Depression Screening and Provider Education Within a County Health Department

Background: Depression is a common problem affecting about 1 in 10 women in the United States (U.S.). Rates of depression among women are increasing in Utah from 14.4% in 2016, 17.4% in 2017, and 23.6% in 2020. Depression and can impact quality of life and cause potential suicidality and is often unrecognized due to low rates of screening. Less than 5% of adults in the U.S. are screened which makes diagnosing and treating it very difficult. This lack of screening and recognition of depression could have lasting effects on individuals' ability to function and have an impact on their families, friends, and communities. Purpose: The purpose of this project was to develop a depression screening and referral implementation plan and provider training that would result in universal screening of all women who were seen at 3 clinics in rural Utah for clinical care.Methods: This quality improvement project took place at a Health Department in rural Utah that mainly serves women who are uninsured or underinsured and who are mostly of Hispanic and non-Hispanic white populations. On average, 45 patients are seen every month at the 3 clinics. The clinical staff includes 3 Nurse Practitioners, 3 Nurses, 4 front Desk Associates, and 1 nurse director. The Plan Do Study Act (PDSA) theoretical framework was used to guide the project. With input from the clinic staff, a screening and referral plan was developed. Descriptive statistics were used to evaluate the percentage of women seen at the clinics who received PHQ-9 screening from pre- and post-implementation data, in addition to the percent of women with a positive screen who 2 were referred. A Fisher's exact test was used to evaluate the increase in screening rates. The two cross-sectional analyses that were conducted likely included different groups of patients. Results: Pre-implementation data collection found 2.2% or 5 of 226 patients were screened for depression using the PHQ-9 screening tool from January to June 2019. Post-implementation collection data collection included 2 phases which began with the front desk distributing forms and changed to RN's handing out the forms. Screening rates during phase 1 were 26.1% or 6 of 23 patients. Phase 2 screening rates were 44.4% or 8 of 18 patients. In total, 34.1% or 14 of 41 patients were screened for depression from November 2019 to January 2020. The Fisher's exact test was statistically significant at 0.00001 (p<0.5). Screening rates increased and providers reported wanting to continue universal screening. Conclusion: Universal depression screening using a validated tool can increase recognition of depression and lead to better treatment and use of referral resources when necessary. The application of the PDSA cycle facilitated additional phases to increase screening rates. Although numbers were small for this project, provider and staff motivation to change is an important factor in creating sustainable changes in a primary care setting. Involving staff and providers in the PDSA cycle resulted in refinements and improvements to the implementation plan and led to increased screening rates.