IMPLEMENTATION OF PHQ DEPRESSION SCREENING & URGENT CARE COUNSELING IN A COLLEGE HEALTH CENTER Joy...
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IMPLEMENTATION OF PHQ DEPRESSION SCREENING & URGENT CARE COUNSELING IN A COLLEGE HEALTH CENTER Joy Stewart-James, Ed.D. Executive Director Student Health & Counseling Services California State University, Sacramento
IMPLEMENTATION OF PHQ DEPRESSION SCREENING & URGENT CARE COUNSELING IN A COLLEGE HEALTH CENTER Joy Stewart-James, Ed.D. Executive Director Student Health
IMPLEMENTATION OF PHQ DEPRESSION SCREENING & URGENT CARE
COUNSELING IN A COLLEGE HEALTH CENTER Joy Stewart-James, Ed.D.
Executive Director Student Health & Counseling Services
California State University, Sacramento
Slide 2
OBJECTIVES Describe 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 SERVICES
Slide 3
SACRAMENTO STATE 4 yr. public university, urban area 6th
largest campus in CSU system Enrollment 29,500 Avg age 24 with 25%
of students over age 25 Resimmuter campus Diverse student body 38%
Caucasian 7% African American 22% Asian 11% Multi-ethnic 23% Latino
1.7% Pacific Islander SAC STATE STUDENT HEALTH & COUNSELING
SERVICES
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The WELL
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SAC STATE STUDENT HEALTH & COUNSELING SERVICES Fully
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
SHCS
Slide 6
College 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, 2009 MENTAL HEALTH &
COLLEGE STUDENTS SAC STATE STUDENT HEALTH & COUNSELING
SERVICES
Slide 7
National 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 SERVICES
Slide 8
MENTAL HEALTH & COLLEGE STUDENTS Students reported
experiencing the following within the last 12 months: Sac State
NCHA Reference Group Felt things were hopeless Felt so depressed
that it was difficult to function Seriously considered suicide
42.8% 29.3% 4.9% 46.5% 31.8% 8% ACHA/NCHA Spring 2013 SAC STATE
STUDENT HEALTH & COUNSELING SERVICES
Slide 9
DEPRESSION & ACADEMIC SUCCESS College 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 SERVICES
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TOP 10 DIAGNOSES STUDENT HEALTH CENTER 2012-2014 TOP 10
DIAGNOSES STUDENT HEALTH CENTER 2012-2014 1. Pharyngitis 2.
Depression 3. Anxiety 4. Viral Illness 5. Dysuria 6. Cough 7. URI
8. Dermatitis 9. Allergic Rhinitis 10. Abdominal Pain SAC STATE
STUDENT HEALTH & COUNSELING SERVICES
Slide 11
National 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
SCREENING
Slide 12
PATIENT 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 SERVICES
Slide 13
PATIENT 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 index Screens for presence of suicide
ideation. SAC STATE STUDENT HEALTH & COUNSELING SERVICES
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PATIENT HEALTH QUESTIONNAIRE (PHQ-9) SAC STATE STUDENT HEALTH
& COUNSELING SERVICES
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PATIENT HEALTH QUESTIONNAIRE (PHQ-9) SAC STATE STUDENT HEALTH
& COUNSELING SERVICES PHQ scores > 10 sensitivity of 88% and
a specificity of 88% for major depression. (Kroenke et al,
2002)
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BARRIERS TO IMPLEMENTATION Time 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
SERVICES
Slide 17
Spring 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-2 77 were screened using
PHQ-9 47 score 10-14 25 scored 15 PILOT STUDY SAC STATE STUDENT
HEALTH & COUNSELING SERVICES
Slide 18
PILOT STUDY 27 students referred to CAPS as a new Urgent Client
11 already being seen in CAPS 12 already on antidepressants &
being followed by outside provider or SHCS medical provider 5% of
students were newly diagnosed with depression 2 patients referred
to outside psychiatrist 3 declined treatment SAC STATE STUDENT
HEALTH & COUNSELING SERVICES
Slide 19
PRECIPITATING EVENT Fall 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 SERVICES
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Decision 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 ACTION
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URGENT CARE COUNSELOR Hired 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
SERVICES
Slide 22
PHQ IMPLEMENTATION All 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 SERVICES
Slide 23
PHQ STATS PHQ 2 ConductedPHQ 9 Conducted Score of > 3 were
positive prompting the PHQ-9. SAC STATE STUDENT HEALTH &
COUNSELING SERVICES
SAC STATE STUDENT HEALTH & COUNSELING SERVICES 90% of
unique patients are screened 6% scored positive on PHQ-2 54% scored
positive on PHQ-9 28% scored > 15 prompting an UC counseling
visit OVERALL PHQ FINDINGS 2011- 2014
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VISIT 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 SERVICES
Slide 27
MH Screenings MH Urgent Care Brief Intervention UC Counselor
(started Jan 2012) MH Screenings MH Urgent Care Brief Intervention
TOTALS 735 33 623 247 434 601 1028 168 263 123 151 253 816 387 -
2011-122012-132013-14 1,203 1,986 2,673 VISIT TYPES SAC STATE
STUDENT HEALTH & COUNSELING SERVICES
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COUNSELING VISITS Counseling SAC STATE STUDENT HEALTH &
COUNSELING SERVICES
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REASONS FOR REFERRAL TO UC COUNSELOR High PHQ Score Suicide
Ideation Acute Stressor Trauma Loss Sexual Assault SAC STATE
STUDENT HEALTH & COUNSELING SERVICES
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SOURCES OF REFERRAL TO UC COUNSELOR High PHQ Score Triage RN
CAPS Triage Medical Providers Victim Advocate Academic Advising
Faculty Housing Student Conduct SAC STATE STUDENT HEALTH &
COUNSELING SERVICES
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SPRING 2014 SNAPSHOT OF UC COUNSELING VISITS Reason for UC
referral: 26% Suicide Ideation 40% Depression 22% Anxiety 12%
Subjective Distress Not Otherwise Specified
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SPRING 2014 SNAPSHOT UC counselor referred to: 53% Individual
counseling 27% Group counseling 12% Medical 8% Community referral
Referrals from: 48% Student Health 30% Self 12% CAPS 4% Academic
advising 4% Faculty 2% Other SAC STATE STUDENT HEALTH &
COUNSELING SERVICES
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SUMMARY SAC STATE STUDENT HEALTH & COUNSELING SERVICES
Early 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.
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SAC STATE STUDENT HEALTH & COUNSELING SERVICES Resources
DeRoma. 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.pdfhttp://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.
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SAC STATE STUDENT HEALTH & COUNSELING SERVICES Resources
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
www.sciencedaily.com/2009/07/090706161302.htm
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QUESTIONS Email: [email protected] SAC STATE STUDENT HEALTH
& COUNSELING SERVICES
