CAPSTONE PART 2

Implementation of Standardized Depression Screening 1

Implementation of Standardized Depression Screening

Implementation of Standardized Depression Screening

Student’s name: Dunia Barrueta

Florida National University

Instructor: Dr. Carmen Lazo, DNP, MSN, APRN-BC, APN

Course: Capstone Project

Date: July 15, 2026

Introduction

Depression is one of the most common mental diseases, and also one of the leading contributors to morbidity and poor quality of life, as well as utilization of health services globally. In the U.S., millions of people suffer from depression each year, but a significant percentage have symptoms that are unrecognized or not treated in their routine/primary care visits (Greenberg et al., 2023). A sleep issue can have a bad influence on consuming drugs, managing chronic medical conditions, job fulfillment, relationship achievement, and overall well-being. Depression is a common condition in primary care clinics, and often patients do not have emotional symptoms; it is therefore important that there is systematic screening for its early detection. Primary care physicians with nurse practitioners (NPs) are well placed to identify depression symptoms, as they often have established long-term therapeutic relationships with patients (Trexler, et al., 2023). Use of standardized assessment, such as the Patient Health Questionnaire-9 (PHQ-9), not only increases the likelihood of early identification of depression but also prompts timely referral to behavioral health services. The practice problem that has been considered for this exercise is the lack of consistency about screening for depression in adults accessing treatment in primary care clinics across Miami-Dade County, Florida. The objective of this proposed capstone project is to determine if the standardized use of the PHQ-9 depression screening instrument, coupled with a nurse practitioner (NP) led referral and follow-up program, will increase depression identification and behavioral health referrals of adults receiving primary care within Miami-Dade County over 6 months.

Significance of the Practice Problem

Miami-Dade County has challenges with depression that are related to the County's large and diverse population and its socioeconomic differences. Behavioral healthcare challenges may exist for many residents, including limited insurance coverage, financial strain, transportation issues, language issues, stigma associated with mental illness, and inadequate behavioral health providers (Sulzer, et al., 2024). All these factors often delay the resolution of the problem and lead to a sequence of worsening symptoms until treatment is initiated. If left untreated, depression has high financial costs. Compared to people who do not have depression, individuals with depression suffer from higher health care costs, as a result of multiple primary care visits, utilization of emergency care, hospitalizations, decreased compliance with treatments, and lost time from work. Preventable complications add to the cost burden on healthcare organizations, especially when they lead to complications in patients with chronic health issues. Time-of-treatment and timely intervention can contribute to the prevention of excess utilization of health care services and improve long-term health care outcomes for the patients.

The proposed intervention is realistic and measurable as it features an evidence-based screening instrument that has been in use in healthcare settings. The PHQ-9 has a small number of items, was validated in a wide range of groups, is easily integrated into electronic health records, and only takes a minimal amount of staff training to use (Rahman, et al., 2022). In addition to nurse practitioner-led follow-up, standardized screening could also increase the number of depression cases diagnosed, encourage referrals to be completed, help get treatment started, and enhance continuity of care.

PICOT

“In adults 18 years and older receiving care in primary care clinics in Miami-Dade County, Florida (P), how does implementing a standardized PHQ-9 depression screening protocol with a nurse practitioner-led referral and follow-up program (I), compared with usual care without standardized screening (C), affect depression identification and behavioral health referrals (O) over six months (T)?”    

The population consists of adults (18 years and older) who participate in routine care in primary care clinics across Miami-Dade County. This population is heterogeneous, with people from a variety of racial, ethnic, cultural, and socioeconomic backgrounds who experience recognized and/or unrecognized signs and symptoms of depression.

The intervention involves; 1, Screening of patients using the standardized PHQ-9 in routine primary care visits; - An intervention level 2 – The development of a structured nurse practitioner-led PHQ-9 screen referral and follow-up program. Nurse practitioners will follow up with patients to verify treatment initiation, administer/review PHQ-9 scores, establish behavioral health connections and treatments, and coordinate behavioral health treatments and follow-up assessments to ensure continuity of care. The comparison group involves what is generally done currently, which is mixed: screening for depression is not consistent and is reliant on the provider's judgment and not on standard guidelines.

Expected Results include better patient identification of depression, improved behavioral health referral, earlier initiation of treatment, improved care coordination, and improved patient engagement. The six-month assessment period provides adequate length of time to measure results for improving screening compliance, referral completion, and integration of behavioral health services in primary care practice.

Vulnerable populations and settings.

The proposed project will reach adults aged 18+ receiving primary care in primary care clinics throughout Miami-Dade County, FL. This group of people is at risk due to their social, economic, and health disadvantages, which make them more susceptible to undiagnosed and untreated depression. Miami-Dade is one of the most culturally diverse counties in the United States and is home to large, diverse Hispanic, Black, and Caribbean communities and an immigrant population. While this diversity adds to the richness of the community, it also presents problems of access to health services, differences in language, beliefs about mental illness, and literacy.

Chronic diseases such as depression occur at high rates among people with other chronic medical conditions, such as heart and blood vessel disease, diabetes, hypertension, obesity, and pain (Vadakkiniath, 2023). Adverse medication compliance, poor health management, and increased healthcare use related to depression are associated with decreased adherence to medication, healthy lifestyle, and follow-up appointments. So, a chance exists to embed depression screening in the primary care environment to help identify mental health issues early before they arise, in the context of routine health care delivery.

