Depression Remission at Twelve Months

Measure Specification

Adults: Depression is a common and treatable mental disorder. During 2013-2016, 8.1% of American adults age 20 and over had depression in a given 2 week period. Women (10.4%) were almost twice as likely as were men (5.5%) to have had depression. The prevalence of depression among adults decreased as family income levels increase. About 80% of adults with depression reported at least some difficulty with work, home, or social activities because of their depression symptoms.

Depression is a risk factor for development of chronic illnesses such as diabetes and CHD and adversely affects the course, complications and management of chronic medical illness. Both maladaptive health risk behaviors and psychobiological factors associated with depression may explain depression's negative effect on outcomes of chronic illness. Adolescents and Adults: The Centers for Disease Control and Prevention states that during 2009-2012 an estimated 7.

6% of the U.S. population aged 12 and over had depression, including 3% of Americans with severe depressive symptoms. Almost 43% of persons with severe depressive symptoms reported serious difficulties in work, home and social activities, yet only 35% reported having contact with a mental health professional in the past year. Depression is associated with higher mortality rates in all age groups.

Depression is also a leading cause of medical disability and depressed people lose 5.6 hours of productive work every week when they are depressed, 50% of which is due to absenteeism and short-term disability. Adolescents: In 2014, an estimated 2.8 million adolescents age 12 to 17 in the United States had at least one major depressive episode (MDE) in the past year.

The 2013 Youth Risk Behavior Survey of students grades 9 to 12 indicated that during the past 12 months 39.1% of female (F) and 20.8% of male (M) students indicated feeling sad or hopeless almost every day for at least 2 weeks,16.9% (F) and 10.3% (M) indicated a planned suicide attempt, and 10.6% (F) and 5.4% (M) attempted suicide. Adolescent-onset depression is associated with chronic depression in adulthood.

Many mental health conditions (anxiety, bipolar, depression, eating disorders, and substance abuse) are evident by age 14. The 12-month prevalence of MDEs increased from 8.7% in 2005 to 11.3% in 2014 in adolescents and from 8.8% to 9.6% in young adults (both P < .001). The increase was larger and statistically significant only in the age range of 12 to 20 years.

The trends remained significant after adjustment for substance use disorders and sociodemographic factors. Mental health care contacts overall did not change over time; however, the use of specialty mental health providers increased in adolescents and young adults, and the use of prescription medications and inpatient hospitalizations increased in adolescents.

Adults: Source: Institute for Clinical Systems Improvement (ICSI) Health Care Guideline for Adult Depression in Primary Care (Trangle, 2016) Recommendations and algorithm notations supporting depression outcomes and duration of treatment according to ICSI's Health Care Guideline: Recommendation: Clinicians should establish and maintain follow-up with patients.

Appropriate, reliable follow-up is highly correlated with improved response and remission scores. It is also correlated with the improved safety and efficacy of medications and helps prevent relapse. Proactive follow-up contacts (in person, telephone) based on the collaborative care model have been shown to significantly lower depression severity (Unutzer, 2002).

In the available clinical effectiveness trials conducted in real clinical practice settings, even the addition of a care manager leads to modest remission rates (Trivedi, 2006; Unutzer, 2002). Interventions are critical to educating the patient regarding the importance of preventing relapse, safety and efficacy of medications, and management of potential side effects.

Establish and maintain initial follow-up contact intervals (office, phone, other) (Hunkeler, 2000; Simon, 2000). The Patient Health Questionnaire-9 (PHQ-9) is an effective monitoring and management tool, and should be used routinely for subsequent visits to monitor treatment outcomes and severity. It can also help the clinician decide if/how to modify the treatment plan (Duffy, 2008; Lowe, 2004).

Using a measurement-based approach to depression care, PHQ-9 results and side effect evaluation should be combined with treatment algorithms to drive patients toward remission. A five- point drop in PHQ-9 score is considered the minimal clinically significant difference (Trivedi, 2009). The goals of treatment should be to achieve remission, reduce relapse and recurrence, and return to previous level of occupational and psychosocial function.

