Using the Patient Health Questionnaire (PHQ-9): The Hgb A-1-C for Depression

Using the Patient Health Questionnaire (PHQ-9):

The Hgb A-1-C for Depression

Neil Korsen, MD, MSMedical Director,

MaineHealth Caring for ME/ Depression in

Primary Care Program

Key Points Depression is a common problem that

causes much morbidity and mortality Most patients treated for depression

receive all their treatment in the primary care setting

There is solid evidence that a model of depression care consistent with the Planned Care Model leads to better outcomes for people with depression.

The PHQ-9 Is a validated tool to screen for and

diagnose depression. Has also been validated as a tool for

measuring response to treatment. Is easy to use and has been found to

be helpful by Maine primary care clinicians who have been using it for several years.

VIDEO PRESENTATION

PATIENT QUESTIONNAIRE (PHQ-9)

Name: Date: Over the last 2 weeks, how often have you been bothered by any of the following problems? (use “ ” to indicate your answer)

Not at all

Several days

More than half the days

Nearly every day

1. Little interest or pleasure in doing things 0 1 2 3

2. Feeling down, depressed, or hopeless 0 1 2 3

3. Trouble falling/staying asleep, sleeping too much 0 1 2 3

4. Feeling tired or having little energy 0 1 2 3

5. Poor appetite or overeating 0 1 2 3

6. Feeling bad about yourself – or that you are a failure or have let yourself or your family down

0 1 2 3

7. Trouble concentrating on things, such as reading the newspaper or watching television

0 1 2 3

8. Moving or speaking so slowly that other people could have noticed. Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual

0 1 2 3

9. Thoughts that you would be better off dead, or of hurting yourself in some way.

0 1 2 3

Add Columns: _____ + _____ + _____

(Healthcare professional: For interpretation TOTAL: of TOTAL, please refer to back of page)

_______

Not difficult at all _______

Somewhat difficult _______

Very difficult _______

If you checked off any problem on this questionnaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Extremely difficult _______

Patient Health Questionnaire (PHQ) Copyright© 1999 Pfizer Inc. All rights reserved. Reproduced with

permission. PRIME-MD ® is a trademark of Pfizer Inc.

Guideline for Using the PHQ-9 for Initial Management

Score/Symptom

Level

Treatment

0-4No depression

Consider other diagnoses

5-9Minimal

Consider other diagnosesIf diagnosis is depression, watchful waiting is appropriate initial management

10-14Mild

Consider watchful waitingIf active treatment is needed, medication or psychotherapy is equally effective

15-19Moderate

Active treatment with medication or psychotherapy is recommendedMedication or psychotherapy is equally effective

20-27Severe

Medication treatment is recommended For many people, psychotherapy is useful as an additional treatmentPeople with severe symptoms often benefit from consultation with a psychiatrist

What is Watchful Waiting?

It is estimated that a third of people with mild symptoms will recover without treatment.

Watchful waiting means you are seeing the patient about once a month and monitoring their PHQ-9 score, but not starting active treatment.

Self-care activities such as exercise or relaxation are usually a component of watchful waiting.

If the patient’s symptoms have not resolved after 2-3 months, active treatment ought to be considered.

PHQ-9 - Change from last score, measured monthly

Treatment

Response

Treatment Plan

Drop of 5 or more points each month

Good Antidepressant &/or Psychotherapy

No treatment change needed. Follow-up in 4 weeks.

Drop of 2-4 points each month

Fair Antidepressant: May warrant an increase in dose.

Psychotherapy: Probably no treatment change

needed. Share PHQ-9 with psychotherapist.

Drop of 1 point, no change or increase each month

Poor Antidepressant: Increase dose or augment or switch; informal or formal psychiatric consult; add psychotherapy.

Psychotherapy: 1. If depression-specific

psychotherapy discuss with supervising psychiatrist, consider adding antidepressant.

