Running head: CLINICAL JOURNAL REFLECTION

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Unit 6 Assignment – Diagnostic Tools Paper

Patient Health Questionnaire (PHQ-9)

Tina Singh

Purdue University

Nursing 673

Dr. Pedro Morante, DNP, PMHNP-BC, AGPCNP-C

October 14, 2021

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Patient Health Questionnaire (PHQ-9)

According to Ford et al. (2020) depressive disorders affect 5%-10% of patients in the

primary care setting and it has a higher prevalence among individuals with a family history of

depression. Common triggers of major depressive episodes include significant losses, stress, or

medical illness. Luckily, many patients respond well to medications and therapy. Methods for

screening for depression have evolved over the years to become more practical and time

efficient. The Patient Health Questionnaire (PHQ-9) is tool that allows for quick assessment of

depressive symptoms, and allows the clinician to move forward with treatment planning if

necessary.

Discussion of Tool

Why the Patient Health Questionnaire (PHQ-9) is used:

The Patient Health Questionnaire (PHQ-9) is used to diagnosis depression and various

versions have evolved to meet the needs of providers in various settings. For example, other

versions include the PHQ-2, PHQ-8, and PHQ-15. The tool was originally developed for use in

the primary care setting to quickly identify the presence of depression and to accurately

determine the severity in less than 3 minutes (Ford et al., 2020). The need to be able to come to

recognize symptoms of depression quickly prompted the development of PHQ-9 and other

versions which all stemmed from the historical tool developed in the 1990s called, The Primary

Care Evaluation of Mental Disorders Patient Questionnaire (PRIME-MD).

The original tool which inspired the abbreviated versions was intended for use in the

primary care setting; however, it was too lengthy and labor intensive for both the patient and

clinician. For example, the tool was intended to be applied to all new patients and every year

after that. The patient would first complete a 27 item questionnaire independently and then the

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clinician would determine if the patient had a mental disorder, if a mental disorder is suspected,

another 12 minutes of the providers time would be required. This time consuming, yet systematic

approach was not realistic and did not last long due to the burden it created in the clinical setting.

This is why the PHQ-9 is used instead because it accomplishes the same goal in a fraction of the

time.

How to Use the Patient Health Questionnaire (PHQ-9)

The PHQ-9 is used in a variety of settings and is a self administered questionnaire that takes

just a few minutes to compete. The PHQ-9 is often completed by the patient on a tablet in clinic.

The tool uses questions to determine the presence and severity of the depression by utilizing the

following questions. After the completion of the questionnaire the clinician must apply clinical

judgment ensure the patient meets the diagnostic criteria in the Diagnostic and Statistical Manual

of Mental disorders prior to diagnosis (APA, 2013).

 Little interest or pleasure in doing things?

 Feeling down, depressed, or hopeless?

 Trouble falling or staying asleep, or sleeping too much?

 Feeling tired or having little energy?

 Poor appetite or overeating?

 Feeling bad about yourself — or that you are a failure or have let yourself or your family

down?

 Trouble concentrating on things, such as reading the newspaper or watching television?

 Moving or speaking so slowly that other people could have noticed? Or so fidgety or

restless that you have been moving a lot more than usual?

 Thoughts that you would be better off dead, or thoughts of hurting yourself in some way?

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The questions are answered by the patient by using 1 of 4 options: (1) not at all, (2) several

days, (3) more than half the days, or (4) nearly every day. The plan of care is dependent on the

severity of depression. For example, mild depressive symptoms may require minimal

interventions, or monotherapy, such as antidepressant treatment, psychotherapy, and supportive

interventions. Some supportive intervention examples are: self help books, regular exercise,

yoga, and acupuncture. Whereas, moderate depressive symptoms will include all of the previous

interventions for mild depressive symptoms; however, monotherapy is discouraged and a

combination of treatment modalities are required. These patients with moderate depressive

symptoms will best benefit from simultaneous treatment of antidepressant medication and

psychotherapy – this combination has been proven to be effective at a relatively low cost.

