Even briefer versions may be desirable where the aim is to include just a few depression questions in multi-purpose health questionnaires. 29. Brevity coupled with its construct and criterion validity makes the PHQ-9 an attractive, dualpurpose instrument for making diagnoses and assessing severity of depressive disorders, particularly in the busy setting of clinical practice. 1994; 272:1749-1756. Second, we focused on major depression, and compared the sensitivity, specificity, and positive predictive value of the PHQ-8 and PHQ-9 across a range of cutpoints that were examined in the original PHQ-9 article.9 Again, as shown in Table 3, the PHQ-8 and PHQ-9 had similar operating characteristics, regardless of the cutpoint. 14. 1998; 280:1665-1672. Sensitivity to change is clearly a necessary feature, but other pragmatic considerations include the number of items, time required for completion, mode of administration (self-rating versus interviewer-administered scale), complexity of scoring, inter-rater agreement, and special training requirements. Unutzer J, Williams JW Jr, Callahan CM, et al. PHQ-9 Scoring Instructions and Interpretation Scoring Add the scores indicated for each item in each column and add the columns together for the Total score. We concur with NICE that the choice of intervention will be influenced by the duration of the episode, the trajectory, and experience from previous courses of depression and response to treatment along with the patient’s treatment preferences and priorities. The PHQ-9 might be considered a type of lab test. 3. Nine Symptom Checklist (PHQ-9) Appendix C: Suicidality Appendix D: Pharmacotherapy D-1. A score of 3 or more on the PHQ-2 has a probability of 83% for a depressive mood disorder. In this primary care review 7 of 11 studies included patients with HAM-D scores >18 which is considered the severe range.18. Patient level meta-analysis found that the NNT for milder-to-moderate depression was 16, 11 for severe, and for very severe 4.16 The median control event rate (the placebo response) is about 47% in primary care trials of antidepressants.18 An NNT of 16 represents a 6% gain in terms of a better outcome. Thus, in a randomised controlled trial of patients in the mild-to-moderate range 53% would get better with an active medication and 47% would get better with placebo. Although an exhaustive review of depression measures is beyond the scope of this article (but can be found elsewhere4,11) a brief discussion of selected measures is warranted. The recommended cut point is a score of 3 or greater. Screening for depression: recommendations and rationale. Tell us what you think about Healio.com », Get the latest news and education delivered to your inbox, https://doi.org/10.3928/0048-5713-20020901-06, Guidelines for Antipsychotic-Induced Hyperprolactinemia, A 20-Year-Old Man with a Suicide Attempt Using Helium, A 28-Year-Old Man with Lack of Concentration and Inability to Focus. Major depression is diagnosed if five or more of the nine depressive symptom criteria have been present at least "more than half the days" in the past 2 weeks, and one of the symptoms is depressed mood or anhedonia. However, even in primary care patients depressed enough to warrant antidepressant therapy, few of those endorsing this ninth item actually have true suicidal ideation when further probed about the meaning of their response.21 Still, because nearly half of suicide victims have contact with a primary care provider within 1 month of suicide, the PHQ-9 should be the measure of choice in most instances where the aim is to evaluate clinical populations for depression.22 However, the PHQ-8 may be an acceptable alternative to the PHQ-9 in certain research studies that meet one of the three criteria initially outlined above. Kroenke K, Taylor-Vaisey A, Dietrich AJ, Oxman TE. 16. Detecting depression at a single GP visit is difficult as 70–90% of patients with depression and anxiety present with symptoms of somatic illness.11 Psychosocial issues, which may be the main reason for the visit, are likely to be left until the last minute and mentioned as the patient is about to leave (hence the name ‘exit’ or ‘doorknob’ comment).12 The GP often has to make a split second decision on whether to explore the issues at that visit and run late or re-book for another time. The Montgomery-Asberg Depression Scale: reliability and validity. The correlation between SCL-20 and PHQ-9 change scores was 0.50. 11. 5-9 Mild PCPacknowledge &discuss,watchfulwaiting,repeat PHQ-9atfollow-up visit 10-14 Moderate Treatment plan &follow-up, bringinIntegrated Behavioral Healthprovider(ifavailable) or referto Specialty Behavioral Health,consider pharmacotherapy. McDowell I, Kristjansson E, Newell C. Depression. Kobak KA, Taylor LvH, Dotti SL, Greist JH, Jefferson JW, Burroughs D, et al. PHQ-9 Scores and Proposed Treatment Actions . The presence or absence of psychotic features, such as hallucinations or paranoia, help determine specific treatments. 