IMPLEMENTING A DEPRESSION SCREENING PROTOCOL IN A PRIMARY CARE

PRACTICE

Alison Marie Stroh

A Doctorate of Nursing Practice Project submitted to the faculty at the University of North
Carolina at Chapel Hill in partial fulfillment of the requirements for the degree of Doctorate of
Nursing Practice in the School of Nursing.

Chapel Hill
2020

Approved by:

Victoria Soltis-Jarrett

Leslie Sharpe

Schquthia Peacock
 ProQuest Number: 27830956

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ii
 ABSTRACT
Alison Marie Stroh: Implementing a Depression Screening Protocol in a Primary Care Practice
(Under the direction of Victoria Soltis-Jarett)

Background: Major Depressive Disorder (MDD), a life-threatening psychiatric illness, is

the most significant global cause of disability, with approximately 300 million people affected

(Maurer, Raymond, & Davis, 2018). When the signs and symptoms are unrecognized or left

untreated, MDD increases the risk of medical comorbidities, particularly heart disease, stroke,

Alzheimer’s disease, obesity, and diabetes (Maurer, Raymond, & Davis, 2018). Untreated MDD

also increased the risk of suicide by 0.5-4% compared to the general population, and completed

suicides are the 10th leading cause of death in the United States (Maurer, Raymond, & Davis,

2018).

Objective: To assist a midsize patient-centered medical home (PCMH) in North Carolina

to integrate and sustain a standardized screening protocol for MDD using the PHQ-9.

Methods: Develop a standardized depression screening protocol algorithm to initiate

depression screening in a primary care practice. Measure rate of screening by each provider

involved in the project and determine if the subsequent management of the patient with a positive

screen was appropriate. Determine if provider satisfaction increased with a standardized protocol

for depression screening.

Results: During this quality improvement project, 65 adults aged 18-65, were assessed for

the signs and symptoms of depression using the PHQ-9. A total of 107 patients fit the inclusion

criteria for a screening rate of 60.74%. As a result of this screening, 3 patients scored at or above

iii
the threshold of 10 on the PHQ-9 screening tool and adherence to the implemented protocol was

observed. Screening rates for patients between the ages of 18-65 attending either a new patient or

yearly physical appointment, approximately 17% of the total patient population at this primary

care practice, increased from 1.59% to 60.49%. All three providers that participated in the project

acknowledged that their satisfaction with depression screening improved.

Conclusion: This quality improvement project has shown that implementing a depression

screening protocol in a primary care setting can improve patient outcomes and improve provider

satisfaction.

iv
 TABLE OF CONTENTS
LIST OF TABLES…………………………………………………………………………….…vii
LIST OF FIGURES……………………………………………………………………………..viii
LIST OF ABBREVIATIONS…………………………………………………………………….ix
CHAPTER 1: INTRODUCTION…………………………………………………………………1
Problem Statement………………………………………………………………………...2
Local Context……………………………………………………………………………...3
Purpose Statement…………………………………………………………………………3
CHAPTER 2: REVIEW OF LITERATURE……………………………………………………...5
History, Validity, and Reliability………………………………………………………….6
Recommendations for Use………………………………………………………………...7
Barriers…………………………………………………………………………………….8
Consequences of Unrecognized Depression in Primary Care…………………………….8
Summary and Application……………………………………………………………….10
CHAPTER 3: THEORETICAL FRAMEWORK………………………………………………..11
CHAPTER 4: METHODS……………………………………………………………………….13
Context…………………………………………………………………………………...13
Process…………………………………………………………………………………...14
Setting and Population…………………………………………………………………...14
Data Collection Instruments……………………………………………………………..15
Procedures for Project Implementation………………………………………………….16
Pre-intervention…………………………………………………………………..16
Intervention………………………………………………………………………17
Post-intervention…………………………………………………………………17
Key personnel/Stakeholders……………………………………………………...18
Evaluation (Data Analysis)………………………………………………………18
v
 Ethics and Human Subjects Permissions………………………………………...19
CHAPTER 5: RESULTS………………………………………………………………………...20
CHAPTER 6: DISCUSSION…………………………………………………………………….35
Limitations……………………………………………………………………………….37
Sustainability……………………………………………………………………………..37
Future Study……………………………………………………………………………...38
CHAPTER 7: CONCLUSIONS…………………………………………………………………39
APPENDIX A: PATIENT HEALTH QUESTIONAIRE (PHQ-9)……………………………...40
APPENDIX B: LIPPITTS CHANGE THEORY………………………………………………..41
APPENDIX C: MODEL FOR IMPROVEMENT……………………………………………….42
APPENDIX D: PRE-IMPLEMENTATION SURVEY…………………………………………43
APPENDIX E: PROVIDER RESOURCES……………………………………………………..47
APPENDIX F: DEPRESSION SCREENING PROTOCOL ALGORITHM……………………48
APPENDIX G: POST-IMPLEMENTATION SURVEY……………………..…………………49
APPENDIX H: UNC-CHAPEL HILL INSTITUTIONAL REVIEW BOARD (IRB)………….52
REFERNCES…………………………………………………………………………………….54

vi
 LIST OF TABLES

Table 1: Population demographics………………………………………….……………………20

Table 2: DNP project screening demographics………………………………………………….21

Table 3: Fidelity of screening……………………………………………………………………23

Table 4: Pre-implementation survey………………………………………………………….….24

Table 5: Post-implementation survey………………………………………………….……..….26

vii
 LIST OF FIGURES

Figure 1: Patient Demographics: Gender……………………………………….……….….……28

Figure 2: Patient Demographics: Race………………………………………….….…...……….29

Figure 3: Patient Demographics: Age……………………………………….……………...……30

Figure 4: PDSA 1 Scores…………………………………………………...….….………….….31

Figure 5: PDSA 2 Scores by Provider……………………………………………...……………32

Figure 6: Percentage screened for provider one……………….…………….......………………33

Provider 7: Percentage screened for entire project……………………………....………………34

viii
 LIST OF ABBREVIATIONS

CHD Coronary heart disease

CVD Cardiovascular disease

EMR Electronic medical record

FNP Family nurse practitioner

IHI Institute of healthcare improvement

MDD Major depressive disorder

PCMH Patient-centered medical home

PDSA Plan, do, study, act

PHQ-9 Patient health questionnaire

QI Quality improvement

USPSTF U.S. Preventative services task force

ix
 CHAPTER 1: INTRODUCTION
Major Depressive Disorder (MDD), a life-threatening psychiatric illness, is the

most significant global cause of disability, with approximately 300 million people affected

(Maurer, Raymond, & Davis, 2018). More than 16 million American adults met the criteria for at

least one episode of MDD in the last 12 months (Ferenchick, Ramanuj, & Pincus, 2019; Maurer,

Raymond, & Davis, 2018). When the signs and symptoms are unrecognized or left untreated,

MDD increases the risk of medical comorbidities, particularly heart disease, stroke, Alzheimer’s

disease, obesity, and diabetes (Maurer, Raymond, & Davis, 2018). MDD is not only a severe

public health problem; it is the most frequent psychiatric disorder reported in the adult

population, with a lifetime prevalence of 20.6% in the United States (Hasin et al., 2018). MDD

accounts for approximately 210 billion dollars in healthcare spending per year, which continues

to increase annually (Maurer, Raymond, & Davis, 2018).

