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Characteristics, Management, and Depression Outcomes of Primary Care Patients Who Endorse Thoughts of Death or Suicide on the PHQ-9

Journal of General Internal Medicine Aims and scope Submit manuscript

ABSTRACT

BACKGROUND

With increasing emphasis on integrating behavioral health services, primary care providers play an important role in managing patients with suicidal thoughts.

OBJECTIVE

To evaluate whether Patient Health Questionnaire-9 (PHQ-9) Item 9 scores are associated with patient characteristics, management, and depression outcomes in a primary care-based mental health program.

DESIGN

Observational analysis of data collected from a patient registry.

PARTICIPANTS

Eleven thousand fifteen adults enrolled in the Mental Health Integration Program (MHIP).

INTERVENTIONS

MHIP provides integrated mental health services for safety-net populations in over 100 community health centers across Washington State. Key elements of the team-based model include: a disease registry; integrated care management; and organized psychiatric case review.

MAIN MEASURES

The independent variable, suicidal ideation (SI), was assessed by PHQ-9 Item 9. Depression severity was assessed with the PHQ-8. Outcomes included four indicators of depression treatment process (care manager contact, psychiatric case review, psychotropic medications, and specialty mental health referral), and two indicators of depression outcomes (50 % reduction in PHQ-9 score and PHQ-9 score < 10).

KEY RESULTS

SI was common (45.2 %) at baseline, with significantly higher rates among men and patients with greater psychopathology. Few patients with SI (5.4 %) lacked substantial current depressive symptoms. After adjusting for age, gender, and severity of psychopathology, patients with SI received follow-up earlier (care manager contact HR = 1.05, p < 0.001; psychiatric review HR = 1.02, p < 0.05), and were more likely to receive psychotropic medications (OR = 1.11, p = 0.001) and specialty referral (OR = 1.23, p < 0.001), yet were less likely to achieve a PHQ-9 score < 10 (HR = 0.87, p < 0.001).

CONCLUSIONS

Suicidal thoughts are common among safety-net patients referred by primary care providers for behavioral health care. Scores on Item 9 of the PHQ-9 are easily obtainable in primary care, may help providers initiate conversations about suicidality, and serve as useful markers of psychiatric complexity and treatment-resistance. Patients with positive scores should receive timely and comprehensive psychiatric evaluation and follow-up.

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Acknowledgements

The authors would like to thank Community Health Plan of Washington (CHPW) and Public Health of Seattle and King County (PHSKC) for sponsorship and funding of the Mental Health Integration Program (MHIP), and for data on quality of care and clinical outcomes collected in the context of ongoing quality improvement activities. We would also like to thank program leadership from CHPW, clinicians and leadership in the participating community health centers, and consulting psychiatrists and trainers and program support staff at the AIMS Center (Advancing Integrated Mental Health Solutions) at the University of Washington for their ongoing contributions to MHIP. In addition, Dr. Bauer received financial support from the National Institute of Mental Health by National Research Service Award T32-MH20021 (principal investigator, Wayne Katon).

Conflicts of Interest

Dr. Unützer is the principal investigator on a contract from Community Health Plan of Washington to the University of Washington that supports training, technical assistance, and quality improvement for the Mental Health Integration Program. The authors declare no other conflicts of interest.

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Correspondence to Amy M. Bauer MD MS.

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Bauer, A.M., Chan, YF., Huang, H. et al. Characteristics, Management, and Depression Outcomes of Primary Care Patients Who Endorse Thoughts of Death or Suicide on the PHQ-9. J GEN INTERN MED 28, 363–369 (2013). https://doi.org/10.1007/s11606-012-2194-2

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  • DOI: https://doi.org/10.1007/s11606-012-2194-2

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