2000;41:39-52. The US Preventive Services Task Force recently recommended depression screening as part of routine care.23 However, brevity is essential to accomplish this in the busy general medical setting where patient volume is high, most visits are brief, and depression is simply one of many conditions that the primary care clinician is responsible for recognizing and managing.24"26 Previous studies have suggested that one or two questions about depressed mood and, possibly, anhedonia are quite sensitive as a first-stage depression screening procedure.1,2,27, Comparison of the Operating Characteristics of PHQ-8 versus PHQ-9 In Diagnosing Major Depression in 3000 Primary Care Patients. Spitzer RL, Williams JBW, Kroenke K. Validity and utility of the Patient Health Questionnaire in assessment of 3000 obstetric-gynecologic patients: the PRIME-MD Patient Health Questionnaire Obstetrics-Gynecology Study. 30. 2000;9:700-708. 15. One of the nine symptom criteria ("thoughts that you would be better off dead or of hurting yourself in some way") counts if present at all, regardless of duration. Table 1 shows the ranges for each inventory. The MaGPIe study from New Zealand found that 18.1% of primary care patients met the criteria for depression over the past 12 months, but 56% of them had a co-existing DSM IV level anxiety disorder, and 20% had a substance use and dependence disorder.7 The first line drug treatments are identical for both depression and anxiety, as are the psychological therapies and ‘transdiagnostic’ approaches to treatment and diagnosis that are emerging.8,9 Multiple cognitive behavioural therapy (CBT) protocols have been developed to deal with the many subtypes of anxiety, but transdiagnostic treatments are based on the notion that these various protocols contain important but overlapping treatment components that can be distilled into a single treatment to address the symptoms across all of the disorders at once.9 Transdiagnostic terminology is used explicitly for diagnosis in one of the so-called ‘third wave’ cognitive behavioural therapies, known as acceptance and commitment therapy (ACT). Continue treatment and follow-up as planned. The PHQ-9 Score Report includes treatment rec-ommendations based on an individual’s score. Spitzer RL, Kroenke K, Williams JBW, and the Patient Health Questionnaire Study Group. NOTE: We only request your email address so that the person to whom you are recommending the page knows that you wanted them to see it, and that it is not junk mail. Kazis LE, Anderson JJ, Meenan RF. Another challenging example is a patient with depression and a co-existing substance use disorder, of which alcohol is the most common. J Gen Intern Med. 1986;54:54-59. PHQ-9 Score Depression Severity Proposed Treatment Actions 0-4 None - Minimal None 5-9 Mild Watchful waiting; repeat PHQ 9 at follow-up 10-14 Moderate Treatment plan, consider counseling, follow up and/or pharmacotherapy 15-19 Moderately Severe Active treatment with pharmacotherapy and/or psychotherapy 20-27 1989;27:S178-S189. The primary care evaluation of mental disorders (PRIME-MD®) is a novel instrument developed a decade ago to assist primary care clinicians in making criteria-based diagnoses of five types of DSM-IV disorders commonly encountered in medical patients: mood, anxiety, somatoform, alcohol, and eating.5,6 The patient health questionnaire (PHQ) is a 3-page self-administered version of the PRIME-MD® that has been well validated in two large studies involving 3,000 patients in 8 primary care clinics and 3,000 patients in 7 obstetrics-gynecology clinics.7,8 Because it is entirely self-administered and has diagnostic validity comparable to the clinician-administered PRIME-MD®, the PHQ is now the most commonly used version in both clinical and research settings. Measuring depression. J Gen Intern Med. In contrast, the PHQ-9 was administered by the nurses who also were treating the patients, which could introduce a bias toward greater improvement. The most widely accepted definition of depression comes from the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) published by the American Psychiatric Association. Am J Obstet Gynecol. Kroenke K, Spitzer RL, Williams JBW. 9. • Manea L, Gilbody S, McMillan D (2012). Hahn SR, Kroenke K, Williams JBW, Spitzer RL. 'http':'https';if(!d.getElementById(id)){js=d.createElement(s);js.id=id;js.src=p+"://platform.twitter.com/widgets.js";fjs.parentNode.insertBefore(js,fjs);}}(document,"script","twitter-wjs"); BJGP Open Journal Office Examples include mailed questionnaires, telephone-administered interactive voice recording, or Internet surveys. There are a number of case-finding instruments for detecting depression in primary care, ranging from 2 to 28 items.1'2 Typically these can be scored as continuous measures of depression severity and also have established cutpoints above which the probability of major depression is substantially increased. Therefore, we examined the performance of the PHQ-2, (ie, the first two items of the PHQ-9 that inquire about depressed mood and anhedonia). Mahwah, NJ: Lawrence Erlbaum; 2000:191-253. Williams JW Jr., Noel PH, Cordes JA, Pvamirez G, Pignone M. Is this patient clinically depressed? 