Untreated MDD also increased the risk of suicide by 0.5-4% compared to the general

population, and completed suicides are the 10th leading cause of death in the United States

(Maurer, Raymond, & Davis, 2018). In 2014, suicide rates continued to rise in the United States,

with over 40,000 deaths from suicide secondary to a diagnosis of depressive disorder (Smithson

& Pignone, 2017). During 2016, approximately 45,000 people died by suicide nationwide, with

significant increases in suicide rates in almost every state (Stone et al., 2018). About 50% of

completed suicides in adults followed a visit to a primary care physician within the last 30 days

(Ferenchick, Ramanuj, & Pincus, 2019). Primary care visits are the most common type of

healthcare visit before death, with 75% in the previous year and approximately 45% in the last

1
month (Jordan, Shedden-Mora, & Löwe, 2018).

Screening for MDD in a primary care setting is a logical, cost-effective plan of action to

mitigate this public health crisis. The 9-item Patient Health Questionnaire (PHQ-9) (Appendix

A) is a valid and reliable screening tool that objectifies and assesses the extent of depression

severity, and has been successfully administered in primary care environments for the past 18

years (Ferenchick, Ramanuj, & Pincus, 2019; Levis, Benedetti, Thombs, & The DEPRESSD

Collaboration, 2019). The PHQ-9 is self-administered, quickly scored, and has been extensively

researched with consistent findings (Kroenke, Spitzer, & Williams, 2001). Screening all adults in

the primary care setting for depression helps to meet the criteria for a Patient-Centered Medical

Home (PCMH) and works towards achieving the Quadruple Aim of healthcare (Sandoval, Bell,

Khatri, Robinson, 2018). The U.S. Preventative Services Task Force (USPSTF), The American

Academy of Family Physicians, The American College of Preventative Medicine, and The

Institute for Clinical Systems Improvement all recommend regular screening for depression in

primary care for adults (Maurer, Raymond, & Davis, 2018; Siu & and the US Preventative Task

Force (USPSTF), 2016; Trangle et al., 2016). Despite these recommendations, the rate of

screening for depressive symptoms in primary care remains less than 2% (Akincigil & Matthews,

2017).

Problem Statement

Access to screening for MDD is limited, despite healthcare policy aimed at increasing

coverage and engagement with mental health care professionals. As a result, those with MDD are

not obtaining the appropriate screening and management in primary care, which has led to a

public health crisis (Jones et al. 2017). Research and recommendations by multiple professional

organizations have identified primary care as an appropriate location for utilization of screening

2
for MDD; however, primary care settings face barriers to implementation.

Local Context

Similar to national trends, North Carolina’s primary care practices have also struggled

with the planning and implementation of standardized screening protocols for MDD (Christian,

Krall, Hulkower, & Stigleman, 2018). Although behavioral health integration is identified as a

best practice, some primary care settings in NC have not been able to implement the screening

tools that can increase the recognition, assessment, and management of common mental health

disorders. Many clinicians have reported that behavioral health integration is expensive, difficult

to sustain, and, subsequently, it is often avoided (Christian, Krall, Hulkower, & Stigleman,

2018). Primary care providers relate that they have limited knowledge and skill in the follow-up

assessment and management of MDD (Waitzfelder et al., 2018). In reality, screening, evaluation,

and management of MDD in primary care is a less expensive way to address this public health

crisis. Standardized screening for MDD in primary care is also a gateway to achieve and

maintain the distinction of a Patient-Centered Medical Home (PCMH) (Christian, Krall, &

Stigleman, 2018).

Purpose Statement

The purpose of this quality improvement (QI) project was to assist a midsize patient-

centered medical home (PCMH) in North Carolina and to integrate and sustain a standardized

screening protocol for MDD using the PHQ-9. Outcome measures include fidelity of the

screening protocol, including the number of positive screens compared to baseline. Outcome

measures also include patient outcomes, including determining if appropriate management of the

patient with a positive screen was initiated. In addition to identifying the barriers to using the

PHQ-9 screening tool, this project also identified the needs and concerns of the health care

3
providers as they navigate this process in the workflow. Data regarding improved provider

satisfaction was gathered by the administration of a survey before and after implementation of

the screening and management protocol. Improved provider satisfaction and improved patient

outcomes are two of the four critical results of the Quadruple Aim (Sandoval, Bell, Khatri,

Robinson, 2018).

4
 CHAPTER 2: REVIEW OF LITERATURE
This review of literature focuses on articles that were published between 2015 and 2019

and also includes a hallmark study published in 2001 that depicts the development of the PHQ-9.

Databases used included PubMed, CINAHL, and PsycINFO. The search terms used were “Care,

Primary Health” OR “Health Care, Primary” OR “Primary Healthcare” OR “Healthcare,

Primary” OR “Primary Care” OR “Care, Primary” OR "primary health care" OR “Physician,

Primary Care” OR “Primary Care Physician” OR “Primary Care Physicians” AND "depressive

disorder, major" OR "depressive disorder" OR “major depressive disorder” OR "depression" OR

“depression” AND “Patient Health Questionnaire 9” OR “PHQ-9” OR “PHQ Patient Health

Questionnaire” OR “Primary Care Evaluation of Mental Disorders”. The initial search yielded

1,896 articles related to Major Depressive Disorder (MDD) and the Patient Health

Questionnaire-9 (PHQ-9) in primary care. Limiters used in this literature search include articles

written in English and only focused on adult patients ages 18 to 65. After analyzing the first

1,896 articles, and removing duplicates, the compilation was narrowed down to 23 articles which

focus on the use of the PHQ-9 in primary care, relevant barriers associated with the use of the

PHQ-9, and recommendations for implementing the PHQ-9. This literature review will present

and discuss the following subsections: (a) history, validity, and reliability of the PHQ-9; (b)

recommendations for the use of the PHQ-9; (c) barriers to implementation of standardized

depression screening in primary care; and (d) consequences of unrecognized or untreated

depression in primary care.

5
History, Validity, and Reliability

The use of the PHQ-9 as a screening tool for MDD has been extensively tested and

established as a valid and reliable tool (Kroenke, Spitzer, & Williams, 2001). The PHQ-9 is used

for recognizing the presence and severity of symptoms of depression in primary care settings in

the United States (Kroenke, Spitzer, & Williams, 2001). In 2001, a hallmark study in the United

States involving 6,000 patients, determined that the PHQ-9 had both sensitivity and specificity of

88% when using a threshold of 10 or higher (Kroenke, Spitzer, & Williams, 2001). In this study,

the internal reliability of the PHQ-9 in primary care was a Cronbach’s α of 0.89, and the area

under the curve (AUC) of the PHQ-9 was 0.95 (Kroenke, Spitzer, & Williams, 2001). In 2016, a

meta-analysis was conducted of 40 studies and found the overall sensitivity of the PHQ-9 was

“81.3% (95% CI, 71.6-89.3)” and an overall specificity of “85.3% (95% CI, 81.0-89.1)”

(Mitchell, Vadegarfar, Gill, & Stubbs, 2016). The results of these studies demonstrated that the

PHQ-9 was not a diagnostic instrument but rather a screening tool to be used to identify the

signs, symptoms, and severity of MDD (Mitchell, Vadegarfar, Gill, & Stubbs, 2016).

