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Mother's Day Edition: The PHQ-9-Inch Circular Saw

Posted By Randall Reitz, Thursday, May 10, 2012

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 settings:

  • 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 medical/nursing colleagues.

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 PHQ-9.

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.

9-inch saw 1


9-inch saw 2


9-inch saw 3









Randall 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.

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Comments on this post...

Barry J. Jacobs says...
Posted Thursday, May 10, 2012
Great job, Randall, and true. I don't use any other assessment tools any more either. And I agree that the EMR templates drive a lot of clinical care choices now because of convenience and familiarity. If a protocol/guideline/tool isn't a click away on a template, it might as well not exist.
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Randall Reitz says...
Posted Thursday, May 10, 2012
Barry, I find this most troublesome with genograms. I always had a tab for genograms in my paper charts, but have mostly stopped adding genograms to the EMR. I will occasionally have one scanned-in, but then I'm unable to easily update them.

I'm not a Luddite, but neither am I a bright-eyed H.I.T. supporter. This seems to be generally true of people who practice collaborative care. Here's a link to an article on collaboration in an EMR setting that I published in the current issue of FSH:
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Deb Seymour says...
Posted Thursday, May 10, 2012
I don't get around to reading blogs very much...but I will never miss another one of yours....not ever. Today's was a wonderful blast of humor and truth told beautifully!
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Kenny Phelps says...
Posted Thursday, May 10, 2012
While practicing in Primary Care, I typically used the PHQ for screening; however, I now practice in a Psychiatric Outpatient Clinic where we use every diagnostic screening and test under the sun. Looking at this from the other side, I have seen numerous patients referred to us for psychiatric treatment after a high score on the PHQ with their PCP that had resulting in prescription of a SSRI or other antidepressant by the PCP even though the patient actually had more of an Adjustment Disorder that would have benefited from therapy instead of medication intervention as a first line. I also worry that only relying on the PHQ and not other screenings or interviewing skills would lead clinicians to miss necessary symptoms such as mania, co-morbid anxiety, or psychosis that would strongly influence med choices or the focus of therapy. Nevertheless, the PHQ still offers Primary Care a useful "saw" for daily practice.
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Peter Y. Fifield says...
Posted Friday, May 11, 2012
Wonderful post Randall, but I don't know where to start. My head is still reeling from this etched visual of you hacking away at some poor tree with your circular saw. What is the arboreal equivalent to PETA? To be honest, I feel that all of the assessments we use are hack tools IF used as a stand-alone tool. You need to ask more questions but that can become an operational nightmare. As well, if you ask more questions, you obviously have to be ready to deal w/ the answers.

At our FQHC during our initial screening of patients we use the PHQ-9 coupled w/ the MDQ and the GAD-7 [all of which I used when working w/ Randall at the SCCC in Colorado]. All of these assessements are in our Centricity EMR which makes it wonderful to monitor in the flowsheet over time [to see if we can hit the magical 50% reduction for successful tx--according to the IMPACT model]. Therapeutically I tend to use it as a guide to not deal w/ the diagnosis per se but more so to address a few of the symptoms, one at a time. We have found that w/ the short term SFT approach that something this "small steps approach" is a bit less intimidating to the patient and more appropriate for the therapeutic approach. Sometimes just gaining some small bit of movement, to build momentum on is all we need. That being said, we obviously use the DSM-IV criteria [mirroring the PHQ9] to treat w/ psychopharm and as well a severity index "how bad is it [Sheehan disability scale]" mixed w/ a chronicity component "how long has this been going on" to rule out Adj. Disorders and the such. Both of these as well are tracked over time in the EMR's flowsheet.

The Zung, The Beck, The Edinburgh are similar in a way...a hack tool if used in isolation. Chainsaws are for the big logs, then a planner, then circular saw, maybe chop saw comes next, then the jig saw, a miter saw or even a table saw then some nails and even glue. All have their own purpose but fail miserably as a multi-tool.
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Jackie M. Williams Reade says...
Posted Friday, May 11, 2012
I may never look at the PHQ-9 the same after the visual image of a "hack" saw. :) Thank you for that!

I, too, have struggled with how to use the PHQ-9 in a way that is effective and beneficial for all involved. In a way, I see it as any other tool that we use - the tool isn't the problem, it's how we use it. On the other hand, I think if we use a tool that is looking for depression, then depression is what we will find - no matter what is actually going on.

I'd hope we could use the tool to assess for potential problems and that would lead to a conversation with the patient where we discuss these areas and collaborate with the patient about how we can best address these issues. The PHQ-9 addresses some important quality-of-life issues in today's stressed lifestyles - sleep, social activities, energy, mental attitude - and these are all areas we want to be talking about with patients, but talking about them as strictly being elements of "depression" is not always helpful.

In the end, sometimes you use a tool in a way that it is not meant to be used. We have those days, but to make it a common practice and not be aware of the hack saw potential is a dangerous move for all involved. So thank you for raising our awareness in this area, Randall!
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Elizabeth Horevitz says...
Posted Friday, May 11, 2012
What a great metaphor. The PHQ-9 is a wonderful tool, and it is one (along with the GAD-7) that we use regularly at my FQHC. However, I agree with some of the other posts here that bring up the important issue of the PHQ missing signs of mania, panic, substance use, psychosis, etc. While an argument could certainly be made that the PHQ-9 is a sufficient "catch all" tool, given that symptoms of depression are more common than, say, bipolar disorder or psychosis, I wonder if the universal adoption of the PHQ-9 "primes" us to look only for depression? Obviously, this is risky, if, say SSRIs are prescribed for someone who is actually bipolar (though hopefully the prescriber would ask some additional questions!).

One way to circumvent this problem is with a brief universal screen-- I've seen various iterations of Universal screens, but the best one I've seen (although not formally empirically validated yet), combines 13 questions taken from the PHQ-9, GAD-7, AUDIT, etc. and addressed substance use, insomnia, impulse control, depression, anxiety, intimate-partner violence, PTSD, & chronic pain. This type of regular Universal screening would help alert clinicians to areas requiring further and more targeted assessment, and could easily be built into the EMR. So, theoretically, if the patient answered the 2 depression questions positively, then it would be time to "reach for the 9".

Thanks for bringing up this important topic. It is a good sign for the state of the field that the conversation here is about WHICH screening/outcome measure to use, rather than IF screening/outcome measures should be used for behavioral health in primary care.

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Randall Reitz says...
Posted Friday, May 11, 2012
Everyone, thanks for the stimulating conversation. You have opened my eyes to other possibilities and unsettled me enough to consider other possible screening tools. I'm especially interested in the brief universal screen described by Elizabeth Horrevitz. If you can share it with us, please do. A brief all-in-one screen might justify the expense of building an EMR module to support it.

As with Barry, I believe that the EMR environment is the largest obstacle to expanding usage of other tools. But, also share the opinion of Jackie, Pete, and Kenny that the PHQ-9 is a great tool for depression, but entirely insufficient as a catch-all.

I would love to hear of the solutions you find to integrating multiple screens into your electronic charts.

Thanks everyone!
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