Diagnosis related to the Patient Health Questionnaire (PHQ-9)

The Patient Health Questionnaire (PHQ-9) is useful during the initial assessment of

depression and also for monitoring depression during the course of psychotherapy and

medication management. Some versions of the PHQ include questions that assess for somatic

symptoms and for anxiety. The PHQ-9 is an excellent tool to assess for depressive disorders

whether they are mild, moderate, or severe. However, the clinician has the burden of determining

through further assessment if the current presentation is a single episode or recurrent. Further

assessment beyond the PHQ-9 tool is required to determine if psychotic features are present and

if they are in partial remission, full remission, or unspecified (APA, 2013).

Discussion of Interpretation of Scoring for the Tool

Administration of the PHQ-9 screening tool is not a final step in the assessment process.

After the clinician evaluates the outcome and has determined the results of the questionnaire are

consistent with depression the next step begins. Additional assessment criteria must be met to

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determine the source of the stressor. Identifying the trigger of the depressive episode is critical in

choosing the best treatment plan. The provider must determine the duration of the disturbance

and if it has interfered with normal activities at work and at home. It is also important to know if

the patient has had similar episodes in the past, and if any treatment was received, and if so was

it effective (Stocker, 2021).

Interpretation of Scoring the Patient Health Questionnaire (PHQ-9) is as follows:

 0 to 4 points: No Depression

 5 to 9 points: Mild Depression

 10 to 14 points: Moderate Depression

 15 to 19 points: moderately severe depression

 20 to 27 points: Severe depression

Treatment Plan

Positive Result – Score of 6 on the PHQ-9 is Mild Depression. The treatment plan is as follows:

Pharmacologic and Non-pharmacologic interventions:

 START : Cymbalta (duloxatine) 20 mg PO bid for control of depressive symptoms

(Epocrates, 2021).

 Will titrate dose up to the target range of 60 mg bid in one week for the better symptom

control.

 Psychotherapy referral for Cognitive behavioral therapy (CBT)

 Regular exercise, meditation, and skill mastery, self-help books, yoga, relaxation

techniques, and music therapy.

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 Possible referral to dialectic behavior therapy and metacognitive therapy if refractory to

CBT

Patient Education

 Importance of medication and the need to adhere to the plan of care

 Do not take Cymbalta 5 days before or 2 weeks after you have used an MAO inhibitor

 Contracted to safety. Patient received education related to the National Suicide

Prevention Lifeline 800-273-8255

 Discussed worsening signs and symptoms related to suicidal ideation and when to seek

emergency medical assistance in Emergency Department:

 Seek emergency medical assistance immediately if you have symptoms of serotonin

syndrome, such as: agitation, fever, and sweating, shivering, fast heart rate, muscle

stiffness, twitching, loss of coordination, nausea, vomiting, or diarrhea.

 Patient received education related to signs of psychosis such as hallucinations (seeing or

hearing things that are not real), new behavior problems, aggression, hostility, or paranoia

 Patient received education related to concomitant use with non steroidal anti-inflammatory

drug (NSAIDs) may cause bruising easily.

Referrals: to PCP for yearly physical exam and routine screenings

Follow-up: 2 weeks for medication management and further assessment. Patient will complete

labs prior to next visit: CBC, and metabolic panel.

Non-Pharmacological Interventions

Cognitive behavioral therapy (CBT) can also be used as a monotherapy as studies have

revealed its efficacy is comparable to pharmacologic interventions. In addition it has proven to

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reduce the risk of relapse when combined with antidepressants. A particular approach of CBT

called mindfulness-based therapy is especially helpful. Other non-pharmacological approaches

include: interpersonal psychotherapy (IPT), also called problem-solving therapy (PST) to

improve interpersonal relationships and improve self esteem which have been proven to reduce

the rate of relapse as well. However, these approaches, IPT and PST, require the patient have a

certain degree of psychological insight into their condition that allows them to reason and discern

interpersonal subtleties. Effective therapeutic outcome measures are expected after about 3

months. Several other therapies are promising as research continues; these are Bibliotherapy

(reading) and Behavioral Activation encourages education related to identification of values and

goals. The patient is encouraged to engage in the activities that will help them reach their goals

even when they feel burdened by the symptoms of depression (Epocates, 2021).