2. For patients satisfied in other psychotherapy consider adding antidepressant.

3. For patients dissatisfied in other psychotherapy, review treatment options and preferences.

Interpreting Follow Up Scores

Screening – Who and How

US Preventive Services Task Force, 2003 statement supporting screening for

depression:

(We) recommend screening adults for depression in clinical practices that

have systems in place to assure accurate diagnosis, effective

treatment, and follow-up.www.ahrq.gov

Screening for Depression: Who do you screen? All adults at least every 5 years (as

part of a health maintenance visit?) High risk groups every year

– History of depression– Family history of depression or bipolar– Chronic illnesses such as diabetes, heart

disease, pain problems– High utilization of services

People with complaints that suggest depression such as insomnia or fatigue

Screening for Depression:

The first two questions of the PHQ-9 have been validated as a sensitive way to screen for depression– 96% of people with depression will say yes to

one of those two questions– Answer of ‘2’ or ‘3’ on either of those questions

is a positive screen– Administer the full PHQ-9 to those who screen

positive

The PHQ-9-9 is used in two different ways. Initially to assess patients for depression and subsequently to monitor treatment progress should a formal DX of depression be made.

When assessing patients the score of the first two questions will determine whether or not you would need to go forward with the remaining questions. For example if the first two questions score as two or less you will be notified that the patient has screened negative for depression. For patient with a diagnosis of depression all other questions should be answered regardless of score in the first two question.

PHQ-9 Depression Assessment Tool

Things to Consider in Initiating Use of the PHQ-9 in your daily work

How will you identify those patients who should fill out a PHQ?

Who will give the patient the PHQ? Who will score the PHQ? Who will enter the results into the registry?

When will that be done? How often should the PHQ be done?

How often should the PHQ be done? Once a month until the patient

reaches remission (score 0-4) or for the first 6 months of treatment

Every 3 months after that while the patient is on active treatment

Once a year for people with a history of depression who are no longer on active treatment

Practice Case #1: Initial Visit

45 year-old businessman Feeling tired, not sleeping well lately A good friend was killed in a car crash a few

months ago Work has been more stressful for the past

year You recognize that his symptoms suggest

depression and you ask him to fill out a PHQ-9



Not at all

Several days


Nearly every day

1. Little interest or pleasure in doing things 0 1 X 3

2. Feeling down, depressed, or hopeless 0 1 2 X

3. Trouble falling/staying asleep, sleeping too much 0 1 X 3

4. Feeling tired or having little energy 0 1 2 X

5. Poor appetite or overeating 0 1 X 3


0 X 2 3


0 1 2 X


0 1 X 3


0 1 X 3

Add Columns: _____ + _____ + _____


_______



Very difficult ___X___

If you checked off any problem on this questionnaire so far, how difficult have these problems made it for you to do your

work, take care of things at home, or get along with other people?




[Initial PHQ-9]

Case #1: Questions

What is his PHQ-9 score? What is his severity level? Based on his severity level,

what would you recommend?

Case #1: 4-week follow-up visit

He returns after 4 weeks Has been taking medication you

prescribed Had some nausea initially, but that has

improved when he started taking the medication with food.

Says he is feeling better His PHQ-9 today:



Not at all

Several days


Nearly every day

1. Little interest or pleasure in doing things 0 X 2 3

2. Feeling down, depressed, or hopeless 0 1 X 3


4. Feeling tired or having little energy 0 1 X 3

5. Poor appetite or overeating 0 X 2 3


X 1 2 3


0 1 X 3


0 X 2 3


0 X 2 3

Add Columns: _____ + _____ + _____


_______


Somewhat difficult _X_____


If you checked off any problem on this questionnaire so far, how difficult have these problems made it for you to do your work, take

care of things at home, or get along with other people?




[4 week follow-up PHQ-9]


What is his PHQ-9 score today?

How would you describe his response to treatment (good, fair, poor)?

What might you do next?


He returns in another month Reports he is feeling much

better, almost like his old self Continues to take the medicine

and has not been bothered by side effects

His PHQ-9 score today is:



Not at all

Several days


Nearly every day

1. Little interest or pleasure in doing things X 1 2 3

2. Feeling down, depressed, or hopeless 0 X 2 3

3. Trouble falling/staying asleep, sleeping too much 0 X 2 3

4. Feeling tired or having little energy 0 X 2 3

5. Poor appetite or overeating X 1 2 3


X 1 2 3


0 X 2 3


X 1 2 3


X 1 2 3

Add Columns: _____ + _____ + _____


_______

Not difficult at all ____X__







[8 week follow-up PHQ-9]


What is his score today? Has he reached remission? What is your advice about

continuing on treatment?

