Implementation of PHQ Depression screening & Urgent Care counseling in a college Health Center

Implementation of PHQ Depression screening & Urgent Care counseling in a college Health CenterJoy Stewart-James, Ed.D.Executive DirectorStudent Health & Counseling ServicesCalifornia State University, Sacramento

ObjectivesDescribe implementation of routine depression screening.List outcomes from depression screening.Identify appropriate referral to counseling services.Describe the implementation of an urgent care counselor position.SAC STATE STUDENT HEALTH & COUNSELING SERVICESSACRAMENTO STATE4 yr. public university, urban area6th largest campus in CSU systemEnrollment 29,500 Avg age 24 with 25% of students over age 25Resimmuter campusDiverse student body38% Caucasian 7% African American22% Asian 11% Multi-ethnic23% Latino 1.7% Pacific IslanderSAC STATE STUDENT HEALTH & COUNSELING SERVICESSAC STATE STUDENT HEALTH & COUNSELING SERVICES

The WELLSAC STATE STUDENT HEALTH & COUNSELING SERVICESFully integrated health, counseling, and health promotion services.

SHC Visits CAPS Visits 36,000 + Visits/Annually 10,000 + Visits/Annually 50% Utilization 7% Utilization

SACRAMENTO STATE SHCSCollege students with depression are twice as likely as classmates to drop out.Studies show 1 in 3 college students experience depression.College students have a higher than average rate of suicide.Depression is the 4th most common health problem. (ACHA, 2007) * University of Michigan, 2009MENTAL HEALTH & COLLEGE STUDENTSSAC STATE STUDENT HEALTH & COUNSELING SERVICESNational survey of counseling center directors reported over 80% suicides were students with no current or prior counseling. (Gallagher, 2005; Echlinger, 2008)In the general population, as many as 40% of adults saw a PCP at least once within one month of a lethal suicide attempt. (Pirkis & Burges, 1998)Healthy minds study at NYU indicated that 80% of students with serious suicide ideation did use medical services; only 30% use counseling. (NCDP)Mental Health & College Students SAC STATE STUDENT HEALTH & COUNSELING SERVICESMental Health & College Students Students reported experiencing the following within the last 12 months:Sac StateNCHA Reference Group Felt things were hopelessFelt so depressed that it was difficult to functionSeriously considered suicide42.8%29.3%

4.9%46.5%31.8%

8% ACHA/NCHA Spring 2013SAC STATE STUDENT HEALTH & COUNSELING SERVICESDEPRESSION & ACADEMIC SUCCESSCollege students with depression are twice as likely to drop out of school. (University of Michigan, 2009)Academic problems are cited as the most frequent cause of depression. (College Student Journal, 2009)Students experiencing symptoms of depression are likely to be at risk for lower academic performance. (NCMJ, 2012)SAC STATE STUDENT HEALTH & COUNSELING SERVICES9TOP 10 DIAGNOSES STUDENT HEALTH CENTER2012-2014PharyngitisDepressionAnxietyViral IllnessDysuriaCoughURIDermatitisAllergic RhinitisAbdominal Pain

SAC STATE STUDENT HEALTH & COUNSELING SERVICES10SAC STATE STUDENT HEALTH & COUNSELING SERVICESNational guidelines and Healthy Campus 2010 strongly recommend screening for depression among adults and teens in primary care as evidence based approaches. (US Preventative Task Force, 2002; NCDP).PHQ-2 & 9 was selected for several reasons i.e. ease of administration and use in college health. (NCDP)

DEPRESSION SCREENINGPATIENT HEALTH QUESTIONNAIRE (PHQ-2)

Two-item inquiry about the frequency of depressed mood over the past two weeks.Patients who screen positive (Score >3) should be further evaluated with the PHQ-9.SAC STATE STUDENT HEALTH & COUNSELING SERVICESPATIENT HEALTH QUESTIONNAIRE (PHQ-9)Multi-purpose instrument for screening, diagnosing, monitoring & measuring the severity of depression.Incorporates DSM-IV depression diagnostic criteria with other major depressive symptoms.Rates the frequency of symptoms & severity indexScreens for presence of suicide ideation.SAC STATE STUDENT HEALTH & COUNSELING SERVICESPatient Health Questionnaire (PHQ-9)

SAC STATE STUDENT HEALTH & COUNSELING SERVICESPatient Health Questionnaire (PHQ-9)

