Sarah K. Brown, DrPH

As more behavioral health organizations embrace the use of patient outcomes in treatment planning and quality measurement, the goal becomes identifying appropriate measures. Ideally, measurements would be brief, easy-to-use, and sensitive to patients’ concerns. For inpatient psychiatric settings, one such assessment may be the Patient Health Questionnaire (PHQ-9), as it is only 9 items, open-domain, patient self-report, and addresses mental health.

 in primary-care settings, the PHQ-9 has attracted interest as a measure of treatment outcomes in psychiatric settings.

 Research suggests the PHQ-9 can detect change in depression symptoms in a medical population and in outpatient psychiatric settings,

but it has not been validated as a measure of symptom improvement in acute inpatient psychiatric care.

One pitfall preventing validation of the PHQ-9 in inpatient settings may be the timeframe of symptom evaluation on the measure. On the typical PHQ-9, patients are asked to respond how frequently an item has been a concern in the last 2 weeks, ranging from “Not at all” to “Nearly every day.” However, inpatient stays in acute settings are rarely even 2 weeks in length, so this timeframe could undercut capturing change since admission. We propose an alternative evaluation period of 1 week, to fall within the length of a modern inpatient stay. Other studies have altered the timeframe of the PHQ-9 to address research questions,

 but routine use of the PHQ-9 with an altered timeframe has not been examined previously.

This analysis provides an example for use of a shortened-timeframe (1 week) PHQ-9 as a measure of outcomes for adult and geriatric patients in acute psychiatric inpatient treatment. We demonstrate that the PHQ-9 is far from limited in its applicability and can detect symptom improvement for patients—including those with diagnoses other than depression—within the span of an inpatient stay.


Admission and discharge PHQ-9 records were available for 27,991 adult and geriatric encounters from facilities participating in routine outcomes monitoring and benchmarking for acute psychiatric inpatient programs. The data represented 41 geographically diverse facilities across 2018 and 2019. For this sample, 43.5% of patients had a primary diagnosis of major depressive disorder (MDD). Average length of stay for the overall sample was 8.8 days, just over the modified PHQ-9’s 1 week evaluation period.

1 . The PHQ-9 can categorize depression in an acute inpatient psychiatric setting

At admission, average depression severity falls between the moderate and moderately severe category cutoffs for the total sample (14.6 of a possible 27 points, with higher scores indicating greater symptom severity). Patients with a primary diagnosis of MDD and patients without primary 

 scored in these category ranges (15.7 and 13.7 respectively).

By discharge, the overall sample’s average PHQ-9 severity was between mild and minimal ranges (score of 4.9). Both patients with a primary diagnosis of MDD and those without scored in these ranges (5.1 and 4.8 respectively).

As anticipated, patients with a primary diagnosis of MDD reported greater severity at both admission and discharge compared to non-MDD patients. Although those differences were significant, the effect is too small for meaningful conclusions.

2. The PHQ-9 can detect change in depressive symptomology

At discharge, the average decrease in severity indicates a significant and meaningful change (9.7 points) from admission to discharge (p<.001, Cohen’s d=1.155). Patients with a primary diagnosis of MDD reported a higher average change score compared to those without (10.6 and 9.0 respectively).

Change scores were evaluated using a reliable change index, revealing the majority (76.8%) of patients’ symptom improvement were statistically reliable. A higher proportion of patients with a primary diagnosis of MDD demonstrated reliable improvement than non-MDD patients (81.5% versus 73.1% respectively; p<.001).

3. The PHQ-9 captured depressive symptomology for most, but not all patients:

Roughly 6% of all patients in the sample reported no depression symptoms at admission (ie, a PHQ-9 score of 0), and the proportion was higher in the non-MDD group (8.4%) than the MDD group (3.7%).

4.4% of all patients reported a 0 at both admission and discharge. This group of patients showed 2 notable differences from other patients: a higher rate of primary diagnosis of anxiety disorders (including adjustment disorders and PTSD) than other patients and a shorter length of stay.

