Improving depression screening in patients with chronic illness

Each day, nurses care for thousands of patients in a variety of healthcare settings. It’s expected that nurses assess patients thoroughly, honing in on any specific piece of data that may signify a potential problem or worsening medical condition. Unfortunately, the mental health assessment of patients tends to be overlooked. Although there are current published recommendations for annual screening for depression, many healthcare professionals aren’t following these guidelines (See Recommended practice).

Recommended practice

The Institute of Medicine’s (IOM) report “The Future of Nursing: Leading Change, Advancing Health” stresses the importance of nurses practicing to their fullest capability. A major component of the Healthy People 2020 goals developed by the United States Department of Health and Human Services (DHHS) focuses on mental health and mental disorders. Specifically, Health People 2020 includes the following goal statement: “Improve mental health through prevention and by ensuring access to appropriate, quality mental health services.”

Patients at particularly high risk for the development of depression include those also diagnosed with a chronic health condition such as diabetes mellitus (See Diabetes and depression). Chronic medical conditions represent more than 70% of death, disability, and healthcare costs in the United States alone. With so many individuals currently living with one or more chronic illness, it is imperative that we are aware of the emotional toll this may take on our patients.

Diabetes and depression

Diabetes and depression are among the most expensive health conditions to treat in the United States. More importantly, unrecognized or untreated depression impacts the disease burden of patients with diabetes. For example, patients with depression and diabetes are more likely to miss medication doses, become nonadherent with treatment regimens, and have poorly controlled diabetes and higher hemoglobin A1c levels when compared with individuals living with diabetes without concurrent depression.

It’s been reported that nearly 33% of adults with diabetes also have depression, and nearly half of those cases remain untreated. In a recent quality improvement project, patients screened for depression in a primary care clinic demonstrated a three-fold increase in the diagnosis of depression in those with diabetes when compared with those without diabetes. With the implementation of a depression-screening tool, previously undiagnosed cases of depression were recognized in close to 10% of the population seen in that one clinic alone.

Missed opportunity

When we don’t assess mental health in patients with chronic disease, we miss an opportunity for health promotion and reduce optimal disease management. Of course, it’s also vital to assess for depression in all patient populations: In any 2-week period, approximately 8% of the US population is struggling with depression. This mental health disorder accounts for more than 8 million health care visits each year, resulting in over 83 billion dollars in healthcare spending annually.

Assessing for depression

Nurses can incorporate both the IOM and DHHS recommendations into daily practice through simple screening measures to assess for the presence of depression in patients with chronic disease. In addition, the National Guidelines Clearinghouse recommends annual depression screening in patients diagnosed with a chronic illness. This screening may identify depression that would otherwise go unnoticed and untreated, worsening clinical outcomes and disease management.

Nurses, practicing to the fullest extent of their licensure and capability, can use a simple tool during each patient encounter to help identify a possible depressive disorder. The Patient Health Questionnaire-2 (PHQ-2) is a screening tool that has demonstrated excellent reliability and validity in a variety of patient populations. This tool consists of two questions asking the client to reflect upon the past two weeks:


1. Have you been bothered by little interest or pleasure in doing things?

2. Have you been feeling down, depressed, or hopeless?

The client rates his or her answers on the following scale:

0 = Not at all

1 = Several days

2 = More than half of the days

3 = Nearly every day

If the total score for the two questions combined is three or more, additional information should be obtained to help determine the reason for the elevated score. While a score greater than three is not diagnostic of depression, it prompts the healthcare team to evaluate the client more thoroughly and enable early recognition of depression or other possible medical conditions that may contribute to these symptoms.

Even such a simple formal screening tool as the PHQ-2 isn’t required to assess patients for possible depression; simply discussing the symptoms most commonly associated with depression is an acceptable way to assess mental health concurrently with physical health. These symptoms include: hopelessness, loss of interest in activities that were once enjoyable, insomnia or hypersomnia, weight loss or gain, frequent crying, sadness, and anhedonia.

Another option is to use one of the many tools available to screen for depression that are free of charge and readily available on the Internet.

Whichever option a nurse chooses, it’s important to use it on a regular basis for assessment.

Advocating for care

Although nurses are not diagnosticians, they are patient advocates on the front line of care management. As one of the most trusted professions in the nation, nurses can act as gatekeepers to vital health information that patients may not share with anyone else. Using the two-question screening may alert the nurse to mental health disorders affecting the success of treatment regimens and the overall well-being of patients with depression and chronic illnesses. Nurses can advocate for patients using this data; they may also provide symptomatic management, psychosocial support, as well as community resources available for patients struggling with disease management as well as depression.

Encourage your patients to discuss symptoms or feelings with their healthcare provider. In addition, recommend implementation of a screening tool into daily practice where you work; it may positively impact the care provided to your patient population.

Rebecca R. Hill is an assistant professor at MCPHS University School of Nursing in Boston, Massachusetts.

Selected references

Agency for Healthcare Research and Quality. Big money: cost of 10 most expensive health conditions near $500 billion. U.S. Department of Health & Human Services Web site. Available at: http://archive.ahrq.gov/news/nn/nn012308.htm. Published January 23, 2008. Accessed August 19, 2013.

Agency for Healthcare Research and Quality. Major depression in adults in primary care. National Guidelines Clearinghouse Web site. http://www.guideline.gov/content.aspx?id=37277. Published 2012. Accessed September 19, 2013.

Alberti G. The DAWN (Diabetes Attitudes, Wishes and Needs) Study. Pract Diab Int 2002:19(1):22-4.

American Diabetes Association. Diabetes basics. Available at: http://www.diabetes.org/diabetes-basics/diabetes-statistics/. 2011. Accessed August 18, 2013.

Bian C, Li C, Duan Q, et al. Reliability and validity of patient health questionnaire: depressive syndrome module for outpatients. Sci Res Essays. 2011;6(2):278-82.

HealthyPeople.gov. Mental health and mental disorders. US Department of Health and Human Services. Available at: http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=28. Accessed August 18, 2013.

Hill R, Vorderstrasse A, Turner B, et al. Screening for depression in patients with diabetes: addressing the challenge. J Nurse Pract. 2013: 9(4):281-89.

Institute of Medicine of the National Academies. The future of nursing: Leading change, advancing health. Institute of Medicine Website. Available at: http://www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/workforce/IOM-Future-of-Nursing-Report-1. Accessed August 18, 2013.

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One thought on “Improving depression screening in patients with chronic illness”

  1. psynurs says:

    I’m a psych nurse. When I have an appointment with my family practice MD, I never see my nurse. I see the CNA for vitals and med review, and my MD for 5 minutes. Where does the actual nurse come into this? I find it most aggravating that family practice schedules so little time with patients and that the person most likely to observe or question depression in a patient, doesn’t actually see the patient.

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