This Sunday marks my tenth Mother’s Day married to the dynamic Ana
Reitz. Thus, it is also the tenth
anniversary of when I gave her a 9-inch circular saw as a Mother’s Day gift. Now, please save your maternalistic eye rolls
for another blog post. She asked for the
saw and even picked out the model for purchase.
Unfortunately, as men and their tools go, I am a disorganized wuss. My ownings are scant and strewn amongst a
number of broken-down cardboard boxes in the garage. I don’t value them enough to invest in
them. I tend to buy them at garage sales
and in bargain bins because my children break and lose them along with the rest
of their playthings.
As a result, I am often required to make suboptimal usage of the tools
I do have accessible at any one time.
For example, during spring clean-up this year, I was forced to use my
wife’s 9-inch saw to prune trees. As sap
smeared the blade and sawdust sprayed my face, I reflected on the PHQ-9. A syllogism quickly formed in my mind:
9-inch saw :
Household cutting :: PHQ-9 : Clinical screening.
If you recently took the GRE, introduced yourself to an integrated care
referral, or pruned a tree, I’m sure this logic is readily apparent to you. To
the skilled craftsman or contractor, the 9-inch saw is of limited use. It is
only helpful for shortening lumber with quick, imprecise cuts. A professional would cry inside to see me use
it for pruning, ripping, demolishing, splitting, or chopping (all of which I
have done with my wife’s saw).
Rather than investing in a table saw, chain saw, miter saw, hack saw,
or ax, I grab the 9.
Such is the PHQ-9 in the integrated care setting. A clinician in a traditional private practice
would maintain a fully-stocked tool box of clinical assessments: Becks, GAD-7s,
Vanderbilts, Edinburghs, MDQs, OQ45s, Family Environment Scales, genograms, and an assortment of positive psychology
screens. Each tool would be closely fit to
a specific condition or patient. The
tools would provide precise diagnosis and symptom management.
Despite the myriad advantages, I rarely use the other assessment tools.
I grab the 9.
Don’t hate me
because I’m undutiful.
The PHQ-9 presents numerous advantages in primary care and teaching
- It is unbeatably easy to take and
score—especially when paired with the PHQ-2.
- Many EMR systems have
built-in smart forms that calculate the score, interpret the result,
auto-populate the HPI, and track the levels across time like a lab value.
- Health systems work most efficiently when the
operations are kept simple. While I’d
love to have nurses giving GAD-7s for patients with anxiety and MDQs for
bipolar, that level of sophistication is a fantasy.
- Integrated care charting is mostly a means of
communicating with other members of the primary care team. I prefer to use tools that are familiar to my
Our clinic’s experience with the Edinburgh Postnatal Depression Scale
and the "PHQ-12” provide compelling reasons for the PHQ-9 hegemony in primary
care. The Edinburgh is an excellent
depression screen that is more reliable in the pre- and post-partum periods
because it teases out the symptom overlap between pregnancy and
depression. Before going live on our EMR
it was our clinical standard to administer the Edinburgh to OB patients. However, our EMR isn’t hard-wired to easily
track and communicate the Edinburgh, so we reverted to using the PHQ-9 instead.
Regarding the "PHQ-12”, I invented it about 10 years ago while at Marillac Clinic. We were 1 of the first clinics to
widely adopt the PHQ-9. Back in the day
I noticed that the PHQ-9 and the GAD-7 had an overlap of 4 items and that by
adding the extra 3 GAD-7 items to the PHQ-9 we could create a brief screen that
gave scores for both depression and anxiety.
Many other clinics have adopted it and loved it. I loved it, too, until
we adopted the EMR. Because of the way
we needed to move the items around on the PHQ-9 to have them line up with
GAD-7, it made it much more difficult to enter the scores into the EMR’s PHQ-9
form. So, we reverted to the traditional
Who knows, maybe in a few years (after we haven’t adopted a new EMR 2
times within 1 residency cycle) I’ll up the bar and re-institute the Edinburgh and
PHQ-12 as first steps in reversing the
trend of trading precision for convenience. But, for this Mother’s Day, I’m giving all my
depressed (and anxious, grieving, and relationally conflicted) patients the
PHQ-9-Inch Circular Saw.
Shhh…don’t tell Ana, but I’ve wrapped up a miter saw for Sunday.
Reitz , PhD, LMFT is the Director of Social Media of CFHA and the Director of Behavioral
Science at St Mary’s
Family Medicine Residency in Grand Junction, CO. He and Ana Reitz have
3 children: Gabriela, Paolo, and Sofia. He posts his ideas at CFHA's Collaboblog and tweets at @reitzrandall.