1. Suter, Paula RN, MA
  2. Suter, W. Newton PhD
  3. Johnston, Donna RN


Depression is common among both the elderly and those with chronic conditions. Unidentified and inadequately treated depression in home health patients has serious and costly consequences. The authors argue that many negative consequences can be avoided by careful management. They discuss the importance of adding a structured depression tool to routine assessments when indicated, present a 3-step approach for depression screening and monitoring, and describe 1 method for tool selection based on measurement soundness and utility.


Article Content

Norman has a history of coronary artery disease and type 2 diabetes. Discharged recently from the hospital after coronary artery bypass surgery, he has been receiving home healthcare for approximately 4 weeks. He currently is receiving treatment for a sternal wound infection and deconditioning resulting from his surgery.


Norman is 71 years old and married with 3 adult children. Active in the community most of his life, he has no known history of depression or any other psychological disorders. When the home care nurse conducted the "start of care" visit 4 weeks previously, she inquired about depressed mood, sense of failure or self-reproach, hopelessness, and recurrent thoughts of death or suicide, all of which Norman denied. At that time, he reported fatigue and difficulty concentrating after his surgery. His wife also reported that he "appears a bit down" and not interested in things he used to enjoy. She concluded that "this is to be expected after all he has been through." Norman has been prescribed a selective serotonin reuptake inhibitor medication for depression, together with cardiac medications, and reports taking them as prescribed without side effects.


At 6 weeks after surgery, the home health nurse conducts another visit. The wound is assessed to be well healed and free of infection. Norman's walking distance has incrementally increased. The patient continues to report fatigue and poor concentration and states that he has mentioned this to his doctor. The physician attributes this to the effects of his surgery and the beta-blocker he is taking.


The nurse prepares to discharge Norman from home healthcare. She is unaware that a serious problem remains.


Depression Is Widespread

Depression is one of the most prevalent disorders afflicting both the elderly and those with chronic conditions. Unidentified and inadequately treated depression in home health patients can have grave consequences. This article outlines the scope of the depression problem in the two populations commonly under the care of home health nurses: the chronically ill and the elderly. We discuss the importance of adding a structured depression tool to routine assessments when indicated, describe a 3-step approach for depression screening and monitoring, and explain 1 method for tool selection based on measurement soundness and utility.


In general medical practice, the incidence of depression is estimated to involve nearly 25% of outpatients (Gill & Dansky, 2003). The link between depression and chronic disease is well documented, and the rate of depression in chronic disease is reported to reach 50% (Chapman, Perry, & Strine, 2005). Home health professionals now care for an increasing number of patients with chronic diseases, and a high proportion of these are elderly.


Recent data from a sample of geriatric home care patients demonstrate the high prevalence of depression in the elderly population (Brown, McAvay, Raue, Moses, & Bruce, 2003; Sherlock, 2005). An accumulated knowledge base from the research literature supports several conclusions:


* Depressive disorders are associated with an increased prevalence of chronic disease.


* Depressive disorders tend to precipitate chronic disease.


* Chronic disease exacerbates symptoms of depression.


* Untreated depression is associated with poor disease self-management.



A majority of depressed patients report unexplained physical symptoms as their chief complaint during a physician office visit, likely contributing to the incidence of unidentified depression (UMHS Depression Guideline Update, 2004, p. 1). Furthermore, those with chronic diseases and depression report more medical symptoms than those who have chronic diseases without depression (Katon, Lin, & Kroenke, 2007). Gallo and Rabins (1999, p. 820) state that "older persons may not exhibit the typical symptoms of depression, including sadness." Physical disabilities resulting in a decreased zest for activities that once caused pleasure may be falsely attributed to the sequelae of common chronic diseases such as arthritis or heart disease. A core depression symptom, anhedonia, can therefore be easily missed.


Depression frequently is unrecognized in the elderly and chronically ill, often because of an expectation that it is a natural process of aging or the result of the burdens associated with disease management self-care. This expectation may lead to a "normalization" of this condition in these populations. The patient also may harbor the misconception that depression is a personality weakness or stigma and must be overcome independently through sheer will.


