Research ArticleOriginal Research

Enhancing Electronic Health Record Measurement of Depression Severity and Suicide Ideation: A Distributed Ambulatory Research in Therapeutics Network (DARTNet) Study

Robert J. Valuck, Heather O. Anderson, Anne M. Libby, Elias Brandt, Cathy Bryan, Richard R. Allen, Elizabeth W. Staton, David R. West and Wilson D. Pace
The Journal of the American Board of Family Medicine September 2012, 25 (5) 582-593; DOI: https://doi.org/10.3122/jabfm.2012.05.110053

Article Figures & Data

Figures

  • Figure 1.
    Figure 1.

    Conceptual diagram of the DARTNet population, data sources, and study cohorts. EHR, electronic health record; PHQ-9, 9-item Patient Health Questionnaire.

Tables

  • Table 1. Overview of Demographic and Clinical Characteristics of Depression Episodes
    EHREHR + FulfillmentEHR + Fulfillment + PHQ-9
    Episodes, n81,02846,131284
    Subjects, n61,46437,416259
    Episodes per subject
        Mean1.31.21.1
        Median1.01.01.0
        Range1–111–61–5
    Demographic characteristics of episodes
        Age at start of episode (years)
            Mean57.7163.1852.47
            Median59.0067.0053.00
            Range13–8913–8916–88
        Age group
            Adolescent, 13–18 years1649 (2.04)472 (1.02)7 (2.46)
            Adult, 19–64 years44,208 (54.56)19,197 (41.61)192 (67.61)
            Older adult, ≥65 years35,171 (43.41)26,462 (57.36)85 (29.93)
        Female sex56,547 (69.79)30,818 (66.81)204 (71.83)
    Clinical characteristics of episodes
        Length of episode (days)
            Mean655.53701.03759.47
            Median436.00477.00626.00
        Primary diagnosis of episode*
            296.2x9305 (11.48)5437 (11.79)9 (3.17)
            296.3x7107 (8.77)5528 (11.98)7 (2.46)
            300.4x11,319 (13.97)6922 (15.01)22 (7.75)
            311.x53,297 (65.78)28,244 (61.23)246 (86.62)
        Episode severity†
            Unspecified7819 (47.64)5365 (48.93)3 (18.75)
            Mild2934 (17.88)2436 (22.22)4 (25.00)
            Moderate3043 (18.54)1394 (12.71)5 (31.25)
            Severe without psychosis539 (3.28)378 (3.45)1 (6.25)
            Severe with psychosis225 (1.37)200 (1.82)0 (0.00)
            Severity missing1852 (11.28)1192 (10.87)3 (18.75)
        Type of episode at start
            Index60,361 (74.49)37,222 (80.69)258 (90.85)
            Recurrent20,667 (25.51)8909 (19.31)26 (9.15)
        Episode end type
            Full70 (0.09)68 (0.15)0 (0.00)
            Partial72 (0.09)47 (0.10)0 (0.00)
            Continuation/unknown80,886 (99.82)46,016 (99.75)284 (100.0)

    • All data provided as n (%) unless otherwise indicated.

    • ↵* Code from the International Classification of Diseases, Ninth Revision (ICD-9).

    • ↵† Among ICD-9 codes 296.2 or 296.3; severity levels defined as 0–4 (no depression), 5–9 (minimal), 10–14 (mild), 15–19 (moderate), and 20–27 (major).21 Scores from item 9 (suicidality) of the 9-item Patient Health Questionnaire (PHQ-9) were characterized by raw scores indicating frequency of suicidal thoughts in the past 2 weeks: 0 (none), 1 (several days), 2 (more than half the days), or 3 (nearly every day).

    • EHR, electronic health record; PHQ-9, 9-item Patient Health Questionnaire.

