PHQ 9 – Opening Pandora’s Box
“Here you go Sally, Dr. Whittle would like you to fill out this questionnaire today.” A medical assistant in Dr. Whittle’s office hands Sally a PHQ 9 depression screening. After the Medical Assistant scores the screening it shows that Sally scores a 15 Moderately Severe Depression. She answers questions 9 in the following way:
· Thoughts that you would be better off dead, or of hurting yourself in some way?
o Response: More than half the days
Because of the comorbidities between depression and many other areas of physical medicine, Primary Care and Specialists are dealing with depression almost daily. Some choose to treat depression inhouse and some refer patients out to Psychiatrists. In either scenario, these physicians see the effects of depression on their outcomes. When underlying depression is dealt with, outcomes improve. This has led to the large national push to screen for depression, from almost every major medical association.
The PHQ 9 is a powerful tool Doctors like Dr. Whittle can use to help determine whether patients like Sally are suffering from depression. It can help determine the severity of the depression, and whether to consider Major Depressive Disorder or Other Depressive Disorder. Provided that each score is charted, it is an excellent way to track results over time.
The issue with the PHQ 9 and other similar instruments, is that they are exposing the underlying depression, but they do not provide all of the information for a Physician to make a diagnostic decision. This leaves a Physician with an “open wound” of sorts. They must now spend the time to dig for more information. Information like potential bereavement, effects of drugs or alcohol, or potential physical issues that may be factor. They are also exposing a risk for suicide, but not digging deep enough to determine either plan or intent, requiring as many as 7 more questions related to potential self-harm.
Verbal questioning has the tendency to “uncork the bottle” of emotion in patients, compared to computer or even paper-based screening and testing. This can increase visit time by up to 43% over a non-mental health related visit. In an already hectic and busy clinic, this additional time can create significant issues. Studies also show that a patient tends to be less honest face to face when dealing with a sensitive issue like mental health*. It is not a wonder that so many Physicians chose to take a naïve approach to mental health in their clinics.
With the significant improvement in technology in recent years there is a solution emerging; intelligent, computer-based testing. These types of instruments use computer-based, branching logic engines to provide Physicians with the answers they need to determine next steps, prior to entering the room with a patient. These systems can dig, where appropriate, to expose suicide ideation, plan, and intent. They can ask all the necessary questions for a Physician to diagnose a patient. Unlike paper-based screenings, these tools do not need to ask questions unless they are necessary. This means that for most patients, testing is simple and short. Only patients that trigger more extensive questioning are asked for more details.
There is a way for Physicians to have their cake and eat it too, they can screen without slowing down their workflow. They can determine when patients need more care without increasing visit times. Most of all they can improve their outcomes.
*Administering an iPad questionnaire in physician waiting rooms proved an effective way for patients to report unhealthy behaviors and mental health issues, according to a study published online September 9, 2013 in the Annals of Family Medicine.