Screen for depression on admission

When a 29-year-old woman was admitted to Cedars-Sinai Medical Center for gallbladder removal in January, the staff nurse asked two questions that might have seemed irrelevant to the procedure.

“Have you felt down lately? Or had little interest in doing things?” the nurse inquired. The patient's response would significantly alter the care provided.

It turns out the woman had a history of major depression and post-traumatic stress disorder, and she was receiving regular infusion treatments of an antidepressant prescribed to people with severe mental illness.

Had the nurse not asked about depression, the hospital's clinicians might not have known to continue the infusions so the patient's mental-health treatment could continue uninterrupted. Nor would they have called in the psychiatrist who managed her care and educated the team on handling psychologically vulnerable patients.

“People tend to pull themselves together and look good on the outside,” said Dr. Itai Danovitch, chairman of the department of psychiatry and behavioral neurosciences at Los Angeles-based Cedars-Sinai. “But having a systematic mechanism helps to identify people with high levels of distress that have gone undetected.”

Since April 2014, the hospital has routinely screened all admitted patients for depression, making it one of the first U.S. hospitals to do so. About 1% of the 4,700 patients screened each month are found to be at risk for suicide, which hospital leaders say would have been hard to detect in the past.

Last week, the U.S. Preventive Services Task Force expanded its recommendations for depression screening to apply to all adults over age 18, including pregnant and postpartum women. The panel also said the benefits of mental-health treatment, even with antidepressants known to have side effects, far outweigh any potential risks.

While the task force specifically reviewed evidence supporting primary-care screening, its statement also called for collaborative efforts among mental-health specialists, family physicians and health systems.

“There's quite good evidence that treatment can occur in many different settings, by many different professionals, and still be of benefit to the patient,” said task force member Karina Davidson, a professor in the departments of medicine, cardiology and psychiatry at Columbia University Medical Center in New York.

A confluence of factors led Cedars-Sinai to launch its program. Like most hospitals, it has been intently focused on federal programs that impose penalties for high readmissions and poor outcomes. Hospital leaders were also more broadly seeking to reduce costs and overutilization of services.

They had taken note of the Preventive Services Task Force's 2009 recommendations for widespread depression screening and the Joint Commission's sentinel-event alert on patient suicides, which the accrediting organization said hospitals could reasonably address. The Joint Commission said preliminary data suggested inpatient suicides were the third most-common sentinel event in 2015, after incidences of objects left in the patient during surgery and wrong-site surgeries.

At Cedars-Sinai, nurses provide depression screenings for about 95% of all admissions. Patients can choose to opt out of the screening, and some cannot be screened because of their health condition on admission.

The first set of screening questions asks whether the patient has felt depressed or unmotivated over the past month. About 7% of patients respond in a manner that triggers a follow-up questionnaire.

The questionnaire delves deeper. Has the patient felt hopeless? Had troubles concentrating, sleeping or eating? Considered suicide or inflicting self-harm? About 3% of those patient responses trigger red flags, and another 1% are deemed at risk for suicide. In those cases, nurses alert social workers, attending physicians and psychiatrists.

The physician may test the patient's thyroid function or look for other chronic diseases that can either trigger or manifest as depression. The social worker develops an action plan, which may include coordinating with the patient's outpatient providers or making referrals for services if needed. A psychiatrist may also be called in to initiate therapy in the hospital.

Cedars-Sinai has been tracking screening outcomes for two years and plans to publish case studies. It may adjust its processes based on lessons learned, such as conducting screenings after admission when patients are less distracted or tapping social workers to conduct the longer depression survey.

Danovitch said patients with underlying mental-health issues tend to return to the hospital more often, have worse outcomes and cost more. “When you fail to identify if someone is in distress, it makes it harder to care for them later on,” he said.