10 – 14 Moderate Referral for counseling, follow-up and/or pharmacotherapy 15 – 19 Moderately Severe Refer for treatment with pharmacotherapy and/or psychotherapy Easy-to-remember cutpoints of 5, 10, 15, and 20 represent the thresholds for mild, moderate, moderately severe, and severe depression, respectively.9 If a single screening cutpoint were to be chosen, we currently recommend a PHQ-9 score of 10 or greater, which has a sensitivity for major depression of 88%, a specificity of 88%, and a positive likelihood ratio of 7.1. A number of comparable measures exist for detecting depression1,2,4,11,27 including multiple self-administered scales. Depressive symptoms range on a continuum from everyday sadness to suicidal despair, and a challenge for practitioners is deciding at what level to intervene. The PHQ-9 is the 9-item depression module from the full PHQ (Sidebar, page 514). Group treatment could be provided through the IAPT programme in the UK, but many services are already stretched. Drop of 2-4 points from baseline. Mulrow CD, Williams JW, Gerety MB, Ramirez G, Montiel OM, Kerber C. Case-finding instruments for depression in primary care settings. Lambert MJ, Hatch DR, Kingston MD, et al. US Preventive Services Task Force. Referral to specialist mental health services is necessary for individuals who are at a significant risk of self-harm, have psychotic symptoms, require complex multiprofessional care, or where an expert opinion on treatment and management is needed. Effect sizes for interpreting changes in health status. Funnel plot of SSRI and TCA versus placebo from primary care antidepressant versus placebo review. If our preliminary data on sensitivity to change of the PHQ-9 is substantiated in several large ongoing clinical trials, it could also prove to be a useful measure for mortitoring outcomes of depression therapy. In ACT, patients are described as being 'stuck'.10 Those who use ACT in primary care spend less time on diagnosis in order to give more time to therapy.10. The PHQ-2 consists of the first 2 questions of the PHQ-9. 13. Comparison of the Likelihood Ratios for Different Levels of PHQ-8 and PHQ-9 Severity Scores In Diagnosing Any Depressive Disorder. 2002;136:760-764. Where time is short, an option is to give the PHQ-9 form to the patient to complete at home and book an appointment in the near future. Other depression is diagnosed if two, three, or four depressive symptoms have been present at least "more than half the days" in the past 2 weeks, and one of the symptoms is depressed mood or anhedonia. The diagnosis of 'personality disorder' can be a useful signal to take a more reflective approach and remember to focus on the main message without getting side-tracked, and to empathise and separate the person from the behaviour. Patients can have high and very high PHQ-9 scores and not have a major depression (Table 2) and the PHQ-9 should be considered as a measure of distress rather than a diagnostic tool per se. Efficacy of nurse telehealth care and peer support in augmenting treatment of depression in primary care. 31. The PHQ-9 was completed by 6, 000.Discordant scores in 82 women included 17 with elevated PHQ-9 scores but normal EPDS scores and 65 with elevated EPDS scores and PHQ-9 scores 10.PHQ-9 Scores and Proposed Treatment Actions for Depression in Adults. The temptation is to follow the biomedical model of diagnosis and treatment. If our preliminary data on sensitivity to change of the PHQ-9 is substantiated in several large ongoing clinical trials, it could also prove to be a…, PHQ-9 Scores and Proposed Treatment Actions*. Therefore, steering away from labels and focusing on skilful communication to optimise the relationship may give the best chance of a successful outcome. Treatment of dysthymia and minor depression in primary care: a randomized controlled trial in older adulte. 2002;159:909-916. Multiply that number by the value indicated below, then add the subtotal to produce a total score. The reason that deletion of the ninth item has only a minor effect on the actual PHQ-9 score is that thoughts of death or self-harm are typically less common in a primary care depressed population than in the more severely depressed patients referred to a mental health specialist. Zung, Beck, and Hamilton rating scales as measures of treatment outcome: a meta-analytic comparison. 