Abstracts

Rationale: Optimal epilepsy outcome depends on recognition and effective treatment of co-morbid depression. This study assessed epileptologist adherence to depression treatment guidelines. Methods: The study population is 1,714 patients seen from Oct 2008 to Jun 2009 in a tertiary epilepsy outpatient setting. Patients routinely complete a health status survey before each visit using touch-screen computer technology. The Patient Health Questionniare-9 (PHQ-9), one of the survey instruments, is used for depression screening. Each of the 9-items is rated from 0-3 resulting in a total score of 0 to 27. A score of 10 or more is significantly correlated with a DSM-IV diagnosis of major depression. Item 9 of the PHQ-9 assesses presence of suicidal ideation (SI). Survey responses are automatically uploaded to the electronic medical record for inspection by the patient's assigned clinician. A PHQ-9 total score of >10, or an item-9 rating of 1, 2 or 3, triggers a flag that alerts the clinician to the possible diagnosis of depression and/or elevated suicide risk. Both investigators (EF and GET) reviewed the records of all patients who endorsed suicidal thoughts on item 9 and a random sample of the records of all patients with PHQ-9?10. Records were reviewed for evidence of adherence to depression treatment guidelines including documentation that the clinician addressed PHQ-9 results with the patient, initiated antidepressant medication, appropriately adjusted existing antidepressant medication, and/or referred the patient to another clinician (behavioral expert, neurologist, or primary care clinician) for further depression care. Data were derived from a single encounter per patient. Results: 494 patients (28.9%) had a PHQ-9?10 and 192 (11.2%) endorsed some degree of suicidal ideation. The records of 228 patients were reviewed including the 192 with SI and 36 with pHQ-9?10 and no SI (item 9 score of 0). Ten clinicians, including nine epileptologists and one epilepsy nurse practitioner saw a mean 22.8 patients per clinician (median=24; range, 6 - 56). Mean rate of appropriate documentation per clinician was 82% (median=85%, range, 59%-100%). 136 patients (60%) were not on antidepressant and only 11 (8%) were advised to start medication. Of the 92 patients already on antidepressant medication treatment modification was recommended to only 9 (10%). Many of these patients, however, were referred appropriately for further evaluation and treatment of depression resulting in 179 instances in which patient was judged to have received appropriate depression care (mean, 78.5%; range, 60-100%). Conclusions: Epilepsy clinicians fell short of satisfying the portion of the guideline that addresses appropriate prescription of antidepressant medication. However, in most of these instances, clinicians appropriately delegated antidepressant management to other providers resulting in a nearly 80% rate of guideline adherence. This serves as a benchmark against which to judge future depression care by these same clinicians and those in other neurological disciplines.