Cricket Mitchell, PhD

CiMH Senior Associate

Use of the Patient Health Questionnaire-9 (PHQ-9) with DTQI

in Ventura County

Overview of Training Overview of Training • Importance of Incorporating Standardized Data• Patient Health Questionnaire (PHQ-9) with DTQI

– PHQ-9 Description– Administration– Scoring– Clinical Utility– Tracking Clinical Progress in DTQI– Outcome Assessment using the PHQ-9

• Materials you will need– PHQ-9– Individual DTQI Client PHQ-9 Progress Graph

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Importance of Incorporating Standardized Importance of Incorporating Standardized Data Collection into Clinical PracticeData Collection into Clinical Practice

• Assessment is the beginning of developing a relationship with the client– Demonstrates a desire to know what the youth

is experiencing– By incorporating standardized measures of

functioning, the efficiency and thoroughness of assessment is enhanced

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Importance of Incorporating Standardized Importance of Incorporating Standardized Data Collection into Clinical PracticeData Collection into Clinical Practice

• Using standardized measures of functioning…– Assists in initial clinical impressions– Provides valuable information to guide

treatment/interventions– Tracks treatment progress over time– Assesses sufficiency of treatment delivered– Demonstrates treatment-related improvements

in youth functioning

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Patient Health Questionnaire - 9 Patient Health Questionnaire - 9 (PHQ-9)(PHQ-9)

CIMH PHQ-9TrainingCIMH PHQ-9Training• Information on the administration, scoring, and

clinical utility of the PHQ-9 was obtained from:– The PHQ-9: Validity of a Brief Depression Severity

Measure (Kurt Kroenke, Robert Spitzer, and Janet Williams; Journal of General Internal Medicine, 2001)

– Patient Health Questionnaire 9 Validated for Depression Screening in Adolescents (Penny Murata; Pediatrics, 2010)

– The National Council for Community Behavioral Healthcare, http://www.thenationalcouncil.org/cs/best_practices_programs

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PHQ-9 DescriptiPHQ-9 Description• Target-specific/Symptom-specific measure of

functioning– To be used when the focus of treatment is

depression• Measures the current severity of depressive

symptoms– Self-report for ages 12+

• Brief• Valid and reliable• Sensitive to clinical change• Available in the public domain at no charge

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PHQ-9 DescriptiPHQ-9 Description• 9 items – reflect the 9 symptoms of DSM-IV

diagnostic criteria for depression• 4-point Likert scale response options

– Not at all (0)– Several days (1)– More than half the days (2)– Nearly every day (3)

• 10th item not scored, assesses functional impairment

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Let’s take a look at the Let’s take a look at the PHQ-9...PHQ-9...

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PHQ-9 AdministrationPHQ-9 Administration• Approximately 2 minutes to complete• Youth complete independently

– Can be read aloud if necessary/desired• “Over the last 2 weeks...”• Encourage honest responses

– Informants can easily be influenced by the attitude of the person administering the scale

– Let youth know that this questionnaire will help you, as a clinician, better understand how they are doing and how you can best help them

• Encourage responses on all items

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PHQ-9 ScoringPHQ-9 Scoring• Sum the items in the column labeled “Several days”, and

put that number on the line below that column– Alternatively, you could count the number of items that

have been circled in this column and multiply by 1• Sum the items in the column labeled “More than half the

days”, and put that number on the line below that column– Alternatively, you could count the number of items that

have been circled in this column and multiply by 2• Sum the items in the column labeled “Nearly every day”,

and put that number on the line below that column• Alternatively, you could count the number of items that

have been circled in this column and multiply by 3• Add the three subtotals together to obtain the Total

Severity Score• In other words… sum all responses on items 1 thru 9

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Clinical Utility of the PHQ-9Clinical Utility of the PHQ-9

• The PHQ-9 is a multipurpose tool that has been used for:– Screening– Diagnosing– Monitoring– Measuring the severity of depression

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Clinical Utility of the PHQ-9Clinical Utility of the PHQ-9• For initial provisional diagnosis...