SAC STATE STUDENT HEALTH & COUNSELING SERVICESPHQ scores > 10 sensitivity of 88% and a specificity of 88% for major depression. (Kroenke et al, 2002) BARRIERS TO IMPLEMENTATIONTime constraints in medical visits.Not feasible to implement in urgent care.Increase referrals to counseling that is already at capacity.At the time, medical did not share records with counseling so there was concern about not knowing follow-up.SAC STATE STUDENT HEALTH & COUNSELING SERVICESSpring 2011 implemented PHQ depression screening in primary care clinic. Collected data from 3/28 5/1/2011.846 (84%) students screened 87 (10%) scored > 3 on PHQ-277 were screened using PHQ-947 score 10-1425 scored 15PILOT STUDYSAC STATE STUDENT HEALTH & COUNSELING SERVICES17Pilot Study 27 students referred to CAPS as a new Urgent Client11 already being seen in CAPS12 already on antidepressants & being followed by outside provider or SHCS medical provider5% of students were newly diagnosed with depression2 patients referred to outside psychiatrist3 declined treatmentSAC STATE STUDENT HEALTH & COUNSELING SERVICES18PRECIPITATING EVENTFall semester 2011, student suicide, 22 yr. old female.Newly diagnosed HSV2 one week prior to suicide in UC.Medical record no history of mental illness.CAPS record two hospitalizations for previous suicide attempts, previous counseling client.SAC STATE STUDENT HEALTH & COUNSELING SERVICESSAC STATE STUDENT HEALTH & COUNSELING SERVICESDecision was made to implement PHQ in both UC & PC. Hire an urgent care counselor (Jan 2012).Subsequent integration of medical & counseling records (Sep 2012). CALL TO ACTIONURGENT CARE COUNSELORHired in January 2012.Full-time LCSW.Located in urgent care clinic of the SHC.No regular case load.Triage, crisis intervention, risk assessment, brief intervention, referrals.Provides consultation to medical providers, faculty & staff.SAC STATE STUDENT HEALTH & COUNSELING SERVICESPHQ IMPLEMENTATIONAll students presenting at PC & UC complete PHQ-2 via Ipad (90% compliance) as part of registration.Score >3 MA or RN launches PHQ-9 in the exam room.Medical provider reviews results during the visit.Score between 10-14 are referred to CAPS for MH screening.Score > 15 or suicide ideation are referred to UC counselor and seen same day.SAC STATE STUDENT HEALTH & COUNSELING SERVICESPHQ STATSPHQ 2 ConductedPHQ 9 Conducted Score of > 3 were positive prompting the PHQ-9.SAC STATE STUDENT HEALTH & COUNSELING SERVICESPHQ STATSPOSITIVE PHQ- 9SAC STATE STUDENT HEALTH & COUNSELING SERVICESPositive Scores > 10 MH screening, >15 UC Counselor visit SAC STATE STUDENT HEALTH & COUNSELING SERVICES90% of unique patients are screened6% scored positive on PHQ-254% scored positive on PHQ-928% scored > 15 prompting an UC counseling visit

Overall PHQ Findings 2011-2014Visit Type Definitions

MH Screenings initial screening to assess need and appropriate course of care.

MH Urgent Care same day contact for an acute condition that cant wait or is viewed as a risk.

Brief Intervention- session to stabilize; provide follow-up; and monitor for safety until CAPS counseling appointment or community referral is available. SAC STATE STUDENT HEALTH & COUNSELING SERVICESMH ScreeningsMH Urgent CareBrief InterventionUC Counselor (started Jan 2012)MH ScreeningsMH Urgent CareBrief Intervention

TOTALS73533623

247434601

1028168263

123151253

816387-

2011-122012-132013-141,2031,9862,673VISIT TYPESSAC STATE STUDENT HEALTH & COUNSELING SERVICES27COUNSELING VISITSCounselingSAC STATE STUDENT HEALTH & COUNSELING SERVICESREASONS FOR REFERRAL TO UC COUNSELORHigh PHQ ScoreSuicide IdeationAcute StressorTraumaLossSexual AssaultSAC STATE STUDENT HEALTH & COUNSELING SERVICESSOURCES OF REFERRAL TO UC COUNSELOR

High PHQ ScoreTriage RNCAPS TriageMedical ProvidersVictim AdvocateAcademic AdvisingFacultyHousingStudent ConductSAC STATE STUDENT HEALTH & COUNSELING SERVICESSAC STATE STUDENT HEALTH & COUNSELING SERVICESSPRING 2014 SNAPSHOT OF UC COUNSELING VISITSReason for UC referral:

26% Suicide Ideation40% Depression22% Anxiety12% Subjective Distress Not Otherwise SpecifiedSPRING 2014 SNAPSHOT UC counselor referred to:

53% Individual counseling27% Group counseling12% Medical8% Community referralReferrals from:

48% Student Health30% Self12% CAPS4% Academic advising4% Faculty2% OtherSAC STATE STUDENT HEALTH & COUNSELING SERVICESSUMMARYSAC STATE STUDENT HEALTH & COUNSELING SERVICESEarly detection with 90% of all students in PC & UC screened for depression a minimum of once/year. Changed service delivery model to accommodate increased referrals (e.g. UC counseling, brief interventions).UC counselor has improved the predictability of schedules for FT counselors.Increased our CAPS utilization rates from 3-7%. Improved our integration of services.SAC STATE STUDENT HEALTH & COUNSELING SERVICESResourcesDeRoma. Leach. Leverett. The Relationship between Depression and College Academic Performance. College Student Journal. Vol. 43, No. 2, June 2009.

Klein, Michael C. National College Depression Partnership (NCDP): Expanding Health and Counseling Services Role in Prevention to Support Student Learning and Retention. Retrieved from http://www.hsaccc.org/ncdp_Mar2011.pdf

Klein. Ciotoli. Chung. Primary Care Screening of Depression and Treatment Engagement in a University Health Center: A Retrospective Analysis. Journal of American College Health. Vol. 59, No. 4, pp. 289-295, Feb 2001.

Kronenke. Spitzer. Williams. The PHQ-9: Validity of a Brief Depression Severity Measure. Journal General Internal Medicine. 16:606-616, Sept 2001.

SAC STATE STUDENT HEALTH & COUNSELING SERVICESResources cont.Kronenke. Spitzer. Williams. The Patient Health Questionnaire -2: Validity of a Two-Item Depression Screener. Medical Care. 41:1284-1294, 2003.

Turner. Thompson. Brunner Huber. Arif. Depressive Symptoms an Academic Performance of North Carolina College Students. NCMJ. Vol. 73, No. 3, pp 169-175.

University of Michigan. Students With Depression Twice As Likely To Drop Out Of College. Science Daily. July 7, 2009. www.sciencedaily.com/2009/07/090706161302.htm

QUESTIONS

Email: jsjames@csus.eduSAC STATE STUDENT HEALTH & COUNSELING SERVICES