The National Cancer Institute (NCI) estimates that depression affects approximately 15% to 25% of cancer patients and that identifying and treating depression is an important part of cancer care.
Following the practice of other physician offices in the Edward Health System in Greater Chicago, we implemented the use of the Patient Health Questionnaire (PHQ-9) depression screening tool to provide consistency across the organization, more effective communication, and improved collaboration of care.
The PHQ incorporates depression criteria included in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Question No. 9 of the PHQ screens for the presence and duration of suicidal ideation. Data also was collected on the number of referrals generated to Social Work and monthly audits are done on the depression scores and interventions initiated.
From March-May 2012, 161 referrals were generated to our Social Work staff, and the average depression score out of 170 patients audited was 4.76, indicating an intervention of providing support service information and education to the patient. Patients are assessed with the use of a standardized screening tool, depression scores identified and appropriate interventions initiated.
Validity & Reliability
Depression remains under diagnosed among the general population, and is more prevalent in patients with a chronic illness such as cancer.
Although the National Comprehensive Cancer Network (NCCN) and the American College of Surgeons Commission on Cancer (CoC) have developed standards to incorporate the psychosocial component of cancer care, it remains a challenge for cancer programs to implement this successfully.
Research has shown that patients with increased distress and anxiety can impact the tolerance of treatment, side effects, and outcomes. It also plays a role in survivorship and overall emotional well-being for not only the patient, but also the family and caregivers of the patient.
In order to accurately assess patients, a standardized screening tool must be implemented so that all providers can utilize the tool and maintain an unbiased, objective assessment of the patient. This will help ensure continuity of care and communication across providers.
After researching the various tools available, Edward Cancer Center, Naperville and Plainfield, Ill., chose the PHQ-9 Depression Screening tool.
Based on the literature, the PHQ-9 has shown validity and reliability along with the advantage of it being a shorter version of many of the other depression screening tools available allowing it to be incorporated into the patient assessment process more effectively.
Due to the fact that the primary physician offices along with the heart hospital and diabetes center were already utilizing the PHQ-9, we also wanted to maintain continuity of care.
Study Methods
Implementation of a depression screening program began as a project for the ONS Institute of Evidence Based Practice Change (IEBPC) conference in 2011.
Once establishing a screening tool, it needed to be decided who, when, where, and how often we would screen patients. How realistic was the goal, how comfortable was the staff, and how could it be successfully incorporated into the current workflow?
A PICO (Population, Intervention, Comparison, and Outcome) question was developed: “In outpatient adult oncology patients, what is the effect of objectively screening patients for depression on the implementation of evidence based interventions compared with the general subjective toxicity assessment?” A pilot study was set up to evaluate these questions.
We chose one physician clinic and patient population to pilot the PHQ-9 screening process over a two-week period.
The PHQ-9 would be given to the patient when they were taken to the exam room, the nurse would review the answers and initiate the appropriate interventions based on the PHQ-9 score. Before beginning the pilot, all staff attended mandatory education. After the pilot study was complete, we met with staff again to determine what worked with the process and what needed to be revised.
A patient education sheet was created to explain the purpose of the new PHQ-9 screening and that this would be part of assessing patient care in a more holistic manner. The practice change went live March 1, 2012, and audits have been done to follow compliance.
Study Results
In the beginning, compliance levels were low, and re-education was done with staff and clarification was provided on the process. We had to overcome a few barriers such as staff reluctance, organizing a new workflow, staff communication and understanding.
When the process was first implemented, our Social Work staff was overwhelmed with an influx of referrals, but after the first few months, the referrals tapered down and became more balanced. Although it was hectic at first, our Social Work staff found that they were seeing patients more appropriately and intervening earlier, not only at the time of severe crisis.
The screening made a positive change to their role in caring for patients, and they are pleased with the outcomes they have seen with the use of the screening tool (see Figure1).
Revisions to the process were made based on staff feedback and ongoing evaluation of the clinic workflow to maximize the appropriate use of the PHQ-9 tool. Keeping the nurse as the primary resource of the assessment keeps the process more consistent and allows the nurse to answer any questions about the screening during the visit.
The RN compliance audits slowly improved each month and after re-educating staff and making process improvements to aid nurses with the assessment, we met our 90% goal in April of 2013 (see Figure 2).
Continuum of Care
The implementation of the PHQ-9 Depression Screening has provided a standardized assessment tool not only for the Edward Cancer Center, but throughout other departments within Edward Health Services.
We have successfully met the goal of incorporating psychosocial assessment into our practice as recognized by the CoC, which highlighted it as Best Practice on their website.
Social workers are helping patients before they reach crisis mode so they can focus on their cancer care plan more effectively and receive the support they need. The nurses are consistently screening and initiating interventions.
Finally, we have built our screening tool into our new EMR and look to share this not only in the outpatient areas, but also on the inpatient units to follow patients along the continuum in all aspects of their care.
References for this article can be accessed here.
Amy M. McGovern-Phalen is clinical educator/quality coordinator, Edward Cancer Center, Naperville & Plainfield, Ill.
