The National College Depression Project: The Journey Thus Far

1. The National College Depression Project:The Journey Thus Far Eleanor W Davidson MD Susan Kimmel MD May 20 2014

2. Background: What’s the rationale for this project? • Depressive disorders are highly prevalent, enormously costly, and a leading cause of disability and reduced quality of life* • Depressed adolescents are at increased risk for impaired academic performance and attainment** • Among college students stress-related symptoms are major impediments to academic performance*** *Langlieb, et al: JOEM 2005;47:1099-1109 **Asarnow, et al: J Adolesc Health 2005;37(6):477-83 ***ACHA data

3. American College Health Association - National College Health Assessment (ACHA-NCHA) Web Summary. Updated April 2006. http://www.acha.org/projects_programs/ncha_sampledata.cfm. 2006.

4. ACHA data

5. JED Foundation Report 2006 • Approx 90% of those who die by suicide at any age: • have a diagnosable mental illness, • most often depression, • Hence identification & treatment of students with emotional disorders is critical to suicide prevention efforts. • ACHA, ACPA, AUCCCD, NASPA

6. JED report 2006 • Counseling service directors report # of students seeking help for serious emotional problems has been rising, but… • The majority of students who die by suicide • have never been to their counseling center!

7. National data • The vast majority of individuals who suicide have never seen a behavioral health professional. • Have they been to primary care? • AFSP website

8. Guidelines • US Preventative Services Task Force Recommendation: • Adult primary care practice settings should screen for depression—but only within the context of a “prepared practice.” • http://www.uspreventiveservicestaskforce.org/

9. College Breakthrough Series-Depression: 2006-07 • NYU, Princeton, Cornell, CUNY (Hunter & Baruch), CWRU, St Lawrence

10. Quality Improvement in NCDP • “Trying harder will not work. Changing systemsof care will.” • Don Berwick MD • Institute for Healthcare Improvement

11. Phase I: challenges • ● How would students react to depression screening in the health service? • ● Could the health service achieve an 80% rate of screening all patients once during a school year? • ● How would clinicians react to screening for depression in primary care? • -Use of Plan-Do-Study-Act cycles • -Start small and grow.

12. Some of us imagined that our biggest challenge was identification of depressed students who would then be referred to the counseling service for treatment. • Next step: implement depression screening

13. Changing our systems of care • Which patients will be screened for depression? • What tool will be used for screening? • How will the screening be done? • When? • By whom? • Where will results of screen be recorded? • What will be the plan for follow-up of patients after depression screening?

14. PHQ-2 During the past two weeks, have you been bothered by: Little interest or pleasure in doing things? □ No □ Yes Feeling down, depressed or hopeless? □ No □ Yes

15. Change process : start small and grow • Paper PHQ2 • 10 students tried it • No resistance • Screen 1/2 day of my patients. • Add more of my patients. • Bring on another provider to screen • Screen in allergy clinic • Medical assistants: “Just as we screen you for high blood pressure, we also screen for depression.”

16. Evaluate each change: PDSA cycles

17. Over the last 2 weeks, how often have you been bothered by the following problems? Not At All (0) Several days (1) More than half the days (2) Nearly every day (3) 1. Little interest or pleasure in doing things □ □ □ □ 2. Feeling down, depressed, or hopeless □ □ □ □ 3. Trouble falling or staying asleep, or sleeping too much □ □ □ □ 4. Feeling tired or having little energy □ □ □ □ 5. Poor appetite or overeating □ □ □ □ 6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down □ □ □ □ 7. Trouble concentrating on things, such as reading the newspaper or watching television □ □ □ □ 8. Moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual □ □ □ □ 9. Thoughts that you would be better off dead, or of hurting yourself in some way □ □ □ □ Subtotals (add columns) Total Score PHQ-9 If you checked off any problems, how difficult have these problems made it for you to do your work, study, go to class or get along with other people? __ Not difficult at all (0) __ Somewhat difficult (1) __ Very difficult (2) __ Extremely difficult (3)

18. Design multiple options for administering PHQ9 • 1. Clinician can do the PHQ9 right then (or bring the patient back for the PHQ9) • 2. Nurse care manager can do PHQ9 • 3. Clinician can refer for a PHQ9 (Women’s Health Advocate) • 4. Nurse could refer directly to counseling • You can individualize the model to suit your own circumstances; you have to have the elements but not a single solution. • You’re creating the “prepared practice.”

