O) over a period of 8 weeks (T)?

Hypothesis: It is hypothesized that through targeted education and training, licensed healthcare providers will demonstrate increased awareness, proficiency, and utilization of the PHQ-9 for screening depression in clinical practice. Furthermore, it is hypothesized that early detection and treatment of depression will lead to improved patient outcomes, reduced risk of complications, and ultimately enhanced quality of life.

Objectives

Objective 1: Assess the baseline knowledge level of licensed healthcare providers regarding depression screening using the Patient Health Questionnaire 9 (PHQ9) before implementing the education program.

Objective 2: Implement an educational program for licensed healthcare on the Patient Health Questionnaire 9 (PHQ9), focusing on understanding the tool's administration, interpretation, and implications for depression screening.

Objective 3: Evaluate the effectiveness of the educational program by comparing the post-intervention knowledge level of licensed healthcare providers regarding depression screening using the PHQ9 with their baseline knowledge level, measured at the end of an 8-week period.

Theoretical Framework

Renowned author and leadership specialist John Kotter created the highly regarded Theory of Change, which offers a methodical framework for managing the organizational transition. Fundamentally, Kotter's Theory of Change strongly emphasizes establishing a coalition that will lead, cultivating a culture of ongoing learning and adaptation, and generating a feeling of urgency. This idea can act as a guide for implementing successful educational programs and fostering long-lasting change when it comes to depression screening in primary care. This idea provides important direction for encouraging educational initiatives to improve primary care providers' screening methods for depression.

The "8-Step Process for Leading Change," based on John Kotter's theory of change, provides a framework for managing organizational transformation. This model has been used for medical residence didactics and other medical applications (Haas et al., 2019). The principles of the Kotter model are:

Create a Sense of Urgency: Kotter stresses the need of giving stakeholders a compelling rationale for change to inspire action and combat complacency.

Form a Powerful Coalition: A guiding coalition is a broad group of prominent leaders and stakeholders committed to change. This coalition guides, supports, and funds change.

Create a Vision for Change: Kotter emphasizes the need for a compelling vision of the organization's future. A compelling vision guides transformation efforts and unites support.

Effective communication is needed to spread the change vision throughout the business and ensure that all stakeholders understand the reasons, objectives, and benefits of the proposed changes. Consistent communication reduces opposition and builds support.

Empower Broad-Based Action: Kotter encourages all employees to own and implement change. By incorporating many people in decision-making and problem-solving, organizations can tap into their employees' intelligence and creativity.

Short-Term Wins: Celebrating early triumphs and generating real results keeps momentum and builds trust in the change endeavor. Kotter suggests identifying fast wins to show vision progress and change program effectiveness.

Consolidate successes and Produce More Change: Kotter stresses the necessity of consolidating initial successes and building on them. Reinforcing new behaviors, procedures, and structures and resolving lingering change resistance is required.

To sustain change, implant new behaviors and practices within the organization's culture. Kotter recommends leaders institutionalize change by aligning systems, structures, and processes with intended objectives and values to ensure sustainability. Applying Kotter's theory in healthcare settings has demonstrated the validity of these principles and their current practice. A recent compilation of Change Theories developed by Harrison and colleagues found that among the 38 studies that discussed applying 12 different change management approaches in healthcare settings among ten different nations, Kotter´s Model was the most frequently used with 19 studies (Harrison et al., 2021).

A methodical strategy for enhancing depression screening procedures in primary care settings is offered by Kotter's theory of change. Healthcare companies can improve patient outcomes and well-being by implementing Kotter's eight-step procedure to help staff members identify depression and deliver prompt interventions. The model was used in various healthcare scenarios in these studies, including emergency services, teaching for quality improvement in hospitals, rural healthcare services in the US and UK, frontline staff in surgical units, Canadian academic teaching hospitals, nurses providing palliative care, Australia, frontline staff in maternity wards, nurses providing acute inpatient mental health units, surgical orthopedic trauma units, cancer units, and so on (Harrison et al., 2021).

