5-point PHQ-9 changes are clinically important in elder depression
The 5-point threshold comes from 434 patients in a trial of 1,801 older adults with depression. Before each follow-up, compare the newest score with the last.
Head of Engineering, JotPsych
Do you review the last two Patient Health Questionnaire-9 (PHQ-9) scores before a follow-up with an older adult you treat for depression? Patients in the trial had major depression, dysthymic disorder, or both. Most had both.
Patients: 434 from the intervention group of a trial of 1,801 adults aged 60 or older with depression, mean age 71
Retest: 2 groups of study patients took the PHQ-9 twice, 7 days apart
Finding: a change of 5 points or more on the 0 to 27 scale is clinically important for one patient
Basis: 2 standard errors of measurement
The study tracked PHQ-9 change over 6 months of treatment. A change under 5 points can fall within the questionnaire's measurement error, so ask about a change of 5 points or more.
What a 5-point change tells you
Use the 5-point threshold when you treat older adults for depression. Löwe and colleagues rated the PHQ-9's test-retest reliability, how closely repeat scores agree, as excellent. In the same study, PHQ-9 change scores accurately distinguished patients with persistent major depression, partial remission, and full remission, as judged by structured diagnostic interviews.
The study's patients were treated in primary care. Each patient had access to a depression care manager supervised by a psychiatrist and a primary care expert, in a collaborative care trial in 18 clinics. The study gives no threshold for your patients under 60.
Before the visit
- Send the PHQ-9 before the visit. Patients can finish the questionnaire the day before, so the newest score is in your chart when you're preparing.
- Compare the newest score with the one before it. Check each score's date.
- Ask about any PHQ-9 change of 5 points or more. Whether the score rose or fell, start the visit by asking your patient what's changed since the last score, and write the answer in the note.
Kroenke, Spitzer, and Williams set these cut points in 2001 from 6,000 patients in primary care and obstetrics-gynecology clinics. A score of 5 starts the mild band, and a change of 5 points between two scores is a separate measure.
The same nine PHQ-9 questions give you the severity band and the change score. Read your patient's band and the change since the last score before you decide whether to adjust the plan.
In the JotPsych chart, choose the PHQ-9 under Assessments to see each score with its date and source.
Book 15 minutes- Löwe B, Unützer J, Callahan CM, Perkins AJ, Kroenke K. “Monitoring depression treatment outcomes with the Patient Health Questionnaire-9.” Medical Care 2004;42(12):1194-1201. PMID 15550799.
- Unützer J, Katon W, Callahan CM, and colleagues. “Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial.” JAMA 2002;288(22):2836-2845. PMID 12472325: 1,801 patients aged 60 or older.
- Kroenke K, Spitzer RL, Williams JB. “The PHQ-9: validity of a brief depression severity measure.” Journal of General Internal Medicine 2001;16(9):606-613. PMID 11556941.