Optimizing Depression Care
 
By Tony J. Kreuch, Psy.D, CEAP


Depression is a major workplace concern with significant impact on productivity, morale, and turnover. Despite this fact, EAPs are often not well-equipped to fully address these employees. In many cases, the individual will either be directed to a 24-hour call center or be seen briefly on-site by an EA professional and referred to a provider without a full assessment or comprehensive approach.
However, an EAP ideally placed within an organization can have a significant impact on this condition. This article will summarize my recommendations regarding optimizing depression care. I will also briefly review a model for assessing and treating depression that we have developed at my company, using best practices and a collaborative model for tracking outcomes.

Depression in the Workplace
Depressive disorders affect approximately 15 million adults (6-7%) age 18 and older annually, and suicide is considered to be the 10th-leading cause of death. Unfortunately, there is a significant “services gap” as only 22% of those diagnosed with depression receive adequate and effective treatment.
Depression also has a significant impact on companies’ bottom lines. Workers with diagnosed depression miss 68 million days of work annually and the estimated cost to the employer per depressive episode ranges from $5,000 to over $25,000 (Gallup, 2013). This adds up to approximately $26 billion in direct costs and $51 billion in indirect costs to employers (Kessler, 2003). This data clearly supports the need for more comprehensive measures to address depression in the workplace.

Towards a Model of Comprehensive Care
Any worksite screening for depression should ideally include the following components: depression assessment, employee functional status, and risk assessment.

* Depression Assessment. It is important for the EA professional to “ask the right questions” and conduct a comprehensive interview that includes historical, social/interpersonal, medical and substance use information in order to differentiate health conditions and/or substance use that might be misinterpreted as depression.
Not all individuals with depressive disorders report feelings of sadness or a lessened mood. As such, thoroughly questioning symptoms such as changes in sleep, appetite or energy levels, poor concentration, and feelings of despair or guilt are important. Use of validated measures such as the Patient Health Questionnaire-2 (PHQ-2) for initial screening and the Patient Health Questionnaire-9 (PHQ-9) for confirmation of diagnosis are recommended in the Journal of General Internal Medicine (Kroenke, 2001, 2003).

* Employee Functional Status. This component can be completed with instruments such as the Stanford Presenteeism Scale-6 (2001) or the newer Workplace Outcome Suite (2013), both of which can determine the level of work engagement, including time away from work and the ability to focus on work-related tasks when on the job.
Additionally, the clinician should inquire as to whether the employee has been experiencing any significant changes in behavioral functioning while at work. Questions that should be asked include: “Are you finding yourself more withdrawn or less social at work?”, “Are you having difficulty getting along with co-workers and/or getting your work done?” and “Has your supervisor discussed concerns about you or your work?”
Depending on circumstances, a supervisor may be involved and may make a direct referral to the EAP. Obtaining the appropriate level of consent and release is crucial in these situations, but it can ultimately offer a very effective path for getting an employee the appropriate help.

* Risk Assessment. Evaluation of the potential for self-harm is a crucial aspect of any depression assessment. The EA practitioner should inquire as to whether the employee has had any prior history of suicidal thoughts, or if there is any family history of depression or suicide.
Current status with respect to intent and available means should be addressed as well. For instance, “Do you have any firearms or other weapons at home?” or “What is your level of access to pills or weapons?” The PHQ-9 also includes a question on suicide.
Finally the individual’s social support should be evaluated. Does the employee live alone or with family, and what is the quality of those relationships? An evaluation of the level of risk in terms of the employee’s job should also be completed. Jobs that are connected to safety, whether it is public safety (e.g. airline pilots, law enforcement, firefighters) or the safety of others at the worksite (e.g., power plant workers), frequently involve judgment and the ability to reason and problem solve. Since depressive disorders often impact cognitive functions, the level of risk among affected individuals in these occupations can be substantial.

Recommendations
Once a diagnosis of depression has been confirmed by the EA professional, best practices treatment should be coordinated (American Psychiatric Association, 2010). For mild to moderate depression, including Major Depressive Disorder or Persistent Depressive Disorders (DSM-V), counseling alone is often indicated.
Cognitive Behavior Therapy (CBT) is a well-validated therapeutic approach for depression and has been effectively used as a stand-alone treatment for many years. Interpersonal and dynamic approaches have also been shown to be beneficial (American Psychiatric Association, 2010).
For moderate to severe depressive disorders, in particular when the individual is experiencing impairments in functionality such as sleep, appetite, motivation, and concentration (along with suicidal thoughts), antidepressant medications are often recommended.
Patient education is also included in best practices since antidepressants frequently have side effects such as gastrointestinal problems, headaches, dizziness and even suicidal thinking. This last potential effect is rare and typically reported in younger populations (adolescents), but given the possible impact on an already depressed individual, it is important to review this area once an individual begins a medication.
Finally, a collaborative approach in which all providers are communicating regularly about the person’s care, including approaches, goals and targeted outcomes is crucial. Taking this collaborative aspect of depression care to the “next level” includes using assigned care managers once treatment has begun.

