Introduction
Depression remains a prevalent and debilitating mental health condition, profoundly affecting individuals’ quality of life, physical health, and healthcare utilisation. In primary care settings, where many patients first seek help, routine screening and structured follow-up are critical to early detection and effective management. Guidelines such as those from the U.S. Preventive Services Task Force advocate for systematic screening, while initiatives like the Merit-Based Incentive Payment System (MIPS) in the United States include specific quality measures such as “Screening for Depression and Follow-Up Plan.” Despite these recommendations, implementation challenges persist in many primary care clinics, leading to missed diagnoses and inadequate care. This literature review, written from the perspective of a student in DNP NDNP Quality Improvement and Patient Safety, explores recent evidence on strategies to improve depression screening and follow-up in primary care. The essay examines the effectiveness of standardised screening protocols, structured follow-up mechanisms, and innovative implementation approaches, with a focus on their potential to enhance patient outcomes and align with quality improvement goals.
The Role of Standardised Screening Protocols
Standardised screening tools, such as the Patient Health Questionnaire-9 (PHQ-9), have been widely endorsed as effective means to improve the detection of depression in primary care settings. Research demonstrates that integrating these tools into routine clinical workflows can significantly enhance screening rates. For instance, Blackstone et al. (2022) conducted a quality improvement initiative in family medicine clinics, employing Plan-Do-Study-Act (PDSA) cycles alongside health information technology reminders and staff education. Their intervention resulted in an increase in patients up-to-date with depression screening from 61% to 82% over eight months, illustrating the feasibility of structured approaches (Blackstone et al., 2022). Similarly, Blake (2022) implemented a PHQ-9 screening protocol in a primary care clinic for first responders, achieving a remarkable rise in screening rates from under 1% to over 90%. This dramatic improvement was attributed to comprehensive staff training and policy changes, underscoring the importance of organisational support in sustaining screening practices (Blake, 2022). These studies collectively highlight that, while the tools themselves are crucial, their success depends heavily on embedding them into daily practice through training and technological aids. However, a limitation noted in both studies is the lack of long-term data to assess whether these gains persist beyond the intervention period, raising questions about sustainability.
Addressing Gaps in Follow-Up Care
While screening is a vital first step, the gap in consistent follow-up after a positive screen remains a significant barrier to effective depression management. Without structured follow-up, patients risk receiving inadequate support or treatment, undermining the benefits of early detection. Lindsay and Decker (2022) tackled this issue by introducing electronic reminders, routine PHQ-9 administration, and a clinical treatment algorithm in a primary care setting. Their intervention led to notably higher screening and treatment rates compared to baseline, suggesting that embedding follow-up plans into clinic protocols can bridge this gap (Lindsay and Decker, 2022). Furthermore, Creighton (2020) developed a standardised follow-up plan using provider and nurse call templates post-PHQ-9 screening. This approach enhanced care continuity and adherence to clinical guidelines, demonstrating the value of structured outreach in maintaining patient engagement (Creighton, 2020). These findings collectively indicate that follow-up care, when systematised, can transform initial screening into actionable care plans. Nevertheless, implementing such protocols requires resources and staff buy-in, which may pose challenges in under-resourced settings—a limitation that warrants further exploration.
Measurement-Based Care and Systematic Monitoring
Beyond initial screening and follow-up, ongoing monitoring using measurement-based care (MBC) has emerged as a promising strategy to improve clinical outcomes in depression management. MBC involves regular assessment of symptoms using tools like the PHQ-9, with results used to adjust treatment plans dynamically. A recent randomised controlled trial by Kendrick et al. (2024) evaluated the impact of ongoing PHQ-9 monitoring with patient feedback in group practices. Over 26 weeks, the intervention group showed measurable improvements in clinical outcomes compared to the control group, highlighting the value of sustained tracking beyond the initial screen (Kendrick et al., 2024). This evidence suggests that routine monitoring, when integrated into care processes, not only supports follow-up but also enhances treatment effectiveness. Indeed, MBC aligns with quality improvement principles by providing data-driven insights into patient progress, though its implementation may be constrained by time and resource demands in busy primary care environments. Future research could usefully explore strategies to streamline MBC integration without disrupting existing workflows.
Implementation Strategies and Stakeholder Engagement
The successful adoption of screening and follow-up protocols often hinges on effective implementation strategies that prioritise stakeholder engagement and workflow adaptation. Participatory approaches, such as involving clinicians and administrative staff in the design of interventions, alongside rapid-cycle testing, have been shown to sustain improvements without overwhelming clinical routines. For example, studies suggest that flexible adaptations to clinic workflows, supported by quality improvement frameworks like the Model for Improvement, can facilitate the integration of depression screening and follow-up (Blackstone et al., 2022). These strategies often involve iterative testing (e.g., PDSA cycles) to refine processes based on real-time feedback from stakeholders. Moreover, engaging staff through education and shared decision-making fosters a culture of ownership, which is critical for long-term adherence to quality measures. However, while such approaches appear promising, the literature lacks detailed analysis of their cost-effectiveness or scalability across diverse primary care contexts—a gap that limits their immediate applicability in policy and practice.
Conclusion
In summary, this literature review underscores the potential of evidence-based strategies to improve depression screening and follow-up in primary care settings. Standardised screening tools like the PHQ-9, when supported by training, technology, and policy changes, significantly enhance detection rates, as demonstrated by studies such as those by Blackstone et al. (2022) and Blake (2022). Structured follow-up protocols, including reminders and templates, address critical gaps in care continuity, while measurement-based care offers a pathway to sustained clinical improvement (Lindsay and Decker, 2022; Kendrick et al., 2024). Additionally, implementation strategies that prioritise stakeholder engagement and workflow flexibility appear essential for embedding these practices into routine care. However, challenges such as resource constraints and the sustainability of interventions remain underexplored in the literature. For quality improvement initiatives, particularly within the context of DNP NDNP studies, these findings highlight the importance of tailoring interventions to local needs while aligning with broader quality measures like those in MIPS. Future research should focus on long-term outcomes and cost-effectiveness to ensure that these promising strategies can be scaled effectively across diverse primary care environments, ultimately improving patient outcomes on a wider scale.
References
- Blackstone, S. R., Sebring, A. N., Allen, C., Tan, J. S., & Compton, R. (2022). Improving depression screening in primary care: A quality improvement initiative. Journal of Community Health.
- Blake, C. (2022). Depression screening implementation: Quality improvement project in a primary care clinic for first responders. Workplace Health & Safety.
- Creighton, F. L. R. (2020). Standardized follow-up plan for depression through implementation of provider note and nurse follow-up templates. Journal of Nursing Practice.
- Kendrick, T., Dowrick, C., et al. (2024). Depression follow-up monitoring with the PHQ-9: An open cluster-randomized controlled trial. British Journal of General Practice.
- Lindsay, M., & Decker, V. B. (2022). Improving depression screening in primary care. Journal of the Doctor of Nursing Practice.
