Critical Review & Evaluation of Health Promotion Protocol/Practice

Selected Screening Tool: Geriatric Depression Scale (GDS-15)

• Tool Name: Geriatric Depression Scale (GDS-15)
• Purpose: To screen for depressive symptoms in older adults (typically 60 years and older). It aims to distinguish depressive symptoms from normal aging or medical conditions, as somatic symptoms common in depression might be misattributed to physical illness in the elderly.
• Target Population: Older adults in various settings (community, primary care, long-term care, hospitals).
• Utility for Nurse Practitioners: The GDS-15 is an excellent tool for NPs to quickly and reliably screen for depression during routine health assessments, especially in primary care, geriatrics, or specialized settings like pain management where chronic pain can co-occur with depression. It guides further assessment and intervention.

2. Ethical, Economical, and Legal Issues Relative to the Practice in Relation to Health Promotion Protocol/Practice

The use of the GDS-15, like any screening tool, must be considered within a broader health promotion protocol that addresses ethical, economical, and legal dimensions.

Ethical Issues:

1. Stigma and Confidentiality:

   • Issue: Asking about depressive symptoms can be perceived as stigmatizing, especially in older generations or certain cultural contexts where mental health issues are not openly discussed. Patients might fear judgment, loss of autonomy, or institutionalization. Ensuring confidentiality is paramount.
   • Health Promotion Context: If a positive screen leads to disclosure without consent (e.g., to family members who the patient doesn't want to know), or if the referral process isn't confidential, it erodes trust and discourages future engagement in mental health promotion.
   • Example for GDS-15: An NP administering the GDS-15 must clearly explain its purpose (screening, not diagnosis), assure confidentiality, and obtain informed consent for any subsequent referrals. A positive screen should never lead to automatic family notification without the patient's explicit permission.

2. False Positives/Negatives and Consequences:

   • Issue: No screening tool is 100% accurate. A false positive can lead to unnecessary anxiety, labeling, or even inappropriate referral/treatment. A false negative can delay crucial intervention, allowing depression to worsen and potentially contributing to secondary issues like alcoholism.
   • Health Promotion Context: Over-screening or misinterpreting results can lead to over-medicalization of normal aging or transient sadness. Under-screening can miss opportunities for early intervention in preventable conditions.
   • Example for GDS-15: Given the GDS-15 primarily screens for symptoms, a positive score necessitates a more in-depth clinical interview and assessment (e.g., DSM-5 criteria) by a qualified professional to confirm a diagnosis. The NP must be trained to differentiate between clinical depression and transient sadness.

3. Informed Consent and Right to Refuse:

   • Issue: Patients have the right to understand why they are being screened and to refuse participation without prejudice. Coercion, subtle or overt, is unethical.
   • Health Promotion Context: Health promotion efforts should be empowering, not compulsory.
   • Example for GDS-15: The NP should clearly explain that the GDS-15 is a tool to help understand their emotional well-being, assure them that their responses are confidential, and clarify that they can decline to answer any question or complete the screen without affecting their care.

4. Resource Availability and "Screen and Abandon":

   • Issue: Ethically, if you screen for a problem, you must have resources in place to address a positive finding. Screening without adequate referral pathways or available treatment options constitutes "screen and abandon," which can be harmful.
   • Health Promotion Context: Promoting early detection is futile and potentially damaging if there's no system to support intervention.
   • Example for GDS-15: If the GDS-15 identifies potential depression, the NP must have established pathways to mental health specialists (psychiatrists, therapists), support groups, or case management services within the community or health system. For patients with depression leading to alcoholism, these pathways must include SUD treatment.

Economical Issues:

1. Cost of Screening and Follow-Up:

   • Issue: While the GDS-15 itself is free, the time spent by the NP or other staff administering and interpreting it, the costs associated with follow-up diagnostic assessments (e.g., psychiatric evaluations), and subsequent treatment (medications, therapy sessions) accumulate.
   • Health Promotion Context: Budget constraints can limit the feasibility of widespread screening programs or the availability of resources for treatment.
   • Example for GDS-15: For a pain management office, routine GDS-15 screening adds to visit time. Positive screens require additional time for counseling, coordination, and referral. If these services aren't adequately reimbursed or if there are insufficient mental health providers covered by insurance, the economic burden can limit the program's sustainability.

