Introduction

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The PHQ-9 is the nine item depression scale of the Patient Health Questionnaire. The PHQ-9 is a powerful tool for assisting primary care clinicians in diagnosing depression as well as selecting and monitoring treatment. The primary care clinician and/or office staff should discuss with the patient the reasons for completing the questionnaire and how to fill it out. After the patient has completed the PHQ-9 questionnaire, it is scored by the primary care clinician or office staff. There are two components of the PHQ-9: Assessing symptoms and functional impairment to make a tentative depression diagnosis, and Deriving a severity score to help select and monitor treatment The PHQ-9 is based directly on the diagnostic criteria for major depressive disorder in the Diagnostic and Statistical Manual Fourth Edition (DSM-IV). For easy of use, Pfizer and others have suggested using a simpler scoring proxy system to estimate diagnostic categories. The MacArthur Initiative on Depression and Primary Care recommends using the initial two component scoring system. We also recommend regular use of a chronicity question to aid consideration of mild chronic depression (dysthymic disorder). On the following pages we provide the listed items to assist in learning about using the PHQ-9. For more extensive training and/or consultation please contact us. Sample PHQ-9 Guide for Making a Tentative Diagnosis Guide for Severity Scoring Provisional Diagnosis Table Treatment Response Table Reproduction Quality Blank PHQ-(Download - English version) Reproduction Quality Blank PHQ-(Download - Spanish version) References Spitzer R, Kroenke K, Williams J. Validation and utility of a self-report version of PRIME-MD: the PHQ Primary Care Study. Journal of the American Medical Association 1999; 282: 17371744. Abstract Kroenke K, Spitzer R L, Williams J B. The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine 2001; 16(9): 606-613 Abstract Rost K, Smith J. Retooling multiple levels to improve primary care depression treatment. Journal of General Internal Medicine 16: 644-645, 2001 PubMed Citation Kroenke K, Spitzer RL. The PHQ-9: A new depression and diagnostic severity measure. Psychiatric Annals 2002; 32: 509-521. Williams JW, Noel PH, Cordes J A, Ramirez G,Pignone M. Is this patient clinically depressed? Journal of the American Medical Association 2002; 287: 1160-1170. Abstract Lowe B, Unutzer J, Callahan CM, Perkins AJ, Kroenke K. Monitoring depression treatment outcomes with the patient health questionnaire-9. Medical Care, 2004. 42(12): 1194-201. Abstract Pinto-Meza A, Serrano-Blanco A, Penarrubia MT, Blanco E, Haro JM. Assessing depression in primary care with the PHQ-9: can it be carried out over the telephone? Journal of General Internal Medicine, 2005. 20(8): 738-42. Abstract The PHQ-9 is adapted from PRIMEMDTODAY, developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, and colleagues, with an educational grant from Pfizer Inc. For research information, contact Dr Spitzer at rls8@columbia.edu. The names PRIME-MD

and PRIMEMDTODAY are trademarks of Pfizer Inc. PHQ9 Copyright Pfizer Inc. All rights reserved. Reproduced with permission of Pfizer, Inc. PRIME-MD is a trademark of Pfizer Inc.

Patient Health Questionnaire (PHQ-9)

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NAME:___________________________________________

DATE:______________________

Over the last 2 weeks, how often have you been bothered by any of the following problems? (use to indicate your answer) 1. Little interest or pleasure in doing things 2. Feeling down, depressed, or hopeless 3. Trouble falling or staying asleep, or sleeping too much 0 0 0 0 0 0 1 1 1 1 1 1 2 2 2 2 2 2 3 3 3 3 3 3

4. Feeling tired or having little energy 5. Poor appetite or overeating Feeling bad about yourselfor that 6. you are a failure or have let yourself or your family down 7. Trouble concentrating on things, such as reading the newspaper or watching television

Moving or speaking so slowly that other people could have noticed. Or the oppositebeing so fidgety 8. or restless that you have been moving around a lot more than usual 9. Thoughts that you would be better off dead, or of hurting yourself in some way

0 add columns:

1 +

2 +

(Healthcare professional: For interpretation of TOTAL, TOTAL: please refer to accompanying scoring card).

10.If you checked off any problems, how

Not difficult at all

_________

difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Somewhat difficult Very difficult Extremely difficult

_________ _________ _________

Patient Health Questionnaire (PHQ-9)

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Using PHQ-9 Diagnosis and Score for Initial Treatment Selection

A depression diagnosis that warrants treatment or treatment change, needs at least one of the first two questions endorsed as positive (little pleasure, feeling depressed) indicating the symptom has been present more than half the time in the past two weeks. In addition, the tenth question about difficulty at work or home or getting along with others should be answered at least somewhat difficult. When a depression diagnosis has been made, patient preferences should be considered, especially when choosing between treatment recommendations of antidepressant treatment and psychotherapy. PHQ-9 Score Provisional Diagnosis Treatment Recommendation Support, educate to call if worse; return in 1 month Support, watchful waiting Antidepressant or psychotherapy Antidepressant or psychotherapy

5-9 Minimal Symptoms* Minor depression++ 10-14 Dysthymia* Major depression, mild

15-19

Major depression, moderately severe

Antidepressant or psychotherapy Antidepressant and psychotherapy (especially if not improved on monotherapy)

20 Major depression, severe

If symptoms present two years, then probable chronic depression which * warrants antidepressants or psychotherapy (ask, "In the past 2 years have you felt depressed or sad most days, even if you felt okay sometimes?"). If symptoms present one month or severe functional impairment, consider ++ active treatment. Using the PHQ-9 to Assess Patient Response to Treatment

The goal of acute phase treatment is remission of symptoms as indicated by a PHQ-9 Score of < 5 points. Patients who achieve this goal enter into the continuation phase of treatment. Patients who do not achieve this goal remain in the acute phase of treatment and require some alteration in treatment (dose increase, augmentation, combination treatment). Patients who do not achieve remission after two adequate trials of antidepressants and/or psychological counseling or by 20 to 30 weeks would benefit from a formal or informal psychiatric consultation for diagnostic and management suggestions.

Initial Response after Four - Six weeks of an Adequate Dose of an Antidepressant Treatment PHQ-9 Score Treatment Plan Response Drop of 5 points from No treatment change needed Adequate baseline Follow-up in four weeks. Drop of 2-4 points from Probably Often warrants an increase in baseline Inadequate antidepressant dose. Increase dose: Augmentation; Drop of 1 point or no Switch; Informal or formal Inadequate change or increase psychiatric consultation; Add psychological counseling. Initial Response to Psychological Counseling After Three Sessions over Four - Six Weeks Treatment PHQ-9 Score Treatment Plan Response Drop of 5 points from No treatment change needed Adequate baseline Follow-up in four weeks. Possibly no treatment change Drop of 2-4 points from Probably needed. baseline Inadequate Share PHQ-9 with psychological counselor. If depression-specific psychological counseling (CBT, PST, IPT*) discuss with therapist, consider adding antidepressant. Drop of 1 point or no change or increase Inadequate For patients satisfied in other type of psycholgical

change or increase

counseling, consider starting antidepressant. For patients dissatisfied in other psychological counseling, review treatment options and preferences.

* CBT - Cognitive-Behavioral Therapy; PST - Problem Solving Treatment; IPT- Interpersonal Therapy