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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 Center. Joy Stewart-James, Ed.D. Executive Director Student Health & Counseling Services California State University, Sacramento. Objectives. Describe implementation of routine depression screening.

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

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  1. 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

  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

  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

  4. The WELL SAC STATE STUDENT HEALTH & COUNSELING SERVICES

  5. SACRAMENTO STATE SHCS • Fully integrated health, counseling, and health promotion services. • SHC VisitsCAPS Visits • 36,000 + Visits/Annually 10,000 + Visits/Annually • 50% Utilization 7% Utilization SAC STATE STUDENT HEALTH & COUNSELING SERVICES

  6. MENTAL HEALTH & COLLEGE STUDENTS • 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 SAC STATE STUDENT HEALTH & COUNSELING SERVICES

  7. Mental Health & College Students • 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) SAC STATE STUDENT HEALTH & COUNSELING SERVICES

  8. Mental Health & College Students Students reported experiencing the following within the last 12 months: Sac State NCHA Reference Group 42.8% 29.3% 4.9% 46.5% 31.8% 8% • Felt things were hopeless • Felt so depressed that it was difficult to function • Seriously considered suicide  ACHA/NCHA Spring 2013 SAC STATE STUDENT HEALTH & COUNSELING SERVICES

  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

  10. TOP 10 DIAGNOSES STUDENT HEALTH CENTER 2012-2014 Pharyngitis Depression Anxiety Viral Illness Dysuria • Cough • URI • Dermatitis • Allergic Rhinitis • Abdominal Pain SAC STATE STUDENT HEALTH & COUNSELING SERVICES

  11. DEPRESSION SCREENING • 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) SAC STATE STUDENT HEALTH & COUNSELING SERVICES

  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

  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

  14. Patient Health Questionnaire (PHQ-9) SAC STATE STUDENT HEALTH & COUNSELING SERVICES

  15. Patient Health Questionnaire (PHQ-9) PHQ scores > 10 sensitivity of 88% and a specificity of 88% for major depression. (Kroenke et al, 2002) SAC STATE STUDENT HEALTH & COUNSELING SERVICES

  16. 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

  17. PILOT STUDY • 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 SAC STATE STUDENT HEALTH & COUNSELING SERVICES

  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

  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

  20. CALL TO ACTION • 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). SAC STATE STUDENT HEALTH & COUNSELING SERVICES

  21. 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

  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 ideationare referred to UC counselor and seen same day. SAC STATE STUDENT HEALTH & COUNSELING SERVICES

  23. PHQ STATS PHQ 2 Conducted PHQ 9 Conducted Score of > 3 were positive prompting the PHQ-9. SAC STATE STUDENT HEALTH & COUNSELING SERVICES

  24. PHQ STATS POSITIVE PHQ- 9 Positive Scores > 10 MH screening, >15 UC Counselor visit SAC STATE STUDENT HEALTH & COUNSELING SERVICES

  25. Overall PHQ Findings 2011-2014 • 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 SAC STATE STUDENT HEALTH & COUNSELING SERVICES

  26. 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 can’t 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

  27. VISIT TYPES 2011-12 2012-13 2013-14 735 33 623 247 434 601 1028 168 263 123 151 253 816 387 - MH Screenings MH Urgent Care Brief Intervention UC Counselor (started Jan 2012) MH Screenings MH Urgent Care Brief Intervention 1,986 1,203 2,673 TOTALS SAC STATE STUDENT HEALTH & COUNSELING SERVICES

  28. COUNSELING VISITS • Counseling SAC STATE STUDENT HEALTH & COUNSELING SERVICES

  29. REASONS FOR REFERRAL TO UC COUNSELOR • High PHQ Score • Suicide Ideation • Acute Stressor • Trauma • Loss • Sexual Assault SAC STATE STUDENT HEALTH & COUNSELING SERVICES

  30. 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

  31. SPRING 2014 SNAPSHOT OF UC COUNSELING VISITS • Reason for UC referral: • 26% Suicide Ideation • 40% Depression • 22% Anxiety • 12% Subjective Distress Not Otherwise Specified SAC STATE STUDENT HEALTH & COUNSELING SERVICES

  32. 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

  33. SUMMARY • 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. SAC STATE STUDENT HEALTH & COUNSELING SERVICES

  34. 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.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 SERVICES

  35. 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 SAC STATE STUDENT HEALTH & COUNSELING SERVICES

  36. QUESTIONS Email: jsjames@csus.edu SAC STATE STUDENT HEALTH & COUNSELING SERVICES

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