The Patient Health Questionnaire

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The Patient Health Questionnaire

• Public Health Detailers Training
• NYC Department of Health and Mental Hygiene
• Judy Stein, LMSW, MS
• Co-Director, NYC DOHMH Depression Initiative

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Outline

• Why Screen
• Consequences
• Depression in Primary Care
• Mental Health Sector
• How to Screen
• PHQ 2
• PHQ 9
• Scoring
• Case Study

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Detection of Depression Why Screen?

• To find people who may be depressed or at risk
  for depression who dont know it
• Screening for depression in the primary care
  setting improves detection rates
• US Preventative Service Task Force (USPSTF)
• Failure to detect and treat depression leads to
  unnecessary suffering and disability and
  increases the use of health care services.

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Consequences of Untreated Depression

• Distress, disability, suicide
• May increase and/or exacerbate
• risky behaviors, ie. unprotected sex, drug and
  alcohol abuse
• behaviors that contribute to poor health, ie.
  smoking, poor nutrition
• symptoms of chronic medical illness, ie.
  cardiovascular disease, diabetes
• use of general medical services

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Depression in Primary Care

• Depression is more commonly seen in primary care
  than any other condition except
  hypertension/diabetes.
• 6-9 of patients in a primary care practice have
  a treatable depressive disorder.
• PCPs fail to diagnose depression in up to 50 of
  their depressed patients.

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Mental Health Sector

• Only 50 of those referred to specialty mental
  health practitioners complete more than one visit
• Of the 12 of New Yorkers identified to have a
  Major Depression and/or Generalized Anxiety
  Disorder in the recent NYC HANES (2004), only 37
  receive mental health treatment
• Of this 37 in treatment, only a quarter of
  African Americans and Hispanics (26 and 27
  respectively) receive treatment compared with
  nearly half (49) of Whites (HANES, 2004)

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How to Screen Patient Health Questionnaire (PHQ)

• PHQ2
• PHQ9 (scored by health professional)

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PHQ 2

• A quick and simple screen for depression that
  consists of 2 questions
• During the past two weeks, have you been bothered
  by
• 1. little interest or pleasure in doing things
  ?
• 2. feeling down, depressed, or hopeless?

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PHQ 2

• Valid and practical tool for depression screening
  in busy medical settings
• Positive score should be followed up with PHQ9
  and/or more thorough diagnostic assessment
• Sensitivity 83 for major depression
• Specificity 92 for major depression

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PHQ 9

• A 9-item, self-administered questionnaire
• A screening tool not a diagnostic tool
• Corresponds with the 9 signs and symptoms of
  DSM-IV diagnosis

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PHQ 9

• Can quantify the severity of depression
• Provides measurement over time
• Available in multiple languages
• Strong evidence of reliability and validity
• Sensitivity 88 for major depression
• Specificity 88 for major depression

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Compare DSM-IV Depression Diagnosis and PHQ9

• Five (or more) of the following symptoms have
  been present during the same 2-week period,
  nearly very day, and represent a change from
  previous functioning at least 1 of the symptoms
  is either (1) depressed mood or (2) loss of
  interest or pleasure
• Depressed mood most of the day
• Markedly diminished interest or pleasure in all,
  or almost all, activities most of the day
• Significant weight loss when not dieting, or
  weight gain, or decrease or increase in appetite
• Insomnia or hypersomnia

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Compare DSM-IV Depression Diagnosis and PHQ9

• Psychomotor agitation or retardation
• Fatigue or loss of energy
• Feelings of worthlessness or excessive or
  inappropriate guilt
• Diminished ability to think or concentrate, or
  indecisiveness
• Recurrent thoughts of death, recurrent suicidal
  ideation without a specific plan, or a suicide
  attempt or specific plan for committing suicide

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Scoring the PHQ 9

• For a screen to indicate a presence of
  depression, there must be a v in the shaded
  section for questions 1 or 2.
• Add up vs in each column
• Several days 1
• More than half the days 2
• Nearly every day 3
• Add together column scores to get a total score.

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Scoring the PHQ 9

• Scorecard for Severity Determination
• Total Score Depression Severity
• 1-4 Community Norms
• 5-9 Mild Depression
• 10-14 Moderate Depression
• 15-19 Moderately Severe Depression
• 20-27 Severe Depression

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Case Study

• 55 year old dentist
• PCP visit
• Somatic complaints
• Loss of interest
• Insomnia
• Fatigue
• Irritable
• Difficulty concentrating
• Feelings of guilt, worthlessness, hopelessness