Use of the Patient Health
Questionnaire-9 (PHQ-9) with DTQI
in Ventura County
Cricket Mitchell, PhD
CiMH Senior Associate
Overview of Training
• Importance of Incorporating Standardized Data
• Patient Health Questionnaire (PHQ-9) with DTQI
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PHQ-9 Description
Administration
Scoring
Clinical Utility
Tracking Clinical Progress in DTQI
Outcome Assessment using the PHQ-9
• Materials you will need
– PHQ-9
– Individual DTQI Client PHQ-9 Progress Graph
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Importance of Incorporating Standardized
Data Collection into Clinical Practice
• Assessment is the beginning of developing
a relationship with the client
– Demonstrates a desire to know what the youth
is experiencing
– By incorporating standardized measures of
functioning, the efficiency and thoroughness of
assessment is enhanced
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Importance of Incorporating Standardized
Data Collection into Clinical Practice
• Using standardized measures of
functioning…
– Assists in initial clinical impressions
– Provides valuable information to guide
treatment/interventions
– Tracks treatment progress over time
– Assesses sufficiency of treatment delivered
– Demonstrates treatment-related improvements
in youth functioning
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Patient Health Questionnaire - 9
(PHQ-9)
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CIMH PHQ-9Training
• Information on the administration, scoring, and
clinical utility of the PHQ-9 was obtained from:
– The PHQ-9: Validity of a Brief Depression Severity
Measure (Kurt Kroenke, Robert Spitzer, and Janet
Williams; Journal of General Internal Medicine, 2001)
– Patient Health Questionnaire 9 Validated for
Depression Screening in Adolescents (Penny Murata;
Pediatrics, 2010)
– The National Council for Community Behavioral
Healthcare,
http://www.thenationalcouncil.org/cs/best_practices_p
rograms
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PHQ-9 Description
• Target-specific/Symptom-specific measure of
functioning
– To be used when the focus of treatment is
depression
• Measures the current severity of depressive
symptoms
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– Self-report for ages 12+
Brief
Valid and reliable
Sensitive to clinical change
Available in the public domain at no charge
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PHQ-9 Description
• 9 items – reflect the 9 symptoms of DSM-IV
diagnostic criteria for depression
• 4-point Likert scale response options
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Not at all (0)
Several days (1)
More than half the days (2)
Nearly every day (3)
• 10th item not scored, assesses functional
impairment
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Let’s take a look at the
PHQ-9...
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PHQ-9 Administration
• Approximately 2 minutes to complete
• Youth complete independently
– Can be read aloud if necessary/desired
• “Over the last 2 weeks...”
• Encourage honest responses
– Informants can easily be influenced by the attitude of
the person administering the scale
– Let youth know that this questionnaire will help you,
as a clinician, better understand how they are doing
and how you can best help them
• Encourage responses on all items
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PHQ-9 Scoring
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Sum the items in the column labeled “Several days”, and
put that number on the line below that column
– Alternatively, you could count the number of items that
have been circled in this column and multiply by 1
Sum the items in the column labeled “More than half the
days”, and put that number on the line below that column
– Alternatively, you could count the number of items that
have been circled in this column and multiply by 2
Sum the items in the column labeled “Nearly every day”,
and put that number on the line below that column
• Alternatively, you could count the number of items that
have been circled in this column and multiply by 3
Add the three subtotals together to obtain the Total
Severity Score
In other words… sum all responses on items 1 thru 9
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Clinical Utility of the PHQ-9
• The PHQ-9 is a multipurpose tool that has
been used for:
– Screening
– Diagnosing
– Monitoring
– Measuring the severity of depression
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Clinical Utility of the PHQ-9
• For initial provisional diagnosis...
– If there are at least 4 “3’s” – including Q#1 and/or
Q#2 – consider a depressive disorder
• Consider a Major Depressive Disorder
diagnosis...
– If there are at least 5 “3’s”
• One of which must correspond to either Q#1 or Q#2
• Consider Other Depressive Disorder...
