The National College Depression Project:
The Journey Thus Far
Eleanor W Davidson MD
Susan Kimmel MD
May 20 2014
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
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.
ACHA data
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
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!
National data
The vast majority of individuals who suicide have
never seen a behavioral health professional.
Have they been to primary care?
Visit to primary care
% of suicides
Within 3 months of death
45%
Within 12 months of death
77%**
AFSP website
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/
College Breakthrough Series-Depression: 2006-07
NYU, Princeton, Cornell, CUNY (Hunter & Baruch), CWRU, St
Lawrence
Gap
Strategy
Under-detection of students Maximize existing medical
with depression & suicidal
& mental health resources
ideation
to identify and treat
depression
All studies show that follow
up after initiation of
treatment (in any setting) is
a critical factor for
successful outcomes
Create a safety net for
identified depressed
students including
systematic planned follow
up, treatment monitoring &
coordinated referrals to
community links.
Quality Improvement in NCDP
“Trying harder will not work.
Changing systems
of care will.”
Don Berwick MD
Institute for Healthcare Improvement
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.
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
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?
PHQ-2
During the past two weeks, have you been
bothered by:
Little interest or pleasure in doing things?
Feeling down, depressed or hopeless?
□ No □ Yes
□ No □ Yes
Change process : start small and grow
1. Paper PHQ2
10 students tried it
No resistance
2. Screen 1/2 day of my patients.
3. Add more of my patients.
4. Bring on another provider to screen
5. Screen in allergy clinic
Medical assistants: “Just as we screen you for high
blood pressure, we also screen for depression.”
Evaluate each change: PDSA cycles
PHQ-9
Over the last 2 weeks, how often have you
been bothered by the following problems?
Not At
All
Several
days
Nearly
every day
(1)
More than
half the
days
(2)
(0)
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
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)
(3)
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.”
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.
Next step: score the PHQ9
Minimal depression
0-4
Mild depression
Moderate depression
5-9
10-14
Moderately severe
Severe
15-19
20-27
Positive # 9 always needs to be addressed (written
emergency information provided & documented).
1. Discuss results with student.
2. High score does not equal depression.
3. Other primary disorders ruled out.
4. Initiate evidence-based treatment for
depression (counseling, medication, selfmanagement).
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
Monitor progress in screening
Weekly lists of students screened
Finding when we missed an opportunity to screen.
Figure out why & redesign system.
Depression Screening in Primary Care
Aggregate CBS-D Depression Screening Totals for 2007
(N = 58,759 as December 31, 2007)
70,000
60,000
55,489
50,000
58,759
48,903
42,504
40,000
35,705
32,012
30,000
28,643
24,920
20,000
20,489
15,146
10,000
9,759
4,492
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
- 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.
Depression Registry
Growth in the CBS-D Depression Registry Size
(N = 801 as of December 31, 2007)
900
801
800
700
768
710
623
600
561
545
500
471
400
412
371
304
300
240
200
161
100
0
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
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.
CWRU experience
The team embraced the PHQ9:
- routine measurement
- routine documentation in EHR
- communication tool between services
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
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
42 Partnering Institutions
Since 2006
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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
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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
The information presented herein may not be
distributed without express permission from
New York University as coordinating center of
the National College Depression Partnership.
Population perspective: Healthy minds study
Permission to use next set of slides from
Daniel Eisenberg PhD
Director, Healthy Minds Network
Healthymindsnetwork.org
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
Healthy Minds Study
 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
29
HMN Survey Research
Healthy Minds Study (nearly 100 schools, 2005-present);
Healthy Bodies Study (beginning 2013)
28
Main Findings from Healthy Minds
 “Treatment gap” of >50% in college populations
 Stigma low and knowledge high for many untreated students
 Help-seeking interventions require new approaches
 Mental health predicts academic success
 GPA & retention
 Economic case for mental health services/programs
31
Prevalence of MH problems
50
40
34%
30
17.9%
20
10
15.7%
9.9%
9.8%
7.2%
0
Major dep.
(PHQ-9)
Any dep.
(PHQ-9)
Anxiety
(PHQ)
Suicidal
Ideation
Data source: HMS, 2007-2013
Self-injury
Any
Past-year Treatment for MH problems
(Medication or counseling/therapy)
100
90
80
70
60
50
40
30
20
10
0
53%
45%
Major dep.
(PHQ-9)
52%
38%
Any dep.
