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The reflection of her face in the mirror has faded from memory, although I often recall the red yarn that held her hair away from her face. The red hue was impossible to ignore.

I cannot remember her name and would never recognize her facial features if I saw her again—which I would not and could not. All I see in my mind’s eye is a static image, like a cut-out paper doll that never changes, forever fossilized in time.

She tied the yarn loosely behind her head, in tune with the fashion dictates of the day. It was not the yarn that grandmothers used to knit sweaters or socks—this yarn was made from many twines. That yarn became a bow, with loose ends trailing down, but not too far down. The yarn turned a low-slung 1950s-era ponytail into a professional woman’s fashion statement. It was worlds away from the high-perched ponytails of bubble gum-chewing bobbysoxers of yesteryear. This ponytail was perfect, without a hair out of place. According to the male chief resident, who reminded me to mirror this same woman whom I saw in the mirror, that was the way female physicians should dress—or so he said.

Loose locks left over from the free-wheeling 1960s, when women wore flowers in their hair, San Francisco-style, were discouraged, if not disdained. The only thing worse, that same senior resident mused, was a Jewfro, which was too ethnic for poker-faced psychoanalytically trained psychiatrists. Yet tight hair buns were too severe; psychiatrists-in-training were expected to project some empathy—but not enough to break tight boundaries.

The woman in the mirror was a senior resident, about to complete her program at a time when American women were still relatively rare in medicine. A few outstanding female physicians had made inroads in psychiatry. This young woman was also said to be outstanding, or so I was told—but not by her, for she never said a word.

More than once, I calculated how much time she devoted to perfecting her appearance, since she always seemed to be standing in the same place, like a mannequin, whenever I entered the anteroom to the restroom. She never spoke and never even turned her head; she merely nodded as she looked me in the eye, via that ever-present intermediary: the mirror. And I nodded back, too intimidated to start a conversation with a senior resident and one, at that, who was identified as “perfect.”

A short grosgrain ribbon encircled her collar and crisscrossed above the top button, somewhat like a man’s necktie, but feminized, as per the dictates of the day. In another era, that part of her “uniform” would have screamed Catholic school girl, especially if accompanied by a plaid skirt. But in this era it said “professional woman’s apparel,” which evolved into a uniform of its own. In hindsight, that picture-perfect ribbon that wrapped around her neck, like a noose, foreshadowed events to come.

There was something film noir-ish about this silent reflection, but film noir was not on my radar yet. Yet film noir was intimately linked to psychoanalysis, with Freudian-informed dream scenes and psychoanalytic-style voiceovers that simulated internal monologues or unconscious ideas. Voiceovers—rather than direct dialogue—narrated acts from the past or expressed unspoken thoughts in the present. Yet, there were no sounds in our superficial exchanges, no conversation at all. To this day, I wonder what that voiceover might have said or what she herself was thinking, had she chosen to speak. And I wonder if I should have spoken first.

For now, what I do know is that she died by her own hand, hanging herself some months later, shortly before finishing residency. As typically happens in the aftermath of 

—years or even decades later—we wonder what we could have said or should have seen. Perhaps tears had been streaming down her face, carefully concealed by makeup before modeling in the mirror.

Apparently, no one saw this coming, for surely someone in charge might have said something or done something. I can say nothing with certainty, save for the fact that a Jungian term, persona, and not a Freudian concept, best explains the indelible impression she made on me back then and decades later.

The reasons behind her suicide remain as mysterious as her reflection in the mirror. I first heard of the tragedy through a billing clerk, who dashed about frantically, checking on the residents’ well-being, and looking relieved whenever she saw someone alive. It was she who said that a young female resident had died, whose name was still unknown. The concept of copycat suicides had not been coined, but this middle-aged, motherly woman intuited this possibility. Other information arrived via rumor only. Post-suicide debriefings were not part of the protocol back then, although they are now standard when residents or medical students take their lives. The chief resident—the one who anointed her as the chosen one, the one to be emulated, for she was perfect in appearance—never said another word.

Perfection is one trait that is most closely linked with depression. Perfectionists are always operating at a deficit, because it is impossible to be perfect. The unquenchable need to be perfect at all costs and under all circumstances has been loosely linked to 

 in general and to physician suicides as well.

