One of the most common conditions I manage in primary care is depression. Occasionally, this is a person’s chief complaint when they make an appointment, but more often than not, I find out about this through routine screening. I made the decision while I was at my first clinic to have my medical assistant administer the PHQ-2 (Patient Health Questionnaire 2) to all my patients, and I’ve continued it at my current practice because I find it so valuable.
I know that many providers cringe at the thought of treating a mental health disorder, but I really enjoy treating patients with depression. It can be such a rewarding experience, and I’ve found that patients with depression (particularly previously-undiagnosed depression) are often so grateful to have someone to talk to about how they’re feeling and to help normalize their experience as much as possible.
Screening Patients for Depression
You wouldn’t see a new patient without taking a set of vital signs, right? Well, consider the PHQ-2 depression screening tool the “vital sign of mental health.” There are multiple screening tools, but the PHQ-2 is well-validated, easy to administer, and reliable, so it’s the one I use. Here’s a link to a downloadable PDF of the version of the PHQ-2 I use with my patients. Here’s what the 2 screening questions look like:
If you look at the scoring guidelines on the first page of the PDF, the authors identified a cut score of 3 (or higher) to determine whether or not to proceed with administering the PHQ-9. I have chosen in my practice to administer the PHQ-9 to patients with a combined score of 2 or higher on the PHQ-2, which increases sensitivity and adds negligibly to the time required to properly screen and evaluate patients.
So how does this work, practically? I have a clipboard set up in each of my exam rooms with the PHQ-2 screening tool on one side of the page, and the PHQ-9 tool (see below) on the other side. As my LPN rooms each patient, she will hand the patient the clipboard with the PHQ-2 side face-up and ask him or her to complete those 2 questions; this does not add to the time needed to room a patient, as she’ll log into the computer and EMR while the patient is completing those questions, which typically takes less than 1 minute. She will get the clipboard back from the patient at that point, and then complete the remainder of her rooming process (going over medications, history, taking vital signs, etc.). If the patient has scored 2 or higher on the PHQ-2, she will then hand them the clipboard back with the PHQ-9 side facing up, and ask them to complete that side. They will do that while they are waiting for me to come in for their visit, and I rarely have to wait for a patient to complete this; usually, it takes me a few minutes to get into the exam room with the patient after the LPN is finished, so the timing works out well most of the time.
As a sidenote, my current practice setting requires the LPN/MA to administer the PHQ-2 at least annually; this is a quality control/meaningful use thing (I think), along with negligibly useless screenings like a fall risk assessment and learning needs assessment. I strongly advise you to have your patients complete the PHQ-2 (and PHQ-9, if necessary) on paper, rather than verbally responding to the questions posed by the LPN or MA. While I was shadowing, I saw a very experienced and very thorough LPN ask the 2 questions of the PHQ-2 question orally to her patients; I don’t think she meant to influence her patients’ responses with her tone and rewording of the questions, but it seemed as though patients felt they needed to respond in a certain way. I definitely think it would be harder for patients to feel completely comfortable answering the questions honestly if they are answering out loud rather than circling a number on a sheet of paper. Also, it can get SUPER confusing to read the answer choices out loud; “not at all, several days, more than half the days, nearly every day.” That’s a lot for a patient, especially an older patient, to keep track of. All that to say, I strongly recommend giving the paper version of the PHQ-2 to your patients (and having the nurse or you help them complete it if reading is a struggle), and having it entered electronically later, if needed.
So, if the patient screens positive on the PHQ-2, they’ll complete the PHQ-9; I’ve already discussed my workflow for getting this done while not adding to my workload/delaying patient care (see above). Here is a link to a downloadable version of the PHQ-9, and you can see the questions below.
To score the PHQ-9 and make a tentative diagnosis of depression, the following cut-offs are used:
Score 5 – 9: Mild depression
Scores 10 – 14: Moderate Depression
Scores 15 – 19: Moderately Severe Depression
Scores 20+: Severe Depression
In addition to the total numeric score on questions 1 – 9, in order for it to be a diagnosis of depression, the patient must have checked one of the last 3 boxes on question #10; if these problems do not pose any difficulty in the patient’s life, there is no indication to initiate or modify treatment.
I usually use the PHQ-9 as a conversation starter. When I bring it up with the patient, I typically say something like, “Well, I was reviewing your sheet here, and this tells me that you screen positive for depression. What are your thoughts on this?” At this point, usually the patient just starts talking and my job is to sit back and listen. Sometimes the patient will say, “oh no, I’ve just had a rough few days at work OR I’ve been sick OR I’ve been dealing with the death of my dog last week OR whatever…” I’ll document that in my note, and then just plan to re-evaluate at the next office visit.
If, however, the patient starts talking about what’s been going on and how they’ve been feeling (which is much more typical), my job is just to sit back and be quiet. These patients often just need to “let it out” as they may not have had the ability to do this in the past; I try extremely hard not to interrupt these patients and to let them have a few minutes to tell me what’s going on. (As a sidenote, we’re bad at interrupting our patients: this interesting article from the New York Times documents that most providers wait an average of only 18 seconds before interrupting their patients!). I make good eye contact, maybe take a few notes, but mostly just sit and listen. This is my #1 job in this situation, and patients are often very grateful for the opportunity to tell their story to someone who will listen. I only ask clarifying questions later, once they’ve finished.
Of course, it is important to rule out both suicidal and homicidal ideation. Sometimes it can be uncomfortable to ask patients this, but after my experience as an ER nurse, I have just gotten in the habit and it doesn’t phase me any more. My typical verbage is, “do you have any thoughts of hurting yourself or anyone else?” I also ask about auditory and visual hallucinations routinely; “do you see anything or hear any sounds or voices that other people don’t see or hear?” If the answers to any of these questions are positive, we stop. Acute suicidal or homicidal ideation warrants immediate transfer to the ED by EMS. Auditory or visual hallucinations are usually indicative of a deeper psychiatric problem (ie. schizophrenia) that I’m not qualified to diagnose or manage, so I’ll attempt to set the patient up with psychiatry as soon as possible.
In the vast majority of cases, though, the answers to those questions are negative, and I discuss the diagnosis of depression with the patient and talk about treatment options. We’ll talk about that next week in part 2 of this 3-part series on depression!
Note: This is part 1 in a 3-part series on depression. Click here to read part 2!