One Effective Model
Sandia National Laboratories is a major research and development facility with approximately 9,500 employees. Our EAP is uniquely positioned within an occupational medicine program that offers a range of services including management of chronic conditions such as hyperlipidemia and diabetes, in addition to wellness and an urgent care clinic for acute medical disorders.
We were well aware of the potential impact of depression on our workforce and in 2008 we completed a needs and risk analysis and reviewed best practices currently in use such as the DIAMOND Initiative (2008) and the STAR*D Project (2007). The result was the development of our on-site depression program, which recently completed its 5th full year in operation.

Critical Elements
The critical elements of the program include: Collaborative Care, including use of On-site Care Managers; Ongoing Psychiatric Consultation; Initial Screening; Clinical Confirmation of Diagnosis; Treatment (or referral) Using Best Practices Care for Depression; and Ongoing Outcomes Tracking. Some of these elements are explained in this section.

* Care Managers. Our care managers are on-site health educators who complete a seven-session depression training program. They are assigned to the patient at the outset of treatment and provide a point of contact and support for continuity of care and follow-up for program outcomes.

* Psychiatric Consultation. We utilize a consulting psychiatrist who provides valuable input regarding our cases including treatment, recommendations and additional referral options. This combination of care manager collaboration and the use of a consulting psychiatrist are important aspects of the program.

* Initial Screening. The PHQ-2 occurs within one of our clinics as part of the standard medical assessment and it is voluntary. The PHQ-2 items are highly sensitive to depressive disorders. For instance: “Over the past two weeks I have had little interest or pleasure in doing things” and “Over the past two weeks I have felt down, depressed or hopeless”. Scores at or above 3 are considered to be significant and referral to a clinician is initiated.

* Clinical Confirmation/Treatment. A positive PHQ-2 triggers a referral to either one of our on-site medical providers or the EAP for a full evaluation. The PHQ-9 is used as part of this assessment and a diagnosis is either confirmed or ruled out with a PHQ-9 score above 5 and clinical confirmation.
The patient can then decide to obtain care on-site with our internal providers, obtain referrals for off-site care or decline care. If treatment is chosen (whether on- or off-site) the individual is entered into the program and a care manager is assigned. Best practices care for depression is followed, as per the American Psychiatric Association (APA).

* Program Outcomes. Outcomes are tracked using the PHQ-9 at pre-treatment, 6 months post-remission and 12 months post-remission. As of June 2014, we have screened approximately 400 employees, with 235 eventual enrollees. We have had 161 either “complete” the program (to 12-month remission PHQ-9) or complete post-measures if not reaching remission.
An analysis of 103 cases with complete data revealed a remission rate of over 70% and the following PHQ-9 Mean Scores: Pre-treatment, 13.8; Six-month remission, 3.8; and 12-month remission, 3.0. These scores reflect a significant reduction in PHQ-9 scores at the p<.001 level.
Our additional data analysis indicated that factors such as age, gender, site or type of treatment were not significant variables with respect to score reductions.

Summary
We have demonstrated positive outcomes with a combination of a high rate of remission and PHQ-9 data. Our view is that it is the comprehensive, integrated nature of the program that has made it successful. We recognize that our self-study does not include a control group and has not been replicated, but the initial results are promising. Future goals include the inclusion of productivity and absenteeism and presenteeism measures for additional outcomes tracking.

Dr. Tony Kreuch is a licensed psychologist with over 25 years’ clinical experience and more than 10 years’ experience in employee assistance. He is currently the Program Coordinator for the EAP at Sandia National Laboratories in Albuquerque, NM.


References
American Psychiatric Association (2010). Practice guidelines for the treatment of patients with major depressive disorder, 3rd edition, Arlington, VA: American Psychiatric Publishing.

Gallup Poll (2013).  Depression Costs in the Workplace.

Institute for Clinical Systems Improvement (2008). The DIAMOND Initiative: Depression Improvement Across Minnesota, Offering a New Direction, Bloomington, MN: ICSI.

Kessler, RC, et al (2003).  The epidemiology of major depressive disorder: results from the National Comorbidity Survey replication (NCS-R), Journal of the American Medical Association, 289(3), 3135-3144.

Kroenke, K, et al (2001). The PHQ-9: validity of a brief depression severity measure, Journal of General Internal Medicine, 16(9), 606-613.

Kroenke, K, et al (2003). The Patient Health Questionnaire -2: validity of a 2-item measure of depression, Medical Care, 41(11), 1284-1292.

National Institute of Mental Health. Retrieved from: http://nimh.nih.gov.

Stanford Presenteeism Scale-6 (2001). Stanford University/Merck & Company, Inc.

Warden, D, et al (2007). The Star*D project results: a comprehensive review of findings, Current Psychiatry Reports, 9, 449-459.

Workplace Outcome Suite (2013). Chestnut Global Partners.