Physician suicides have been on the radar for decades, if not for centuries, but these tragic events are attracting even more attention today. More and more doctors complain about burnout and many chose early retirement, even in the face of physician shortages. Statistics show that half of all physician 

Today’s buzzword is burnout—perhaps to soften the fear of impending suicide and perhaps to prevent the worst consequences. There are many reasons for physician burnout, including among other factors, dissatisfaction with unwieldy electronic health records, loss of professional autonomy in the face of managed care, overwhelming medical school loans, declining prestige or power in society, and stigma associated with seeking psychiatric help. Age-old scourges of drugs and alcohol may also be involved; although doctors are no more likely to develop alcohol problems than non-doctors, they can access lethal drugs more easily.

There are many contributors to professional dissatisfaction, just as there are many contributors to depression itself (besides plummeting dopamine levels). And there are many contributors to that final act of suicide. However, this is not news, even though contemporary stressors have changed. According to a recent Medscape article, the high rate of physician suicide, compared with the general population, was known 150 years ago.

The numbers are striking, yet most suspect that the rates of doctor suicides are underestimated and that many unexplained deaths are not recorded as suicides. Between 300 and 400 physician suicides occur each year. To put it differently, about one doctor dies by their own hand every day. The size of an entire medical school class completes suicide every year. Male physicians have twice the risk for suicide as men in the general population, even though they care for their medical health better than average, with lower rates of smoking, cardiovascular disease, or cancer. 

 by female physicians approximate the number of male physician suicides but, because women overall are half as likely to complete suicide as men, the comparisons between rates of suicides of female physicians and rates among female members of the general population is glaring. Female physicians are 4 times as likely to die from suicide as women who are not physicians. (Computing the statistics gets confusing, but it is worth doing.)

What does this say about this unnamed resident whose reflection I saw in the mirror? That her untimely death was consistent with statistics? Yes, but no. She was in a program that mandated personal analysis, which may or may not have been helpful, so we cannot blame stigma for avoiding psychiatric treatment. What can we blame, if anything at all? Perhaps nothing, or perhaps our own refusal to see past the mask and to admit that outward perfection is not necessarily perfect.

What I can say with near certainty is that I never saw her personal reflection in the mirror. I saw only the reflection of her persona, the theatrical mask presented to the public used to conceal the inner anima or soul or authentic being. Jung borrowed this term from Greek theater, where masks established an actor’s fictional identity on stage. Thousands of years later, this word remains relevant.

Perhaps this persona also hid an unexpressed and unacceptable shadow side, to use Jung’s vocabulary. As per Jung (and I have no proof that he was even remotely correct), each of us has a shadow side, which we must confront and eventually reconcile. Yet it is probably extra difficult for people who must be perfect to come to terms with such imperfections.

What can we learn from this sad story, other than the fact that perfect poses may be nothing more than poses and that the poseur may be enduring greater distress than is apparent to the untutored eye? Perhaps this vignette can remind us of the need to pay even closer attention to those who appear perfect—and to avoid imposing demands for perfection at every step along the way.

 is assistant clinical professor of Psychiatry and Behavioral Sciences at Icahn School of Medicine at Mt Sinai, New York, NY.

1. LoboPrabhu S, Summers RF, Moffic HS, Eds. 

Combating Physician Burnout: A Guide for Psychiatrists, 

1st ed. Washington, DC: American Psychiatric Association Publishing; 2020.

3. Gold KJ, Schwend TL. Physician suicide—a personal and community tragedy. 

4. Duarte D, El-Hagrassy MM, Castro e Couto T, et al. Male and female physician suicidality: a systematic review and meta-analysis. 

As typically happens in the aftermath of suicide—years or even decades later—we wonder what we could have said or should have seen.

Of Personas and Perfection—and Physician Suicide

Major depressive disorder (MDD) is the leading cause of global disease burden.

 of MDD in the United States has continued to increase among all age groups.

 Patients with these disorders are twice as likely to suffer from a comorbid substance use disorder (SUD) compared with the general population, and the severity of the S6UD parallels that of MDD.

