Brief Screening Tools Can Improve Patient Care

November 29, 2012
Heidi Anne Duerr, MPH

Medical colleagues routinely monitor patients with sphygmomanometers, peak flow meters, and glucometers. Similarly, psychiatrists can and should incorporate the use of screening tools to help with diagnosis and treatment management.

Brief screening scales should be a clinician’s best friend, according to Kurt Kroenke, MD, Professor of Medicine at Indiana University School of Medicine. Medical colleagues routinely monitor patients with sphygmomanometers, peak flow meters, and glucometers, so should psychiatrists incorporate the use of screening tools in their office to help with diagnosis and treatment management.

The benefits do not end there, Kroenke added. In addition to their clinical utility for physicians, patients appreciate scales in psychiatric settings.1 For instance, patients in one study said they felt screenings served as “efficient and structured supplement to medical judgment.” Patients also said the screenings were evidence that their physicians were taking their problems seriously through a full assessment.

Kroenke shared several basic screening scales for psychiatric disorders that have proven to be effective.  The Patient Health Questionnaire (PHQ-9) and a variety of other mobile-ready clinical scales are available on Psychiatric Times’ website at http://www.psychiatrictimes.com/clinical-scales.

PHQ-9
Validated in about 10,000 patients, the PHQ-9 screens against 9 DSM criteria for major depressive disorder. It is a self-administered and brief scale. The PHQ-9 can help with probable diagnosis and can help rule out bipolar disorder, acute grief, and organic issues. It is available in more than 80 different languages, and it has been incorporated into professional guidelines. Similarly, all 16,000 nursing homes that participate in Medicare utilize the PHQ-9.

Based on the 9 brief questions, patients can receive scores ranging from 0 to 27. Patients who score between 5 and 10 are considered to have mild depression. Those who score more than 10 have moderate depression. A score of 15 to 20 is indicative of moderate to severe depression, and a score of more than 20 indicates severe depression.

To avoid medicating when it is not necessary, Kroenke uses the score value as guide in determining when to initiate pharmacological treatment. He said he treats patients who score 15 or higher. If the patient’s score is between 5 and 9, he monitors the patient, but he does not provide medication. If the patient’s score sits between 10 and 14, he will consider initiating pharmacological treatment on a case-by-case basis.

The PHQ-9 can also help clinicians monitor patient improvement on medications. If a patient’s score drops 5 points, Kroenke considers the patient to have significant improvement. For response, he is looking for a reduction in score by about 10% or a score of less than 10.  If the score drops to 5 or less, he considers the patient to be in remission.

The PHQ-9 has been studied in special populations, including adolescents, postpartum depression, and geriatric depression, and was found to be comparable or better than its population-specific competitors, Kroenke said.  For geriatric populations, for example, it performed better than the Geriatric Depression Scale, he noted. Information on the PHQ-9 can be found at http://www.psychiatrictimes.com/clinical-scales/patient-health-questionnaire.

GAD-7
The GAD-7 brief screening instrument was developed to optimize accuracy and divergent validity, Kroenke told attendees. It can help detect generalized anxiety disorder, social anxiety disorder, posttraumatic stress disorder, and panic. Probably as good as any other general anxiety screener out there, Kroenke said the GAD-7 is better when used for screening than for monitoring treatment.

PHQ-15
To account for the “triangulation” of depressive, anxiety, and somatic symptoms, Kroenke and colleagues developed the PHQ-15 Somatic Symptom Severity Scale. Patients receive a score ranging from 0 to 30, with 0 to 2 points scored for items such as pain (back, head, stomach, chest, arm or leg), fatigue, sexual problems, and bowel problems. In all, the 15 symptoms account for 90% of non-upper respiratory tract symptoms. The somatic scale captures the majority of items on the other 4 major somatic screeners, Kroenke added.

Other Brief Scales
To help clinicians detect problems with pain or risk for suicide, Kroenke suggested attendees use the PEG-3 and P4 screeners, respectively. The PEG-4 screener asks patients 3 questions that rate pain, the impact pain has on their enjoyment of life, and how the pain affected their general activity. Kroenke noted the PEG-3 performs as well as longer scales.

The P-4 is used as a follow-up to patients who answer positively to the question regarding thoughts of hurting yourself or that you would be better off dead on the PHQ-9. Responses are graded into minimal, lower, or higher risk categories.

Concluding Clinical Tips
Screening tools should be integrated in routine psychiatric care, Kroenke told attendees. He noted it can be used a basis for discussions with patients in addition to indicating when patients need further screening and treatment. He cautioned that while the tools are very useful, they are not the gold standard, and clinicians still need to use their best judgment when working with patients.

[Note: To access mobile-friendly psychiatric clinical scales, please click here.]

Reference 1. Dowrick C, Leydon GM, McBride A, et al. Patients' and doctors' views on depression severity questionnaires incentivised in UK quality and outcomes framework: qualitative study. BMJ. 2009;338:b663.