"The two words ‘information’ and ‘communication’ are often used interchangeably, but they signify quite different things. Information is giving out; communication is getting through." -- Sydney J. Harris

Driving Improvement in Depression Care

MNCM_10thAnnivLogo_RibbonOnly_FNLDepression is more than feeling sad or “blue.” When sad feelings are intense, last for more than a few days, and/or interfere with daily activities, its depression – a very treatable medical condition.

According to the Centers for Disease Control and Prevention (CDC), depression is a serious medical illness affecting 18.8 million American adults, or 9.5 percent of the adult population in a given year.

More than half of those who experience a single episode of depression will continue to have episodes that occur as frequently as once or even twice a year. Most people who seek treatment make progress toward feeling better, which means they’re responding well to treatment. Without treatment, the frequency of depressive illness as well as the severity of symptoms tends to increase over time.

Depression is a major cause of disability, absenteeism, absenteeism and productivity loss among working-age adults and is estimated to cause 200 million lost workdays each year at a cost to employers of $17 to $44 billion. Untreated depression can also result in suicide.

Increasing Quality Care for Depression

Providing high-quality depression care is critical to the health and economy of Minnesota, which is why MN Community Measurement focused on it just a few years into our existence. Measurement and public reporting of quality results improves patient care and outcomes.

MNCM began publicly reporting depression care measures in 2009 and currently reports the results of seven depression measures:

The PHQ-9 is a widely-used, validated tool that asks nine questions about the patient’s concerns and how they feel, which helps their provider know if their depression symptoms are under control or if a change in their treatment plan is needed.

The Six Month Remission, Response and Follow Up measures have been endorsed by the National Quality Forum (NQF), which is considered the gold standard for health care measurement in the United States. They were the first patient-reported outcome measures to gain NQF endorsement. Additionally, several are utilized by the MN Department of Health, Centers for Medicare and Medicaid Services and most state pay-for-performance programs. Most recently, the National Committee for Quality Assurance (NCQA) added one of the measures to its Healthcare Effectiveness Data and Information Set (HEDIS) program.

The most recently reported results show rates of high-quality care depression care holding steady or increasing, with the most notable coming in follow up at the six and 12 month milestones. In the past year, the statewide average for depression follow-up six months after diagnosis jumped three percentage points from 31 to 34 percent, and for follow-up 12 months after diagnosis from 23 to 26 percent. Both measures had increases the previous year as well.

Follow up is a critical part of depression care and treatment, because depression can cause people to isolate themselves and stop reaching out for care – often when they need it most. This measure looks at how many patients with depression completed a PHQ-9 six months and 12 months after their diagnosis.

The statewide averages for other depression care measures were:

  • Depression remission six months after diagnosis remained at eight percent after several years of successive increases. Similarly, remission 12 months after diagnosis also remained steady at six percent. Remission is defined as patients reporting few to no symptoms of depression – in other words, their depression is under control.
  • Depression response six months after diagnosis increased from 13 to 14 percent, which continues a steady increase in the results of this measure since 2011; while response 12 months after diagnosis remained steady at 10 percent. Response is defined as patients reporting half as many symptoms as when they were first diagnosed – in other words, they’re making progress and responding to their treatment plan.
  • Use of the PHQ-9 tool remained steady at 70 percent of Minnesota clinics.
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Developing Patient Tools

As part of MNCM’s commitment to depression care, we have also developed and linked to resources that assist patients over the past few years. These are available on our public reporting website to help patients manage and find quality care for their depression. Tools include:

  • Depression Calculator – Better understand if your symptoms are under control or if you should see your doctor to discuss a change in your treatment plan.
  • Depression Health Tracker – Record your depression symptoms to help with self-management and reporting symptom duration, intensity and triggers to your provider.
  • Depression Fact Sheet – Educational information about identifying depression and treatment options.
  • Help and Healing Toolkit – Robust resource for depression care and recovery, including:
    • Information about depression and treatment options
    • How to evaluate symptoms of depression
    • Ways to feel better, manage symptoms and prevent depression from returning
    • Links to services, advocacy and information about depression and mental health in Minnesota
    • Quality practice strategies to identify and treat depression
Moving into Depression Screening for Teens

In October, MNCM publicly reported and released first-time results for a new measure looking at the frequency of mental health and/or depression screenings for adolescents and teens. The measure evaluates whether patients ages 12 through 17 were screened for mental health conditions during their preventive care visits. The results are reported for 513 clinics throughout Minnesota and neighboring communities at

Extreme variation in screening exists across clinics, with some screening none and others screening all of their adolescent patients. Only eight clinics in Minnesota screened 100 percent of their adolescent patients for mental health and/or depression conditions last year. When clinicians did screen for depression, they found 9.7 percent – or 4,300 young people– had indications of a mental health condition, such as depression, anxiety or attention disorders.

Half of all lifetime cases of mental illness begin by age 14, according to the CDC. Untreated depression in adolescence has been tied to an increase in social isolation, academic failure, teenage pregnancy, substance abuse, tobacco use and suicide.

“The kids who I see with depression or anxiety are really children in pain,” said Dr. Laura Saliterman, a pediatrician and Associate Medical Director at South Lake Pediatrics. “This is different than being sad. If you’re depressed, you’re not going to be doing what you need to in school, in life and you’re not going to be able to handle your physical health.”

A More Actionable Measure

Medical groups in Minnesota report clinical data for a variety of measures and to varied entities. This work informs critical improvements in quality of care, but is also resource intensive and challenging for medical groups.

With this awareness, MNCM recently evaluated the depression measure set after it was identified by medical groups as particularly burdensome. The evaluation resulted in the measure set being simplified technically simplified, which should help make it less resource-intensive and more actionable for medical groups.

The changes include:

  • ALL index events will require an elevated PHQ-9 result AND an accompanying diagnosis of major depression or dysthymia (this includes an initial index and subsequent “re-index” events).
  • When diagnosis codes are available on a contact record, medical groups are to submit the code for the patient’s major depression or dysthymia and not suppress codes following any index event(s). This does not mean that diagnosis codes are required for all PHQ-9 results submitted; only that an index will not occur when a diagnosis is not present.

The change will make internal reproduction of this measure set within medical groups more feasible, leading to a greater ability to use it to drive internal quality improvement activities and greater value to the community.

As we look into the next decade of our work, we continue to seek new and innovative ways to drive the improvement of mental health and mental health care through measurement and public reporting.