 The comorbidity poses treatment challenges, and patients have been found to have poor outcomes (eg, increased substance use, more severe disease burden, higher rates of suicide attempts and behaviors), as well as an overall increased mortality.

The tight association between MDD and SUD does not necessarily hint at causation, as substance use can lead to mental health symptoms and conditions; mental illness can lead to self-medicating with substance use; and both conditions may co-occur independently as in the case of overlapping predisposing genetic factors. For patients with the comorbidity treatment gaps exist. 90% of those with SUD do not get MDD treatment, and 55% of those with MDD do not get SUD treatment when addressed independently, while 33% of them get no treatment at all.

Both MDD and SUD are in the DSM-5 and hence it is our responsibility to treat them as part of our routine psychiatric practice. Treating depression and substance use independently and in isolation of each other is incongruent with 

 Guidelines recommend simultaneous and integrated treatment with pharmacotherapy and/or psychotherapy for MDD depending on disease severity.

As for how closely these guidelines are followed, no study to date has investigated whether those with the SUD comorbidity receive similar MDD care to those without SUD among the pharmacotherapy and psychotherapy-based treatment modalities, or the degree to which specific SUDs are differentially associated with the receipt of guideline-specific MDD treatment. 

 Do patients with MDD and comorbid SUD receive similar, guideline-concordant, care as those without SUD?

 of 53,034 patients in whom MDD was diagnosed in the 2017 fiscal year in the US Veterans Health Administration (VHA).

 The patients were all veterans receiving care through the US Veterans Health Administration system. They all had a diagnosis of depression made in 2017.

 Electronic medical record data was reviewed to identify patients from both inpatient and outpatient encounters who were diagnosed with depression using ICD-10 codes and Patient Health Questionnaire (PHQ) screens. The PHQ was required to have been documented within a 30-day window of the depression diagnosis in order to capture active depressive episodes. Exclusionary criteria targeted patients with a past depressive diagnosis or who had received prescription antidepressants (except trazodone) or 

 in the past 12 months prior to the index diagnosis date. Also excluded were those with positive PHQ scores documented between 30 days and 12 months before the index depression diagnosis. Patient with comorbid bipolar disorder, schizophrenia, psychosis, personality disorder or developmental disorders, or those with more than 30 days of inpatient treatment in the last year were also excluded. Patients with comorbid SUD were identified as receiving a SUD diagnosis in the year before the depression diagnosis, as identified using ICD-10 codes meant to capture alcohol, opioid, cannabis, cocaine, stimulants, and other SUDs.

The outcomes measure assessed was adherence to treatment guidelines. For this, the authors used 

Healthcare Effectiveness Data and Information Set

 (HEDIS), which is a set of performance measurement tools developed and maintained by the National Committee for Quality Assurance (

) and widely used to assess where improvements can make a difference. HEIDIS is intended to allow comparisons among various health plans, systems, as well as adherence to national benchmarks and guidelines.

Among patients who received an initial prescription for antidepressants within 90 days of the index, depressive disorders to HEDIS based measures related to pharmacotherapy were applied. These resulted in measurements of adequate acute phase treatment (receipt of an antidepressant prescription within 90 days of diagnosis that provides medication for at least 84 of the 114 days following initial prescription); adequate continuation phase treatment (continuing antidepressant for 180 of the first 231 days following initial script).

) was also examined using metrics analogous to HEDIS. Here they evaluated both acute phase treatment (psychotherapy sessions that occurred within 90 days of the index depression diagnosis), as well as continuous phase treatment (at least 3 psychotherapy sessions in the 12 weeks following the first session). Additionally, the authors considered the confounding element that psychotherapy could be delivered for both depressive disorders and SUDs hence, in the analysis-only sessions for whichdepressive disorders were the primary diagnosis were included.

The authors also aimed to adjust for patient demographics (age, gender, race, geographical locality, and distance from the VA) and clinical characteristics (comorbid mental health disorders, measured by the Elixhauser score for severity).

. Sample characteristics across all described covariates were compared between those with and without SUD. Four multivariate logistic regression models were conducted to assess the associations between the presence of a SUD diagnosis and adequate acute and continuous phase antidepressant or psychotherapy treatment. Adjustments for covariates were done for each model.

