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Implementation of PHQ-9 to Improve Depression Screening in a Primary Care Clinic
The World Health Organization [WHO] (2006) defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” This definition puts emphasis on the fact that health goes beyond the physical dimension but rather extends beyond dimensions that may not be immediately observable. Mental health, in particular, receives less attention than physical health, and this problem has been exacerbated by the emergence of the COVID-19 pandemic in late 2019. The world is now almost two years into the pandemic, and the psychological effects of the pandemic cannot be overestimated. Already, researchers have detected significant increases in the rate of mental health conditions including depression brought about by a multitude of factors (Shader, 2020; Choi et al., 2020). Such factors include social isolation caused by lockdowns, the myriad challenges of contracting the virus, financial instability due to COVID-19’s impact on the economy , and social stigma (Fitzpatrick et al., 2020; Stein, 2020). The rising rates of mental health issues indicate a need to mobilize mental health services. But with hospitals and healthcare facilities currently swamped with COVID-19 cases, healthcare providers may be forced to scale back services or look for faster and more cost-efficient ways. In line with this new challenge, this nursing paper looks into the potential of implementing PHQ-9 as a depression screening tool in a primary care clinic.
PHQ-9 Screening Tool
The PHQ-9, or Patient Health Questionnaire-9, is a short questionnaire designed to quickly and efficiently screen respondents for depression. The tool features nine (9) Likert-style questions ranging from “not at all” with a score of 0 to “nearly every day” with a score of 3. Possible scores are from 0 to 27. A score of 0-4 is deemed indicative of minimal depression that may require no treatment; a score of 5-9 is considered indicative of mild depression while a score of 10-14 is deemed as moderate depression, and both score brackets may require treatment based on the clinical judgment of a doctor; finally, a score of 15-19 is considered moderately severe depression while a score of 20-27 is deemed severe depression, and both are regarded as warranting multimodal treatment including medication and psychotherapy (Kroenke and Spitzer, 2002).
As a tool for screening depression, PHQ-9 offers a number of advantages. Firstly, the tool is quick and easy to use, being far shorter than other tools including the full PHQ. It is also simple enough to be self-administered, which means it can be readily answered by individuals from virtually every demographic group barring any special considerations such as non-native speakers or individuals with special needs. Secondly, the tool helps quantify the severity of depression if indeed it is present, as the answers have corresponding numerical scores. Finally, multiple studies both in the past and in the present show that it has considerably high sensitivity and specificity. PHQ-9 scores of 10 or higher have 88% sensitivity and 88% specificity (Kroenke et al., 2002). However, a major limitation of the tool is its sensitivity, with one study showing that as many as 50% of positives turn out to be false-positives (Levis et al., 2019). This information engenders a number of considerations in implementing PHQ-9 as a screening tool. More recent studies also exhibit the tool’s validity, with PHQ-9 having a higher sensitivity when conducted alongside semistructured interviews (Levis et al., 2020).
Primary Care Clinic: St. Isadora Primary Health
St. Isadora Primary Health is a primary care center located in the center of Bellevue City. The center was established in 2014. The center’s goal is to provide optimal medical services to its clients. It has a medical clinic offering primary healthcare services (including subunits dedicated to adult women, adult men, and pediatric patients), a radiology department, a laboratory department, an emergency department, and other specialty services. The center has a staff of about forty (40) including six (7) full-time physicians, eighteen (20) nurses and nurse assistants, six (6) medical and radiologic technologists, and ten (8) administrative and support staff.
St. Isadora’s behavioral health services include screenings for mental health conditions, referrals to specialists and larger healthcare facilities, and referrals to government and non-government organizations catering to the mental health needs of the public. Over the past few months, St. Isadora has noted an increase in the number of clients seeking mental health services. Visits to the emergency unit by clients seeking mental health services have increased, as did calls to the center’s hotline. Unfortunately, the ongoing pandemic has compelled St. Isadora to operate at only half its regular capacity, with the workforce reduced to a skeletal staff in order to minimize the risk of further outbreaks of the virus. With demand up and capacity down, the center is looking at improvements that will enable quicker delivery of quality service.
Improving the Screening Process for Depression at St. Isadora
One of the possible solutions to optimizing services during this time is streamlining the screening process for mental health conditions. Utilizing PHQ-9, therefore, can be pursued as among these measures. Not only is the screening tool quick and easy to utilize, the simplicity of the process means that it is suitable for the staff and accessible to the general public. As noted by Kroenke et al. (2002) and more recently by Levis et al. (2020), it is for the most part a valid and reliable tool for screening for depression.
The following are the goals of implementing PHQ-9 as a screening tool for depression at St. Isadora Primary Health:
Increase capacity for screening process for depression from eight (8) clients a day to at least twelve (12) clients a day in two (2) weeks.
Provide quality behavioral health services in light of the increase in the number of clients seeking consultation.