Synthesis of the Literature

A study published in 2022 by Blackstone et al. described a quality improvement program that was applied in five Family Medicine clinics to increase the rates of depression screening, which was especially pertinent during the COVID-19 pandemic. The Journal of Community Health released an article titled "Improving Depression Screening in Primary Care: A Quality Improvement Initiative," which summarized the initiative's findings. The program included distributing instructional materials, working with health information technology, standardizing workflows, and offering staff and clinicians follow-up training.

23,745 clinic encounters between September 2020 and April 2021 were analyzed, and the results showed that the percentage of patients who were up to date on depression screening had significantly increased, going from 61.03% to 82.33%. According to a multi-level logistic regression model, patients who were attending in-person appointments, had comorbidities, and were 65 years of age or older were more likely to be up to date on screening. Telemedicine visits, on the other hand, were linked to decreased probabilities. In addition to offering suggestions for future interventions, the study sheds light on a successful intervention that improved depression screening in a primary care context (Blackstone et al., 2022).

The Journal of the American Psychiatric Nurses Association published an article by Brown et al. (2020) titled "Enhancing PHQ-9 Utilization Rates in a Primary Care–Mental Health Integration Setting," which summarizes the research findings. In order to enhance the use of the Patient Health Questionnaire-9 (PHQ-9) in a primary care-mental health integration (PC-MHI) environment, the study focuses on a quality improvement (QI) procedure. Baseline and follow-up PHQ-9 administration rates were 76% and 35%, respectively, prior to the intervention. In 2017, the QI program was put into action, involving motivational improvement sessions and educational initiatives. Provider utilization rates for PHQ-9 increased dramatically after the intervention, reaching 88% at follow-up and 98% at baseline.

The study highlights the potential for better patient care through systematic monitoring by showing that a brief educational intervention effectively boosts clinician utilization of Measurement-Based Care (MBC) within a PC-MHI scenario. The paper also emphasizes how critical it is to conduct additional research on the meaningful application of MBC to inform treatment choices (Brown et al., 2020).

"Barriers to Healthcare Access among U.S. Adults with Mental Health Challenges: A Population-based Study" was the title of the Coombs study. The purpose of this cross-sectional study was to measure the prevalence of barriers to healthcare access among individuals in the United States, with a particular focus on mental health problems (MHC). The study used data from the 2017–2018 National Health Interview Survey. 50,103 adults participated in the study by Coombs and colleagues, who divided the participants into three categories of psychological distress: none, moderate, and severe.

Even though most participants said they had faced at least one obstacle to receiving healthcare, the study found no significant correlation between severe psychological distress and not having a regular source of care (NUSC). Rather, NUSC was linked to variables like Hispanic ethnicity, male gender, and worries about the cost of healthcare. The study found that having dependents, a current partner, and access to paid sick leave were protective variables. The findings support more research into how social and environmental factors affect the degree of obstacles faced by people with mental health issues and emphasize the significance of addressing financial concerns to improve healthcare access (Coombs et al., 2021).

A systematic evaluation was carried out by Costantini and associates to assess the efficacy of the Patient Health Questionnaire 9 (PHQ-9) as a depression screening instrument in primary care settings. In 2021, their research was presented in a paper titled "Screening for depression in primary care with Patient Health Questionnaire-9 (PHQ-9): a systematic review." 42 research publications from 1995 to 2018 were retrieved from different databases and examined for this review. Most of the research was cross-sectional (95%), concentrated on adult populations (90%), and was carried out in high-income nations (71%).

The PHQ-9's accuracy was evaluated in 74% of the studies through a two-stage screening process that frequently including organized interviews with mental health and primary care providers. In most investigations, a cut-off score of 10 was recommended. PHQ-9 overall showed a range of values for specificity (0.42 to 0.99), positive predictive value (0.09 to 0.92), negative predictive value (0.8 to 1), and sensitivity (0.37 to 0.98). The review emphasizes the need for longitudinal research to determine the long-term efficacy of depression screening in primary care, even if it also emphasizes the PHQ-9's widespread validation and recommendation in a two-stage screening approach (Costantini et al., 2021).