Several countries in Europe, including Spain and Latvia, and Asian countries, including

Japan, have also tested the validity and reliability of the PHQ-9 in primary care. These countries,

however, have more variability in the cutoff points between mild and moderate depression. Two

studies in Latvia reported on the validity of the PHQ-9 in primary care using cutoff points of 8

and 10. These studies found the sensitivity of the PHQ-9 to be 75%-86.5%, specificity to be

79%-89%, and Cronbach’s α to be 0.81-0.84, respectively (Rancans, Trapencieris, Ivanovs, &

Vrublevska, 2018; Vrublevska, Trapencieris, & Rancans, 2018). In Spain, a study was conducted

comparing two cutoff points of 10 and 12 and the subsequent effect on reliability. These

researchers found a sensitivity of 0.95-0.84 and specificity of 0.67-0.78, respectively (Muñoz-

6
Navarro et al., 2017). Studies conducted in Japan used cutoff points 10 and 11, yielding a

sensitivity of 90.5%-76% and specificity of 76.6%-81%, respectively (Muramatsu et al., 2018;

Suzuki, Kumei, Ohhira, Nozu, Okumura, 2015).

The PHQ-9 has also shown to be valid and reliable when screening patients with

comorbid medical diseases and illnesses such as diabetes, coronary heart disease, HIV, and

hypertension. According to Trangle et al., (2016), there is research that found that the PHQ-9 is a

better tool for assessing depression in patients who have other chronic conditions. A study using

the PHQ-9 on patients with comorbid diabetes found that at a cutoff point of 10 or higher,

Cronbach’s α was 0.87 for patients with diabetes and 0.82 for patients without diabetes (Janssen

et al., 2016). Another study screened for depression in patients with comorbid coronary heart

disease (CHD) using a cutoff of 10 or higher, found a “sensitivity of 84%, a specificity of 82%,

and AUC of 0.88” (Van der Zwaan et al., 2016). Finally, patients with comorbid HIV and

hypertension found that at a cutoff of 9, sensitivity was 51%, specificity was 94%, and the area

under the curve (AUC) was 0.85 and 0.86, respectively (Bhana, Rathod, Selohilwe, Kathree, &

Petersen, 2015). Collectively, these studies demonstrate the strength of the PHQ-9 screening tool

for depression alone and in conjunction with comorbid illnesses.

Recommendations for Use

The U.S. Preventative Services Task Force (USPSTF) and the American College of

Physicians recommend screening for depression in primary care (Siu & and the US Preventative

Task Force (USPSTF), 2016; O’Conner et al., 2016; Crowley & Kirschner, 2015). The American

College of Preventative Medicine and The Institute for Clinical Systems Improvement also

recommended screening for depression in primary care for adults who have not already been

screened or during routine visits (Maurer, Raymond, & Davis, 2018; Trangle et al., 2016). While

7
these institutions recommend screening for depression in primary care, they do not outline

screening intervals or the use of a particular screening tool (Maurer, Raymond, & Davis, 2018).

The use of the PHQ-9 as a screening instrument has been recommended based on a meta-

analysis of 40 studies (Mitchell, Vadegarfar, Gill, & Stubbs, 2016).

Barriers

There are several barriers to primary care settings implementing the PHQ-9 cited in the

literature. These barriers include lack of time to implement and score the PHQ-9, lack of

provider education and comfort using the screening tool, and patient resistance to completing the

PHQ-9 (Waitzfelder et al., 2018). Willborn et al. (2016) found that the PHQ-9 guidelines for use

were not clear, and despite the need for identification of depressive symptoms and severity of

symptoms, they postulate that there are no known consequences for not screening for depression.

Many providers have also identified concern for using a screening tool that identifies depressive

symptoms when they are unable or uncomfortable initiating and managing treatment options.

Other barriers include billing codes and reimbursement, as well as difficulty implementing or

integrating screening into the current workflow (Akincigil & Matthews, 2017). In a study aimed

at examining the use of the PHQ-9 for screening in patients with diabetes, patients who already

carried the diagnosis of MDD were much more likely to be screened using the PHQ-9 than

patients without a prior diagnosis of depression (Barnacle, Strand, Werremeyer, Maack, & Petry,

2016). These findings suggest clinicians used the tool to manage the symptoms rather than to

screen for depression and severity in patients.

Consequences of Unrecognized Depression in Primary Care

There are many unfortunate consequences of unrecognized MDD in primary care. While

the U.S. Preventative Services Task Force (USPSTF) decided that there was inadequate evidence

8
to screen specifically for suicidality in adults in a primary care setting, suicide has been linked to

MDD and is included as a question on the PHQ-9 (Siu & and the US Preventative Task Force

(USPSTF), 2016). Increased severity of depression, as determined by screening using the PHQ-

9, is associated with an increased risk of suicide (Ferenchick, Ramanuj, & Pincus, 2019).

Ferenchick, Ramanuj, & Pincus (2019) also found that almost 50% of those who completed

suicide had a primary care visit inside the last month before their death. Unrecognized

depression in the primary care setting can increase the risk of suicide, which necessitates

screening with the PHQ-9, as it includes suicidal ideation.

Unrecognized and untreated MDD can also exacerbate comorbid chronic medical

conditions and lead to decreased patient outcomes and increased mortality. In particular,

comorbid cardiovascular disease (CVD), heart failure, and coronary heart disease (CHD) are

associated with worsening outcomes secondary to unrecognized depression. Comorbid CHD,

diabetes, and depression led to an increased risk of mortality and decreased quality of life (Van

der Zwaan et al., 2016). A study in a Latvian primary care clinic found that patients with MDD

were 2.08 times more likely to have comorbid CVD (Ivanovs, Kivite, Ziedonis, Mintale,

Vrublevska, & Rancans, 2018). In a study of 425 patients, those with depression and heart failure

were 2.02 times more likely to die and 1.42 times more likely to be hospitalized for cardiac

complications (Jani, Mair, Roger, Weston, Jiang, Chamberlain, 2016). Screening for MDD with

the PHQ-9 in the primary care setting can improve outcomes for patients who also suffer from

cardiovascular disease (Ivanovs, Kivite, Ziedonis, Mintale, Vrublevska, & Rancans, 2018; Jani,

Mair, Roger, Weston, Jiang, Chamberlain, 2016).

Summary and Application

The PHQ-9 is a valid and reliable tool for the screening and severity rating of MDD in a

9
 primary care setting (Ferenchick, Ramanuj, & Pincus, 2019; Levis, Benedetti, Thombs, &

The DEPRESSD Collaboration, 2019; Kroenke, Spitzer, & Williams, 2001). Numerous studies

have shown that the PHQ-9 has high sensitivity and specificity at a threshold of 10 or greater,

indicating moderate to severe depression. Although various professional associations, including

the U.S. Preventative Services Task Force (USPSTF), advocate for the use of screening for

depression in primary care, screening rates remain low because of the barriers presented. The

benefit of using the PHQ-9 for screening for MDD in primary care far outweighs the risk.