The authors estimated percentages of those receiving treatment across each of the depression care metrics (those with and without comorbid SUD) as the marginal means of balanced population based on the model. Associations of specific SUDs with depression treatment were examined via the 4 models with each SUD independently analyzed. Authors also descriptively examined the setting where patients with SUD were receiving depression treatment.

Among the 53,034 participants diagnosed with a new episode of depression during the 2017 fiscal year, 52.9% received antidepressant treatment and 34.9% received psychotherapy within 90 days following diagnosis. Of this cohort, 14.2% had a SUD diagnosis in the year prior to the depression diagnosis.

Patients with SUD comorbidity had more visits in mental health and primary care settings in the year following the depressive diagnosis (average of 14.1 visits [SD 18.1] compared with 10.2 visits [SD 10.9] among those without SUD). Unfortunately, despite this higher opportunity for depression treatment, those with SUD received significantly less guideline-concordant depressive treatment across all metrics.

Before adjusting for covariates, observed rates show acute and continuation-phase antidepressants were provided to 59.4% and 36.3% of those with SUD and MDD versus 66.2% and 44.8% of those with just MDD (

. In terms of psychotherapy, 31.6% and 26.8% of those with SUD received acute and continuation-phase treatment respectively, compared to 35.4% and 32.2% of those with just MDD (

). For those with SUD, most received treatment in metal health clinics (47% psychotherapy [N = 1117]; 59.1% antidepressants [N = 2390]); or in primary care/mental health integration clinics (42.7% psychotherapy [N = 1014] and 31.8% antidepressants [N = 1287]). A very small minority received depression treatment in SUD specialty clinics (3.5% psychotherapy [N = 83] and 2.5% antidepressants [N = 102]).

In terms of patient characteristics, those with SUD were slightly younger, male, African American, homeless, and had comorbid psychiatric conditions. Those without SUDs were more likely to be service connected, live in rural areas, and have more comorbid diagnosed medical conditions.

Patients with SUD had lower odds of receiving guideline-concordant care, specifically 21% lower odds of receiving acute antidepressant treatment, 13% lower odds of initial psychotherapy treatment, 26% lower odds of adequate continuation of antidepressant, and 19% lower odds of continuation of psychotherapy.

Based on predicted probabilities of receipt of guideline-concordant depression treatment, an estimated 55% of individuals with comorbid SUD, compared with 61% without, received adequate acute antidepressant treatment, and 27% of individuals with comorbid SUD, compared with 29% without, received initial psychotherapy. As for cotinuation of treatment, 33% of individuals with comorbid SUD, compared with 40% without, received adequate continuation of antidepressants, and 22% of individuals with SUD, compared with 25% without, received adequate continuation of psychotherapy.

In terms of specific SUDs, lower quality depression care was evident across all evaluated substance types. Alcohol and cannabis use disorders were associated with significantly lower odds of adequate continuation of antidepressants (adjusted OR 0.81, 95% CI = 0.75, 0.88, p < 0.001 and adjusted OR 0.74, 95% CI = 0.63, 0.87, p < 0.001 respectively). Alcohol and cocaine use disorders were associated with lower odds of initiation of psychotherapy for depression (adjusted OR 0.86, 95% CI = 0.81, 0.91, p < 0.001 and adjusted OR 0.78, 95% CI = 0.66, 0.92, p < 0.001 respectively). Alcohol use disorders alone were associated with lower odds of adequate psychotherapy continuation (adjusted OR 0.81, 95% CI = 0.72, 0.90, p < 0.001).

There were also several covariates associated with lower odds of guideline-concordant care. These included homelessness, racial and ethnic minority groups, those in rural areas, and those with high psychiatric disease burden living farther away from a health care facility.

This retrospective review study of patients in the Veteran Healthcare Administration system points to a treatment gap in the delivery of guideline-concordant care for depression among those with SUD compared with those without it.

This study assessed an interesting question: do patients with comorbid MDD and SUD receive different care for depression than those without SUD? Consistent with previous data

 in a large national sample of veteran patients within the VHA system, the authors found that having the comorbid SUD diagnosis is associated with lower quality of depression treatment compared with those without it.

