Using the PHQ-9. Depression Screening in the Office Setting

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1 Using the PHQ-9 Depression Screening in the Office Setting Russell Geoffrey, M.D., M.S. Associate Health Officer, Lane County H&HS Lane County Behavioral Health

2 PHQ-9 and Depression 1. What s Depression? Today s Discussion: 2. What s PHQ-9? PHQ-2? 3. How are they Used? 4. Brief Overview: Depression & its management 5. Some video clips of a patient being screened using PHQ-9 in a PC office setting 6. Your questions

3 Depression is NOT... Having a bad day, a bad attitude, normal sadness, or part of normal aging Can ask patients: Is it a little d or Big D Depression? DSM diagnoses require significant Impairment, or Distress, or both

4 What is Depression? Pervasive depressed mood / sadness Loss of interest / pleasure Lack of energy, fatigue, poor sleep and appetite, physical slowing or agitation, poor concentration, physical symptoms (aches and pains), irritability, thoughts of guilt, and thoughts of suicide Easy Mnemonic: 5 of: + S G: E CAPS = Major Depression Sleep ( or ) Interest/Pleasure Guilt, helplessness, hopelessness Energy ( ) Concentration Appetite ( or ) Psychomotor ( or agitation) Suicidality A miserable state that can last for months or even years

5 PHQ-9: Easy to use Can be self-administered, can be done over the phone, but also in person Tracks the 9 core symptoms of Major Depression Item 10 rates functional impairment ½ the length but with comparable sensitivity and specificity to other D tools A useful Tool: 1. Gives a provisional depressive disorder diagnosis 2. Grades depression symptom severity 3. Follows change in severity over time 4. A good teaching tool

6 Scoring the PHQ: Over the last 2 weeks, how often have you been bothered by 0-3 for each item Add columns, total to determine severity Quick Screens: Consider a depressive disorder if: 1. PHQ-2: Add score of Q1 + Q2. Depression Screen cutoff = 3+ --OR 2. PHQ-9: 4+ s in shaded area (one must be Q1 or Q2)

7 Scoring the PHQ-9 Total Score Depression Severity 0-4 Minimal depression 5-9 Mild Moderate Moderately severe Severe

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9 PHQ-9: How Often Do I Follow Up? See the patient back in 1-2 weeks if AD started 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

10 Major Depression Confirm at least 5 s in the shaded section to consider a diagnosis of Major Depressive Disorder (MDD) 1 must be for Item 1 (anhedonia) or 2 (depressed mood) At least 4 s in the shaded area to consider another depressive diagnosis Confirm functional impairment (Question #10)

11 PHQ-9: Don t forget to: 1. Consider whether the patient understood the questionnaire! 1. Consider these depression RULE OUTS: Not due to a biological cause of the depressive symptoms -- drugs/alcohol, Rx medications, or a physical disorder (ex, hypothyroidism) NO Bipolar Disorder (history of Manic/Hypomanic/Mixed episodes) Mood Disorders Questionnaire (MDQ can help to identify) Not due to normal bereavement (hints: >2mos, impairment, worthlessness, SI, psychosis, psychomotor retardation) [In DSM-5, can diagnose depression in grief]

12 Mood Episodes Mania Mixed Episode Hypomania Normal Mood Depression

13 Managing Depression by PHQ-9 Severity PHQ-9 Score Depression Severity Proposed Treatment Actions [Kroenke & Spitzer, 2002] 1 to 4 None/Mini mal None 5 to 9 Mild Watchful waiting; repeat PHQ-9 at follow-up 10 to 14 Moderate Treatment plan, considering counseling, follow-up and/or pharmacotherapy 15 to 19 Moderately severe Immediate initiation of pharmacotherapy and/or psychotherapy 20 to 27 Severe Immediate initiation of pharmacotherapy and, if severe impairment or poor response to therapy, expedited referral to a mental health specialist for psychotherapy and/or collaborative management

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15 Patient Education Messages that Improve Adherence: Take your medicine every day It s NOT addictive It may take 2-4 weeks to work Don t stop it without discussing it with the physician Continue to take it even when you feel better! If you have Q s, call:

16 The Moral: Don t stop treating Major Depression when the patient improves. The Other Moral: Treat to Remission (PHQ-9 <5), not just Response

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18 Using the PHQ-9 in Primary Care g.html IMPACT program from the Univ. of Washington for evidence-based treatment of depression in integrated primary care settings Site offers a free 13 module course

19 Tools: IMPACT: Univ. of Washington s Evidencebased Treatment of Depression in Older Adults in Primary Care MDQ: Mood Disorders Questionnaire - Bipolar screen C-SSRS: Columbia Suicide Severity Rating Scale -see next slide In your Packet: IMPACT Intake, Follow Up and Recurrence Prevention Visit Forms, each containing the PHQ-9 PHQ-9 Depression Screen GAD-7: for anxiety screening (in Packet) National Suicide Prevention Lifeline: TALK (8255) En espanol:

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