(PHQ-9)
Anxiety
(PHQ)
Suicidal
Ideation
Data source: HMS, 2007-2013
41%
39%
Self-injury
Any
Past-year Treatment,
among students with past-year PHQ-2 score ≥3
50
40
37%
32%
30
20
19%
10
0
Antidepressant
Counseling/therapy
Data source: HMS, 2009-2013
Either modality
Duration of Antidepressant Use,
among students with antidepressant use and PHQ-2 score ≥3
100
90
79%
80
70
60
50
40
30
20
10
9%
12%
0
<1 month
1-2 months
Data source: HMS, 2009-2013
>2 months
Prescriber Types,
among students with antidepressant use and PHQ-2 score ≥3
100
90
80
70
60
50
49%
54%
40
30
20
10
3%
0.4%
Other
Don't know
3.5%
0
General
Practitioner
Psychiatrist
Data source: HMS, 2007-2013
Took w/o RX
Number of Counseling/Therapy Visits,
among students w/ counseling/therapy use and PHQ-2 score
≥3
50
40
30
31%
30%
23%
20
16%
10
0
1 to 3
4 to 6
7 to 9
Data source: HMS, 2007-2013
10 or more
Problem and Opportunity
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
Extrapolating Numbers to
Typical Campus of 10,000 Students
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
Gap between perceived need
and use of mental health services
Percentage
100
90
80
70
60
50
40
30
20
10
0
100%
77%
77%
60%
43%
35%
25%
Asian
28%
Black
Latino
Perceived Need
Service Use
White
Among students with depression based on current positive PHQ-9 screen [n = 971].
Healthy Minds Study, 2007
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)
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.
Identification was the easy part.
Our challenge was what to do when students did not
want either counseling or medication
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
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
NCDP Operational Definition
The engagement of patients in a
collaborative partnership with clinicians
to achieve goal-directed behavioral
change and patient activation.
Why self-management?
• It’s evidence-based
• It’s fairly simple
• Focuses on student-activation
• We know these work well to improve outcomes for
both medical and mental health conditions
• It was something we had access to (all of Student
Affairs has self-management tools for students)
Developmental parallels
Many of the tasks of being a student center around
self management skills:
1. Activities of daily living (how much to sleep,
eat, study, play video games, etc)
2. How much caffeine to take in, how many
energy drinks, supplements, etc
3. How much alcohol or other substances to
use
4. How much to sleep
Options
Mindfulness tools
Meditation
Exercise
Diet/nutrition/sleep hygiene
Harm reduction
Positive social supports
DBT skills
More recent changes
We add data from:
Emergency transports (Case EMS & Security)
Students of Concerns committee
Risk assessment discussions
We routinely add these into our records
FERPA v HIPAA
What about sexual assault/intimate partner violence?
Men and women who experienced:
• Rape
• Stalking
• Intimate partner violence
Difficulty
sleeping
Frequent
headaches
Chronic
pain
Activity
limitations
Poor
physical &
mental
health
Higher Rates of Adverse Health Outcomes
Men
Women
Health Outcomes
Asthma
*
*
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Irritable Bowel Syndrome
Diabetes
Frequent Headaches
Chronic Pain
Difficulty Sleeping
Activity Limitations
Poor Physical Health
Poor Mental Health
http://www.cdc.gov/violenceprevention/nisvs/
*
*
*
*
*
*
*
*
*
*
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*
Lessons & Challenges
1. Screening for depression in primary care has
helped all clinicians see sooner and with more
clarity the underlying reasons for visit.
2. The entire staff understands a collaborative,
systems approach to quality care and why teams
are more effective than individuals working alone.
3. Each school must tailor implementation of
depression screening to fit its own assets and
student needs.
Putting the mind & body “back together”
It seems to be a challenge (for students & clinicians):
- continuity of care
- mind-body connection
- not coming to mental health issues only after
every other avenue has been explored—bring
these considerations up early/often & in a
straightforward, transparent manner
- teach the importance of knowing about all
medication taken and who’s prescribing.
Communicate
Your primary care clinician is interested in you as a
whole person—all of these elements are significant
in your care.
Expect us to check in with you as to how these things
are going.
Teach students what they can expect in the future
from healthcare that values them as whole people.
The journey: our current recommendations
Depression screening in a university health service is
feasible, well received by students, and accepted
by staff.
Everyone should be able to screen using the PHQ2,
no matter what the resources available.
We recommend screening all students (not just
elective visits for primary care).
Using a follow up PHQ9 is helpful for both diagnosis
and measuring response to treatment.
Questions?
Comments?
Thanks for listening.
From January 1, 2007 – December 31,2007
CBS-D © New York University
From January 1, 2007 – December 31,2007
CBS-D © New York University
Rates of Functional Improvement Grouped by Site Process
Measure Success
80%
66.5%
70%
60%
50%
31.7%
40%
30%
All Process Goals Met
(n = 260)
Not All Process Goals
Met (n = 224)
20%
10%
0%
All Process Goals Met (n = 260)
Not All Process Goals Met (n = 224)
Sites that reported exceeding designated goals on all three process
measures reported rates of functional improvement at 12 weeks
more than double than those sites who did not surpass all three
goals (66.5% vs. 31.7%).
CBS-D © New York University