Randall F. White, MD, FRCPC (biography and disclosures)
Disclosures: Honorarium from Medscape for CME program reviews. Clinical expert reviewer for the Drug Benefit Council, BC Ministry of Health.
Mitigation statements:
- Only published trial data is presented
- Treatments or recommendations in this article are unrelated to products/services/treatments involved in disclosure statements
What I did before
According to the Canadian Community Health Survey, the one-year prevalence of major depressive disorder is 4.8% and the lifetime prevalence is 12.2%. This is a common and at times disabling disorder. Most Canadians who seek treatment for depression, however, arrive first in primary-care settings, not in psychiatrists’ offices. In British Columbia, for example, approximately 80% of mental-health visits are with family physicians.
As a consultant to primary care physicians, the patients I usually see are not responding to an antidepressant or have complicating factors. Although I gather information on the symptoms of depression and comment on their severity, I have not always used a standardized measure of depression; nor do most general practitioners. I noticed that in follow-up visits with patients, many of whom are taking medication, the family physicians noted qualitatively how patients were doing, but it was often difficult to tell from chart entries how much patients had improved or what symptoms continued to impair them. Furthermore, some patients struggled with depression for weeks without consideration of change in treatment.
What changed my practice
Many instruments exist to quantify depressive symptoms. Some are observer-rated, such as the Hamilton Depression Rating Scale, which is often used in clinical trials. In primary care, a self-rating scale is more practicable as patients can complete it while waiting for the doctor. Options include the Beck Depression Inventory, which is validated and widely used but must be purchased; and the Patient Health Questionnaire, or PHQ-9, which is validated, simple and free. The PHQ-9, based on DSM criteria, has nine items and takes a few minutes to complete. Furthermore it is recommended by the Practice Support Program, a joint initiative of the Government of BC and Doctors of BC, from which it is downloadable along with other mental-health screening instruments and resources.
A research team tested an intervention with primary care physicians at 74 U.S. practice sites who were treating patients for major depression. For six months following diagnosis and initiation of an antidepressant medication, somewhat more than half the patients received a monthly phone interview with research assistants who obtained information about the patients’ treatment and who administered the PHQ-9. The phone interviewers offered no advice to patients or physicians, but they faxed each patient’s PHQ-9 to the treating physician. The control group had baseline, 3- and 6-month PHQ-9 ratings, but their physicians received results only at study completion. The criterion for treatment response was a PHQ-9 reduction of 50%, and for remission, it was a 6-month score of 5 or less.
Of 915 patients enrolled, 642 were included in the final analysis. The patients whose doctors received the PHQ-9 results were significantly more likely to get better. Compared to the control group, in the intervention group the odds ratio for remission was 1.59, and for response, it was 2.02.
What I do now
I now have each patient I treat for depression complete a PHQ-9 on every visit, and I recommend that family physicians do likewise; for a patient undergoing acute treatment, once every 1-2 weeks would suffice. Just seeing the change in the total score, or the lack of it, clarifies the patients’ status, and the checklist prompts the clinician to ask about specific symptoms. Trends may stand out, such as a patient whose insomnia is getting worse or one who is beginning to eat again.
What is considered an adequate response to treatment must be individualized. The goal, of course, is remission or resolution of all symptoms, but unfortunately in many patients with recurrent depression, this is elusive. If a patient does not have at least a 50% reduction in total PHQ-9 score within a month of taking a therapeutic dose of medication, the physician should consider either maximizing the dose, switching medication or using adjunctive treatment such as cognitive-behavior therapy. The COMET study found that the simple use of a self-rated symptom checklist can double the odds of response to antidepressant medication in primary-care patients.
References
- Patten SB Wang JL, Williams JV et al. Descriptive epidemiology of major depression in Canada. Can J Psychiatry. 2006;51(2):84-90. (View with CPSBC or UBC)
- Kroenke K, Spitzer RL, Williams JB. The PHQ-9: Validity of a brief depression severity measure. J Gen Intern Med. 2001(9);16:606-613. (View)
- Yeung AS, Jing Y, Brenneman SK et al. Clinical outcomes in measurement-based treatment (COMET): a trial of depression monitoring and feedback to primary care physicians. Depress anxiety. 2012(10);29:865–873. (View with CPSBC or UBC)
Resources
- http://www.gpscbc.ca/practice-support-program
- http://www.gpscbc.ca/psp-learning/adult-mental-health/tools-resources
- http://www.gpscbc.ca/sites/default/files/Patient%20Health%20Questionnaire%20for%20Depression%20%28PHQ9%29.pdf
- Patient Health Questionnaire: http://www.gpscbc.ca/sites/default/files/Patient%20Health%20Questionnaire%20for%20Depression%20%28PHQ9%29-BC%20Guidelines.pdf
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Had an idea reading this. One could have a “Depression/anxiety Awareness Month” and screen patients while sitting in the waiting room, using the PHQ or GAD screening tool. Their score could simply be recorded on that visit but they could be invited to follow up if appropriate. It would be a way of highlighting that Mental Health is important and part of what family physicians treat/counsel. It could be an interesting learning experience for both physician and patient. I would be curious how many of my patients have scores in the moderate range, as that might give insight into such issues as compliance, chronic pain, insomnia etc.
I use the PHQ9 and GAD7 with all of my depressed and anxious patients. The difficulty is with the non responders. The author suggests CBT as an augmentation strategy. It is the rare patient who can afford or access long term CBT, sadly. So we are left too often with medication “band aids” and multiple trials of different agents. I look forward to the day when we can tailor treatments to the genes of the patients.
This is a great idea because it is easy to miss this devastating illness. That said the rating scales mentioned are not so helpful with elderly patients. An “awareness month” for an office would be a fantastic way to screen patients and also get the doctor used to talking about depression and social problems. ( Retired psychiatrist)
“Bounce Back.”
On-line resource for patients. CBT. Free.
I find it useful.
MoodGym online CBT is free and also good I find. I seem to remember seeing a study that showed free online CBT to be as good as one to one in person.
I have been using the PHQ 9 and GAD scales for many years and have also found it useful in the ways the author described. Patients seem to appreciate comparing scores as time progresses and appear to use the change in the scores as encouragement and hope (if the scores are reducing!). It also allows us to get many of the ‘basic’ questions answered so that we can move more quickly to what their most pressing concerns are or what their positive changes have been since the last visit.