Pharmacological Interventions

According to Sadock and Sadock (2015) antidepressant medication is generally the first-

line option if symptoms are severe. For patients who also present with psychotic features a

sedative such as lorazapam in given, in addition to an antipsychotic. Agitated patients generally

respond well to this combination. For, mild to moderate depression monotherapy can be

considered, such as selective serotonin reuptake inhibitors (SSRI) such as citalopram and

fluoxetine or serotonin and norepinephrine reuptake inhibitors (SNRI) such as duloxetine and

venlafaxine. The drug of choice is based on the effectiveness of the drug for the individual

patient and their tolerability. Narvaez (2021) reports caution must be exercised with young adult

patients due to the risk of activation during the first week of treatment that may result increased

suicidal ideation.

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Patient Education

Patient is strongly encouraged to take medication as prescribed and fully engage in CBT

for best outcomes. The patient will receive education of side effects and benefits of the

medication. Patient will discuss outcomes and tolerability at the next scheduled visit in two

weeks. The patient will verbalize understanding that follow up visits will be monthly after the

first twelve (12) weeks of therapy (Sun et al., 2020).

Additional Testing Required

There are other potential reasons why depressive symptoms are present and other testing

may be required. Tests to order include basic metabolic panel, complete blood count, and a

thyroid function test. Other tests to consider are vitamin B12 and folic acid to rule out deficiency,

and 24- hour free cortisol to rule out Cushing’s disease (Epocrates, 2021).

Follow-Up

Patients should be seen for a follow up visits within the first 2 week after starting a new

antidepressant. During this visit the patient will be re-evaluated for suicidal ideation using the

PHQ-9, report and side effects, and for the evaluation of symptom severity. During the follow up

visit the provider may decide to titrate up the dose based on the target dose. Adults over the age

of 65 require special consideration as their risk for side effects increases.

Conclusion

The PHQ-9 has proven to be a very special tool in the diagnostic process in completing

the assessment in a time effective and accurate manner. The PHQ-9 has evolved over the years

and now supports clinicians in a variety of settings, including the acute and chronic settings.

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Primary care offices, telehealth settings, and Emergency Departments employ the use of the tool

– which has gained the popularity, but more over the respect of the usefulness of the PHQ-9.

References

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American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental

Disorders, Fifth Edition.

Costantini, L., Pasquarella, C., Odone, A., Colucci, M. E., Costanza, A., Serafini, G., … &

Amerio, A. (2021). Screening for depression in primary care with Patient Health

Questionnaire-9 (PHQ-9): A systematic review. Journal of affective disorders, 279, 473-

483.

Epocrates Online (2021). Depression in Adults. Retrieved from

https://online.epocrates.com/diseases/5541/Depression-in-adults/Treatment-Approach

Ford, J., Thomas, F., Byng, R., & McCabe, R. (2020). Use of the Patient Health Questionnaire

(PHQ-9) in Practice: Interactions between patients and physicians. Qualitative health

research, 30(13), 2146-2159.

Narvaez, A. (2021). Pediatric Primary Care Depression Screening Using PHQ-9 Modified for

Teens.

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan and Sadock’s synopsis of

psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). London, England:

Lippincott Williams, and Wilkins.

Stocker, R., Tran, T., Hammarberg, K., Nguyen, H., Rowe, H., & Fisher, J. (2021). Patient Health

Questionnaire 9 (PHQ-9) and General Anxiety Disorder 7 (GAD-7) data contributed by

13,829 respondents to a national survey about COVID-19 restrictions in Australia.

Psychiatry Research, 298, 113792.

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Sun, Y., Fu, Z., Bo, Q., Mao, Z., Ma, X., & Wang, C. (2020). The reliability and validity of PHQ-

9 in patients with major depressive disorder in psychiatric hospital. BMC psychiatry,

20(1), 1-7.