Case #2

32 year-old woman 6 weeks of depressed mood, poor

sleep and appetite Had an episode of depression

about 5 years ago, which was successfully treated with Zoloft

Her PHQ-9:



Not at all

Several days


Nearly every day

1. Little interest or pleasure in doing things 0 X 2 3




5. Poor appetite or overeating 0 1 X 3


0 X 2 3


0 1 X 3


0 X 2 3

9. Thoughts that you would be better off dead, or of hurting yourself in some way. X 1 2 3

Add Columns: _____ + _____ + _____


_______


Somewhat difficult _X_____






Case #2: Questions

What is her PHQ-9 score? What is her severity level? Based on her severity level,


Case #3

28 year-old man Several weeks of feeling down,

trouble concentrating, and frequent awakening at night

You recognize that this might be depression and administer a PHQ-9:



Not at all

Several days


Nearly every day




4. Feeling tired or having little energy 0 1 X 3


6. Feeling bad about yourself – or that you are a failure or have let yourself or your family down X 1 2 3


0 X 2 3


X 1 2 3


Add Columns: _____ + _____ + _____


_______


Somewhat difficult _ X____






Case #3: Questions



Case #4

74 year-old man Complaints of fatigue and

trouble with his memory History of hypertension, but is

otherwise fairly healthy. His PHQ score:



Not at all

Several days


Nearly every day


2. Feeling down, depressed, or hopeless 0 X 2 3




6. Feeling bad about yourself – or that you are a failure or have let yourself or your family down X 1 2 3


0 1 2 X


0 X 2 3


Add Columns: _____ + _____ + _____


_______



Very difficult _ X ____





Case #4: Questions



Accessing our e-learn modules

elearn.mmc.org/depression

Sign in either using your MMC login name as your user name and password, or by using welcome as your user name and password.

Depression Collaborative Participants

Portland area:– Bowdoin Medical Group – S. Portland– Andrew Candelore, DO– Joseph DeKay, DO– Maine Med Family Practice Centers– Maine Med Medical Clinic– Maine Med Ob-Gyn Clinic– Sacopee Valley Health Center– Scarborough Family Physicians

Depression Collaborative Participants Damariscotta area:

– Miles Family Medicine/ Damariscotta– Miles Internal Medicine

Augusta area:– Augusta Family Physicians– Capital Family Practice– Gardiner Family Practice– Sheepscot Valley Health Center– Winthrop Health Center

Institute of Medicine “Quality Chasm” Report for Mental Health

Clinicians should: Increase their use of valid and reliable patient questionnaires … that are feasible for routine use to assess the progress and outcomes of treatment systematically and reliably.

Paying for the PHQ-9 The National Business Group on

Health (a group of more than 200 large employers):– “Monitor patient progress with standardized,

evidence-based instruments. Reimburse patient monitoring as a lab test.”

Aetna is piloting paying for the PHQ-9.– We are negotiating to be included in that pilot.

References ‘Improving the Quality of Health Care for Mental and

Substance-Use Conditions’, Institute of Medicine, 2006. Accessed at http://fermat.nap.edu/catalog/11470.html, 6/2/06

‘An Employer’s Guide to Behavioral Health Services’, National Business Group on Health, 2005. Accessed at http://64.78.6.200/prevention/et_behavioralhealthreport.cfm?%20Health%20Services:%20Tools%20and%20Solutions%20-%20&, 6/2/06

Spitzer, Kroenke et al, JAMA, 1999, V.282, pp.1737-44.

Lowe, Unutzer et al, Medical Care, 2004, V.42, pp. 1194-1201.

http://fermat.nap.edu/catalog/11470.html

http://64.78.6.200/prevention/et_behavioralhealthreport.cfm?%20Health%20Services:%20Tools%20and%20Solutions%20-%20&



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Using the Patient Health Questionnaire (PHQ-9): The Hgb A-1-C for Depression