– If there are at least 4 “3’s” – including Q#1 and/or Q#2 – consider a depressive disorder

• Consider a Major Depressive Disorder diagnosis...– If there are at least 5 “3’s”

• One of which must correspond to either Q#1 or Q#2

• Consider Other Depressive Disorder...– If there are between 2 and 4 “3’s”

• One of which must correspond to either Q#1 or Q#2

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Clinical Utility of the PHQ-9Clinical Utility of the PHQ-9

• Diagnoses of Major Depressive Disorder or Other Depressive Disorder also require:– Impairment of social, occupational, or other

important areas of functioning • See Q#10

– And ruling out normal bereavement, a history of a Manic Episode (Bipolar Disorder), and a physical disorder, medication, or other drug as the biological cause of the depressive symptoms

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Clinical Utility of the PHQ-9Clinical Utility of the PHQ-9

• Total Score indicates Depression Severity:

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Total Score Depression Severity

1-4 Minimal depression

5-9 Mild depression

10-14 Moderate depression

15-19 Moderately severe depression

20-27 Severe depression

Clinical Utility of the PHQ-9Clinical Utility of the PHQ-9

• Question #9– Assesses presence and duration of suicidal

ideation– Review this carefully after a youth has

completed the measure• A “2” or “3”, reflecting more than half the days or

nearly every day, requires additional assessment

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Clinical Utility of the PHQ-9 with Clinical Utility of the PHQ-9 with DTQIDTQI• Assessing Initial Severity of Depression

• Treatment Monitoring / Tracking Clinical Progress– Periodic assessments provide valuable

information regarding symptom severity relative to treatment/interventions

• Outcome Assessment

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Clinical Utility of the PHQ-9 with Clinical Utility of the PHQ-9 with DTQIDTQI• In DTQI, the PHQ-9 will be administered

(at least) four times:1. Pre-DTQI2. After Phase I (presumably, as you transition

from the Activities module to the Thoughts module)

3. After Phase II (presumably, as you transition from the Thoughts module to the Social module)

4. Post-DTQI

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Clinical Utility of the PHQ-9 with Clinical Utility of the PHQ-9 with DTQIDTQI• Individual client PHQ-9 scores are shared

with Maggie Rea (or other DTQI clinical expert/trainer) to guide the clinical consultation– Total scores on the PHQ-9 provide valuable

information regarding the severity level of an individual client’s depressive symptomotology

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Individual DTQI Client PHQ-9 Progress GraphIndividual DTQI Client PHQ-9 Progress Graph

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DTQI Therapist:: _________________________________

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Date:

Year:

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15-19 = Moderate Severe Depression

10-14 = Moderate Depression

20-27 = Severe

0-4 = None/minimal

Client Name: __Example_____________________

5-9 = Mild Depression

VCBH ID: ________________

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X

X

X

X

Clients appreciate

seeing their treatment

progress as much as you

do!!

Using the Individual DTQI Client Using the Individual DTQI Client PHQ-9 GraphPHQ-9 Graph• Print as a ‘Slide’ and you will get the graph on a

full-page • Use one per client• Enter the Date of the Assessment at the

appropriate interval (Pre-DTQI, End of Phase I, etc.)

• Plot the PHQ-9 score on the graph within the appropriate assessment interval

• Once multiple scores are plotted, connect the scores with a solid line

Outcome Assessment Using the Outcome Assessment Using the PHQ-9PHQ-9• Comparisons of Pre- and Post- scores

reveal specific areas of treatment-related improvement in child depression– e.g.,

• Does the severity of depression symptoms decrease substantially after participation in DTQI?

• Is there improvement across all domains of depressive symptoms?

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Outcome Assessment Using the Outcome Assessment Using the PHQ-9PHQ-9• Data entry instructions for the Pre-DTQI and

Post-DTQI PHQ-9 scores will be forthcoming from Behavioral Health– Anticipated to begin July 1, 2012

• Data collection for outcome assessment will begin with new clients– Must have a true Pre-DTQI score to evaluate

outcomes

• Data collection for monitoring clinical progress should begin immediately with current clients

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Materials You Will NeedMaterials You Will Need

• PHQ-9– Provided in English and in Spanish– Additional language versions are available at:

http://www.phqscreeners.com/overview.aspx?Screener=02_PHQ-9

• Individual DTQI Client PHQ-9 Graph– Provided in PowerPoint along with Example

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QuestionsQuestions

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The EndThe End

Contact InformationContact Information•Cricket Mitchell, PhD

•Email: cmitchell@cimh.org•Cell phone: 858-220-6355