Our results suggest a modified 1 week timeframe PHQ-9 is effective at registering depression severity at admission and measuring change during a stay for most adult and geriatric psychiatric inpatients. The PHQ-9 may be tailored for people with depression, but depression symptoms overlap with many disorders, and there is often significant comorbidity in an acute setting.

Based on these findings, we believe the PHQ-9 is a broadly useful tool for treatment outcome measurement in psychiatric inpatient units. As is true with any measure, the PHQ-9 will not serve as the best measure of outcomes for all patients. There will be patients who report no difficulty with the PHQ-9 items, patients who report no improvement, or, unfortunately, patients who report greater difficulty at discharge. A patient may see an increase in depression symptoms while addressing addiction or trauma, for example.

As such, the PHQ-9 may be an effective asset in a clinician’s toolkit, along with their clinical judgment and therapeutic alliance to ensure treatment planning and outcome tracking is personal to each patient. 

are data analysts for Mental Health Outcomes, LLC., a subsidiary of Universal Health Services, Inc, Lewisville, TX.

1. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: Validity of a brief depression severity measure. 

2. Löwe B, Kroenke K, Herzog W, Gräfe K. Measuring depression outcome with a brief self-report instrument: Sensitivity to change of the Patient Health Questionnaire (PHQ-9). 

3. Beard C, Hsu KJ, Rifkin LS, Busch AB, Björgvinsson T. Validation of the PHQ-9 in a psychiatric sample. 

4. Cannon DS, Tiffany ST, Coon H, Scholand MB, McMahon WM, Leppert MF. The PHQ-9 as a brief assessment of lifetime major depression. 

5. Feng Y, Huang W, Tian T-F, et al. The psychometric properties of the Quick Inventory of Depressive Symptomatology-Self-Report (QIDS-SR) and the Patient Health Questionnaire-9 (PHQ-9) in depressed inpatients in China. 

Articles

The PHQ-9 may be an effective asset in a clinician’s toolkit, along with their clinical judgment and therapeutic alliance, to ensure treatment planning and outcome tracking is personal to each patient. 

Monitoring Patient Treatment Outcomes in Inpatient Psychiatric Care with the PHQ-9

Slideshows

Patients with serious mental illness such as schizophrenia are more likely to report greater impairment in general functioning as a result of trauma, which is why trauma-informed care is so important.

3 Essential Elements of Trauma-Informed Care

Compared with the general population, patients with serious mental illness are more likely to:

• Experience a traumatic event and have a higher number of overall trauma exposures

• Meet criteria for a diagnosis of PTSD during their lifetime and in the previous 12 months

• Report greater impairment in general functioning due to trauma

• Have increased use of health care services related to trauma

Previous research suggests that comorbid mental illness and post-traumatic stress interact to produce worse outcomes in patients, making trauma an important facet of a patient’s overall psychiatric care. However, diagnosis rates of PTSD in psychiatric inpatient treatment settings are consistently lower than expected given the rate of trauma exposure. It seems inpatient psychiatric treatment may focus more on primary psychiatric symptoms (eg, psychosis) that brought the patient in, while identifying and treating PTSD may be secondary.

Identifying trauma symptoms and psychological distress

Inpatient psychiatric outcomes data provide a unique opportunity to examine the presence of PTSD symptoms and diagnoses for patients with mental illness and how PTSD symptoms are related to overall psychiatric symptoms and functioning.

Data were analyzed for 4126 patient records with an Abbreviated PTSD Checklist (PCL-C-6) completed at admission to an inpatient psychiatric treatment program. The average admission severity for patients exceeded the suggested cutoff, indicating the likelihood of PTSD (patient average was 17.5 compared to cutoff of 14). A subset of these patients (29.6%) also had admission scores on the Behavior and Symptom Identification Scale (BASIS-32®), a measure of general functioning useful for monitoring behavioral health outcomes. Patients who scored at or above the cutoff on the PTSD screener had significantly higher levels of dysfunction on the BASIS-32 compared with patients who scored low (below the cutoff) on the screener.

Does routine trauma screening identify trauma in inpatient units?