  • Table 2. Treatment Utilization Patterns during Antidepressant Exposure for Episodes Receiving an Antidepressant within 30 Days of Depression Diagnosis
    EHREHR + FulfillmentEHR + Fulfillment + PHQ-9
    Episodes, n81,02846,131284
    Episodes receiving an AD within 30 days, n17,385 (21.46)996 (2.16)23 (8.10)
    AD Utilization
        AD used to treat episode
            SSRI12,697 (73.03)750 (75.30)17 (73.91)
            SNRI2146 (12.34)111 (11.14)4 (17.39)
            TCA393 (2.26)29 (2.91)0 (0.00)
            Buproprion1581 (9.09)52 (5.22)0 (0.00)
            MAOI5 (0.03)0 (0.00)0 (0.00)
            PP316 (1.82)16 (1.61)1 (4.35)
            Tetracyclics247 (1.42)38 (3.82)1 (4.35)
        Days to first AD Rx
            Mean1.146.987.61
            Median0.002.000.00
        Persistence*
            Mean37.87158.67150.04
            Median30.0091.0090.00
        Adherence†
            Mean1.261.000.95
            Median1.001.001.00
    Other psychotropic medications prescribed
        Anxiolytics2243 (12.90)290 (29.12)4 (17.39)
        Antipsychotics1806 (10.39)77 (7.73)4 (17.39)
        Stimulants456 (2.62)11 (1.10)0 (0.00)
        Narcotic analgesics311 (1.79)40 (4.02)0 (0.00)

    • Data provided as n (%) unless otherwise indicated.

    • ↵* Persistence: days between first and last prescription.

    • ↵† Adherence: medication possession ratio.

    • AD, antidepressant; EHR, electronic health record; MAOI, monoamine oxidase inhibitor; PHQ-9, 9-item Patient Health Questionnaire; PP, phenylpiperazine antidepressant; Rx, prescription; SNRI, serotonin-noradrenergic reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic antidepressant.

  • Table 3. Nine-Item Patient Health Questionnaire (PHQ-9) Instruments Collected in DARTNet Practices
    All DARTNet PatientsDepression CohortDepression Cohort + Fulfillment Data Available
    PHQ-9s collected, n49001892309
    Patients with at least one PHQ-9, n29691019259
    PHQ-9s collected per patient, n
        Mean1.71.91.2
        Median1.01.01.0
        Range1–321–321–5
    Age at time of first PHQ-9 (years)
        Mean49.151.153.2
        Median49.051.054.0
        Range1–8915–8916–89
        Age group
            Adolescent (13–18 years)76 (2.56)22 (2.16)8 (3.09)
            Adult (≥19 years)2768 (93.23)997 (97.84)251 (96.91)
        Female sex2005 (67.53)707 (69.38)186 (71.81)
    PHQ-9 total score information
        Mean8.99.19.2
        Median8.08.08.0
        Range0–270–270–27
        Score ranges
            0–4 (no depression)1,448 (32.05)544 (30.49)67 (29.13)
            5–9 (minimal)1,215 (26.89)517 (28.98)63 (27.39)
            10–14 (mild)883 (19.54)349 (19.56)47 (20.43)
            15–19 (moderate)544 (12.04)202 (11.32)29 (12.61)
            20–7 (severe)428 (9.47)172 (9.64)24 (10.43)
    PHQ-9 item 9 (suicidality) information
        Score
            Mean0.40.50.3
            Median0.00.00.0
            Range0–30–30–3
        Specific scores
            0 (no thoughts in past 2 weeks)2,807 (69.43)1,027 (63.71)243 (81.00)
            1 (thoughts on several days)913 (22.58)449 (27.85)32 (10.67)
            2 (thoughts on more than half the days)201 (4.97)92 (5.71)18 (6.00)
            3 (thoughts nearly every day)122 (3.02)44 (2.73)7 (2.33)

    • Data provided as n (%) unless otherwise indicated.

    • PHQ-9, 9-item Patient Health Questionnaire.

  • Table 4. Baseline Severity of Illness and Suicidality Measurement Using the 9-Item Patient Health Questionnaire (PHQ-9) and Electronic Health Record Data among Depressed Patients in DARTNet Practices
    Depression CohortDepression Cohort + Fulfillment Data Available
    PHQ-9s collected, n1440192
    Episodes with at least one PHQ-9, n738169
    Patients with at least one PHQ-9, n670149
    Baseline severity of illness measurement
        Episodes with a baseline PHQ-9,* n13522
        Days between index depression diagnosis and closest PHQ-9, n
            Mean−8.9−5.3
            Median0.00.0
            Range−116 to 6−116 to 5
        Baseline PHQ-9s collected
            Before index diagnosis date (T−120 to T−1)26 (19.26)2 (9.09)
            On index diagnosis date99 (73.33)16 (72.73)
            After index diagnosis date (T+1 to T+7)10 (7.41)4 (18.18)
        Baseline severity of illness levels
            ICD-9 severity level
                Level 1 (mild)8 (10.96)—
                Level 2 (moderate)11 (15.07)—
                Level 3 (severe without psychosis)0 (0.00)—
                Level 4 (severe with psychosis)0 (0.00)—
            PHQ-9 severity level
                0–4 (no depression)25 (18.52)0 (0.00)
                5–9 (minimal)39 (28.89)5 (22.73)
                10–14 (mild)31 (22.96)8 (36.36)
                15–19 (moderate)23 (17.04)3 (13.64)
                20–27 (severe)17 (12.59)6 (27.27)
    Baseline suicidality measurement
        ICD-9 suicidality
            Ideation0 (0.00)0 (0.00)
            Suicide attempt0 (0.00)0 (0.00)
            None135 (100.0)22 (100.0)
        PHQ-9 item 9 (suicidality) score
            Mean0.40.6
            Median0.00.0
            Range0–30–3
        Specific scores
            0 (no thoughts in past 2 weeks)76 (73.08)14 (63.64)
            1 (thoughts on several days)20 (19.23)4 (18.18)
            2 (thoughts on more than half the days)6 (5.77)3 (13.64)
            3 (thoughts nearly every day)2 (1.92)1 (4.55)