How Is Depression Diagnosed?

Psychiatric diagnoses are categorized according to the criteria specified by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association, 1994). Mental health professionals use the DSM-IV when working with patients to provide appropriate treatment and to categorize patients for third-party payers. The specific DSM-IV criteria for depression include 5 (or more) of the symptoms listed in Table 1 present during the same 2-week period that represent a change from previous functioning. At least 1 of the symptoms must be either depressed mood or loss of interest or pleasure.

Table 1 - Click to enlarge in new windowTable 1. DSM-IV Criteria for Major Depressive Episode

Consequences of Depression

The consequences of depression-especially untreated or undertreated depression-are well documented in the literature. Patients depressed at the time of an acute myocardial infarction have significantly higher mortality rates than patients who were not depressed (Frasure-Smith, Lesperance, & Talajic, 1993). Mallik et al. (2005) evaluated nearly 1,000 coronary artery bypass graft surgery patients and found that 25% had substantial perioperative depressive symptoms. The authors reported an inverse relationship between the severity of symptoms and improvement in physical functional status 1 year later.


Other researchers have found that depression is associated with hyperglycemia and an increased risk of diabetic complications (Anderson, Freedland, Clouse, & Lustman, 2001). Giardino and Borson (2002) report that about half of patients with chronic obstructive pulmonary disease (COPD) have clinically significant signs of depression and that symptoms are stronger predictors of quality of life than the objective measures of pulmonary function.


Certainly, the most compelling consequence is increased mortality from suicide that may result from untreated depression. Elderly persons have the highest completed suicide rate of any age group (Conwell & Thompson, 2008).


The National Institutes of Health (NIH) (1992) consensus development conference on the diagnosis and treatment of late-life depression showed that about 17% of elderly patients seen in primary care are affected by depression, and that a large majority of these have no appropriate diagnosis or treatment. The aggregate findings from multiple studies and the preponderance of evidence speak to the gravity of the effects that depression has on health outcomes. These are summarized in Table 2.

Table 2 - Click to enlarge in new windowTable 2. Effects of Depression on Health Outcomes Based on Preponderance of Evidence

Depression is associated not only with greater morbidity and mortality of co-occurring diseases but also with increased healthcare use believed to be in the tens of billions of dollars. Depression also is associated with a 50% increase in the cost of managing the chronic disease (Katon, 2003), even after control is used for illness severity. If depression can be well managed on an ongoing basis, healthcare cost reductions could be significant (Rost, Pyne, Dickinson, & LoSasso, 2005). It seems that targeting at-risk populations would result in even greater savings.


Depression and Home Health

The required question (MO590) from the Outcome Assessment and Information Set (OASIS): Implementation Manual (2002) for assessment of depression is as follows:


Depressive Feelings Reported or Observed in Patient (mark all that apply):


___1. Depressed mood (e.g., feeling sad, tearful)


___2. Sense of failure or self-reproach


___3. Hopelessness


___4. Recurrent thoughts of death


___5. Thoughts of suicide


___6. None of the aforementioned feelings observed or reported.



This required OASIS question addresses only 1 of the 2 DSM-IV criteria for a probable diagnosis of depression: depressed mood. It does not address the second criteria: anhedonia (lacking interest or pleasure). The ability of home health nurses to recognize depression using the required OASIS screening question (M0590) as a sole means of depression assessment jeopardizes the opportunity to identify depression in a large percentage of patients. Research clearly shows that the presence of depression can be easily missed using OASIS. Using OASIS alone, depression was accurately documented, and most likely identified, in only 37% of cases (Brown et al., 2004). Nurses also may be uncomfortable assessing depression due to the personal nature of this disorder and thus may not explore the possibility with further questioning (Ell, Unutzer, Aranda, Sanchez, & Lee, 2005).


