Psychiatry and primary care practices are the real-world laboratories in an
unprecedented collaboration that is seeking to revolutionize depression
screening and treatment.
As part of the National Depression Management Leadership Initiative, a
group of 38 physicians—20 psychiatrists and 18 primary care
physicians—has begun administering a depression screening and monitoring
tool known as the Patient Health Questionnaire-9 (PHQ-9) to patients.
The initiative is designed so that the physicians can make small changes in
their practices over time that facilitate the administration of the PHQ-9 as
part of routine clinical care.
Among the participants are psychiatrists, internists, and family practice
physicians recruited through the practice research networks of the American
Psychiatric Institute for Research and Education (APIRE), American College of
Physicians, and American Academy of Family Physicians.
Physicians and study leaders met for the first time at a learning session
held in Chicago in early April, which served as an orientation to the
initiative and included suggestions about how to integrate the PHQ-9 into
participants' practices with increasing numbers of patients.
Participants will come together for two more learning sessions with the
initiative's leaders over the next year to discuss their experiences and share
ideas about how to expand use of the instrument so that it becomes a routine
part of all medical care.
The initiative is divided into two tracks—one for psychiatrists and
one for primary care physicians.
Though an overarching goal of the initiative is to improve depression
screening, monitoring, and treatment for all patients, psychiatrists will
focus on helping researchers to understand how the PHQ-9 facilitates
depression treatment, according to David Katzelnick, M.D., primary care
physicians will help study leaders understand the barriers to widespread
dissemination of the PHQ-9.
Katzelnick is a clinical professor of psychiatry at the University of
Wisconsin Medical School in Madison and distinguished scientist at the Madison
Institute of Medicine. He heads the initiative with Paul Nutting, M.D.,
M.S.P.H., director of research at the Center for Research Strategies LLC and a
clinical professor of family medicine at the University of Colorado Health
The PHQ-9 is an inventory of depression symptoms based on each of the nine
DSM-IV criteria for depression
(see box). Each of the
nine items is scored along a continuum from 0 to 3, so the highest possible
score on the instrument is 27, which indicates severe depression.
In addition to tracking patients' PHQ-9 scores longitudinally, physicians
will note how the instrument's scores affected their treatment decisions for
each patient. Study leaders will then analyze the data provided by the
physicians to determine whether and to what extent the PHQ-9 was helpful in
monitoring and treating depression.
"Our goal is to increase the availability of effective treatment for
depression and to improve clinical-management practices for the treatment of
depression," said Katzelnick at the Chicago learning session. "We
are on the edge of discovering the impact of systematically monitoring
According to Darrel Regier, M.D., M.P.H., APIRE's executive director, the
PHQ-9 has been well tested in primary care settings. "Each of the
studies found that you can substantially improve depression outcomes using the
PHQ-9," he told physicians at the learning session.
Regier developed the depression-management initiative with Katzelnick and
the co-principal investigators for the psychiatry track, Henry Chung, M.D.,
and Madhukar Trivedi, M.D.FIG1
Regier said he hoped to discover "how we take a technology that
people aren't necessarily trained in and introduce it in a manner that will
change the way physicians practice."
Regardless of medical specialty, Regier explained, when physicians
incorporate some element of change as part of a clinical trial, "as soon
as the study stops, people revert to the same patterns of practice. The
challenge is for all of us to get over that hump."
Regier and Katzelnick noted that diabetes care improved dramatically with
the introduction of the hemoglobin A1C test, which provides physicians with a
standard measurement with which to measure blood glucose levels over time.
"We thought, `Why can't we have a metric like that for
depression?,'" Katzelnick said.
Ideally, a PHQ-9 score will facilitate dialogue between primary care
doctors and psychiatrists and become as easily understandable by both
physicians and patients as a blood-pressure reading.
When primary care physicians refer patients with severe or
treatment-resistant depression to psychiatrists, there is plenty of room for
miscommunication, Regier noted. The lack of any standardized depression
measurement in clinical practice "diminishes the ability of primary care
physicians to communicate effectively with psychiatrists" on the
severity of a patient's depression or whether the patient is responding to
"At this point, it's all guesswork," Regier said. "We
hear, `The patient looks more depressed,' but we have no way of knowing how
much more depressed."
Initiative leaders touted additional benefits of the PHQ-9. For instance,
Regier pointed out that it is an important tool for monitoring suicidality in
patients with depression.
The initiative also seeks to educate patients about the symptoms and
overall management of depression, said Trivedi. In addition to being
co-principal investigator of the psychiatry track, Trivedi is co-principal
investigator of the Sequenced Treatment Alternatives to Relieve Depression
trial, which is based at the University of Texas Southwestern Medical Center
in Dallas, and director of the depression algorithm for the Texas Medication
"If patients begin to monitor their symptoms with physicians on an
ongoing basis, they become partners in the treatment rather than just
bystanders," he noted, and tend to be more proactive about notifying
their physicians when depressive symptoms return or worsen.
Measuring depression severity with the PHQ-9 could also help physicians
treat patients more effectively.
"Many times I've placed a patient on an antidepressant, and the
patient comes back in a few weeks and tells me, `I think I'm feeling a little
better,' and we go on to something else," said Nutting. "But if we
had an objective way to measure depression severity, we might discover that [a
patient's] PHQ-9 score only dropped from 20 to 18. We can do better than
Chung agreed that the PHQ-9 will help physicians "target
treatments" to achieve more desirable outcomes.
"For 20 years, we have had a depression guideline that tells us to
consider augmenting or changing treatment if symptoms are not reduced by 50
Chung asked, "How do you measure a 50 percent reduction? Do we ask
our patients, `Are you one-half better?'" The PHQ-9 will allow for"
tailored treatment planning and better management to remission,"
Chung said he also sees the PHQ-9 as a "critical" way to
achieve mental health coverage parity for all Americans.
"I think it is hard to advocate for parity when we don't have
outcomes demonstrating what we know we can achieve in the real world,"
Funding for the project is being provided by the American Psychiatric
Foundation through unrestricted educational grants from AstraZeneca
International, Eli Lilly and Co., Lilly Foundation, Forest Laboratories Inc.,
Pfizer Inc., Sanofi Aventis, and Wyeth.
More information about the initiative is available by contacting
Farifteh Duffy, Ph.D., by e-mail at
or phone at (800) 713-7123. ▪