1995;273:1026-1031. PHQ-9 Scores and Proposed Treatment Actions for Depression in Adults PHQ-9 SCORE DEPRESSION SEVERITY PROPOSED TREATMENT RECOMMENDATION 0 – 4 None-minimal None 5 – 9 Mild Watchful waiting, repeat PHQ-9 at follow-up visit 10 – 14 Moderate Treatment plan, considering counseling, follow-up and/or pharmacotherapy 15 – 19 Moderately severe Active treatment with pharmacotherapy or … Brevity coupled with its construct and criterion validity makes the PHQ-9 an attractive, dualpurpose instrument for making diagnoses and assessing severity of depressive disorders, particularly in the busy setting of clinical practice. This was confirmed by Kirsch et al and they reported a lower placebo rate in the very severe group in a review where all studies registered with the FDA were included.19 A systematic review of antidepressants in primary care found that medication appeared to be effective for depression but there was evidence of publication bias for both selective-serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs).18 Indeed when the SSRIs and TCAs were pooled in the same analysis there were no small studies (<150 participants) with negative results (Figure 1), yet there were four small studies with positive results. Effective management of depression in primary care: a review of the literature, Elaine Gurr Chair of General Practice and Primary Health Care, and Director of the Goodfellow Unit, Department of General Practice and Primary Care, Senior Lecturer, Department of General Practice and Primary Care, Professor of Primary Care, Primary Care and Population Sciences, Range of depression scores versus severity for PHQ-9 and HADS, PHQ-9 scores at diagnosis and proposed treatment actions. 7, 8, 10 PHQ-15 Somatic symptom scale from PHQ. If the examinee endorses suicidal ide-ation on item 9, immediate risk assessment is necessary. The goal of acute phase treatment is remission of symptoms as indicated by a PHQ-9 Score of < 5 points. 6. • Metanalysis of cut-off scores for diagnosing depression with PHQ-9 • For detecting Major Depression, suggest cut-off scores between 8-11. PHQ-9 Depression scale from PHQ. 24. On the other hand, some may argue that instruments including symptoms not in the DSM-IV criteria (eg, loneliness, hopelessness, anxiety) may have additional clinical value. Thus, this item typically contributes, on average, only a point or two to the overall PHQ score. 10. There is also the issue of having a withdrawal syndrome when trying to stop these medications which can in turn lead to long-term use of antidepressants. What is depression: a biochemical disorder or a social construct or both? Kuyken and colleagues’ group MBCT helped 70% of participants stop antidepressants, without increasing relapse. The National Institute of Health and Care Excellence (NICE) recommends the use of depression symptom inventories to assess severity and to monitor improvement.2 Commonly used inventories include the patient health questionnaire 9 (PHQ-9) and the Hospital Anxiety and Depression Scale (HADS). 1998;13:137-139. The Hamilton Depression Rating Scale (HAMD) has been the criterion standard outcome measure in clinical trials, but it can require 15 to 30 minutes of clinician time to administer and is therefore not feasible in many practice settings. Spitzer RL, Williams JBW, Kroenke K, Linzer M, deGruy FV, Hahn SR, et al. New York: Oxford University Press, 1996:238-286. To access the article, you may purchase it or purchase the complete back file collection here, Depression is one of the most prevalent and treatable mental disorders presenting in general medical as well as specialty settings. Whooley MA, Avins AL, Miranda J, Browner WS. 47 Photos of the Phq 9 Scores And Proposed Treatment Actions. The Index is the sum of the scores for the nine items, and ranges from 0 to 27. 1979; 134:382-389. Competing demands in psychosocial care: a model for the identification and treatment of depressive disorders in primary care. There is an argument that clinicians are medicalising normal human suffering in many of their patients. Also, even patients who endorse this item often do so at a low threshold (eg, "several days"). Arch Gen Psychiatry. 25. PHQ-9 Scores and Proposed Treatment Actions * PHQ-9 Score Depression Severity Proposed Treatment Actions 0 – 4 None None 5 – 9 Mild Watchful waiting; repeat PHQ-9 at follow-up 10 – 14 Moderate Treatment plan, considering counseling, follow-up and/or pharmacotherapy … The HAM-D is also rather complicated to score and requires substantial training to get reasonable interrater agreement. As with the original PRIME-MD®, before making a clinical diagnosis of a depressive disorder, the clinician is expected to rule out physical causes of depression, normal bereavement and history of a manic episode. Phq-9 total score for a depressive mood disorder rules of thumb that require clinical evaluation of the is. 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