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

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

• Neil Korsen, MD, MS
• Medical Director, MaineHealth Caring for ME/
  Depression in Primary Care Program

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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.

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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.

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VIDEO PRESENTATION
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Guideline for Using the PHQ-9 for Initial
Management
Score/ Symptom Level Treatment
0-4 No depression Consider other diagnoses
5-9 Minimal Consider other diagnoses If diagnosis is depression, watchful waiting is appropriate initial management
10-14 Mild Consider watchful waiting If active treatment is needed, medication or psychotherapy is equally effective
15-19 Moderate Active treatment with medication or psychotherapy is recommended Medication or psychotherapy is equally effective
20-27 Severe Medication treatment is recommended For many people, psychotherapy is useful as an additional treatment People with severe symptoms often benefit from consultation with a psychiatrist
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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 patients symptoms have not resolved after
  2-3 months, active treatment ought to be
  considered.

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Interpreting Follow Up Scores
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.
Drop of 2-4 points each month Fair 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.
Drop of 1 point, no change or increase each month Poor 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.
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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

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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

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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

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PHQ-9 Depression Assessment Tool
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.
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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?

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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

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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

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Initial PHQ-9
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Case 1 Questions

• What is his PHQ-9 score?
• What is his severity level?
• Based on his severity level, what would you
  recommend?

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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

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4 week follow-up PHQ-9
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Case 1 4-week follow-up visit

• What is his PHQ-9 score today?
• How would you describe his response to treatment
  (good, fair, poor)?
• What might you do next?

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Case 1 8-week follow-up visit

• 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

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8 week follow-up PHQ-9
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Case 1 8-week follow-up visit

• What is his score today?
• Has he reached remission?
• What is your advice about continuing on treatment?

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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

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Case 2 Questions

• What is her PHQ-9 score?
• What is her severity level?
• Based on her severity level, what would you
  recommend?

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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

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Case 3 Questions

• What is his PHQ-9 score?
• What is his severity level?
• Based on his severity level, what would you
  recommend?

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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

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Case 4 Questions

• What is his PHQ-9 score?
• What is his severity level?
• Based on his severity level, what would you
  recommend?

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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.

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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

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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

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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.

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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.

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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 Employers Guide to Behavioral Health
  Services, National Business Group on Health,
  2005. Accessed at http//64.78.6.200/prevention/et
  _behavioralhealthreport.cfm?20Health20Services
  20Tools20and20Solutions20-20, 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.

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Questions or Comments?