19. Additional benefits of the PHQ9 • Turned out to be a great teaching tool: • for patients (what is depression) • for clinicians • Leads clinicians from the easier questions (typical for a primary care setting) into the more difficult ones—gives them a script to follow.

20. Next step: score the PHQ9 • Minimal depression 0-4 • Mild depression 5-9 • Moderate depression 10-14 • Moderately severe 15-19 • Severe 20-27 • Positive # 9 always needs to be addressed (written emergency information provided & documented).

21. Discuss results with student. • High score does not equal depression. • Other primary disorders ruled out. • Initiate evidence-based treatment for depression (counseling, medication, self-management).

22. Other elements • Design clinical information system (registry): • Track more highly affected students using enhanced care management. • Use registry to plan next visits & achieve process measures (check PHQ9 scores for evidence of improvement). Change treatment if no improvement. • Assign care manager who reaches out to students who haven’t followed up

23. Monitor progress in screening • Weekly lists of students screened • Finding when we missed an opportunity to screen. • Figure out why & redesign system.

24. Depression Screening in Primary Care - A stretch goal of 80% for primary care screening was set for the 6 sites that committed to implement standardized depression screening - The collaborative achieved an aggregate screening rate of 65% by the end of 2007.

25. Depression Registry

26. CWRU experience • We could achieve 80-90% screening throughout the Health Service (we excelled at using it through all visit types). • Screening was well-received by students.

27. CWRU experience • The team embraced the PHQ9: • - routine measurement • - routine documentation in EHR • - communication tool between services

28. CWRU experience • Certain populations disproportionately accessed care in the Health Service: • 1. Non majority students • 2. Men • So we did appear to be expanding access to care. • A Pyati PhD

29. Next phases of NCDP • More partners, more diversity of schools • Connections to Healthy Minds (Daniel Eisenberg PhD) • Other measures (anxiety, alcohol, mental health flourishing) • Expanded self-management focus

30. Rio Hondo College Rutgers University Sarah Lawrence College School of the Art Institute of Chicago St. Lawrence University Skidmore College Texas A&M University Texas Christian University Tufts University University of Arizona University of California, Los Angeles University of Central Florida University of Louisville University of Maryland University of Missouri - Columbia University of Nevada, Las Vegas University of Pennsylvania University of Vermont University of Wisconsin - Madison Wagner College West Valley College Baruch College Boston University Bowling Green State University Case Western Reserve University Colorado State University Columbia University Cornell University Evergreen State College Finger Lakes Community College Hunter College/CUNY Lewis-Clark State College Louisiana State University McMaster University Michigan State University Montana State University The New School Northeastern University New York University Penn State – Altoona Princeton University Rensselaer Polytechnic Institute 42 Partnering Institutions Since 2006

31. Population perspective: Healthy minds study • Permission to use next set of slides from • Daniel Eisenberg PhD • Director, Healthy Minds Network • Healthymindsnetwork.org

32. Data from the Healthy Minds Network: Prevalence and Treatment of Depression among College Students Daniel Eisenberg, Ph.D. Director, Healthy Minds Network University of Michigan School of Public Health

33. HealthyMindsStudy • Began in 2005 • Fielded at approximately 100 campuses • ~100,000 survey respondents • Main measures • Mental health (depression, anxiety, self-injury, suicidality, disordered eating, positive mental health) • Lifestyle and health behaviors (substance use, exercise, sleep, etc.) • Attitudes and awareness about services • Service utilization • Academic and social environment

