Tools Primary Care Physicians Can Use to Effectively Treat Depression

Damara N. Gutnick, MD

Clinical Assistant Professor
Departments of Medicine (GIM Div) and Psychiatry
NYU Langone Medical Center
New York, NY
Primary Care Physician
Bellevue Hospital
New York, NY

The Patient Health Questionnaire (PHQ-9), the P4 screening tool, and the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study can all be used by primary care physicians (PCPs) to screen, manage, and classify depressed patients.

The first 2 questions of the PHQ-9 (aka, the Whooley Scale) can be used to determine whether a patient is experiencing a simple depressed mood or clinical anhedonia (an inability to experience pleasure from previously pleasurable activities). If a patient provides an affirmative answer to the Whooley Scale, the clinician should administer the rest of the questionnaire. Patients can receive a PHQ-9 score of between 0-27, ranging from mild depression to severe depression. The higher the score, the more sensitive and specific the screening tool becomes. A score of 10 or higher has an 88% sensitivity and specificity. The PHQ-9 does not screen for bipolar disorder, so a PCP should use other techniques to determine if there is a history of bipolar episodes.

The PHQ-9 can also provide a scaled guideline to help PCPs manage depression over time. For example, if a patient’s score decreases from 20 to 15, the patient may be responding well to treatment. If the change in score is insignificant (eg, 20 to 19), medications and self-management strategies should be re-assessed and possibly altered.

For patients who answer yes to question 9 of the PHQ-9 (“Over the last 2 weeks, have you had thoughts that you would be better off dead, or of hurting yourself in some way?”), the PCP should administer the P4 screening tool to assess suicide risk. Using the P4, patients are asked if they plan to hurt themselves, if they have made any attempts to hurt themselves in the past, and the probability that they will try to hurt themselves in the future. Patients are also asked to reflect on any factors that would prevent them from committing suicide such as fear, family, religious beliefs, or hopes for the future.

As the STAR*D study demonstrated, patients often do not respond to the initial round of antidepressant treatment. In most cases, this necessitates treatment augmentation with other antidepressants or with other classes of antidepressants. While many PCPs will initiate antidepressant medication, they often do not feel comfortable titrating a drug to its maximum dose or switching to a different drug or drug class. There are many reasons why PCPs must address this problem when treating depressed patients. Patients with chronic disease are more likely to be depressed, and that depression may hinder both their ability to manage the disease and to adhere to treatment. By effectively treating depression in their patients, PCPs may avoid referring reluctant patients to a psychiatrist. Likewise, effective treatment by the PCP would help improve access to psychiatrists for those patients with severe or treatment-resistant depression.

References

Anhedonia. Merriam-Webster Medical Dictionary Web site. http://www.merriam-webster.com/medical/anhedonia?show=0&t=1308595722. Accessed June 20, 2011.
Patient Health Questionnaire. Patient Health Questionnaire (PHQ) Screeners Web site. http://www.phqscreeners.com/pdfs/02_PHQ-9/English.pdf. Accessed July 6, 2011.
Priyanka D, Kroenke K, Blair MJ, Theobald D, Williams LS. The P4 Screener: Evaluation of a Brief Measure for Assessing Potential Suicide Risk in 2 Randomized Effectiveness Trials of Primary Care and Oncology Patients. Prim Care Companion J Clin Psychiatry. 2010;12(6):doi:10.4088/PCC.10m00978blu.

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