By utilizing the American Academy of Pediatrics (AAP) Guidelines for Adolescent Depression in Primary Care (GLAD-PC), Costello and colleagues conducted a descriptive and exploratory study with the goal of improving the identification and treatment of adolescent depression in a pediatric primary care setting. The Journal of Clinical Psychology in Medical Settings published their findings under the heading "Addressing Adolescent Depression in Primary Care: Building Capacity Through Psychologist and Pediatrician Partnership." Between January 2017 and August 2018, 2,107 adolescents, ages 11 to 18, received depression screenings using the PHQ-9A, thanks to the collaboration of integrated psychologists, clinicians, and clinic personnel.

Results were published in 2019 and showed that 7% of adolescents tested positive for suicidal thoughts and 11% of adolescents had heightened screening (scoring ≥ 10). Increased use of integrated behavioral health services by psychologists, psychiatrists, and psychology trainees was brought about by the identification of depressed symptoms. The implementation's success demonstrated the value of psychologists in helping primary care practitioners follow GLAD-PC principles and get past implementation roadblocks in practical situations. The importance of universal screening and response strategies for teenage depression in pediatric primary care is highlighted by this study (Costello et al., 2019).

A study titled "Psychological Treatment of Depression in Primary Care," carried out in 2019 by Cuijpers and colleagues, provides information on the most recent developments in psychological therapies for depression in basic care settings. The study presents a number of important findings, such as the efficiency of using e-health applications to deliver psychotherapies, the successful use of lay health counselors in low- and middle-income nations, and the similar effectiveness of behavioral activation and cognitive behavior therapy.

In addition, managing subthreshold depression not only mitigates symptoms but also acts as a deterrent to the development of major depression. Psychological therapy are effective for a wide range of populations, such as the elderly, those with general medical issues, and pregnant women who are depressed. All things considered, psychological therapies used in primary care are more patient-preferred, have longer-lasting effects than pharmaceutical interventions, and may be applied in a variety of ways to different target groups and formats. The study's findings were released in 2019 by Cuijpers et al. in the Journal Current Psychiatry Reports.

According to a report in The Lancet Psychiatry, the same researcher oversaw a study titled "Treatment Outcomes for Depression: Challenges and Opportunities." The wide-ranging effects of depressive disorders on quality of life are highlighted by this study, underscoring the urgent need for efficient treatments. Even though antidepressant drugs and psychotherapies are examples of current interventions that have proven effective, there are still areas that might use better and some noticeable limits. The paper outlines ten important data that shed light on these limitations, one of which is the noteworthy finding that a considerable number of patients—especially children and adolescents—show improvement in the absence of official treatment.

The effectiveness of treatments is still unknown despite a large number of randomized trials because of biases, low statistical power, and a variety of outcome measures. The results of the study highlight knowledge gaps on the fundamental causes of depression, the limits of its diagnosis, and the intrinsic variability of the illness. In order to address these issues and encourage the creation of novel methods and treatments for depression in the upcoming ten years, the paper presents the Wellcome Trust's innovative mental health program strategy as a possible solution (Cuijpers et al., 2020).

In 2020, Davis and associates carried out research with the goal of using depression screening to determine the risk of teenage suicide. The results of this study, titled "Identifying Adolescent Suicide Risk via Depression Screening in Pediatric Primary Care: An Electronic Health Record Review," were published in the Journal Psychiatric Services. Retrospective data from electronic health records was used in this study. The researchers looked at the suicide risk rates found using a depression screener that was used in a sizable pediatric primary care system. They also examined the one-year follow-up care that was given to teenagers who expressed a risk of suicide.

To determine suicide risk rates based on items affirmed on the Patient Health Questionnaire-Modified for Teens (PHQ-9-M), retrospective electronic health record data were collected. The evaluation covered teenagers between the ages of 12 and 18 between September 1, 2014, and August 31, 2016. After a manual review of the charts, the charts were coded to record different follow-up care actions in the year that followed the suicidality endorsement. These actions included referrals to mental health practitioners and the distribution of information about crisis lines.