Evidence-Based Proposal

The proposed intervention is for a national standardized Patient Health Questionnaire-9 (PHQ-9) depression screening to be implemented for all adult attendees to participating primary-care clinics. The PHQ-9 is a brief, reliable, and evidence-based screening tool that has been validated and is highly sensitive and specific for the diagnosis of a depressive disorder in a variety of patient populations, and requires a few minutes to arrive at a diagnosis.

The proposed program will involve having each adult patient fill out the PHQ-9 in their routine primary care contacts. Depending on how severe a patient's symptoms are, the nurse practitioner will triage the score and follow through with a plan of action. Patients who are mildly depressed will receive information on depression and motivational strategies and will be seen again at subsequent visits.

Several resources are needed to successfully implement this, including educational opportunities for the staff on how to administer a PHQ-9, having the screening tool integrated into an EHR system, creating standardized pathways for referrals, other behavioral health providers' involvement, education materials for patients, and administrative support. The initial cost of implementing the PHQ-9 is relatively low due to the low cost of the screening, and given the fact that the screening is currently being used in health care settings, operational costs need not be a factor for consideration (Brooks, 2023).

The proposed project will have an implementation period of six months. Staff training, workflow design, and changes in the electronic health record will be finished after the first month. Effort will be placed on universal screening from months 2-5, coordinating referrals and follow-up for patients, and continued monitoring of implementation outcomes. To verify the effect of the project, the rates of screening, identification for depression, referrals completed, and program efficacy will be measured at the 6-month mark.

Theoretical Framework

The Chronic Care Model (CCM) would be an appropriate theory to utilize for this capstone given its emphasis on proactive, coordinated care of chronic conditions delivered by an inter-professional team in the context of evidence-based clinical decision making and patient-centeredness. A single-episode treatment is not always the best treatment for depression since often this is a chronic condition that should be evaluated, given a treatment, and monitored over time.

The Chronic Care Model is linked to better outcomes via patient-client engagement and an empowered clinical team. The model can enable systematic depression screening, standardized depression treatment, coordinated referrals to behavioral health, self-management education, and follow-up care. However, the nurse practitioner plays a key role in ensuring the various professionals of the health care team collaborate, follow patients' progress, and educate on how to manage depression, as well as coordinating care.

The model also includes support from the healthcare system, resources from the community, clinical information systems, and supporting evidence-based decisions. When implemented as clinical tools and made mandatory by integrating the PHQ-9 into routine clinical practice, these provisions are in line with these principles by facilitating standardized assessment, better documentation, and better clinical decision-making between different providers (Brooks, 2023). The Chronic Care Model helps make this project work by expanding mental health services into primary care instead of providing separate health support for depression, which helps to embed treatment for depression into the care cycles of patients.

Conclusion

Depression is a serious public health problem often missed in primary care environments that have a significant effect on patient health, quality of life, and health care costs. Living with depression in adults can be related to any number of social determinants of health, and patients in Miami-Dade County may be more vulnerable to undiagnosed depression and delayed treatment. A consistent depression screening tool (PHQ-9), along with a nurse practitioner-led referral and follow-up program, is an evidence-informed approach towards better identification, higher behavioral health referrals, and better continuity of care. This project aims to implement aspects of the Chronic Care Model, including interdisciplinary care, patient-centeredness, and systematic follow-up to optimize mental and physical health outcomes. When implemented effectively within the proposed six-month timeframe, this intervention could lead to better depression identification, prompt action when identified, decreased health disparities, and better primary care for depression for adults in Miami-Dade County.

References

Brooks, S. M. (2023). Implementing the Patient Health Questionnaire-9 (PHQ-9) to identify and refer adults with depression.  International Journal of Depression and Anxiety,  6(1), 40. https://doi.org/10.23937/2643-4059/1710040

Greenberg, P., Chitnis, A., Louie, D., Suthoff, E., Chen, S. Y., Maitland, J., ... & Kessler, R. C. (2023). The economic burden of adults with major depressive disorder in the United States (2019).  Advances in Therapy,  40(10), 4460-4479. https://link.springer.com/article/10.1007/s12325-023-02622-x

Rahman, M. A., Dhira, T. A., Sarker, A. R., & Mehareen, J. (2022). Validity and reliability of the Patient Health Questionnaire scale (PHQ-9) among university students of Bangladesh.  PloS one,  17(6), e0269634. https://doi.org/10.1371/journal.pone.0269634 (journals.plos.org)

Sulzer, S. H., Meier, C., Bopp-Williams, N., Cook, P., & Prest, L. (2024). Challenges and opportunities for rural certified community behavioral health clinics.  Journal of Rural Mental Health,  48(2), 73. https://psycnet.apa.org/doi/10.1037/rmh0000259

Trexler, J. E., Turi, E., & Poghosyan, L. (2023). Team-based depression care in primary care: The role of nurse practitioners.  The Journal for Nurse Practitioners,  19(4), 104579. https://doi.org/10.1016/j.nurpra.2023.104579

Vadakkiniath, I. J. (2023). Prevalence and correlates of stress, anxiety, and depression in patients with chronic diseases: a cross-sectional study.  Middle East Current Psychiatry,  30(1), 66. https://doi.org/10.1186/s43045-023-00340-2