Primary care providers should be encouraged to utilize this tool to identify patients who could

take advantage of the treatment of MDD to improve patient outcomes.

This literature review demonstrates that the PHQ-9 is a valid and reliable tool that needs

to be used to screen for MDD in a primary care setting to mitigate the public health crisis that the

US is experiencing. Education and a standardized screening protocol based on evidence-based

research can improve primary care providers' utilization of the PHQ-9 to screen for the presence

and severity of MDD. Screening using the PHQ-9 would lead to early recognition, potentially

swift treatment, and ongoing management of MDD in primary care.

10
 CHAPTER 3: THEORETICAL FRAMEWORK
The implementation of a standardized screening protocol for Major Depressive Disorder

(MDD) using the PHQ-9 in primary care requires a model of change that will guide the project

and ensure sustainability. Lippitt’s Change Theory (Appendix B), developed in 1958 as an

extension of Lewin’s Theory of Change, outlines a detailed plan for initiating change in an

organization (Lippitt, Watson, & Westley, 1958). Lippitt’s Change Theory has been proven in

the field of healthcare and is frequently used in nursing because it fits in parallel with the

“nursing process elements of assessment, planning, implementation, and evaluation” (Mitchell,

2013). Most change theories focus on the change implemented or the organization where the

change will take place. Lippitt, however, focuses on the people who will be affected by the

change and the person who will implement the change, the change agent (Wagner, 2018).

“Lippitt’s Change Theory separates into seven phases:

1. Diagnose the problem

2. Assess motivation and capacity for change

3. Assess change agent’s motivation and resources

4. Select progressive change objective

5. Choose the role of the change agent

6. Maintain change

7. Terminate the helping relationship.”

(Lippitt, Watson, & Westley, 1958; Mitchell, 2013).

11
 This proposal, particularly the review of literature, serves as the first phase of Lippitt’s

Change Theory. This proposal has identified several possible “diagnoses” or problems that may

influence or impact the introduction of a screening tool for depression to primary care practices.

The problem is that barriers to screening for MDD using the PHQ-9 in primary care prevent the

systematic use of a screening protocol and can harm patient outcomes. For phase two, the focus

will be to assess the identified primary care practice’s level of motivation to implement screening

tools such as the PHQ-9, improve patient outcomes, and continue to meet the requirements for a

Patient-Centered Medical Home (PCMH). In phase three, an external change agent was

identified as the graduate student facilitating this process. As the change agent, I assisted this

practice to serve their patients better by using the ample resources at my disposal for completing

this project. This proposal also served as phase four of Lippitt’s Change Theory in which a

detailed plan was developed to outline implementation. Phases five through seven of Lippitt’s

Change Theory took place throughout the actual implementation of the project.

In combination with Lippitt’s Change Theory, this project will also use The Model for

Improvement (Appendix C), which was developed by The Associates in Process Improvements

and used by the Institute of Healthcare Improvement (IHI) (Silver et al., 2016). This proposal

served as the answers to the first three questions of The Model for Improvement, “what are we

trying to accomplish?”, “How will we know a change is an improvement?” and “what changes

can we make that will result in improvement?” (Langley et al., 2009). The final phases of

Lippitt’s Change Theory took place during the implementation of the project, and were guided

by the Plan, Do, Study, Act (PDSA) cycles of the Model for Improvement (Langley et al., 2009).

12
 CHAPTER 4: METHODS
This quality improvement (QI) project was designed to create a standardized depression

screening protocol for adults ages 18-65 in a primary care setting using the PHQ-9. Quantitative

data was collected from compliance rates to measure fidelity, which was calculated by

comparing the number of positive screens to baseline. Data regarding the management of the

patient with a positive screen was also collected, as well as provider surveys used to determine if

the protocol increased provider satisfaction (appendix D; appendix G). This project focused on

the implementation of the PHQ-9 as a standard depression screening protocol for adult patients,

ages 18-65, that were new to the practice or obtaining their yearly physical.

Context

The primary care practice in which this project was conducted reported challenges with

implementing a depression screening protocol because of time constraints and lack of buy-in

from staff. Before the project implementation of this depression screening protocol, the providers

at this practice only used depression screening tools on patients who verbalized depressive

symptoms to determine severity. The patients were given the PHQ-9 screening tool to be

completed in front of the provider during that visit. On observation, the lack of a standardized

depression screening protocol led to a gap in care in which patients who may be positive for

depressive symptoms were not being adequately screened, assessed, and managed. Provider

reports from the surveys conducted, indicated that screening for depression during the

appointment mentioned above had led to time constraints and frustration towards a consistent

screening protocol. Therefore, this standardized depression screening protocol aided this primary

13
care practice by maximizing time and increasing the opportunity to address underlying MDD in

their adult patient population.

Process

This project implemented a standardized screening protocol for depression, using the

PHQ-9, to determine the presence of symptoms, and if present, the severity of MDD (Kroenke,

Spitzer, & Williams, 2001). All adult patients ages 18-65, at an appointment as a new patient or

obtaining a yearly physical, were screened using the PHQ-9. Patients were handed the PHQ-9 by

the triage staff who took the patient to the examination room, to be filled out by the patient while

waiting for the provider. The PHQ-9 was collected and scored by the provider, who also

conducted a verbal assessment to ensure the appropriate score was obtained. Once the provider

had a patient that scored positively on the PHQ-9, the provider was guided to use the depression

screening protocol to determine the necessary next steps in management. The outcome of

positive scores was discussed between the patient and the provider, and patient-centered

management choices were presented as options for the patient to consider. These options

included but were not limited to a medical workup, including lab work, medications, specialty

referral, or emergency transport for acute safety concerns. PHQ-9 score and management

decisions were documented in the EMR by the provider as well as any follow-up interventions.

Setting and Population

This study was conducted in a private primary care practice in North Carolina, which is

distinguished as a Patient-Centered Medical Home (PCMH). A PCMH delivers patient-centered

care by a multidisciplinary team that is accessible and focused on improved patient outcomes

(Sandoval, Bell, Khatri, & Robinson, 2018). Primary care practices within the United States have

obtained the PCMH distinction as a means of meeting the goals of the IHI’s Triple Aim and,

14
subsequently, the IHI’s improved Quadruple Aim (Sandoval, Bell, Khatri, & Robinson, 2018).

Maintaining this designation requires primary care providers to use screening tools to assess

possible underlying common mental illnesses, such as depression, in their patient population as a

means to provide patient-centered care. Individuals who seek care at this practice primarily use

private insurance, with a small proportion of self-pay and Medicare patients. During the time of

the project, this practice did not accept Medicaid patients. This practice employs two full-time

family nurse practitioners, two part-time family nurse practitioners, one family physician, and

various ancillary staff members.

