Mental Health Initiative Clinical Reference

PHQ-9 Management Summary

DSM-5 diagnostic criteria for a major depressive episode

  • Objectives:
    • PHQ9 (Patient Health Questionare Focusing on MDD):
      • Objectively determines severity of initial symptoms, and also monitors symptom changes and treatmenteffects over time.
      • https://www.mdcalc.com/calc/1725/phq9-patient-health-questionnaire9
  • Workflow:
    • MA:
      • PHQ in ADHOC.
      • If > 15 MA alerts tUC provider
      • Provide patient with info on SJC Behavior Health Services (1212 N California St, Stockton, phone#)
      • Evaluation for SI / HI / GD / inability to care for dependents
        • Positive
          • MA actives crisis stabilization unit / 911 -> ED.
          • tUC provider / staff stays online in interim to counsel until arrival of crisis stabilizationunit / 911.
        • Negative
          • Dispo + f/u contingent upon PHQ9 score + provider discretion
  • SJH tUC Team Work Flow:
    • ***All patients to be seen by tUC provider after MA screening regardless of score.***
      • 0-4:
        • MA
          • tUC f/u in < 3 mo for repeat PHQ9/eval
          • No psych referral
        • tUC provider
          • Diagnostically: Further eval/diagnostics for:
            • medical etiology
            • dual diagnosis (concurrent substance abuse d/o)
              • if + ->referral to substance abuse counselor
            • concurrent psych d/o (mania, hypomania)
          • Therapeutically:
            • Counseling by tUC provider
            • Medications unlikely
      • 5-9:
        • MA
          • tUC f/u in <1mo
          • No psych referral
        • tUC provider
          • Diagnostically: Further eval/diagnostics for:
            • medical etiology
            • dual diagnosis (concurrent substance abuse d/o)
              • if + -> referral to substance abuse counselor
            • concurrent psych d/o (mania, hypomania)
          • Therapeutically:
            • Counseling by tUC provider
            • Rx unlikely
      • 10-14:
        • MA
          • tUC f/u in <1wk
          • Psych referral < 1wk
        • tUC provider
          • Diagnostically: Further eval/diagnostics for:
            • medical etiology
            • dual diagnoses (concurrent substance abuse d/o)
              • if + ->referral to substance abuse counselor
            • concurrent psych d/o (mania, hypomania)
          • Therapeutically:
            • Counseling by tUC provider
            • Rx likely
      • 15-19:
        • MA
          • psych appt in <48 hrs (or next weekday)
        • tUC provider
          • Diagnostically: Further eval/diagnostics for:
            • medical etiology
            • dual diagnoses (concurrent substance abuse d/o)
              • if + ->referral to substance abuse counselor
            • concurrent psych d/o (mania, hypomania)
          • Therapeutically:
            • Counseling by tUC provider
            • Rx likely
            • Pysch eval/tx
      • 20-27:
        • MA
          • Same day v next day psych referral
          • schedules tUC f/u in <1wk
        • tUC provider
          • Confirm no SI/HI.
          • Contract for safety until psych appt.
          • Attempt to activate pt's support system (consent required when pt has capacity)
          • Diagnostically: Further eval/diagnostics for:
            • medical etiology
              • dual diagnosis (concurrent substance abuse d/o)
                • if + ->referral to substance abuse counselor
              • concurrent psych d/o (mania, hypomania)
          • Therapeutically:
            • Pysch eval/tx
            • Counseling by tUC provider
            • Rx likely
          • Dispo:
            • tUC provider and MA connect to confirm f/u plan.
  • Vituity tUC Dispo/Management (by score, diagnostic criteria, clinical impression):
    • Rule out bipolar disorder, normal bereavement, and medical disorders causing depression. (SSRI in context ofhypomanic episode misdiagnosed as MDD may precipate manic episode)
      • Mania:
      • Hypomania:
    • Eval with DSM-5 diagnostic criteria for MDD (major depressive disorder)
  • Tld;
    • Duration: >2 wks
    • Depressed mood or anhedonia
    • >=5 of following sx of depression, anhedonia, diet change, sleep change, fatigue,
  • Specification of depressive symptomatology:​​​​​​​
    • Unipolar major depression (major depressive disorder) (table 3)
    • Persistent depressive disorder (dysthymia) (table 4)
    • Disruptive mood dysregulation disorder
    • Premenstrual dysphoric disorder
    • Substance/medication induced depressive disorder
    • Depressive disorder due to another medical condition
    • Other specified depressive disorder (eg, minor depression)
    • Unspecified depressive disorder
  • Billing/Documentation:​​​​​​​
    • ICD-10-10: F32.9
  • Medical / Non-Pysch Work Up As Indicated:​​​​​​​
    • Consider: cbc, cmp, tsh, neuro-imaging, EKG (baseline QTc)
    • Psychosocial stressors (financial, chronic medical conditions) -> MA for SW referral
    • Review of medications
    • Obvious telehealth exam abnormalities
    • Cognitive dysfunction - mental status examination (ddx: dementia)
      • MoCA Screening (for sx >6 mo)
  • Pharmacological Therapy​​​​​​​
    • SSRI usually. Review FDA approval for pediatric patients.
    • Counsel can increase risk of suicidality
    • Common First Line:
      • Sertraline (Zoloft)
        • Initial dose: 25 mg / day
        • "Activating"
        • Consider drug-drug interactions / polypharmacy
        • GI side effects with irritable bowel syndromes
        • Faster onset (2 wks)
      • Escitalopram (Lexapro)
        • Initial dose: 5-10 mg/day
        • If concurrent anxiety/insomnia, start at lower dose, may titrate up subsequently
        • Consider drug-drug interactions / polypharmacy
        • Similar as celexa though less QTc prolongation
        • Slower onset (6 wks)
      • Paroxetine (Paxil)
        • Initial dose: 10 mg / day
        • "Sedating"
        • Withdrawl sx if abruptly stopped (shorter half life)
      • Fluoxetine (Prozac)
        • Initial dose: 20 mg / day
      • Duloxetine (Cymbalta)
        • Initial dose: 20mg day
        • Useful for neuropathic pain, fibromyalgia
        • Can increase BP (have in-person f/u for monitoring)
    • Side effects of SSRIs: hyponatremia, increased bleeding, reduced bone mineral density
  • Non-Pharmacological Adjuvant Therapy
    • ​​​​​​​
    • Cognitive Behavioral Therapy (there are DYI books/apps)
    • Pyschotherapy
    • Guided imagery (YouTube)
    • Interactive applications (Headspace, Zen, etc)
    • Exercise
    • Walking outside
    • Diet
    • Social support
    • Sleep hygeine
    • Melatonin PRN insomnia, likely least dangerous, ~3 hr half life (not drowsy next day)
    • Hydroxyzine PRN anxiety/insomnia. Not controlled substance. Counsel: do not drink/drive while taking.
  • Caveats:
    • Clinical judgement is always required. This workflow is only to be used as a guideline but should not supersede clincalacumen.
    • How difficult have these problems made it for you to do your work, take care of things at home, or get along with otherpeople?" not in score but is useful for following trajectory.
    • Higher PHQ-9 scores are associated with decreased functional status and increased symptom-related difficulties, sickdays, and healthcare utilization
    • May have high false-positive rates in primary care settings specifically (one meta-analysis found that only 50% ofpatients screening positive actually had major depression) ( Levis 2019 ).
    • A meta-analysis of 35 test-retest reliability studies (sample size not reported) examined agreement between repeatedassessments performed by either the same rater or different raters, and found that reliability was good (18). However,heterogeneity across studies was very large.

Additional References: