1. 1
Performance Measurement
Diagnosis and Treatment of Depression: Review of the Performance Measures by the
Performance Measurement Committee of the American College of Physicians
Writing Committee
Amir Qaseem, MD, David Baker, MD, J Thomas Cross, MD, Andrew Dunn, MD, Ana Maria Lopez,
MD, Sarah West, MSN, RN
ACP Performance Measurement Committee Members*
David W. Baker, MD, MPH (Chair); J. Thomas Cross, MD, MPH; Andrew Dunn, MD, MPH; Mary
Ann Forciea, MD; Robert A. Gluckman, MD; Robert H. Hopkins, MD; Eve Kerr, MD; Kesavan
Kutty, MD; Ana Maria López, MD, MPH; Catherine MacLean, MD, PhD; Stephen D. Persell, MD,
MPH; and Terrence Shaneyfelt, MD
Corresponding author:
A. Qaseem
190 N. Independence Mall West
Philadelphia, PA 19106
Email aqaseem@acponline.org
* Individuals who served on the Performance Measurement Committee from initiation of the
project until its approval

2. 2
Introduction
Depression represents a major disease burden in the US, affecting an estimated 9% of the
population and accounting for some $83 billion per year (in 2003 dollars) in lost productivity
and medical costs (1-2). Antidepressants are the third most prescribed class of medications in
the US, and nearly 80% of such prescriptions are written by primary care physicians (3). Yet
fewer than 5% of primary care patient encounters include screening for depression (4-5). There
is also evidence of flaws in diagnostic accuracy – most commonly false positives – among
primary care physicians (6).
The ACP Performance Measurement Committee (PMC) reviewed performance measures
related to the diagnosis and treatment of depression to assess whether the measures are
evidence-based, methodologically sound, and clinically meaningful.
Methods
We performed a search to identify relevant performance measures from the National Quality
Forum (NQF), the American Medical Association-Physician Consortium for Performance
Improvement (AMA-PCPI), and National Quality Measures Clearinghouse (NQMC) websites.
The inclusion criteria were performance measures currently used in the Centers for Medicare
and Medicaid Services’ (CMS) Physician Quality Reporting System (PQRS) or currently used in
the CMS Electronic Record Incentive program. The PMC identified and reviewed 4 performance
measures.
Conclusion

3. 3
Recommendation
ACP does not support PQRS 106: “Adult Major Depressive Disorder (MDD): Comprehensive
Depression Evaluation: Diagnosis and Severity.”
Rationale
The two issues with this measure are: 1) it specifically requires using DSM-IV criteria rather than
any standardized valid and reliable instrument to diagnose depression; 2) documentation of
complete DSM-IV criteria as described in this measure is highly burdensome to the provider
without improvements in current electronic data entry systems; and 3) the current American
Psychiatric Association (APA) guideline recommends a thorough diagnostic assessment in order
to establish a diagnosis of MDD and does not state that formal DSM-IV criteria need to be met
(7-8). In addition, there is no evidence that there is a current gap in patient care.
Measure Specifications
PQRS 106: Adult Major Depressive Disorder (MDD): Comprehensive Depression Evaluation:
Diagnosis and Severity
Status: Removed from PQRS January 2015, No Longer NQF Endorsed (Formerly
NQF 0103)
Measure
Steward:
American Medical Association - Physician Consortium for Performance
Improvement
Description: Percentage of patients aged 18 years and older with a new diagnosis or
recurrent episode of major depressive disorder (MDD) with evidence that
they met the DSM-IV-TR criteria for MDD AND for whom there is an
assessment of depression severity during the visit in which a new diagnosis
or recurrent episode was identified
Numerator
Statement:
Patients with evidence that they met the DSM-IV-TR criteria for MDD AND
for whom there is an assessment of depression severity during the visit in
which a new diagnosis or recurrent episode was identified
Denominator
Statement:
All patients aged 18 years and older with a new diagnosis or recurrent
episode of major depressive disorder (MDD)
Exclusions: None
Type of
Measure:
Process
Level of
Analysis:
Clinician: Group/Practice, Clinician: Individual, Clinician: Team
Care Setting: Ambulatory Care: Clinician Office/Clinic, Ambulatory Care: Urgent Care,
Behavioral Health/Psychiatric: Outpatient, Other
Data Source: Electronic Clinical Data: Electronic Health Record, Electronic Clinical Data:
Registry

4. 4
Recommendation
ACP does not support NQF 0104: “Adult Major Depressive Disorder (MDD): Suicide Risk
Assessment.”
Rationale
Although assessment of suicide risk is good clinical practice in patients with a new diagnosis of
MDD or with initial prescription of antidepressive pharmacotherapy (8), the denominator
specification is unclear. In particular, it is not well defined what a “recurrent” episode
constitutes. If it is specified that this is an episode with the initiation of new treatment for
depression, then ACP could support this measure. However, as currently stated, it could be
applied to all follow-up visits with the mention of even well-controlled depression. In addition,
the performance gap presented in support for this measure is small (96.5% performance rate).
Measure Specifications
NQF 0104: Adult Major Depressive Disorder (MDD): Suicide Risk Assessment
Status: NQF Endorsed, Updated February 28, 2014 (2015 PQRS Measure #107)
Measure
Steward:
American Medical Association - Physician Consortium for Performance
Improvement
Description: Percentage of patients aged 18 years and older with a new diagnosis or
recurrent episode of major depressive disorder (MDD) with a suicide risk
assessment completed during the visit in which a new diagnosis or recurrent
episode was identified
Numerator
Statement:
Patients with a suicide risk assessment completed during the visit in which a
new diagnosis or recurrent episode was identified
Denominator
Statement:
All patients aged 18 years and older with a new diagnosis or recurrent
episode of major depressive disorder (MDD)
Exclusions: None
Type of
Measure:
Process
Level of Analysis: Clinician: Group/Practice, Clinician: Individual, Clinician: Team
Care Setting: Ambulatory Care: Clinician Office/Clinic, Ambulatory Care: Urgent Care,
Behavioral Health/Psychiatric: Outpatient, Other
Data Source: Electronic Clinical Data: Electronic Health Record, Electronic Clinical Data:
Registry

5. 5
Recommendation
ACP does not support NQF 0105: “Antidepressant Medication Management (AMM).”
Rationale
ACP does not support this measure because it has several issues even though the intent of this
measure is important. First, the time frame used in the measure (12 weeks for acute phase and
6 months for continuation) contradicts the recommendations from evidence-based guidelines
[4-6 weeks for acute phase, 4-9 months for continuation (8-9)]. This measure does not consider
alternative interventions such as psychotherapy, electroconvulsive therapy (ECT) or the
combination of somatic and psychotherapy that are as effective as pharmacological treatment
(8, 10). The measure excludes patient choice to switch to another modality of effective therapy
due to the side effects associated with pharmacological medications. In the management of
patients with depression, a provider-patient discussion on the benefits, harms, and costs of
treatment is important and not accounted for in this measure. The exclusions should include
lack of patient adherence due to the side effects of medication with documentation of
alternative therapy. ACP suggests deleting the requirement for acute phase treatment.
Measure Specifications
NQF 0105: Antidepressant Medication Management (AMM)
Status: NQF Endorsed, Updated February 28, 2014 (2015 PQRS Measure #9)
Measure
Steward:
National Committee for Quality Assurance
Description: The percentage of members 18 years of age and older with a diagnosis of
major depression and were newly treated with antidepressant medication,
and who remained on an antidepressant medication treatment. Two rates
are reported:
a) Effective Acute Phase Treatment. The percentage of newly diagnosed
and treated members who remained on an antidepressant medication
for at least 84 days (12 weeks).
b) Effective Continuation Phase Treatment. The percentage of newly
diagnosed and treated members who remained on an antidepressant
medication for at least 180 days (6 months).
Numerator
Statement:
a) Effective Acute Phase Treatment: At least 84 days (12 weeks) of
continuous treatment with antidepressant medication during the 114-day
period following the Index Prescription Start Date (IPSD) (inclusive). The
continuous treatment allows gaps in medication treatment up to a total of
30 days during the 114-day period. Gaps can include either washout period
gaps to change medication or treatment gaps to refill the same medication.
Regardless of the number of gaps, there may be no more than 30 gap days.
Count any combination of gaps (e.g., two washout gaps of 15 days each, or
two washout gaps of 10 days each and one treatment gap of 10 days).
b) Effective Continuation Phase Treatment: At least 180 days (6 months) of
continuous treatment with antidepressant medication (Table AMM-D)

