The Importance of PHQ-9 Screening at the Primary Care Level for Depression and Severity
Depression and suicide are two major health risks, both in the U.S. and abroad. 20-25% of adult Americans struggle with depression, while 38,000 Americans commit suicide each year. The CDC claims that suicide is the third most prevalent cause of death for youth between 10 and 24 years old. According to the World Health Organization, the past 50 years have seen a 60% increase in suicide rates. It also predicts that by 2020 depression will become the second most widespread medical condition at the global level.
With such high statistics, one must ask what primary care physicians in the U.S. are doing to help reduce these numbers. Approximately two-thirds of American patients with depression see a primary care physician for depression treatment. 40% of suicide victims see a primary care physician one month prior to committing suicide. One would think that these primary care exams would help to treat patients' depression and to curb patients' suicide tendencies. However, the statistics prove that primary care physicians fail to screen and diagnose as many as 30-50% of depressed patients.
Primary care is the first line of defense against both depression and suicide, so it is important for primary care physicians to accurately and effectively screen patients for depression. Depression screening at the primary care level involves a two-step strategy. The first step is to ask the patient two screening questions about their overall mental health: 1) During the past month, have you often been bothered by feeling down, depressed, or hopeless? 2) During the past month, have you often been bothered by little interest or pleasure in doing things? If the patient says yes to one or both of these questions, the primary care physician must proceed to the second step of the strategy: guiding the patient through the PHQ-9, a 9 question patient health questionnaire.
The Adult and Adolescent Depression Screening, Diagnosis, and Treatment Guide is a resource that primary care physicians can use when applying each step of the PHQ-9 screening click here. The first part of the guide lists five major changes that have been made to PHQ9 screening as of 2015. Some of these changes include using the Columbia Suicide Risk Assessment tool for high risk patients, enhancing shared decision making between physicians and patients, and prioritizing antidepressant use only for patients with severe depression. The guide goes on to distinguish between the two PHQ-9 screenings available, based on the patient's age. The PHQ-9 is geared towards adults over 18 years of age; the PHQ-9A is for 12-17 year old patients.
The guide also addresses the physician's approach and perspective when treating patients with depression. It points out that the primary care physician's primary goal is not to eliminate depression in the U.S. population as a whole, but to effectively diagnose and treat depression symptoms in individual patients. The guide also defines the two main treatment goals that physicians should have for depressed patients: 1) to attain complete remission of depression and 2) to prevent a future relapse of the depression. It goes on to stress the particular effectiveness of combination treatment compared to using just one or the other method.
Another aspect of depression treatment is that the primary care physician should provide supportive care for patients during treatment. Supportive care includes educating the patient about the circumstantial and biological causes of depression and its resulting symptoms. It also incorporates follow-up visits and shared decision making.
One of the last aspects is treatment duration and when the patient should stop taking antidepressants. It is advised that primary care physicians wean patients off of antidepressants slowly rather than all at once, to minimize the patient's risk of relapse. Patients that have had only one episode of major depression should continue taking antidepressants 6-12 months after signs of remission. Patients with two or more episodes of major depression should have a longer treatment period of 3 or more years after remission.
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