 After accounting for various demographic, medical, and psychiatric factors, patients with SUD had lower odds of adequate acute phase treatment (21% and 13% lower for antidepressant and psychotherapy, respectively) and lower odds of adequate continuation of treatment (26% and 19% lower for antidepressant and psychotherapy, respectively) for depression. This discrepancy in guideline-concordant care for depression comes despite patients with SUD having higher health care utilization (more visits and medical encounters) and hence more opportunities for MDD treatment initiation. Knowledge of this treatment gap is important because SUD and MDD affect each other bidirectionally, and the most effective approaches involve concurrent treatment.

There are several limitations to this study. As the authors point out, this sample is limited to veterans in care within the VHA system. The generalization outside this system, and to civilians with various insurance coverages, is unknown. Additionally, the analysis does not include or account for services rendered outside the VHA system, where it is not uncommon for veterans to seek care from.

The diagnosis of MDD as well as SUD is identified here based on ICD-10 codes entered in the electronic health records, which can at times contain errors or not even be entered at all.

There is no mention of how closely providers actually adhere to the use of screening tools such as PHQ-9. It is also necessary to consider that there are other widely available tools that are not accounted for here. It is important to keep in mind that lack of training in the assessment and treatment of complex presentations such as comorbidity leads to inaccurate beliefs and stigmas, an inability to accurately identify co-occurring disorders,

 a lack of awareness of appropriate referral sources,

 and a lack of preparedness to treat co-occurring disorders.

 The providers caring for these patients are not explicitly defined here as to whether they are highly trained physicians or independently practicing nurse practitioners.

The severity of the MDD is not specifically described here via the use of any objective measure.

 Because engagement (or refusal) in treatment represents a patient-specific barrier, having a significant MDD severity, which patients with SUD comorbidity do, can lead to low motivation and lack of interest and future outlook, and hence would make it less likely for patients to be interested in and pursue treatment as well as adhere to it.

The sample selection criteria (new diagnosis of depression in fiscal year 2017 and a positive PHQ depression screen 30 days surrounding time of diagnosis) may lead to limits of generalizability of findings to the degree that these criteria may not capture most patients with depression (ie, preexisting diagnosis, noncompletion or adherence with depression screen).

Worthy of mention is that in the context of certain substances (ie, stimulant or cannabis), MDD may have psychotic features and hence require treatment with nontraditional modalities such as antipsychotics, rather than antidepressants. Within the limits of the study design it is also difficult to determine whether the MDD is due substance use or withdrawal.

The primary outcome measures here were based on the HEDIS, which has been criticized in the past for how its individual measures provide a narrow view of health care quality and interventions. There is also a question about whether attainment of their measures actually indicate better outcomes. In this study, the indicators of adequate acute and continuous phases of care (which are most often used measures of the quality of depression care) certainly do not encapsulate all features relevant to high-quality depression care. Nonetheless, HEDIS is part of NCQA’s accreditation process and attainment is globally used as incentive for many health plans and 

The data generated here is consistent with the challenges in treating patients with an SUD comorbidity and it points toward the need to better address the rapidly expanding dual-diagnosis population. From here, next steps towards improvement of delivery of care to this population should include efforts at specifically identifying barriers that account to this gap, whether clinician related, institutional or system.

is assistant professor of psychiatry at Dartmouth’s Geisel School of Medicine and Director of Addiction Services at New Hampshire Hospital, Concord, NH. He is Addiction Section Editor for 

. The author reports no conflicts of interest concerning the subject matter of this article.

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1. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. GBD 2016 Disease and Injury Incidence and Prevalence Collaborators. 

2. McCance-Katz E. US Department of Health and Human Services. National Survey on Drug Use and Health. 2019. September 2020. Accessed November 20, 2020. 

https://www.samhsa.gov/data/sites/default/files/reports/rpt29392/Assistant-Secretary-nsduh2019_presentation/Assistant-Secretary-nsduh2019_presentation.pdf

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https://www.drugabuse.gov/sites/default/files/rrcomorbidity.pdf

4. Trivedi RB, Post EP, Piegari R, et al. Mortality among veterans with major mental illnesses seen in primary care: results of a national study of veteran deaths. 