– If there are between 2 and 4 “3’s”
• One of which must correspond to either Q#1 or Q#2
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Clinical Utility of the PHQ-9
• Diagnoses of Major Depressive Disorder or
Other Depressive Disorder also require:
– Impairment of social, occupational, or other
important areas of functioning
• See Q#10
– And ruling out normal bereavement, a history of a
Manic Episode (Bipolar Disorder), and a physical
disorder, medication, or other drug as the
biological cause of the depressive symptoms
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Clinical Utility of the PHQ-9
• Total Score indicates Depression Severity:
Total Score Depression Severity
1-4 Minimal depression
5-9 Mild depression
10-14 Moderate depression
15-19 Moderately severe depression
20-27 Severe depression
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Clinical Utility of the PHQ-9
• Question #9
– Assesses presence and duration of suicidal
ideation
– Review this carefully after a youth has
completed the measure
• A “2” or “3”, reflecting more than half the days or
nearly every day, requires additional assessment
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Clinical Utility of the PHQ-9 with
DTQI
• Assessing Initial Severity of Depression
• Treatment Monitoring / Tracking Clinical
Progress
– Periodic assessments provide valuable
information regarding symptom severity
relative to treatment/interventions
• Outcome Assessment
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Clinical Utility of the PHQ-9 with
DTQI
• In DTQI, the PHQ-9 will be administered
(at least) four times:
1. Pre-DTQI
2. After Phase I (presumably, as you transition
from the Activities module to the Thoughts
module)
3. After Phase II (presumably, as you transition
from the Thoughts module to the Social
module)
4. Post-DTQI
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Clinical Utility of the PHQ-9 with
DTQI
• Individual client PHQ-9 scores are shared
with Maggie Rea (or other DTQI clinical
expert/trainer) to guide the clinical
consultation
– Total scores on the PHQ-9 provide valuable
information regarding the severity level of an
individual client’s depressive symptomotology
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Individual DTQI Client PHQ-9 Progress Graph
Client Name: __Example_____________________ VCBH ID: ________________
DTQI Therapist:: _________________________________
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20-27 = Severe
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15-19 = Moderate
Severe Depression
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10-14 = Moderate
Depression
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PHQ-9 Score
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5-9 = Mild
Depression
X
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0-4 = None/minimal
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X
11
X
9
7
5
X
3
Year:
20 __
20 __
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20 __
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20 __
Post-DTQI
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End of Phase 2
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Pre-DTQI
Date:
End of Phase 1
0
Clients
appreciate
seeing their
treatment
progress as
much as you
do!!
Using the Individual DTQI Client
PHQ-9 Graph
• Print as a ‘Slide’ and you will get the graph on a
full-page
• Use one per client
• Enter the Date of the Assessment at the
appropriate interval (Pre-DTQI, End of Phase I,
etc.)
• Plot the PHQ-9 score on the graph within the
appropriate assessment interval
• Once multiple scores are plotted, connect the
scores with a solid line
Outcome Assessment Using the
PHQ-9
• Comparisons of Pre- and Post- scores
reveal specific areas of treatment-related
improvement in child depression
– e.g.,
• Does the severity of depression symptoms
decrease substantially after participation in
DTQI?
• Is there improvement across all domains of
depressive symptoms?
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Outcome Assessment Using the
PHQ-9
• Data entry instructions for the Pre-DTQI and
Post-DTQI PHQ-9 scores will be forthcoming
from Behavioral Health
– Anticipated to begin July 1, 2012
• Data collection for outcome assessment will
begin with new clients
– Must have a true Pre-DTQI score to evaluate
outcomes
• Data collection for monitoring clinical progress
should begin immediately with current clients
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Materials You Will Need
• PHQ-9
– Provided in English and in Spanish
– Additional language versions are available at:
http://www.phqscreeners.com/overview.aspx?
Screener=02_PHQ-9
• Individual DTQI Client PHQ-9 Graph
– Provided in PowerPoint along with Example
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Questions
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The End
Contact Information
•Cricket Mitchell, PhD
•Email: cmitchell@cimh.org
•Cell phone: 858-220-6355
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