Data Collection Instruments

The screening tool used to implement the standardized screening protocol in this primary

care practice was the PHQ-9 (Kroenke, Spitzer, & Williams, 2001). O’Byrne & Jacob (2018),

found that the PHQ-9 had the most research and the best performance based on a systematic

review of over 50 screening tools for depression. The PHQ-9 shows sensitivity and specificity of

88% at a threshold of 10 or higher (Mitchell, Yadegarfar, Gill & Stubbs, 2016). Data collected

from the PHQ-9 screening and the EMR, included the percentage of positive and negative scores,

the rate of patients screened, and the interventions used with positive scores.

Providers participated in a pre-project and post-project survey, using Likert scales and

open form questions, regarding their ability to recognize symptoms and severity of MDD,

comfort in further assessment, and comfort initiating treatment once MDD is recognized.

Provider satisfaction, as it relates to being able to treat those with comorbid mental illnesses such

as depression, was also assessed. This survey was developed by the graduate student that

implemented the project, and data was gathered using Qualtrics.

15
Procedures for Project Implementation

Pre-intervention.

A pre-project survey was administered to the providers who agreed to participate in this

project before the implementation of the first PDSA cycle (Appendix D). With this survey,

educational needs were assessed, and the graduate student provided educational sessions to

providers on an as-needed basis. These educational sessions were used to address any gaps in

knowledge identified in the survey. Providers were offered resources to promote the practice

change process (Appendix E), which included information about various types of antidepressant

medications and possible side effects to help guide providers if a medication was warranted

based on PHQ-9 and patient preference (LeBlanc et al., 2016). A protocol was given to the

providers to use as a guide to decision making based on scores on the PHQ-9 (Appendix F). This

protocol was developed by the DNP student and the practice champion and was informed by the

Institute for Clinical Systems Improvement Health Care Guideline (Trangle et al., 2016). The

cutoff point of 10, which served as the point in which providers must intervene, is the evidence-

based cutoff point indicative of a moderate level of depression (Levis, Benedetti, & Thombs,

2019; Kroenke, Spitzer, & Williams, 2001). Providers were instructed on this protocol to follow-

up on positive scores with a verbal assessment of mood and suicidality to ensure that a diagnosis

was not made solely based on PHQ-9 results (Ferenchick, Ramanuj, & Pincus, 2019). This

verbal assessment was also used to ensure that any false positive scores were ruled out to avoid

overtreatment and a subsequent increase in healthcare spending (Levis, Benedetti, & Thombs,

2019). The practice protocol for suicidality was discussed and included in the standardized

depression screening protocol.

16
Intervention.

The implementation phase of this project involved two PDSA cycles intending to have

providers use the PHQ-9 screening tool on every new patient or patient attending their yearly

physical appointment. In the first PDSA cycle, the implementation of the PHQ-9 took place with

one provider, the project champion. The provider scored each PHQ-9 questionnaire, and a verbal

assessment was completed; then, based on the score, the provider and patient determined how to

proceed. All scores greater than or equal to 10, which suggest a moderate to severe depression,

were investigated further by the provider to determine the need for treatment. The provider then

used the US Preventative Services Task Force (USPSTF) evidence-based practice guidelines to

determine the necessary next steps, including the possibility of additional lab work to rule out

organic causes, initiation of medication, or the need for specialty referral (Siu & and the US

Preventative Task Force (USPSTF), 2016). The first PDSA cycle lasted for three weeks and was

then was analyzed for one week. There were no unanticipated problems or concerns to be

addressed from the first PDSA cycle to the second PDSA cycle. Several different types of data

were collected, including compliance rate to determine fidelity, determination of positive versus

negative scores, and interventions provided to the patients with positive scores.

The second PDSA cycle included the implementation of the PHQ-9 screening on every

new patient or patient attending their yearly physical appointment, with the addition of two of the

part-time FNP’s in the practice. The second PDSA cycle lasted for three weeks and then was

analyzed for over two weeks.

Post-Intervention.

After the two PDSA cycles were completed, data collected from completed patient

screens, provider pre-project surveys, and the EMR were analyzed, and providers were given a

post-project survey. The survey was used to determine if the standardized implementation of the

17
PHQ-9 for the detection of MDD increased their knowledge and comfort in treating depression

within primary care. This survey also included a question to determine the likelihood of

continuation and sustainability of using the PHQ-9 as a standardized screening tool for MDD

(Appendix G).

Key personnel/Stakeholders

This practice consists of one family physician, two full-time family nurse practitioners,

and two part-time family nurse practitioners, comprising the majority of the stakeholders

involved in this project. This practice is co-owned by one of the full-time family nurse

practitioner (FNP) and project champion and the full-time family practice physician. Three of the

five providers were willing to participate in this project, all of which were family nurse

practitioners. The part-time FNP that did not participate, refused to complete the pre-project

survey and was not open to discussion with the graduate student. The family private physician

was resistant to change and quickly approaching her retirement. The physician did not interfere

with the project but also refused to complete the pre-project survey or to implement a depression

screening protocol.

Evaluation (Data Analysis)

Quantitative data were derived by gathering compliance rates by collecting the number of

screening tools completed, divided by the number of eligible patient visits to determine fidelity.

Data were collected before implementation of the project and at the end of each PDSA cycle and

were compared. Patient outcome data were obtained by collecting the positive screening rate, or

the number of positive screens divided by the number of patients screened. Patient outcome data

were also obtained by collecting the number of patients who were appropriately managed using

the depression screening protocol. Quantitative patient outcome data were presented with

descriptive statistics due to the small sample size. Data were obtained from surveys administered

18
pre-project and post-project to the providers who took part in the project, and the results were

compared to assess for increased knowledge, comfort, and satisfaction of using a standardized

screening protocol for depression. Graphical representations of all data were produced for

visualization of project outcomes (figures 1-7).

Ethics and Human Subjects Permissions

This quality improvement project was deemed exempt on July 22, 2019, by the UNC-

Chapel Hill Institutional Review Board (IRB) (Appendix H).

19
 CHAPTER 5: RESULTS
During this quality improvement project, 65 adults aged 18-65, were assessed for

evidence of depression using the PHQ-9 (Kroenke, Spitzer, & Williams, 2001). A total of 107

patients fit the inclusion criteria for screening for a screening rate of 60.74%. As a result of

screening, 3 patients scored at or above the threshold of 10 on the PHQ-9 screening tool, and

adherence to the implemented protocol was observed. Demographic data were gathered over the

three weeks before implementation and are presented in Figure 1-Figure 3. Of the demographic

population, 68.25% were female, 68.25% were Caucasian, and 49.20% were between the ages of

42-57 (Table 1).

Table 1. Population demographics

Sex Count Percentage

Female 43 68.25%
Male 20 31.75%
Race
Caucasian 43 68.25%
African American 11 17.46%
Asian 4 6.35%
Pacific Islander 3 4.76%
Refused 1 1.59%
Hispanic 1 1.59%
Age
18-25 6 9.52%
26-33 9 14.29%
34-41 8 12.70%
42-49 16 25.40%
50-57 15 23.81%
58-65 9 14.29%

20
Akincigil & Matthews, (2017), reported similar findings with females representing 63.5% and

Caucasian representing 71.0% of the sample population. This study, however, also found that

screening rates were not consistent between sex, race, and age, and also found less participation

in primary care practices which did not have an electronic health record (Akincigil & Matthews,

2017). Screening rates in this QI project did not find any variance in sex, race, or age on

screening for depression (Table 2).

