Why Cedars-Sinai Screens All Inpatient Adults for Depression

Risk factors that can adversely affect a patient's recovery or trigger a hospital readmission include behavioral issues. The chair of the Cedars-Sinai Department of Psychiatry discusses how screening for depression will become more widespread as hospitals adopt value-based reimbursement models.

By some estimates, about 18 million people in the United States, roughly 7% of the adult population, experience an episode of major depression each year. Undiagnosed and untreated, depression can have a profound effect on hospital patients who are also dealing with seemingly unrelated health issues.

With that in mind, Cedars-Sinai Medical Center in Los Angeles, CA announced this month that it has begun screening all adult inpatients for depression along other risk factors that could adversely affect their recovery.

Itai Danovitch, MD, MBA, chair of the Cedars-Sinai Department of Psychiatry, spoke with methis week about the need for screening, and how it will become more widespread as hospitals enter value-based reimbursement models. The following is an edited transcript.

HLM: Why did you start screening all inpatient adults for depression?

ID: At Cedars Sinai Medical Hospital the psychiatry department does a lot of consultations. That means that doctors call on us when there is a problem with a patient that they think is related to mental health and is affecting their medical care.

Depression is incredibly common and one of the things we know is that often, by the time we get called for helping a patient with depression, they have already had that depression for a period of time. If we could get calls earlier, or if the depression could get recognized sooner, there [would be] opportunities to intervene and help that patient earlier on.

That was our personal experience, and in reading the quite extensive literature on the prevalence of depression in patients with medical illness and also its impact on outcomes.

The rate of depression prevalence in patients who have medical disorders ranges from about 10% to 30% and in some diseases, such as cardiac disease, it is 30%. The presence of depression impacts basically every feature of a patient's medical care. It impacts their experience with care, their satisfaction with care, it impacts their adherence to care regimens. It impacts the disease outcomes from the medical diseases they are suffering from.

For cardiac patients the risk of myocardial infarction goes up substantially when someone also has a history of depression for reasons we don't fully understand. It also impacts their utilization of healthcare services. Having depression is associated with a two-fold increased risk of being readmitted to the hospital.

Essentially virtually every feature of healthcare is impacted in a negative way by depression. You can only address it and help somebody with depression if you first recognize it. The purpose of this initiative is to screen patients so that we can identify them more readily and give the patients information they need to empower them to be able to get help if they choose to.

HLM: What does the screening process involve?

ID: It is quite straightforward. There are a number of screening tools for depression. The ones we are using are called the Patient Health Questionnaire. There are two forms of it: the PHQ-2 and the PHQ-9 that screen for depression. They ask about the symptoms of depression and the purpose of the PHQ 2 is a broad screener. Are they depressed? Have they lost interest in things? That's used by the nurse to then ask the rest of the questions if the patient is positive.

If not, they move on with the rest of their assessment. It is easy to do and it is a measure that has been tested and validated in many different healthcare environments. It can be appropriately administered by many different health professionals.

The challenge of detecting depression in the medical setting is that there are many medical conditions that can cause symptoms or syndromes that can look like depression. So it is important to have a physician or an allied health professional evaluating the patient to disentangle various forms of depression and give the patient guidance on how to find treatment for it.

HLM: Are the screenings expensive or do they require significant time or resources?

ID: The screening cost in and of itself requires a little bit of extra labor on the part of nurses, but our experience here and in other locations is that nurses are readily able to integrate this.

It doesn't impact their work flows too much. Of course, more and more quality demands are placed upon nurses and we are very sensitive to that. But the nurses here really feel that this is a sufficiently important aspect of healthcare to make it a priority and to involve themselves in the screening.

The costly thing is actually referring patients and having them get treatment for their depression. That is a cost that ultimately patients and their insurers bear. What the literature shows is that it is even costlier not to address depression.

HLM: Many providers across the nation have problems accessing behavioral health services. Why bother screening patients if you can't get them the help they need?

ID: It should be the healthcare professionals' role first and foremost to determine what is wrong with a patient, to be able to diagnose them and refer them to the services that the patient needs in order to get better.

How Physicians Can Help Ease Mental Health Provider Shortages

As a society we have a different problem, which is how do we finance the things that we know to be helpful to patients? What we are recognizing now is… that in the long-term some of the interventions that are simple and benign can be helpful in producing long-term gains for patients in reducing costs whereas in the short term it can be hard to recognize those values.

So, the closure of a lot of mental health services is a function of the fact that those services don't reimburse very well because our field and our society haven't done a very good job of recognizing the value of those services.

HLM: What happens if you determine a patient has depression?

ID: We notify the patient's medical doctor and the social worker that the patient has screened positive. Every patient has a social worker assigned to them and the social worker does additional assessments to determine if the patient is already in care.

Do they have a treating psychiatrist, psychologist, or therapist who is able to educate the patient? The physician for the patient is also asked to assess the patient, to advise them about the findings of the screening and their relevance to their medical care and to assist them with a referral if the patient wants that referral.

HLM: Do you see these screenings become more common as hospitals shift to population health and value-based reimbursements?

ID: Absolutely! When we talk about bending the cost curve, which really means trying to get better outcomes without spending more for them, some of the greatest opportunities to do that are in improving the behavioral and mental health of patients.

HLM: How will you know if these screenings are successful and a good return on investment?

ID: The worthiness of the screening has been established by a number of other groups besides us. The U.S. Preventive Services Task Force has adopted depression screenings as a best practice. That is a function of extensive data supporting the idea that identifying and screening depression is cost effective and valuable.

At Cedars-Sinai our measures are how well we identifying patients. Are we screening every admitted patient? Are we educating our allied health providers and nursing staff? Eventually we are going to look at other things such as how do positive scores on depression relate to other important features of care, such as patient satisfaction with care, readmissions, length of stay in the hospital, are we able to increase the referral rate for treatment services for patients who screen positive, etc.

HLM: Can these screenings be done at hospitals where resources are already stretched?

ID: An increasing number of hospitals, including community hospitals, are engaging in various alliances and partnerships with other parts of the health continuum to manage the lives of populations.

Whether it is with insurers or outpatient clinics, the first questions are 'who are the stakeholders in the patients' healthcare and what is the best point of service to screen the patient for depression? So, there is very little question that, from the patients' experience, they need to be screened for depression and they need to be offered services. Exactly who does that and where in the system that happens and how it is managed depends upon the arrangements of those particular health systems. It is hard to answer that question totally generically. A lot of health systems do this in the primary care setting.

HLM: Do you anticipate that this could be mandated at some point by the federal government?

ID: It is a good question and I don't know the answer. Some regulatory bodies like The Joint Commission and others have considered and evaluated some quality metrics that get to behavioral health outcomes and possibly depression. The Joint Commission has established suicide screening as a national patient safety goal and detecting patients at a high risk of suicide is accomplished in part through this measure.

Globally, if we look at trying to enhance value and improve outcomes for patients, this effort to improve value and outcomes is going to drive more health systems to be screening and identifying underlying behavioral health issues. That is an area where overall we haven't done a really great job of meeting patient needs and where the failure to meet patient needs costs us a lot in terms of financial costs, but also more importantly in terms of patients health outcomes.

It's an important opportunity because we can both potentially reduce utilization and improve their health outcomes.