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Patient screened for depression (SUD)

CPT4 code

Name of the Procedure:

Patient screened for depression (SUD) Common name: Depression screening, Substance Use Disorder (SUD) screening Medical term: Depression and SUD screening assessment

Summary

In this brief, non-invasive assessment, healthcare professionals screen patients for signs of depression and substance use disorders. This process involves answering questions on standardized questionnaires or structured interviews, which help clinicians evaluate the patient's mental health status.

Purpose

The procedure addresses mental health conditions and substance use disorders. The goals are to identify if a patient is experiencing depression or has a substance use disorder, enabling early intervention, appropriate treatment and monitoring, and ultimately improving mental health outcomes.

Indications

  • Persistent feelings of sadness or hopelessness
  • Loss of interest or pleasure in activities
  • Changes in appetite or weight
  • Difficulty sleeping or sleeping too much
  • Substance misuse or dependency
  • Patients with risk factors for depression or SUD (family history, significant life changes, chronic stress)

Preparation

  • No special preparation is needed for the patient.
  • Patients may be asked to complete preliminary questionnaires.
  • Healthcare providers may review the patient's medical history and possibly perform other routine health assessments.

Procedure Description

  1. Initial Consultation: A healthcare provider explains the screening process.
  2. Questionnaires: The patient completes standardized questionnaires, such as the PHQ-9 (Patient Health Questionnaire-9) for depression or the AUDIT (Alcohol Use Disorders Identification Test) for alcohol use.
  3. Interview: A clinician may conduct a structured interview to further evaluate symptoms and responses.
  4. Scoring and Evaluation: The results from questionnaires and interviews are scored and assessed to identify any signs of depression or substance use disorders.
    • Tools: Standardized questionnaires, interview forms.
    • No anesthesia or sedation is required.

Duration

The procedure typically takes 15-30 minutes, depending on the depth of the interview and discussion.

Setting

The screening can be performed in various settings, such as a primary care office, outpatient clinic, mental health facility, or via telemedicine.

Personnel

  • Primary care physicians
  • Mental health professionals (psychiatrists, psychologists, specialized nurses, or social workers)

Risks and Complications

  • There are minimal risks involved.
  • Potential discomfort in discussing sensitive topics, which healthcare providers manage with sensitivity and privacy.

Benefits

  • Early detection of depression and substance use disorders.
  • Enables timely intervention and treatment.
  • Improves mental health outcomes and overall quality of life.

Recovery

  • No physical recovery is needed.
  • Psychological support may be provided immediately if acute distress is evident or referrals to mental health professionals are made.
  • Follow-up appointments or further assessments may be scheduled based on initial findings.

Alternatives

  • Observation and informal assessment during regular healthcare visits.
  • Self-assessment tools and online screenings (though professional evaluation is preferred for accurate diagnosis).
  • These alternatives may not be as thorough and may not provide immediate professional guidance.

Patient Experience

  • The procedure is generally comfortable, involving conversation and completing forms.
  • Patients may experience relief and reassurance after voicing their feelings.
  • Healthcare providers offer support and referrals if symptoms of depression or SUD are identified.

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