    • Data provided as n (%) unless otherwise indicated.

    • ↵* Baseline PHQ-9 was defined as the closest total PHQ-9 score within 120 days before and 7 days after the index depression diagnosis date.

    • ICD-9, International Classification of Diseases, Ninth Revision.

  • Table 5. Depression Response and Suicidality Measurement Using 9-Item Patient Health Questionnaire (PHQ-9) and Electronic Health Records (EHR) Data among Depressed Patients in DARTNet Practices
    Depression CohortDepression Cohort + Fulfillment Data Available
    PHQ-9s collected, n1,440192
    Episodes with at least one PHQ-9, n738169
    Patients with at least one PHQ-9, n670149
    Depression response measurement
        Episodes with a response PHQ-9, n684149
        Response PHQ-9s per episode, n
            Mean1.81.1
            Median1.01.0
            Range1–281–4
        Days between index depression diagnosis and closest PHQ-9, n
            Mean796.8802.5
            Median545630
            Range8–33272–2934
        Response PHQ-9s collected after depression diagnosis (days)
            7–60107 (15.64)17 (11.41)
            61–9019 (2.78)1 (0.67)
            >90558 (81.58)131 (87.92)
        Depression response measurement
            ICD-9 severity level
                Level 5 (partial response)1 (0.10%)0 (0.00%)
                Level 6 (full/complete response)1 (0.10%)0 (0.00%)
            PHQ-9 severity level (lowest response)
                <10 (partial response)464 (67.84%)96 (64.43%)
                <5 (full/complete response)272 (39.77%)53 (35.57%)
        Days between baseline and lowest response PHQ-9
            Mean71.142.0
            Median37.042.0
            Range10–37829–55
        Change in PHQ-9 scores (baseline to lowest)
            Mean5.13.0
            Median3.03.0
            Range−3 to 191–5
        Ranges of change
            −5 to −1 point8 (9.88%)0 (0.00%)
            0–5 points42 (51.85%)2 (100.0%)
            6–10 points14 (17.28%)0 (0.00%)
            >10 points17 (20.99%)0 (0.00%)
            ≥50%45 (55.56%)0 (0.00%)
            Baseline ≥10 and response <1029 (35.80%)2 (100.0%)
    Emergent suicidality measurement
        ICD-9 suicidality
            Ideation2 (0.29%)1 (0.67%)
            Suicide attempt1 (0.15%)1 (0.67%)
            None681 (99.56%)147 (98.66%)
        PHQ-9 item 9 (suicidality)
            Mean0.60.2
            Median0.00.0
            Range0–30–3
            Specific scores
                0 (no thoughts in past 2 weeks)317 (53.01%)124 (84.35%)
                1 (thoughts on several days)212 (35.45%)14 (9.52%)
                2 (thoughts on more than half the days)48 (8.03%)5 (3.40%)
                3 (thoughts nearly every day)21 (3.51%)4 (2.72%)
        Emergence vs. resolution of suicidality (for episodes with baseline and response PHQ-9 item 9)
            Episodes
            Episodes with baseline suicidality = 0 and emergent suicidality >010 (16.67)0 (0.00)
            Episodes with baseline suicidality >0 and emergent suicidality = 08 (13.33)0 (0.00)

    • Data provided as n (%) unless otherwise indicated.

    • ICD-9, International Classification of Diseases, Ninth Revision.

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