Sherlock (2005) recommends adding the optional OASIS question (MO600-2, Diminished Interest in Most Activities) to routine assessment, thereby incorporating the second DSM-IV criteria. Adding this 1 question to the routine assessment affords the benefit of a streamlined approach, which requires only minimal staff education and time. When a patient is identified as having a positive screen for depression in this manner, a referral can be made for a more comprehensive evaluation by a mental health professional or the patient's personal physician. Although this is indeed an improvement over the usual care process, this procedure would not provide a method for determining whether the patient is responding to treatment while they continue to receive home healthcare.


Kroenke, Spitzer, and Williams (2003) evaluated a 2-item version of a depression screening tool called Patient Health Questionnaire-9 (PHQ-9). These authors found PHQ-9 to be valid for depression assessment and convenient for practitioners. The first 2 items of the PHQ-9 are used as the abbreviated tool. They are identical to the 2 questions recommended for depression screening by Sherlock (2005).


The body of literature suggests that when depression is identified, many of the patients are in fact not receiving guideline level antidepression treatment. One of the largest studies addressing the treatment of patients with depression is the Sequenced Treatment Alternatives to Relieve Depression Trial (STAR*D) (Insel, 2006). The researchers found that 70% of patients treated with a representative selective serotonin reuptake inhibitor did not experience remission from the initial course of treatment. Furthermore, 1 in 3 depressed patients who had not achieved remission became symptom free with the addition of another medication. Brown, Bruce, and Raue (2003) expressed deep concern about the low rates of adequate depression treatment among home care patients.


Three Prongs

Studies demonstrate major positive outcomes when depression is identified and treated adequately (Insel 2006; Rost et al., 2005). The addition of a simple depression instrument to the practice routines of both the office physician and the home health nurse has been shown to improve depression detection with minimal staff training (Ell et al., 2005; Spitzer, Kroenke, & Williams, 1999).


Best practice guidelines for depression management recommend that when a patient does not experience a symptom response after 4 to 6 weeks of pharmacotherapy, a change in medication or dosage, additional psychotherapy, or referral should be considered (UMHS Depression Guideline, 2004) combined with 3-month and annual follow-up assessments (deSa & Price, 2007). It is therefore imperative that home health nurses, as members of the healthcare team, not only screen for depression but also monitor their patients' response to therapy, thus enabling timely effective interventions.


Sherlock's (2005) recommendation for starting an assessment by asking 2 standardized questions, mentioned earlier, is one step in the right direction. We take this approach 1 step further. When the initial 2-question screener suggests a problem, we use a comprehensive but short validated depression assessment tool that also grades depression severity with a scored approach. This affords the nurse a method for tracking the effects of depression treatment over time while the patient is under care.


Severity scores that remain unchanged or worsen after 6 weeks of medication indicate a need for a different intervention, including psychotherapy. The suggested 3-step approach is as follows:


1. Screen all patients with chronic disease and those older than 65 years using the required MO590-1 plus the M0600-2 (the first 2 questions of the PHQ-9).


2. If these 2 questions suggest depression, conduct a more thorough screening using a standardized quantitative depression screening tool.


3. Reassess the patient's depression at 6-week intervals by comparing the current score with previous scores to evaluate treatment ineffectiveness.



Guidelines for Tool Selection

Depression tool selection can be a daunting task because the Web offers a plethora of depression screening and monitoring tools. Applying a few basic principles when selecting a tool will ensure that it meets your specific agency needs. In selecting a tool, it is important that it be easy to use (efficient) and "psychometrically sound." Measurement specialists assess psychometrics by checking reliability (consistency and dependability) and validity (meaningfulness and accuracy of scores). Reliability and validity maximize a tool's ability to screen and monitor depression more precisely and also facilitate comparison of results across agencies.


It is unlikely that 1 tool will completely miss depression while another shows it fully. Hence, the clinician probably need not obsess over the array of possible instruments. Widely used tools, at least those for the elderly population, include the Beck Depression Inventory (BDI), the Geriatric Depression Scale (GDS), and the PHQ-9. Sharp and Lipsky (2002) reviewed screening measures for depression across the life span in primary care settings.