In a sample of 12,690 teenagers, 5.1% admitted to having thoughts of suicide or self-harm, 3.6% said they had attempted suicide at least once in their lives, and 2.4% said they had had significant suicidal thoughts in the previous month. A manual record review was conducted on a stratified random subsample of 150 out of the 643 teenagers who reported having had a lifetime attempt at suicide, current serious thoughts, or both, in order to evaluate the sorts of follow-up care they had received. High fidelity was shown by the PCPs (primary care physicians) in following the suicide evaluation questions provided by the system. Nonetheless, there was greater variation in the follow-up care provided by PCPs and other healthcare professionals in the year that followed the suicide risk recommendation.

These results highlight how easily suicide assessment processes can be included into pediatric primary care depression screening processes. Additionally, they stress how crucial it is to give adolescents who have been recognized as having an elevated risk of suicide as many options for preventive care as possible (Davis et al., 2020).

In a study published in 2021, Davis and colleagues investigated sociodemographic differences in the frequency of increased depression and suicide risk, as well as adolescent depression screening rates, in a sizable pediatric primary care network in the United States. The study's conclusions, titled "Adolescent Depression Screening in Primary Care: Who is Screened and who is at Risk?" were published in the Journal of Affective Disorders. The network expanded its standard methodology for universal depression screening to include well-visits for all adolescents 12 years of age and older.

The data showed an 81.48% screening rate, with higher screening probabilities seen in female teenagers, those who were 12–14 years old on their first well-visit, White people, Hispanic/Latino people, and people with public insurance. A significant proportion of teenagers (5.92%) met the criteria for depression symptoms, and 7.19% said they had considered suicide. Risk differences were seen for a number of sociodemographic characteristics, highlighting the need for more equal screening procedures to address these differences (Davis et al., 2021).

In order to examine patterns of stability and change in the risk of adolescent depression and suicide identified through universal depression screening in pediatric primary care, Davis and colleagues conducted a study titled "Emerging Risk of Adolescent Depression and Suicide Detected Through Pediatric Primary Care Screening." They also sought to identify factors associated with emerging risk.

Retrospective data from electronic health records was gathered, comprising sociodemographic information and depression screening results at two intervals, for adolescents aged 12 to 17 who received well-visits in a large pediatric primary care network between November 15, 2017, and February 1, 2020. The study included 27,335 teenagers in total who completed depression screening twice.

Some adolescents experienced emerging risk (i.e., low risk initially but elevated risk later), decreasing risk (i.e., high risk initially but low risk later), or consistently high risk for depression or suicide, even though the majority of adolescents maintained low-risk levels for depression and suicide throughout both time points. Adolescents with Medicaid insurance had a higher chance of suffering developing depression and a higher risk of suicide than adolescents with private insurance, as well as a higher likelihood of experiencing these conditions among Black adolescents compared to White adolescents. Furthermore, compared to their younger and non-Hispanic/Latino counterparts, older adolescents and those who identified as Hispanic/Latino were more likely to exhibit emerging depression risk. These results shed light on how to keep an eye on symptoms and spot possibilities for prevention in primary care settings (Davis et al., 2024).

At an academic medical center, Ayvaci and colleagues compared the treatment of teenage depression in pediatric and psychiatric settings. The results, titled "Treatment of Adolescent Depression: Comparison of Psychiatric and Pediatric Settings at an Academic Medical Center Using the VitalSign6 Application," were published in the Journal of Child and Adolescent in 2024. The purpose of the study was to close the knowledge gap regarding the management of pediatric depression in various healthcare settings.

Little is known regarding the management of pediatric depression in primary and psychiatric care settings, despite the fact that treatment outcomes and remission rates for depression in adults have been thoroughly investigated in both settings. Thus, the purpose of this study was to compare pediatric and psychiatric depression treatment modalities. It was hypothesized that patients with milder depression would receive more frequent treatment in pediatric settings and use medication less frequently.

Between May 2017 and May 2022, 3498 patients at a children's hospital were screened for depression using the VitalSign6 initiative, a web-based tool for managing depression. The two-item Patient Health Questionnaire (PHQ) was used for screening, and patients who scored ≥10 on the baseline nine-item PHQ (PHQ-9) were included in the analysis. Measures reported by patients as well as diagnosis and treatment decisions made by providers were included in the data for each clinic visit.