Table 2. DNP project screening demographics

Sex Count Percentage

Female 45 70.31%
Male 19 29.69%
Race
Caucasian 41 64.06%
African American 11 17.19%
Asian 7 10.94%
Pacific Islander 2 3.13%
Hispanic 2 3.13%
Refused 1 1.56%
Age
18-25 2 3.13%
26-33 6 9.38%
34-41 9 14.06%
42-49 13 20.31%
50-57 20 31.25%
58-65 14 21.88%

These results are widely representative of the demographics in the town in which this project was

conducted. Data was gathered before the implementation of the screening protocol to determine

the initial rate of screening for depression. During this time, 63 patients fit inclusion criteria, and

one patient was screened at a rate of 1.59%. The first PDSA cycle involved implementation of

the depression screening protocol with one provider, 26 patients fit inclusion criteria, 15 were

screened, at a rate of 57.69% (Figure 4). The second PDSA cycle implemented the depression

21
screening protocol with three providers; 81 patients fit inclusion criteria, 49 patients were

screened correctly, at a rate of 60.49% (Figure 5). Provider one, which participated in both

PDSA cycles, showed a consistent increase in the percentage of patients screened (Figure 6).

Screening rates for patients between the ages of 18-65 attending either a new patient or yearly

physical appointment, approximately 17% of the total patient population at this primary care

practice, increased from 1.59% to 60.49% (Table 3, Figure 7).

Although only 3 patients scored a positive score above 10, those patients were treated

appropriately by all three providers engaged in this project. The patient who scored a 10 on the

PHQ-9 screening tool was restarted on psychotropic medication and scheduled for a follow-up in

two weeks. The patient who scored a 15 on the PHQ-9 screening tool was referred to a

psychiatric provider the same day and subsequently seen by that provider within one week. This

patient had already been prescribed psychotropic medications and held numerous psychiatric and

medical diagnoses, which necessitated referral and an increased level of psychiatric care. Finally,

the patient who scored an 18 on the PHQ-9 was immediately referred for an increased level of

psychiatric care. This patient had been prescribed a subtherapeutic dose of antidepressant

medication, being monitored by another provider, so a referral was more appropriate than a

medication change. There was also a patient who scored an 8, which was below the threshold of

10, the responses alerted the provider to possible causes of uncontrolled diabetes, and the

frequency of monitoring was increased.

22
Table 3. Fidelity of screening

Pre-implementation First PDSA cycle Second PDSA cycle

# of screening
tools 1 15 49
completed
# of eligible
63 26 81
patient visits
% screened 1.59% 57.69% 60.49%

Providers were encouraged to use their clinical judgment if screening was not appropriate, and

patients were to complete the PHQ-9 voluntarily and were free to decline participation.

Subsequently, some patients fit the screening criteria but were not screened; however, data on the

reason for not participating was not collected. Patients with an existing diagnosis of depression

were not removed from this project, which could skew data gathered (Levis, Benedetti, &

Thombs, 2019). Data related to the PHQ-9 was not collected as this project looked explicitly at

improved screening rates. Although the graduate student was available to provide educational

sessions to providers, this was deemed unnecessary by the providers engaged in the project.

These providers were all confident in their ability to assess for, treat, and manage or refer

patients with depression and only required assistance with implementing the process into their

workflow. During the project, the family physician and a part-time family nurse practitioner

(FNP) chose not to participate and were subsequently excluded from each survey.

The pre-implementation survey, developed by the DNP student, involved the three

providers that participated in the second PDSA cycle of this quality improvement project. This

survey indicated that all three providers had at least a moderate comfort level, both in using the

PHQ-9 screening tool and managing patients with depression. Two of the three providers

indicated not having the time to implement the depression screening protocol in either 15-minute

or 30-minute patient visits. In free text, barriers indicated were concerns about proper

23
reimbursement and time constraints, both of which were highlighted within the literature review

(Waitzfelder et al., 2018; Akincigil & Matthews, 2017) (Table 4).

Table 4. Pre-implementation survey

Provider 1 Provider 2 Provider 3

Q1. How familiar are you with the
Patient Health Questionnaire (PHQ- Somewhat familiar Very familiar Very familiar
9)?
Q2. How likely are you to use the
PHQ-9 screening tool for your adult
Somewhat unlikely Somewhat Likely Very likely
patients to recognize the signs and
symptoms of depression better?
Q3. How confident do you feel
Somewhat Somewhat
about managing a patient with mild Neutral
confident confident
depression?
Q4. How comfortable are you with
prescribing an antidepressant Somewhat Minimally
Very comfortable
(SSRI's, SSNRI's, etc.) to your patient comfortable comfortable
with mild depression?
Q5. Would having more information
about depression, and possible
treatment options make you feel No Yes Yes
more confident in managing a
patient with depression?
Pamphlet
describing types
of
An on-site
antidepressants
consultant
and common
An on-site Current
side effects
Q6. What materials would you consultant research on
An on-site
prefer? (Select all that apply) An on-call outcomes of
consultant
consultant treating
Current research
depression in
on outcomes of
primary care
treating
depression in
primary care

24
 Provider 1 Provider 2 Provider 3
Q7. Would having a protocol
established to assist you with the
management of patients with No Unsure Yes
positive PHQ-9 scores make you
more comfortable?
Q8. Do you know how to handle,
based on practice protocol, a
Yes Unsure Yes
patient who is actively suicidal and
an imminent risk to themselves?
Q9. I have enough time to
incorporate the PHQ-9 screening in
FALSE FALSE TRUE
my new patient and yearly visits
(30-minute visits).
Q10. I have enough time to
incorporate the PHQ-9 screening in FALSE FALSE TRUE
follow-up visits (15-minute visits).
"Time during office
visit, extra concerns
Q11. What barriers do you face that created to address
impact your ability to implement during office visit, Time No response
the PHQ-9? coding concerns to
get proper
reimbursement."
Q12. Do you have any comments,
questions, or concerns that I can No No response No response
address?

The post-implementation survey, also developed by the DNP student, found contradicting

information that indicated that all three providers had time to implement the screening protocol

in their 30-minute visits. Additionally, two of the three providers stated that they felt comfortable

implementing the protocol in their 15-minute appointments. In free text, two of the three

providers continued to report that time was a barrier to screening for depression; however, one of

these providers indicated that it would not deter the use of future screening. All three providers

acknowledge that their satisfaction with depression screening improved, and all three stated they

would continue to use the depression screening protocol in practice. These results were similar to

25
the findings in a cluster-randomized research study, which found that patient and provider

satisfaction increased with the use of a decision aid and shared decision making between patient

and provider (LeBlanc et al., 2016) (Table 5).