2. Return on Investment (ROI):

   • Issue: While screening can lead to better health outcomes, demonstrating the direct financial ROI can be challenging. Payers and administrators often look for quantifiable savings.
   • Health Promotion Context: Convincing stakeholders to invest in mental health screening as a health promotion strategy requires demonstrating its long-term benefits in reducing healthcare costs (e.g., fewer ED visits, hospitalizations for exacerbations of chronic conditions, or complications from untreated depression/AUD).
   • Example for GDS-15: The economic benefits of early detection and treatment of depression include improved adherence to medical regimens for chronic pain, reduced risk of secondary alcoholism (decreasing associated hospitalizations/ER visits for alcohol-related issues), and improved quality of life leading to decreased healthcare utilization overall. Quantifying these can be difficult but is essential for advocacy.

3. Reimbursement for Screening and Integrated Care:

   • Issue: Historically, reimbursement for mental health services, especially integrated care in non-mental health settings, has been complex and often inadequate. Reimbursement for brief screening tools like the GDS-15 may be bundled into general visit codes or have specific CPT codes that might not cover the full cost of administration and follow-up.
   • Health Promotion Context: Lack of clear and equitable reimbursement for health promotion activities (like routine mental health screening) disincentivizes providers and organizations from implementing them broadly.
   • Example for GDS-15: An NP needs to understand current billing codes (e.g., G0444 for annual depression screening) and ensure proper documentation to capture reimbursement for GDS-15 administration and subsequent interventions. Advocating for better reimbursement for integrated mental health and SUD care (which is crucial for alcoholism secondary to depression) is vital for sustainability.

Legal Issues:

1. Confidentiality Laws (HIPAA/HITECH):

   • Issue: Protecting patient health information (PHI) is a fundamental legal requirement. Unauthorized disclosure of screening results or mental health information can lead to severe penalties.
   • Health Promotion Context: All data collected during health promotion activities must adhere to strict privacy regulations.
   • Example for GDS-15: All GDS-15 results and subsequent treatment plans must be securely stored in the EHR, with access limited to authorized personnel. Sharing information with family or other providers requires explicit patient consent, especially for sensitive topics like mental health and SUD (often protected by stricter 42 CFR Part 2 laws for substance use disorder treatment).

2. Mandatory Reporting (e.g., Elder Abuse, Suicidal Ideation):

   • Issue: While confidentiality is key, NPs are mandated reporters for certain situations (e.g., elder abuse, serious suicidal ideation with a plan). A positive GDS-15 could uncover such issues.
   • Health Promotion Context: Balancing patient autonomy/confidentiality with the legal and ethical duty to protect vulnerable individuals is critical.
   • Example for GDS-15: An NP administering the GDS-15 must be aware of their state's mandatory reporting laws. If a patient expresses serious suicidal intent, the NP has a legal and ethical duty to intervene, prioritize safety, and break confidentiality if necessary, while documenting thoroughly.

3. Scope of Practice and Licensure:

   • Issue: NPs must ensure that administering, interpreting, and acting on screening results falls within their state's Nurse Practice Act and their individual scope of practice.
   • Health Promotion Context: Expanding health promotion activities to include new screening tools requires NPs to be appropriately trained and authorized.
   • Example for GDS-15: Administering the GDS-15 for screening is typically within an NP's scope. However, making a definitive diagnosis of major depressive disorder and prescribing complex psychopharmacological agents might require specific training, certification, or physician collaboration/consultation depending on state laws and the NP's own expertise.

3. Recommendations

Based on the analysis of ethical, economical, and legal issues, here are recommendations for utilizing the GDS-15 within a health promotion protocol, especially for older adults with potential alcoholism secondary to depression:

1. Develop a Comprehensive Screening and Referral Protocol:

   • Recommendation: Implement a standardized protocol for routine GDS-15 screening for all older adult patients, ideally integrated within the EHR for ease of use and tracking. The protocol must clearly define next steps for positive screens, including immediate follow-up assessment, defined referral pathways to mental health specialists and SUD treatment (e.g., integrated behavioral health within the pain clinic, external specialists), and emergency procedures for high-risk findings (e.g., suicidal ideation).
   • Rationale: This addresses the "screen and abandon" ethical issue and provides a clear workflow for NPs, ensuring timely and appropriate intervention.

In my role as a DNP-prepared nurse in a pain management setting, the intersection of chronic pain, depression, and potential substance use (including alcohol) in the elderly population is a significant concern. Therefore, I will choose a screening tool relevant to this complex issue: the Geriatric Depression Scale (GDS).

Review of a Screening Tool: Geriatric Depression Scale (GDS-15)

The Geriatric Depression Scale (GDS-15) is a widely used and validated self-report screening tool specifically designed to assess for depressive symptoms in older adults. It consists of 15 "yes/no" questions, making it quick and easy to administer, even for individuals with mild cognitive impairment. A score of 0-4 is considered normal, 5-9 suggests mild depression, and 10-15 indicates severe depression.