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Clinical Guidelines Committee of the American College of Physicians. Nonpharmacologic versus pharmacologic treatment of adult patients with major depressive disorder: a clinical practice guideline from the American College of Physicians

7. VA/DoD Clinical Practice Guideline for the Management of Major Depressive Disorder Management of Major Depressive Disorder Working Group:. US Department of Veterans Affairs, US Department of Defense. 2016. Accessed November 20, 2020. https://www.healthquality.va.gov/guidelines/MH/mdd/VADoDMDDCPGFINAL82916.pdf

8. Coughlin LN, Pfeiffer P, Ganoczy D, Lin LA. 

Quality of outpatient depression treatment in patients with comorbid substance use disorder

9. Han B, Olfson M, Mojtabai R. Depression care among adults with co-occurring major depressive episodes and substance use disorders in the United States. 

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11. Hawkins EH. A tale of two systems: co-occurring mental health and substance abuse disorders treatment for adolescents. 

12. Carey KB, Purnine DM, Maisto SA, et al. Treating substance abuse in the context of severe and persistent mental illness: clinicians’ perspectives. 

13. Foster S, LeFauve C, Kresky-Wolff M, et al. Services and supports for individuals with co-occurring disorders and long-term homelessness. 

14. Sterling S, Weisner C, Hinman A, et al. Access to treatment for adolescents with substance use and co-occurring disorders: challenges and opportunities. 

15. Clark HW, Power AK, Le Fauve CE, et al. Policy and practice implications of epidemiological surveys on co-occurring mental and substance use disorders. 

16. Blumenthal D, Gokhale M, Campbell EG, et al. Preparedness for clinical practice: reports of graduating residents at academic health centers. 

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https://www.va.gov/opa/pressrel/pressrelease.cfm?id=2847

Are patients with depression and substance use disorder getting an appropriate level of care? Our Journal Club piece investigates.

An Inside Look at Depression Treatment Among Patients With Addictive Disorders

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. 

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

People suffering from depression die, on average, 10 years earlier than non-depressed individuals.” You must have heard this while attending a conference, reading a journal, or simply in a discussion with a colleague. It has little to do with the risk of suicide: we are mainly talking about death due to physical causes and, in particular, cardiovascular causes. Any mental health professional, upon learning of this fact, may have felt uneasy, even inadequately prepared to address such a complicated issue. After all, until a few years ago, we thought that colleagues from other branches of medicine would take care of those aspects, right? Well, no. A million times, no.

The clinical perspective of the individual practicing physician may not always align with epidemiological data. The excess mortality in depressed populations is an apt example. Without delving into a detailed analysis of the literature, there has been a wave of studies showing an alarming phenomenon: given a certain period of observation, a higher rate of people with depression die than those without depression—this appears to be the case for both genders, but especially for males, and for healthy as well as physically ill individuals.

Clearly, it is difficult to account for all factors that may underlie this phenomenon, and this association does not necessarily mean that depression causes death, even if we consider longitudinal studies.

 Nonetheless, depression is consistently associated with conditions that are known to increase the risk of cardiovascular diseases (

). More importantly, and arguably more likely to be causally related, individuals with depression tend to engage in unhealthy lifestyles, which are potentially modifiable: unbalanced diet, alcohol use, cigarette smoking, lower adherence to medications, and physical inactivity.

In particular, individuals who are depressed not only spend less time engaging in physical activity, but they also 

 sedentary behaviors more commonly than their non-depressed counterparts.

 Ultimately, individuals with depression have low levels of physical fitness, which may not be surprising, but should raise concerns among clinicians because of the implications for mortality. Both muscular strength and cardiorespiratory fitness are meaningful predictors of all-cause mortality and cardiovascular events in men and women.

The epidemiological and experimental evidence showing the wide-ranging beneficial effects of physical activity and 

 for health has proliferated over the past 70 years. Physical activity and exercise are now recognized as fundamental tools for reducing the impact of chronic diseases, especially cardiovascular mortality, as well as improving their course.

1. Exercise directly improves cardiorespiratory fitness. 

Randomized trials show that even short bouts of exercise can improve cardiovascular function, in younger as well as older individuals.

