If you've come here looking to learn more about patient health questionnaires used to assess mental and behavioral health disorders, you're in the right place. This blog provides information that helps answer the common question "What is a patient health questionnaire?" We'll discuss one of the most common patient health questionnaires and how it's scored and then briefly touch on a popular variant of this patient mental health screener.
More importantly, though, we'll provide an overview of why commonly used patient health questionnaires are coming up short. We'll conclude the piece by sharing some of the key qualities that providers should look for when choosing a better alternative to these flawed solutions.
Despite sounding like a broad concept that could apply to nearly all areas of health and wellness, the term "patient health questionnaire" is typically associated with mental and behavioral disorders. And you'll often see the concept treated as a proper noun and thus capitalized (i.e., Patient Health Questionnaire).
Why is that the case? To answer this question, we'll need to step back for a moment and briefly discuss the Primary Care Evaluation of Mental Disorders (PRIME-MD).
Generally speaking, PRIME-MD is intended to be a diagnostic tool for common mental disorders. More specifically, the PRIME-MD is a two-stage system comprised of a patient screener typically with around 30 yes/no questions for patients to answer and a clinician evaluation guide, both of which are intended to help improve the diagnosing of five types of mental disorders:
The PRIME-MD was developed in the mid-1990s through funding from one of the largest pharmaceutical companies — one that just happens to develop and manufacture antidepressant drugs.
When using the PRIME-MD screener and evaluation guide, which provided clinicians with follow-up questions to ask patients based upon their screener responses, took more time than clinicians wanted to spend on diagnosing mental disorders, the PRIME-MD as a standalone tool was largely abandoned.
Now that we have a general understanding of PRIME-MD, we can look more closely at the concept of the "Patient Health Questionnaire," often referred to with its acronym of PHQ. The PHQ is a self-administered version of the PRIME-MD screener.
The three-page PHQ asks patients to speak to a number of potential mental health problems, signs, and symptoms they may be experiencing concerning the five modules (i.e., classes) of disorders noted above. While some questions ask patients to answer with a yes or no, others ask patients to assess how much and how long a problem "bothered" them.
Once completed, a clinician is supposed to review the questionnaire, focusing on those questions with positive responses, and then apply diagnostic algorithms, which are included and abbreviated at the bottom of each of the three pages.
In the late 1990s, one of the modules from the PHQ was broken out, which led to the creation of perhaps the most used mental health screening tool: the PHQ9.
What is the PHQ9? It's essentially the depression module of the longer, full PHQ. It asks patients to indicate how much they have been bothered by nine items over the previous two weeks. Those items are as follows:
For their responses, patients can choose from:
If a patient indicates they experienced any of the problems, they are then asked to speak to how difficult the problems made it for the patient to work, take care of home responsibilities, or get along with others. This is sometimes referred to as the 10th item of the PHQ9.
How is the PHQ9 scored? Once completed, answers of "Not at all" are scored 0; answers of "Several days" are scored 1; answers of "More than half the days" are scored 2; and answers of "Nearly every day" are scored 3. Thus, the PHQ9 total score for the nine items ranges from 0 to 27.
The National HIV Curriculum summarizes how clinicians should interpret the final score and the proposed treatment actions as follows:
Unfortunately, as we will discuss momentarily, this mechanism for interpretation and action is inadequate for meeting patients' needs.
A tool related to the PHQ9 is the PHQ2. What is the PHQ2? Sometimes described as the "ultra-brief depression screening," it's simply the first two items from the PHQ9:
The PHQ2 is scored the same as the PHQ9, with patients who screen positive on the PHQ2 expected to be further evaluated using the PHQ9.
As we stated at the beginning of this blog, the patient health questionnaires increasingly relied upon and often treated as the "default screeners" can cause more harm than good for patients and clinicians eager to help patients get the most appropriate and timely treatment. There are several reasons why, including the following:
We know that the patient health questionnaires largely in use today are coming up well short of their intended purposes when we look at the concerning state of mental healthcare today. Consider just the following statistics:
Fortunately, while the tools like the PHQ, PHQ9, and PHQ2 are often viewed as the default, they are not the only option for providers. Even better news: Some of the alternatives available can help providers improve patient care while also potentially adding revenue.
Here are some of the recommended criteria when evaluating behavioral health tools:
If you're interested in learning more about the challenges and opportunities around mental healthcare today, you won't want to miss "The Second Pandemic of Mental Health: An Expert Panel Discussion." This complimentary webinar is scheduled for August 17 at 4:30 EDT. Learn more about and register for the program here.
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