Table 5. Post-implementation survey

Provider 1 Provider 2 Provider 3

Q1. After participating in this
quality improvement project, how
likely are you to continue to use the
Very Likely Somewhat likely Very likely
PHQ-9 screening tool for your adult
patients to recognize the signs and
symptoms of depression?
Q2. After participating in this
project, how confident do you feel
Very confident Very confident Neutral
about managing a patient with mild
depression?
Q3. After participating in this
project, did having a step by step
protocol of interventions for
No Yes Yes
patients who obtained a positive
score using the PHQ-9 screening
tool make you feel more confident?
Q4. After participating in this
project, do you still think it would
No Yes No
be more beneficial to have an on-
site or on-call consultant?
Q5. Did the protocol established in
this project increase your
knowledge of interventions for a No Unsure Yes
patient with a positive score using
the PHQ-9 screening tool?
Q6. After participating in this
project, do you feel you have
enough time to incorporate the
Yes Yes Yes
PHQ-9 screening tool in visits with
new patients and yearly physicals
(30-minute appointments)?
Q7. After participating in this
project, do you feel you have
enough time to incorporate the Yes No Yes
PHQ-9 screening tool in 15-minute
appointments?

26
 Provider 1 Provider 2 Provider 3
"A few select
patient reviews of
symptoms
increased and
caused the office
Q8. After participating in this
visit to get out of "None, I
project, what barriers did you face
hand. So, I have to use this
when screening for the signs and "time"
proceed knowing tool
symptoms of depression using the
this is a risk. But it frequently."
PHQ-9?
isinfrequent
enough not to
deter me from
continuing to
screening patients."

Q9. After participating in this

project, does the protocol
established increase your Yes Yes Yes
satisfaction with screening for
depression in primary care?

27
Figure 1: Patient Demographics: Gender

28
Figure 2: Patient Demographics: Race

29
Figure 3: Patient Demographics: Age

30
Figure 4: PDSA 1 Scores

31
Figure 5: PDSA 2 Scores by Provider

32
Figure 6: Percentage screened for provider one

33
Figure 7: Percentage screened for the entire project

34
 CHAPTER 6: DISCUSSION
This quality improvement project was aimed at implementing a depression screening

protocol to assist healthcare providers with the identification of the signs and symptoms of

depression in primary care patients. The aims of this project included improving patient

outcomes with appropriate screening and interventions for positive PHQ-9 scores, enhanced

screening rates to meet criteria for patient-centered medical home (PCMH), and improving

provider satisfaction by creating a process that easily fits into the normal flow of patient care.

The screening rate for depression using the PHQ-9 dramatically increased, and the protocol

developed was used appropriately for every positive score above the predetermined cut off point

of 10 or higher. Also, all three family nurse practitioners (FNP) reported increased satisfaction

with depression screening using the implemented protocol and planned to continue its use after

the project completed.

The screening and handling of depression are arduous in the primary care setting.

Researchers have previously identified that differentiating the signs and symptoms of depression

are challenging to uncover because they may be related to an organic cause, present as comorbid

with other complex psychiatric disorders, or comorbid with chronic medical illnesses, and can

include acute emergencies such as suicidal ideation. This quality improvement project

demonstrated that implementing a depression screening protocol, for new adult patients and adult

patients attending their yearly physical appointments, provided treatment and referral options

guided by workflow triggered by positive PHQ-9 scores. Overall, this protocol improved patient

outcomes and provider satisfaction by quickly and easily identifying patients with signs and

35
symptoms of depression. These patients had improved outcomes based on obtaining either

increased monitoring, treatment, or referral for a psychiatric disorder from a trusted provider.

Provider satisfaction improved by integrating the screening protocol to increase patient screening

and subsequently increase reimbursement. Providers were also more satisfied with the improved

ability to provide holistic patient-centered care to their patients.

Lippitt’s change theory and the Institute of Healthcare Improvement’s (IHI) Model of

Improvement guided this quality improvement project by providing a framework for the

implementation of the depression screening protocol in this primary care practice. The PDSA

cycles were of particular importance; the first cycle provided positive results and subsequently

provided increased buy-in from the additional providers in the office. My role as the change

agent was to provide a combination of on-site and on-call consultation to assist if needed.

Although there were positive scores in the moderate to severe range, a consultation was not

utilized, as the providers were able to use the screening protocol to confidently and appropriately

manage these patients.

This project demonstrated to the nurse practitioners who participated, as well as those

providers who did not participate, that implementing a screening protocol can be successfully

done without a significant impact on their regular workflow. The positive results of this project

have led to the nurse practitioners involved to look to expand the number of patients screened,

which would have a more substantial impact on their entire patient population. The providers

learned from this project that they can efficiently work to the full scope of practice as a family

nurse practitioner and can be confident in their assessment skills, knowledge base, and time

management skills.

36
Limitations

There were several limitations in this quality improvement project. This project

implemented a depression screening protocol in a primary care practice that does not accept

Medicaid patients and is located in an affluent town in North Carolina. Practices that serve

Medicaid patients or that are located in rural areas may face different barriers to implementation,

decreasing the potential generalizability of this project. Stakeholder buy-in was also a limitation

to this project, which narrowed the ability to use the depression screening protocol across the

entire practice. Time continued to be a barrier to the providers who did implement this protocol;

however, providers found value in using the screening protocol regardless of the time constraint.

This project was limited by the number of patients who scored at or above the cut off value of

10. Since there were so few positive scores, it is difficult to know if the protocol would have

continued to increase provider satisfaction if there were more positive screens and patients

needing complex management. This primary care practice is also very well established and is

relatively small, with the same people working day to day. It would be difficult to determine if

the results would remain the same in a larger, less established primary care practice with more

employees. Finally, all three providers who participated in this project already felt comfortable

managing a patient with depression. New providers may be less comfortable with these patients

and may be hesitant to screen for depression or might need additional education on possible

interventions for a positive score.

Sustainability

The depression screening protocol developed in this quality improvement project is easily

sustainable within the practice in which it was implemented. The PHQ-9 is a free instrument that

is open to the public and can be printed from the internet at no cost. The practice where this

37
project took place has updated their EMR, making it easier to find the PHQ-9 screening tool to

increase ease of documentation and to ensure proper reimbursement better. With the appropriate

education, this depression screening protocol could be used in other primary care practices and

could be changed to serve that patient population better.

Future Study

Additional research on implementing screening protocols in primary care settings is

needed to improve overall patient healthcare nationwide. Updating electronic medical records to

contain a section for screening tools that the practice uses, including automatic updates when

screening should be completed, would be a beneficial next step to improve sustainability. Long-

term studies of outcomes for patients who are identified and treated for depression based on a

screening tool result should be conducted to determine the real benefit of screening in primary

care. The use and implementation of a screening protocol have been shown by this project to be

quickly successful, but additional research to support the sustainability needs to be conducted to

improve the chances of continuing to provide holistic care using screening tools in primary care.

38
 CHAPTER 7: CONCLUSIONS
This quality improvement project has shown that implementing a depression screening

protocol in a primary care setting can enhance patient results and improve provider satisfaction.

The PHQ-9 screening tool is a free, reliable, and validated tool for screening for depression in

primary care. The depression screening protocol developed in this project could be expanded in

the current primary care practice to target a higher percentage of patients. The protocol could

also be modified for other primary care practices and utilized to improve patient outcomes and

provider satisfaction. Using this standardized depression screening protocol meets the

recommendation by The U.S. Preventative Services Task Force (USPSTF), The American

College of Physicians, The American College of Preventative Medicine, and The Institute for

Clinical Systems Improvement (Siu & and the US Preventative Task Force (USPSTF), 2016;

O’Conner et al., 2016; Crowley & Kirschner, 2015; Maurer, Raymond, & Davis, 2018; Trangle

et al., 2016). Research has shown that when the signs and symptoms of depression are

unrecognized or left untreated, MDD increases the risk of medical comorbidities such as heart

disease, Alzheimer’s disease, stroke, obesity, and diabetes (Maurer, Raymond, & Davis, 2018).

This protocol can also help to decrease suicide rates and to decrease overall health care spending

(Maurer, Raymond, & Davis, 2018). Overall, the findings in this quality improvement project

support the significance of screening for depression in primary care, and the development of a

standardized protocol can decrease the barriers faced.

39
APPENDIX A: PATIENT HEALTH QUESTIONNAIRE (PHQ-9)

40
 APPENDIX B: LIPPITT’S CHANGE THEORY

Elements in the Lippitt

nursing process
(Pearson)
“Assessment” “Phase 1: Recognize the issue.”

“Phase 2: Assess motivation and ability to change.”

“Phase 3: Assess the resources necessary for the change

and the motivation of the change agents.”

“Planning” “Phase 4: Select the objective of change.”

“Phase 5: Choose a suitable role of the change agent in the

process of change.”

“Implementation” “Phase 6: Maintain change.”

“Evaluation” “Phase 7: Terminate the helping relationship.”

(Lippitt, Watson, & Westley, 1958; Mitchell, 2013).

41
APPENDIX C: MODEL FOR IMPROVEMENT

(Langley et al., 2009).

42
 APPENDIX D: PRE-IMPLEMENTATION SURVEY

Depression Screening in Primary Care

Q1 How familiar are you with the Patient Health Questionnaire (PHQ-9)?

1 (1) 2 (2) 3 (3) 4 (4) 5 (5)

Not familiar
Very familiar
o o o o o at all

Q2 How likely are you to use the PHQ-9 screening tool for your adult patients to recognize the signs and
symptoms of depression better?

1 (1) 2 (2) 3 (3) 4 (4) 5 (5)

Not at all
Very likely
o o o o o likely

Q3 How confident do you feel about managing a patient with mild depression?

1 (1) 2 (2) 3 (3) 4 (4) 5 (5)

Very Not at all

confident o o o o o confident

43
Q4 How comfortable are you with prescribing an antidepressant (SSRI's, SSNRI's, etc.) to your patient
with mild depression?

1 (1) 2 (2) 3 (3) 4 (4) 5 (5) 6 (6) 7 (7)

Very Not at all

comfortable o o o o o o o comfortable

Q5 Would having more information about depression, and possible treatment options make you feel
more confident in managing a patient with depression?

o Yes (1)
o No (2)
o Unsure (3)

Q6 What materials would you prefer? (Select all that apply)

Pamphlet describing types of antidepressants and common side effects (1)

An on-site consultant (2)

An on-call consultant (3)

Current research on outcomes of treating depression in primary care (4)

44
Q7 Would having a protocol established to assist you with the management of patients with positive
PHQ-9 scores make you more comfortable?

o Yes (1)
o No (2)
o Unsure (3)

Q8 Do you know how to handle, based on practice protocol, a patient who is actively suicidal and an
imminent risk to themselves?

o Yes (1)
o No (2)
o Unsure (3)

Q9 I have enough time to incorporate the PHQ-9 screening in my new patient and yearly physical visits
(30-minute visits).

o True (1)
o False (2)

Q10 I have enough time to incorporate the PHQ-9 screening in follow-up visits (15-minute visits).

o True (1)
o False (2)

45
Q11 What barriers do you face that impact your ability to implement the PHQ-9?

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

Q12 Do you have any comments, questions, or concerns that I can address?

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

46
APPENDIX E: PROVIDER RESOURCES

47
 APPENDIX F: DEPRESSION SCREENING PROTOCOL ALGORITHM

PHQ-9 screening for

new patients and
yearly physicals

PHQ-9 score less PHQ-9 score greater

than or equal to 9 than or equal to 10

Patient positive for

Verbal assessment Verbal assessment
suicidality and acute
by provider by provider
risk to self

initiate lab/medical
Treatment/referral: workup to rule out Initiate medication to Refer to mental Follow practice crisis
deferred to provider potential medical target symptoms health provider protocol
causes

Document score and Document score and Document score and

any intervention any intervention any intervention
initiated initiated initiated

Continue yearly
Screen with PHQ-9 Screen with PHQ-9
screening, unless
on next visit on next visit
otherwise indicated

If score is less than If score is less than

10, continue yearly 10 , continue yearly
screening, unless screening, unless
otherwise indicated otherwise indicated

48
 APPENDIX G: POST-IMPLEMENTATION SURVEY

Depression Screening in Primary Care Follow-

up

Q1 After participating in this quality improvement project, how likely are you to continue to use the
PHQ-9 screening tool for your adult patients to recognize the signs and symptoms of depression?

1 (1) 2 (2) 3 (3) 4 (4) 5 (5)

not at all
very likely
o o o o o likely

Q2 After participating in this project, how confident do you feel about managing a patient with mild
depression?

1 (1) 2 (2) 3 (3) 4 (4) 5 (5)

Very Not at all

confident o o o o o confident

Q3 After participating in this project, did having a step by step protocol of interventions for patients who
obtained a positive score using the PHQ-9 screening tool make you feel more confident?

o Yes (1)
o No (2)
o Unsure (3)
49
Q4 After participating in this project, do you still think it would be more beneficial to have an on-site or
on-call consultant?

o Yes (1)
o No (2)
o Unsure (3)

Q5 Did the protocol established in this project increase your knowledge of interventions for a patient
with a positive score using the PHQ-9 screening tool?

o Yes (1)
o No (2)
o Unsure (3)

Q6 After participating in this project, do you feel you have enough time to incorporate the PHQ-9
screening tool in visits with new patients and yearly physicals (30-minute appointments)?

o Yes (1)
o No (2)
o Unsure (3)

50
Q7 After participating in this project, do you feel you have enough time to incorporate the PHQ-9
screening tool in 15-minute appointments?

o Yes (1)
o No (2)
o Unsure (3)

Q8 After participating in this project, what barriers did you face when screening for the signs and
symptoms of depression using the PHQ-9?

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

Q9 After participating in this project, does the protocol established increase your satisfaction with
screening for depression in primary care?

o Yes (1)
o No (2)
o Unsure (3)

51
APPENDIX H: UNC-CHAPEL HILL INSTITUTIONAL REVIEW BOARD (IRB)

52
contact the above IRB before making the changes.

CC:
Leslie Sharpe, School of Nursing
Lisa Miller , School of Nursing Deans Office

page 2 of 2

53
 REFERENCES

Akincigil, A., & Matthews, E. B. (2017). National rates and patterns of depression screening in
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