34. HMN Survey Research Healthy Minds Study (nearly 100 schools, 2005-present); Healthy Bodies Study (beginning 2013)

35. Main Findings from Healthy Minds • “Treatmentgap” of >50%in college populations • Stigmalowandknowledgehighformanyuntreatedstudents • Help-seekinginterventionsrequirenewapproaches • Mentalhealthpredictsacademicsuccess • GPA&retention • Economiccaseformentalhealth services/programs 31

36. Prevalence of MH problems 50 40 34% 30 17.9% 20 15.7% 9.9% 9.8% 7.2% 10 0 Self-injury Any Major dep. (PHQ-9) Any dep. (PHQ-9) Anxiety (PHQ) Suicidal Ideation Datasource:HMS,2007-2013

37. Past-year Treatment for MH problems(Medication or counseling/therapy) 100 90 80 70 60 50 40 30 20 10 0 53% 52% 45% 41% 39% 38% Self-injury Any Major dep. (PHQ-9) Any dep. (PHQ-9) Anxiety (PHQ) Suicidal Ideation Datasource:HMS,2007-2013

38. Past-year Treatment,among students with past-year PHQ-2 score ≥3 50 40 37% 32% 30 19% 20 10 0 Antidepressant Counseling/therapy Either modality Datasource:HMS,2009-2013

39. Duration of Antidepressant Use,among students with antidepressant use and PHQ-2 score ≥3 100 90 80 70 60 50 40 30 20 10 0 79% 12% 9% <1 month 1-2 months >2 months Datasource:HMS,2009-2013

40. Prescriber Types,among students with antidepressant use and PHQ-2 score ≥3 100 90 80 70 60 50 40 30 20 10 0 54% 49% 3.5% 3% 0.4% Psychiatrist Other Don'tknow Tookw/oRX General Practitioner Datasource:HMS,2007-2013

41. Number of Counseling/Therapy Visits,among students w/ counseling/therapy use and PHQ-2 score ≥3 50 40 31% 30% 30 23% 20 16% 10 0 1to3 4 to6 7 to9 10ormore Datasource:HMS,2007-2013

42. ProblemandOpportunity PROBLEM: “Minimally adequate depression care” (Wang et al, 2005 Arch Gen Psych): 8+ psychotherapy visits, or 2+ months of antidepressant use with 4+ discussions with provider Only 20% of students with past-year depression (Healthy Minds 2009-2013) OPPORTUNITY: 80% of students report visiting a health professional at least once in the past year

43. ExtrapolatingNumbers to Typical Campusof10,000Students 2,630 students with past-year depression 530 with minimally adequate care 2,100 without minimally adequate care 1,120 no mental health care, but contact with health care 435 no contact at all with health care

44. Gap between perceived need and use of mental health services Percentage Among students with depression based on current positive PHQ-9 screen [n = 971]. Healthy Minds Study, 2007

45. Models of care : each has challenges • Some with integrated health & counseling: • Stanford, Cornell, Princeton, Wash U, NYU, Penn State Altoona • Some with mostly counseling: • SAIC, Baruch • Some with both elements, parallel reporting: • Shared EHR • Non shared records (both electronic & paper)

46. CWRU model: assets & challenges • Vast majority of students entered into depression registry from Health Service (early adopters more on Health Service side). • Robust, open access counseling service on campus, no charge for visits • We originally thought our task was to identify depressed students and refer to UCS for care • We found that most students wanted to return to the place they originally came for help.

47. Identification was the easy part. • Our challenge was what to do when students did not want either counseling or medication

48. Self-management tools • Phase II and III of NCDP markedly increased the role of self-management skills • Tamara Lazenby MD, NYU (psychiatry) • Evette Ludman PhD Group Health Research Institute

49. What Is Self-Management? Self-management - Goal directed patient behaviors that enhance clinical & functional outcomes: • Medication management and adherence • Self-monitoring of symptoms, treatment status • Managing effects of illness on social role function • Reducing health risks (alcohol misuse, smoking) • Preventive maintenance (e.g., exercise, screening check-ups) • Working with health care professionals

50. NCDP Operational Definition The engagement of patients in a collaborative partnershipwith clinicians to achieve goal-directed behavioral changeandpatient activation.