If using a PHQ-9 tool, remission translates to PHQ-9 score of less than 5 (Kroenke, 2001). Results from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study showed that remission rates lowered with more treatment steps, but the overall cumulative rate was 67% (Rush, 2006). Response and remission take time. In the STAR*D study, longer times than expected were needed to reach response or remission.

In fact, one-third of those who ultimately responded did so after six weeks. Of those who achieved remission by Quick Inventory of Depressive Symptomatology 50% did so only at or after six weeks of treatment (Trivedi, 2006). If the primary care clinician is seeing some improvement, continue working with that patient to augment or increase dosage to reach remission.

This can take up to three months. This measure assesses achievement of remission, which is a desired outcome of effective depression treatment and monitoring. Adult Depression in Primary Care - Guideline Aims Increase the percentage of patients with major depression or persistent depressive disorder who have improvement in outcomes from treatment for major depression or persistent depressive disorder.

Increase the percentage of patients with major depression or persistent depressive disorder who have follow-up to assess for outcomes from treatment. Improve communication between the primary care physician and the mental health care clinician (if patient is co- managed). Adolescents: Source: American Academy of Child and Adolescent Psychiatry Practice Parameter for the Assessment and Treatment of Children and Adolescents with Depressive Disorders (2007) http://www.

jaacap.com/article/S0890-8567(09)62053-0/pdf Recommendations: Recommendations supporting depression outcomes and duration of treatment according to AACAP guideline: Treatment of depressive disorders should always include an acute and continuation phase; some children may also require maintenance treatment. The main goal of the acute phase is to achieve response and ultimately full symptomatic remission (definitions below).

Each phase of treatment should include psychoeducation, supportive management, and family and school involvement. Education, support, and case management appear to be sufficient treatment for the management of depressed children and adolescents with an uncomplicated or brief depression or with mild psychosocial impairment. For children and adolescents who do not respond to supportive psychotherapy or who have more complicated depressions, a trial with specific types of psychotherapy and/or antidepressants is indicated.

Sources: Guidelines for Adolescent Depression in Primary Care (GLAD-PC) (2018) http://pediatrics.aappublications.org/content/141/3/e20174081 Guidelines for adolescent depression in primary care (GLAD-PC): II. Treatment and ongoing management http://pediatrics.aappublications.

This measure contains two strata defined by two submission criteria. This measure produces two performance rates which are used for a weighted average. There are two Submission Criteria for this measure: 1) Adolescent patients with major depression or dysthymia who reached remission at twelve months OR 2) Adult patients with major depression or dysthymia who reached remission at twelve months This measure will be calculated with 2 performance rates: 1) Percentage of adolescent patients (aged 12-17 years) with a diagnosis of major depression or dysthymia and an initial PHQ-9 or PHQ-9M score greater than nine during the index event who reached remission at twelve months as demonstrated by a twelve month (+/-60 days) PHQ-9 or PHQ-9M score of less than 5 2) Percentage of adult patients (aged 18 years or older) with a diagnosis of major depression or dysthymia and an initial PHQ-9 or PHQ-9M score greater than nine during the index event who reached remission at twelve months as demonstrated by a twelve month (+/-60 days) PHQ-9 or PHQ-9M score of less than 5 A weighted average, which is the sum of the performance numerator values divided by the sum of performance denominator values, will be used to calculate performance.

For the purposes of MIPS implementation, this patient-intermediate measure is submitted a minimum of once per patient during the performance period. The most recent numerator option/quality data code will be used if the measure is submitted more than once. To be considered denominator eligible for this measure, the patient must have both the diagnosis of depression or dysthymia and a PHQ-9 or PHQ-9M score greater than 9 documented on the same date or up to seven days prior to encounter (index event) and this date occurs during denominator identification period (11/1/2024 to 10/31/2025).