Of the 1323 patients who tested positive for depression, PHQ-9 ratings were considerably higher in psychiatric settings (15.9 ± 5.0 vs. 12.1 ± 5.5; p < 0.0001) than in pediatric settings. In comparison to pediatric settings, patients with PHQ-9 scores ≥10 in psychiatric facilities had a higher likelihood of receiving medication (54.8% vs. 6.6%) and receiving a major depressive disorder diagnosis (60.6% vs. 24.7%, p < 0.0001). On the other hand, patients in pediatric settings were more likely to obtain an outside referral (27.7% vs. 5.7%) or nonpharmacological treatment alone (36.3% vs. 4.3%). There was no discernible difference in remission rates between the two environments.

According to the study's findings, children and adolescents in psychiatric facilities are more likely than those in pediatric settings to screen positive for depression and to have a more severe form of the illness. Treatment suggestions for moderate-to-severe depression are provided in both settings, however the specific forms of care differ significantly. However, remission rates don't change much. To completely comprehend the subtleties of therapy variations and their ramifications, more investigation is required (Ayvaci, et al., 2024).

Adolescent depression screening and early management are advised, however they can be difficult to execute. at order to increase the number of adolescents who are screened for depression during preventive care visits at twelve primary care clinics, Beck and colleagues carried out a project. The objective was to continue these gains for a full year by raising screening rates from 65.4% to 80% and increasing the percentage of documented initial care for positive screens from 69.5% to 85%.

The study, "Improving Primary Care Adolescent Depression Screening and Initial Management: A Quality Improvement Study," which was published in "Pediatric Quality & Safety," focused on adolescents aged 12 to 17 and involved 12 urban primary care clinics that served over 120,000 patients, the majority of whom were enrolled in Medicaid. Standardized depression screening with tablets that were integrated with automated scoring and electronic health record (EHR) recording were among the interventions. Other strategies included provider education, performance evaluation for individual clinicians and clinics, and the integration of screening results and first management actions into the EHR.

The average rate of depression screening increased to 91.9% after the screening methodology was standardized. However, the percentage of properly documented initial management plans dropped from 89.7% to 67.6% once tablets were introduced into the clinic workflow. In response to this unanticipated variation, the EHR flow was redesigned with regard to result presentation and action prompts after a positive screen, in addition to enhanced provider feedback and education. As a result, by the time the project was finished, 87.3% of the initial management had been properly recorded.

The use of EHR scoring capture during screening resulted in a considerable increase in the number of depression screenings; however, it also required extra work to improve post-positive screening treatment. Meaningful and long-lasting gains in comprehensive adolescent depression screening required a comprehensive system strategy that included EHR upgrades, clinical education, and performance evaluation (Beck et al., 2022).

Global disability-adjusted life years (DALYs) are greatly impacted by major depression, especially in resource-constrained areas where illness often coexists with socioeconomic problems. Therefore, developing depression screening tools for primary healthcare settings is absolutely necessary. Verifying the PHQ-9 in Tanzania was the main goal of the research done in 2019 by Fawzi et al. The validation study involved persons accessing primary healthcare services at public clinics in Dar es Salaam between August and October of 2014. identifying current major depressive episodes by applying the Mini-International Neuropsychiatric Interview (MINI) as the reference standard.

Results from the examination of 174 individuals (six of whom were excluded) showed that the PHQ-9 had acceptable reliability in this situation (α=0.83). Associations with female gender (r=0.16, p=0.04) and food insecurity (r=0.30, p<0.0001) confirmed the construct validity. The most relevant findings from this study were published in 2019 under the heading "Validating the Patient Health Questionnaire-9 (PHQ-9) for Screening of Depression in Tanzania" in the Journal of Neurology, Psychiatry, and Brain Research.

The PHQ-9's overall accuracy was shown to be commendable by the Receiver Operating Characteristic analysis (AUC=0.87, 95% CI: 0.77, 0.96). It was shown that 9 was the ideal cut-off score for this population, with a sensitivity of 78% and a specificity of 87%. It is imperative to recognize the limits of this study, especially with respect to the study sample that was drawn from a primary healthcare environment, since this could potentially limit the study&a

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