Although the majority of patients (65.7%) had high scores on the PCL-C-6, only 7.6% of these patients also had a primary or secondary PTSD diagnosis. Those who were diagnosed may have just been the most severe: patients with PTSD diagnoses had higher PCL-C-6 scores and showed greater distress overall on the BASIS-32 compared with patients with high PCL-C-6 scores but no PTSD diagnosis. These findings suggest PTSD may be underdiagnosed in these populations, especially when symptoms of serious mental illness are at the forefront.

Our data support the presence and role of trauma in this population, and we see evidence of the need for trauma-informed care. Regardless of diagnosis, patients with serious mental illness and post-traumatic stress symptoms would likely experience benefit in both areas from trauma-informed care.

TRAUMA-INFORMED CARE does not mean only focusing on a specific traumatic incident; successful, trauma-informed care for patients with serious mental illness requires providers to do the following: 

 ASSESS TRAUMA: Recognition of a patient’s trauma can be achieved during the admission process via trauma screening. In fact, the current standards for accreditation by The Joint Commission (TJC) in behavioral health already require the use of such screeners. Current TJC estimates show roughly 95% of patients in accredited inpatient psychiatric programs are screened for trauma.

 Thus, many programs already collect these data, which should be made accessible and incorporated into treatment planning. In addition to admission screening, assessment of trauma and PTSD can easily be performed with the addition of a quick trauma screener, such as the PCL-C-6.

 Acknowledge trauma: Once assessed, trauma can be addressed with patient psychoeducation and by entering diagnoses or progress notes into the medical record. If PTSD is present in a reduced form, a remission specifier or “not otherwise specified” may also be considered. Inclusion in the medical record provides a history of the patient’s experiences and encourages a clinical focus on all relevant issues. Moreover, noting PTSD in a chart allows the patient a record of his or her history, which encourages the continuation of trauma-informed care at follow-up once the patient leaves the current facility.

 Treat trauma: While PTSD can be a recurrent disorder that may not be fully treated in one inpatient stay, it is theorized that co-occurring PTSD and serious mental illness are best treated in conjunction. New evidence suggests popular treatments for PTSD can be used with patients with co-occurring serious mental illness, including psychosis.

 Unfortunately, many clinicians report not feeling equipped with the training they need to engage in trauma-specific treatment. Given the high incidence of trauma exposure and PTSD symptoms in the population of patients with serious mental illness, we believe continuing education and training in this area should be a core component of behavioral health care practice.

Ms Nowlin and Dr Brown are data analysts for Mental Health Outcomes, LLC., a subsidiary of Universal Health Services, Inc, Lewisville, TX.

The authors report no conflicts of interest concerning the subject matter of this article. The views expressed in this article are the authors’ own and do not represent the official position of Universal Health Services, Inc. or of its subsidiaries, whose funding supported the data collection and preparation of the article.

 Mueser KT, Goodman LB, Trumbetta SL, et al. Trauma and posttraumatic stress disorder in severe mental illness. 

 Grubaugh AL, Zinzow HM, et al. Trauma exposure and posttraumatic stress disorder in adults with severe mental illness: a critical review. 

 The Joint Commission. Comparison Rates: Q2 2018. 

https://www.jointcommission.org/performance_measurement.aspx

 Alexander AA, Welsh E, Glassmire D M. Underdiagnosing posttraumatic stress disorder in a state hospital. 

 Sacks SA, Schwartz B, Mueser KT. A pilot study of the trauma recovery group for veterans with post traumatic stress disorder and co-occurring serious mental illness. 

 Swan S, Keen N, Reynolds N, Onwumere J. Psychological interventions for post-traumatic stress symptoms in psychosis: a systematic review of outcomes. 

Successful, trauma-informed care for patients with serious mental illness requires providers to assess, acknowledge, and treat trauma.

Sarah K. Brown, DrPH

Articles

Monitoring Patient Treatment Outcomes in Inpatient Psychiatric Care with the PHQ-9

3 Essential Elements of Trauma-Informed Care

Recognizing and Treating Trauma in the Inpatient Psychiatric Setting