Our agency selected the PHQ-9 as a screener and monitor for several reasons. The PHQ-9 is based on the diagnostic criteria for major depressive disorders in the DSM-IV. Scores range from 0 to 27. The cut points for the thresholds of depression are 5 (mild), 10 (moderate), 15 (moderately severe), and 20 (severe).


The PHQ-9 is an appropriate tool for the implementation of a 3-step depression screening and monitoring process (Lowe, Unutzer, Callahan, Perkins, & Kroenke, 2004). The first 2 questions can serve as screening questions and correspond to the 2 required DSM-IV criteria for depression:


1. Over the past 2 weeks, how often have you felt down, depressed, or hopeless?


2. Over the past 2 weeks, how often have you felt little interest or pleasure in doing things?



When either response elicits a score of 2, the clinician administers the remainder of the tool. The ease of using an initial 2-question depression screen affords clinicians quick use of the tool when they have any suspicion of change in a patient's condition at any time during the course of care. Kroenke et al. (2003, p. 1284) used this tool in a physician office practice and stated that "the construct and criterion validity of the PHQ-2 make it an attractive measure for depression screening."


The total score for the PHQ-9 administered in its entirety is used as a benchmark for treatment efficacy evaluation. A template for assessing patient response to treatment based on the anticipated PHQ-9 score change over time is available through resources on the Web site of the MacArthur Initiative on Depression and Primary Care ( This is a valuable resource for primary care physicians who must assess treatment responses. It provides a recommended treatment plan for patients initially placed on antidepressant medications and those prescribed psychological counseling. This template can serve as a reference for home care nurses in anticipation of recommended treatment continuity or augmentation. Lowe, Schenkel, Carney-Doebbeling, and Gobel (2006) concluded that the PHQ-9 is a "practical, valid, and responsive tool for diagnosing and monitoring depression in individual patient care as well as in clinical research" (p. 66).


We recommend that all agencies using the PHQ-9 to gauge responses to pharmacologic and psychotherapeutic treatment in depressed populations collect data over time to evaluate treatment outcomes. The PHQ-9 is a 9-item self- or clinician administered multi-language depression screener or monitoring instrument. It is freely available (, and there is no requirement for a license or permission unless it is used commercially.



Depression among the chronically ill and elderly is widespread. It has serious health consequences, including increased mortality related to poor control of medical conditions. Inadequately treated depression also is widespread and associated with increased healthcare costs, in part because of depression itself and in part because of its worsening effect on many medical conditions.


In the current world of rapid pharmaceutical advances and improved diagnostic (measurement) accuracy, there is little reason why depression cannot be diagnosed and managed. The key to recognizing depression is to maintain a high level of suspicion with vulnerable populations. Modern advances in depression research and treatment are dependent on the quality of the instruments used to measure or classify this pathology and the expressed symptoms. The identification of a reliable and valid tool to screen for depression and monitor treatment effects has the potential to improve the health outcomes for huge numbers of individuals suffering currently.


Home care clinicians must meet the challenge to provide services that are evidence based and to guard against the "tyranny of the acute" and the constraints of time. Home health agencies also must prepare for success in a pay-for-performance environment.


Improving the care of depressed patients is on the Centers for Medicare and Medicaid Services' radar screen. This is evidenced by new OASIS questions being tested that evaluate whether a structured depression tool is being used and whether screening, intervention, and monitoring are addressed in the patient's plan of care. Most importantly, home health professionals must never loose sight of our most important role, that of partner and advocate. If we ignore this imperative, our patients' very lives may be at stake.



In the opening scenario, the acute needs of Norman had taken precedence over other unmet needs in the background. It was obvious 4 weeks after the discontinuation of Norman's home healthcare that his depression had progressed further. He believed he had little hope of full recovery and was no longer refilling his medications. His wife remarked that his hopelessness appeared contagious, and his daughters noticed obvious psychological changes for the worse over time. This unmet need undoubtedly led to an increase in suffering for both Norman and his family. I know that because Norman was my father (first author).


Norman died about 5 years later. Given what we know today, his depression could have been recognized earlier and treated effectively. He may have lived a happier, longer life had he been monitored for depression.




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