6. 6
during the 231-day period following the IPSD (inclusive). Continuous
treatment allows gaps in medication treatment up to a total of 51 days
during the 231-day period. Gaps can include either washout period gaps to
change medication or treatment gaps to refill the same medication.
Regardless of the number of gaps, gap days may total no more than 51.
Count any combination of gaps (e.g., two washout gaps, each 25 days or
two washout gaps of 10 days each and one treatment gap of 10 days).
Denominator
Statement:
Members 18 years of age and older with a diagnosis of major depression
and were newly treated with antidepressant medication
Exclusions: Exclude members who filled a prescription for an antidepressant 90 days (3
months) prior to the IPSD.
Type of
Measure:
Process
Level of Analysis: Health Plan, Integrated Delivery System
Care Setting: Ambulatory Care: Clinician Office/Clinic
Data Source: Administrative claims, Electronic Clinical Data, Electronic Clinical Data:
Pharmacy
Recommendation
ACP does not support NQF 0418: “Preventive Care and Screening: Screening for Clinical
Depression and Follow-Up Plan.”
Rationale
ACP does not support this measure because the denominator should reflect patients seen in
the calendar year instead of all patients. Also, this measure is not supported by the current
United States Preventive Services Task Force (USPSTF) guideline; “Depression in Adults:
Screening”, that says that support services must be available before screening a patient for
depression. USPSTF recommends against screening in the absence of a support system or
follow-up services (11). In addition, this measure does not address frequency of screening for
depression and it is not clear whether this measure applies to all patients in a providers’ panel
or only those seen during the calendar year in a face-to-face visit.
Measure Specifications
NQF 0418: Preventive Care and Screening: Screening for Clinical Depression and Follow-Up
Plan
Status: NQF Endorsed, Updated February 28, 2014, (2015 PQRS Measure #134)
Measure
Steward:
Centers for Medicare & Medicaid Services
Description: Percentage of patients aged 12 years and older screened for clinical
depression using an age appropriate standardized tool AND follow-up plan
documented
Numerator
Statement:
Patient’s screening for clinical depression using an age appropriate
standardized tool AND follow-up plan is documented

7. 7
The standardized screening tools help predict a likelihood of someone
developing or having a particular disease. The screening tools suggested in
this measure screen for possible depression. Questions within the
suggested standardized screening tools may vary but the result of using a
standardized screening tool is to determine if the patient screens positive
or negative for depression. If the patient has a positive screen for
depression using a standardized screening tool, the provider must have a
follow-up plan as defined within the measure. If the patient has a negative
screen for depression, no follow-up plan is required.
Denominator
Statement:
All patients aged 12 years and older
Exclusions: Not Eligible/Not Appropriate – A patient is not eligible if one or more of the
following conditions exist:
• Patient refuses to participate
• Patient is in an urgent or emergent situation where time is of the
essence and to delay treatment would jeopardize the patient’s
health status
• Situations where the patient’s motivation to improve may impact
the accuracy of results of nationally recognized standardized
depression assessment tools. For example: certain court appointed
cases
• Patient was referred with a diagnosis of depression
• Patient has been participating in on-going treatment with screening
of clinical depression in a preceding reporting period
• Severe mental and/or physical incapacity where the person is
unable to express himself/herself in a manner understood by
others. For example: cases such as delirium or severe cognitive
impairment, where depression cannot be accurately assessed
through use of nationally recognized standardized depression
assessment tools
Type of
Measure:
Process
Level of Analysis: Clinician: Group/Practice, Clinician: Individual, Clinician: Team, Population:
Community, Population: County or City, Population: National, Population:
Regional, Population: State
Care Setting: Ambulatory Care: Clinician Office/Clinic, Hospital/Acute Care Facility, Post
Acute/Long Term Care Facility: Inpatient Rehabilitation Facility, Post
Acute/Long Term Care Facility: Long Term Acute Care Hospital, Post
Acute/Long Term Care Facility: Nursing Home/Skilled Nursing Facility
Data Source: Administrative claims, Electronic Clinical Data: Electronic Health Record,
Paper Medical Records

8. 8
Gaps in Performance Measurement — Opportunities to Promote High-Value Care
There is a need for health care systems to develop support systems and necessary resources to
help individual providers manage patients with MDD. A structural measure would be more
appropriate to address gaps in depression care. This measure would allow physicians to opt out
if they do not have systems of care in place. Consumers would be made aware of the decision
to opt out, thereby better informing patients in their decisions about where to seek care and
encouraging healthcare systems to implement care coordination.