The most effective intervention to lose weight remains caloric restriction. Nonetheless, regular exercise can prevent obesity and excess weight and can buffer some of their negative effects.

 This effect seems to depend on improved regulation of appetite hormones and increased metabolic rate.

3. Exercise improves the function of homeostatic systems. 

The hormonal response to stress, such as the activity of the HPA axis, get fine-tuned by regular exercise and higher cardiorespiratory fitness, showing a blunted response to mild or familiar stressors, and faster recovery.

 Moreover, exercise reduces inflammatory responses and delays the aging of the immune system.

 It also improves the autonomic control of the heart in addition to other organs.8

Randomized clinical trials have shown that exercise improves glycemic control and reduces insulin resistance. Moreover, it improves the lipid profile, by lowering triglycerides and low-density lipoproteins and increasing high-density lipoproteins.

The antihypertensive effect is greater in individuals who already have hypertension, but it is also observed among healthy people.

Despite some controversies, the antidepressant efficacy of exercise has been established with methodological rigor, and exercise can be prescribed as a treatment for mild-to-moderate depression alone or for severe depression in conjunction with other treatments.

 If depression improves, this may reflect positively on behavioral sequalae, including unhealthy lifestyle.

Currently, only a few lifestyle-related cardiovascular risk factors have not been shown to respond significantly to exercise, namely alcohol consumption and cigarette smoking. Still, early results related to smoking cessation, problem drinking, and substance use among individuals with mental health disorders show promise.

 of randomized controlled trials indicate that exercise may ultimately have a significant effect on delaying mortality in patients with established coronary heart disease, stroke, heart failure, and diabetes, to an extent that is comparable to that of first-line medications.

 Clearly, enthusiasm for these findings must be tempered by the relative scarcity of available direct head-to-head studies (exercise vs medications), and by the so-called file-drawer bias, whereby negative results may not get published as much as positive ones. On the other hand, however, literature on exercise, compared with other types of interventions, may be less prone to distortions due to financial conflicts of interest.

The clinician may wonder if evidence from populations with physical illness could be directly translated to individuals with depression. Studies pertaining specifically to individuals with depression are not abundant, but preliminary evidence suggests that the benefits of exercise may apply to this population as well. Overall, given the lack of studies directly testing this hypothesis in depressed populations, the evidence is speculative. That said, considering the benefits and the low clinical risks associated with exercise, we believe recommending exercise to patients with depression and physical comorbidities should already be the norm, rather than the exception.

Given the emerging evidence, interventions to improve the lifestyle of patients with depression seems a viable strategy that may ultimately help to reduce mortality risk.

 But, how can a clinician achieve this seemingly ambitious goal? How is it possible to promote physical activity in individuals that already suffer from a lack of motivation, low sense of physical energy, and reduced initiative as intrinsic symptoms of their mental health condition?

Currently, various recommendations have been proposed for prescribing exercise to individuals with depression, based on either empirical evidence or clinical experience.

 The optimal exercise prescription for the treatment of depression is not known, insofar as the relation between the “dose” of exercise (ie, intensity, frequency, duration) and therapeutic response remains mostly unknown. Therefore, 

 are essentially derived from guidelines that were not specifically developed for depression.

First, the treating clinician should confront and reassess their own prejudices.

 Physicians are sometimes resistant to the idea of exercise as a possible treatment option, or even as an adjunct intervention. Skepticism may depend on various perceived barriers, including the belief that depressed individuals will not even start to exercise, or that they will soon abandon this activity.

 However, especially if good therapeutic alliances exist, many individuals with subthreshold, mild, or moderate depressive symptoms will opt for exercise and will demonstrate satisfactory adherence.

Second, consider one of the main drivers of any activity: pleasure. Affect-based exercise prescription is an emerging trend in exercise science and may be especially useful for the treatment of depression.

 This method goes beyond the traditional focus of exercise prescriptions, which is maximizing fitness or health gains and minimizing risk, to include the promotion of pleasant affective experiences. The consideration of pleasure as a central element aims to ultimately promote adherence.

