PHQ-9 Depression Scale Questionnaire

The PHQ-9 is a measurement tool providers can use to ensure measurement-based treatment to target within Collaborative Care. This concise nine-item health questionnaire can function as a screening tool, aids in diagnosis, and measures treatment response.

Advantages of the PHQ-9

Patient filling out PHQ-9

It is shorter than other depression rating scales
Multiple administration options (in person by a clinician, by telephone, or self-administered by the patient)
Facilitates diagnosis of major depression
Assesses symptom severity
Well-validated and documented in a variety of populations
Directly based on the nine diagnostic criteria for major depressive disorder in the DSM-5
Valid for use in adolescents as young as 12 years of age

How to Use the PHQ-9

At the initial visit, the PHQ-9 aids in the diagnosis and identification of potential depressive symptoms. At follow-up visits, it measures treatment response. The Questionnaire can be clinician or self-administered.

Scoring the PHQ-9

The PHQ-9 is a tool to assist clinicians in identifying and diagnosing major depression. It has a maximum score of 27. Elevated scores strongly correlate with a major depression diagnosis. However, it’s essential to remember that not everyone with a high PHQ-9 score will have major depression. Trained clinicians must make the final diagnosis.

Patient Health Questionnaire 2 (PHQ-2)

The Patient Health Questionnaire 2 (PHQ-2) effectively screens large groups for depression. It consists of the first two questions on the PHQ-9. If the patient responds affirmatively to either question on the PHQ-2, the PHQ-9 should be administered. No permission is required to reproduce, translate, display, or distribute the PHQ-2.

PHQ-9 Questionnaire and Translations

The PHQ-9, translations of the measure, and an instruction manual are available at www.phqscreeners.com. No permission is required to reproduce, translate, display, or distribute the PHQ-9.

Protocols for Suicide Prevention

The PHQ-9 asks about suicidal ideation, and clinics should have a plan in place for when a patient scores positive on this question. The Protocols for Suicide Prevention in Primary Care assists clinics in refining existing protocol(s) for responding to patients who present with suicidality or violent behavior.

PHQ-9 Aids

Introducing the PHQ-9

To increase staff comfort in discussing the PHQ-9 with patients, the AIMS Center provides the Helping Clinic Staff Talk about the PHQ-9 tool. This resource equips clinic staff to administer the PHQ-9 by addressing commonly asked patient questions.

PHQ-9 Visual Answer Aid

This answer aid visually represents the PHQ-9 answer scale: English | Spanish.

Brief Pain Inventory (BPI)

The Brief Pain Inventory is a medical questionnaire used to measure pain, developed by the Pain Research Group of the WHO Collaborating Centre for Symptom Evaluation in Cancer Care.

Measurement-Based Treatment to Target

Effective behavioral health integration implementations are informed by measurement-based care and treatment to target. The evidence supporting the effects of these principles is derived largely from the research done on Collaborative Care.

Measurement-Based Care

Using clinical outcome measures is a relatively new idea in the world of behavioral health yet has been in other areas of health care for decades. Every time a patient visits a primary care clinic, someone takes their blood pressure. Increasingly, primary care practices and some behavioral health organizations are using this same principle to screen for the most common behavioral health conditions such as depression or anxiety.

A literature review, led by John Fortney, PhD, examined theoretical and empirical support for measurement-based care (MBC) and found that MBC is at a tipping point in the mental health care field. In addition to the publication, there is a video of Dr. Fortney summarizing the article.

There are a variety of well validated measures that can help identify behavioral health conditions and some track treatment progress over time. The Meadows Mental Health Policy Institute published a comprehensive report outlining a set of validated outcome measures for mental health and substance use conditions. These measures can play an important role in identifying people who may not otherwise be recognized as needing care for a behavioral health condition. However, their most important role is measuring the effect of treatment on symptoms. Once a patient has been identified as having a behavioral health condition and has started treatment for that condition, it’s very important to re-measure the symptoms at each contact so that the treating provider has specific information about whether or not symptoms are improving and which symptoms are or are not improving.

Some people are concerned that the concept of measuring mental health with a validated rating instrument invalidates the patient’s feelings or experience or disregards the complexity of the patient’s story. These measures are an important piece of information about the patient but are not meant to represent the entire clinical picture of the patient, nor are they meant to replace the clinical judgment of the provider. They are an important tool to assist the clinician and the patient with identification of the specific symptoms causing difficulty for the patient and how well those symptoms respond to treatment over time.

Treatment to Target

Adjusting the treatment plan based on symptom measures is one of the most important components of Collaborative Care. Clinicians change the treatment until the patient has at least a 50% reduction in measured symptoms.

Frequent measurement of symptoms allows the treating providers and the patient to know whether the patient is having a full response, partial response or no response to treatment. These measures also provide clues about which symptoms are improving and which are not if there is a partial response to treatment. This information is critically important in making decisions about how to adjust treatment.

Collaborative Care requires a change in the treatment plan every 10-12 weeks if the patient has not had at least a 50% improvement in symptoms using a validated measure. This prevents the clinical inertia that is often found in usual care and is likely one of the key factors behind the better treatment outcomes that can be achieved with Collaborative Care. If the treatment plan started with medication therapy as the primary treatment, the adjustment might be a change in dosage and/or the addition of evidence-based psychotherapy. If the treatment plan started with evidence-based psychotherapy, the adjustment might be the addition of medication therapy.

Why Practice Collaborative Care?

The Collaborative Care Model (CoCM) has a robust evidence base with over eighty randomized controlled trials showing it is the best at treating depression in many populations and settings. CoCM is beneficial for Primary Care Providers (PCPs) and their patients because it offers an established evidence base, better medical outcomes, help with challenging patient cases, faster improvement, and the collaboration of a team.

We highly encourage that this document be shared with PCPs, stakeholders, and others looking to implement CoCM.

AUDIT-C

The AUDIT-C is a 3-item alcohol screen that can help identify persons who are hazardous drinkers or have active alcohol use disorders (including alcohol dependence). The AUDIT-C is a modified version of the 10-question AUDIT instrument.

Generalized Anxiety Disorder subscale (GAD-7)

The Generalized Anxiety Disorder (GAD) subscale of the Patient Health Questionnaire (GAD-7) is a quick and easy tool to help identify patients with anxiety and monitor treatment response. The GAD-7 is available free for clinical use in a variety of languages at the link below.

Comparing Collaborative Care to Usual Care

Compared to usual care, Collaborative Care is shown to increase the effectiveness of depression treatment and lower total healthcare costs. This handout outlines those differences using data from the IMPACT trial.
Updated 1/2/19

Primary Care Provider (PCP) Role Description in Collaborative Care

The role of a primary care provider (PCP) in Collaborative Care is to oversee all aspects of the patient’s behavioral health care including encouraging the patient’s participation, prescribing medications, and making referrals to specialty mental health care when needed. They work in close consultation and collaboration with the patient’s Behavioral Health Care Manager and to a much lesser extent, the designated Psychiatric Consultant.

Tips for Discussing Trauma During an Initial Assessment

Trauma can increase the risk of health, social, and emotional problems. Despite the high prevalence of patients with a past history of trauma, few clinics or Collaborative Care teams have a protocol for addressing it. These three tips can help clinicians safely and effectively discuss the trauma history of their patients during their initial assessment.

Primary Care Provider Role Handout

Primary care providers (PCP) identify and engage patients in collaborative care, make diagnoses, and treat patients. This handout describes the role of the PCP in more detail.