9. 9
References
1. US Department of Health and Human Services. Centers for Disease Control and
Prevention. Current Depression Among Adults --- United States, 2006 and 2008.
MMWR. 2010; 59(38):1229-1235.
2. Greenberg PE, Kessler RC, Birnbaum HG, et al. The economic burden of depression in
the United States: How did it change between 1990 and 2000? Journal of Clinical
Psychiatry. 2003; 64:1465-1475.
3. Mojtabai R, Olfson M. Proportion of antidepressants prescribed without a psychiatric
diagnosis is growing. Health Affairs. 2011;30:1434-1442.
4. US Department of Health and Human Services, Office of the Assistant Secretary for
Planning and Evaluation. Health System Measurement Project. Percentage of Primary
Care Physician Office Visits that Include Depression Screening.
https://healthmeasures.aspe.hhs.gov/measure/26 (Accessed July 8, 2014).
5. Hepner KA, Rowe M, Rost K, Hickey SC, Sherbourne CD, Ford DE, Meredith LS,
Rubenstein LV. The effect of adherence to practice guidelines on depression outcomes.
Ann Intern Med. 2007; 147(5):320-329
6. Mitchell AJ, Vaze A, Rao S. Clinical diagnosis of depression in primary care: a meta-
analysis. Lancet. 2009;374:609-619.
7. American Psychiatric Association. Practice guideline for the psychiatric evaluation of
adults (2nd
ed.). 2006;1-62.
8. American Psychiatric Association. Practice Guideline for the Treatment of Patients with
Major Depressive Disorder (3rd
ed). 2010.
9. Qaseem A, Snow V, Denberg TD, Forciea MA, Owens DK, Clinical Efficacy Assessment
Subcommittee of the American College of Physicians. Using Second-Generation
Antidepressants to Treat Depressive Disorders: A Clinical Practice Guideline from the
American College of Physicians. Ann Intern Med. 2008;149:725-733. doi:10.7326/0003-
4819-149-10-200811180-00007

10. 10
10. Carek PJ, Laibstain SE, Carek SM. Exercise for the treatment of depression and anxiety.
International Journal of Psychiatry in Medicine. 2011;41(1):15-28
11. O’Connor EA, Whitlock EP, Gaynes B, Beil TL. Screening for Depression in Adults and
Older Adults in Primary Care: An Updated Systematic Review. Evidence Synthesis No. 75.
AHRQ Publication No. 10-05143-EF-1. Rockville, Maryland: Agency for Healthcare
Research and Quality, December 2009
Financial Statement: Financial support for the Performance Measurement Committee comes
exclusively from the ACP operating budget.
Conflicts of Interest: Any financial and nonfinancial conflicts of interest of the group members
were declared, discussed, and resolved. A record of conflicts of interest is kept for each PMC
meeting and conference call and can be viewed at:
http://www.acponline.org/running_practice/performance_measurement/pmc/conflicts_pmc.h
tm
APPROVED BY THE ACP BOARD OF REGENTS ON:
April 27, 2015
Members of the PMC:
Individuals who served on the Performance Measurement Committee from initiation of the
project until its approval:
David W. Baker, MD, MPH
J. Thomas Cross, Jr., MD, MPH
Andrew Dunn, MD, MPH
Mary Ann Forciea, MD
Robert A. Gluckman, MD
Robert H. Hopkins, MD
Kesavan Kutty, MD
Eve Askanas Kerr, MD, MPH
Ana María López, MD, MPH
Catherine MacLean, MD, PhD
Stephen D. Persell, MD, MPH
Terrence Shaneyfelt, MD, MPH
Requests and inquiries: Amir Qaseem, MD, PhD, MHA, FACP, American College of Physicians,
190. N Independence Mall West, Philadelphia, PA 19106: email, aqaseem@acponline.org