, the exercise participant is shown a simple rating scale (eg, ranging from +5 or “I feel very good” to -5 or “I feel very bad”) and is instructed to self-regulate their exercise intensity and duration to maintain a rating of +3 (“I feel good”) or higher. Among adults without depression, the affective responses to exercise are associated with the amount of physical activity individuals subsequently choose to do.

 Even if individuals with depression suffer from symptoms of anhedonia, they may still experience exercise as pleasant and affect-enhancing.

Evidence from studies of individuals with depression shows that the affective responses to exercise may predict improvement of depressive symptoms and exercise adherence.

 This method seems to hold promise for clinical application due to its simplicity, making it appealing to physicians who lack specialized training in exercise and to health care organizations concerned about implementation costs. When recommending exercise to patients, the steps and processes for promoting exercise in individuals without depression may prove useful (

Third, mental health professionals should not rely only on themselves to prescribe exercise. Exercise interventions can be delivered by professionals with a variety of disciplinary backgrounds, including group exercise leaders, personal trainers, clinical exercise physiologists, wellness specialists, and physical therapists. 

 that is supervised by a professional is usually associated with lower dropout rates. Given the challenging cognitive and affective features of depression, exercise for individuals with depression should be delivered by professionals with specific experience in mental health care.

 In other words, a well-integrated, collaborative approach is absolutley essential to achieve the best possible effects.

The premature mortality of individuals with depression is an alarming public health concern. Physical exercise may help address this concern, but it represents an underutilized intervention despite substantial evidence documenting its numerous physical benefits. Exercise can simultaneously tackle several mechanisms that likely lead to premature mortality in this population. Moreover, if it is prescribed, delivered, and supported correctly, exercise can be as effective as other first-line treatments in reducing depressive symptoms, while being mostly free of adverse side-effects.

is assistant professor, Department of Neuroscience, University of Ferrara, Parma, Italy; 

 is professor, Department of Kinesiology, Iowa State University, Ames, IA. The authors report no conflicts of interest concerning the subject matter of this article.

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2. Schuch F, Vancampfort D, Firth J, et al. Physical activity and sedentary behavior in people with major depressive disorder: A systematic review and meta-analysis. 

3. Lieberman DE. Is EExercise Really Medicine? An evolutionary perspective. 

4. Magutah K, Thairu K, Patel N. Effect of short moderate intensity exercise bouts on cardiovascular function and maximal oxygen consumption in sedentary older adults. 

5. Ekkekakis P, Vazou S, Bixby WR, Georgiadis E. The mysterious case of the public health guideline that is (almost) entirely ignored: call for a research agenda on the causes of the extreme avoidance of physical activity in obesity. 

6. Chen C, Nakagawa S, An Y, Ito K, Kitaichi Y, Kusumi I. The exercise-glucocorticoid paradox: how exercise is beneficial to cognition, mood, and the brain while increasing glucocorticoid levels. 

7. Campbell JP, Turner JE. Debunking the myth of exercise-induced immune suppression: redefining the impact of exercise on immunological health across the lifespan. 

8. Besnier F, Labrunée M, Pathak A, et al. Exercise training-induced modification in autonomic nervous system: an update for cardiac patients. 

9. Lin X, Zhang X, Guo J, et al. Effects of exercise training on cardiorespiratory fitness and biomarkers of cardiometabolic health: a systematic review and meta-analysis of randomized controlled trials. 

10. Naci H, Salcher-Konrad M, Dias S, et al. How does exercise treatment compare with antihypertensive medications? A network meta-analysis of 391 randomised controlled trials assessing exercise and medication effects on systolic blood pressure. 

11. Ekkekakis P, Belvederi Murri M. Exercise as antidepressant treatment: time for the transition from trials to clinic? 

12. Smits JAJ, Zvolensky MJ, Davis ML, et al. The efficacy of vigorous-intensity exercise as an aid to smoking cessation in adults with high anxiety sensitivity: a randomized controlled trial. 

13. Patten CA, Bronars CA, Douglas KSV, et al. Supervised, vigorous intensity exercise intervention for depressed female smokers: a pilot study. 

Physical activity and exercise are recognized as fundamental tools for reducing the impact of chronic diseases, including depression.

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