Ensure accuracy of data for use by affiliated and partner healthcare providers, facilities, and organizations.
The following are the resources that will be utilized for the implementation of the new screening tool.
Carol McDonald, a psychiatric nurse practitioner from Bellevue City Hospital, will be the one to conduct the training. Original copies of the educational material are also provided by McDonald, with subsequent copies produced by St. Isadora.
Timeline for Implementation
The project is estimated to take place over the duration of 5 working days and will involve 4 members of the center’s behavioral health unit staff (1 physician, 2 nurses, and 1 administrative staff).
September 23, 2021
Formal training stage
September 24-25, 2021
Post-training round-table conference
September 26, 2021
September 27, 2021
The caveat, however, is the potential to determine as positive some clients who are in fact negative for depression. St. Isadora can apply two ways to address the issue of false-positive results. First, the center may supplement the screening process with a semistructured interview. Levis et al. (2020) found that semistructured interviews helped ensure the sensitivity and specificity of PHQ-9, maintaining sensitivity and specificity levels originally determined by Kroenke et al. (2003). Hence, employing these two tools together can act as a safety net against overdiagnosis. Second, all clients who score positive (with a cutoff of ≥10) must undergo more extensive screening and diagnostic interview procedures for clinical correlation and confirmation. The subsequent procedures will be performed by specialists to which the clients who score positive will be referred. With these measures in place, the staff of St. Isadora will be able to integrate PHQ-9 into the consultation for faster screening without sacrificing the accuracy of the process.
To determine the success of the program, the following will serve as the evaluation measures:
Increase in capacity for screening for depression of at least 50% from eight (8) clients a day to at least twelve (12) clients a day two (2) weeks following the implementation of the plan.
Maintain average client review rating at its current 8.5/10.
Maintain accuracy of sensitivity and specificity at 88% and 88%, respectively, as determined by Kroenke et al. (2002) and Levis et al. (2020). Confirmatory data will come from affiliated and partner healthcare providers, facilities, and organizations.
The impact of the ongoing COVID-19 pandemic on the economy, the healthcare system, and social life, in general, have led to a sharp decline in the ability of healthcare facilities and providers to deliver crucial services to the public as well as a steep increase in the number of people seeking mental health services. With demand on the rise and the healthcare system still recovering from the challenges imposed by the pandemic, there is a clear need to further streamline processes in order to deliver services quickly without compromising quality. This paper has looked into the possibility of using the PHQ-9 tool developed by Kroenke and Spitzer (2002) as a screening tool. With its relative simplicity, validity, and reliability as a tool, it offers a feasible solution to increasing St. Isadora Primary Health’s capacity to screen clients for depression. The program will involve four (4) employees of the center and will tentatively take place from September 23 to September 27. Evaluation measures have been established to determine the success of the program. The implementation of the program is expected to increase screening capacity by 50% while maintaining quality and accuracy.
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Fitzpatrick, K. M., Casey, H., and Grant, D. (2020). Fear of COVID-19 and the mental health consequences in America. Psychological Trauma: Theory, Research, Practice, and Policy, 12(S1), S17–S21. https://doi.org/10.1037/tra0000924
Kroenke, K. and Spitzer, R. (2002). The PHQ-9: A new depression diagnostic and severity measure. Psychiatric Annals, 32(9). https://doi.org/10.3928/0048-5713-20020901-06
Kroenke, K., Spitzer, R. L., and Williams, J. B. (2001). The PHQ-9: validity of a brief depression severity measure. Journal of general internal medicine, 16(9), 606–613. https://doi.org/10.1046/j.1525-1497.2001.016009606.x
Levis, B., Benedetti, A., and Thombs, B. D. (2019) Accuracy of Patient Health Questionnaire-9 (PHQ-9) for screening to detect major depression: individual participant data meta-analysis. BMJ, 365. https://doi.org/10.1136/bmj.l1476
Levis, B., Sun, Y., He, C., Yin, W., Krishnan, A., Bhandari, P. M., Neupane, D., Imran, M., Brehaut, E., Negeri, Z., Fischer, F., Benedetti, A., and Thombs, B. D. (2020). Accuracy of the PHQ-2 alone and in combination with the PHQ-9 for screening to detect major depression: Systematic review and meta-analysis. JAMA, 323(22), 2290–2300. doi:10.1001/jama.2020.6504
Shader, R. I. (2020). COVID-19 and depression. Clinical Therapeutics, 42(6), 962-963. https://doi.org/10.1016/j.clinthera.2020.04.010
Stein, M. B. (2020). EDITORIAL: COVID-19 and Anxiety and Depression in 2020. Depression and anxiety, 37(4), 302. https://doi.org/10.1002/da.23014
World Health Organization. (2006). Constitution of the World Health Organization. WHO. https://www.who.int/governance/eb/who_constitution_en.pdf