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.
Similar content being viewed by others
REFERENCES
Kroenke K, Spitzer RL, Williams JB, Lowe B. The patient health questionnaire somatic, anxiety, and depressive symptom scales: a systematic review. Gen Hosp Psychiatr. 2010;32(4):345–59.
Uebelacker LA, German NM, Gaudiano BA, Miller IW. Patient health questionnaire depression scale as a suicide screening instrument in depressed primary care patients: a cross-sectional study. Prim Care Companion CNS Disord. 2011;13(1).
Luoma JB, Martin CE, Pearson JL. Contact with mental health and primary care providers before suicide: a review of the evidence. Am J Psychiatry. 2002;159(6):909–16.
Center for Healthcare Improvement for Addictions MI, and Medically Vulnerable Populations, . Mental Health Integration Program: General Assistance-Unemployable (GA-U). 2009; http://integratedcare-nw.org/docs/CHAMMPReportNov09.pdf. Accessed 7/11/12, 2012.
Katon W, Von Korff M, Lin E, et al. Stepped collaborative care for primary care patients with persistent symptoms of depression: a randomized trial. Arch Gen Psychiatry. 1999;56(12):1109–15.
Katon W, Von Korff M, Lin E, et al. Collaborative management to achieve treatment guidelines. Impact on depression in primary care. JAMA. 1995;273(13):1026–31.
Unützer J, Katon W, Callahan C, et al. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA. 2002;288(22):2836–45.
Thielke S, Vannoy S, Unutzer J. Integrating mental health and primary care. Prim Care. 2007;34(3):571–92. vii.
Unützer J, Choi Y, Cook IA, Oishi S. A web-based data management system to improve care for depression in a multicenter clinical trial. Psychiatr Serv. 2002;53(6):671–73. 678.
Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–13.
Löwe B, Unützer J, Callahan CM, Perkins AJ, Kroenke K. Monitoring depression treatment outcomes with the Patient Health Questionnaire-9. Med Care. 2004;42(12):1194–201.
Gilbody S, Richards D, Brealey S, Hewitt C. Screening for depression in medical settings with the Patient Health Questionnaire (PHQ): a diagnostic meta-analysis. J Gen Intern Med. 2007;22(11):1596–602.
Kroenke K, Strine TW, Spitzer RL, Williams JB, Berry JT, Mokdad AH. The PHQ-8 as a measure of current depression in the general population. J Affect Disord. 2009;114(1–3):163–73.
Kroenke K, Spitzer RL, Williams JB. The patient health questionnaire-2: validity of a two-item depression screener. Med Care. 2003;41(11):1284–92.
Spitzer RL, Kroenke K, Williams JB, Lowe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092–7.
Dennis ML, Chan YF, Funk RR. Development and validation of the GAIN Short Screener (GSS) for internalizing, externalizing and substance use disorders and crime/violence problems among adolescents and adults. Am J Addict. 2006;15(Suppl 1):80–91.
Gensichen J, Teising A, Konig J, Gerlach FM, Petersen JJ. Predictors of suicidal ideation in depressive primary care patients. J Affect Disord. 2010;125(1–3):124–7.
Harris EC, Barraclough B. Suicide as an outcome for mental disorders. A meta-analysis. Br J Psychiatr. 1997;170:205–28.
Nock MK, Hwang I, Sampson N, et al. Cross-national analysis of the associations among mental disorders and suicidal behavior: findings from the WHO World Mental Health Surveys. PLoS Med. 2009;6(8):e1000123.
Unützer J, Chan YF, Hafer E, et al. Quality Improvement With Pay-for-Performance Incentives in Integrated Behavioral Health Care. Am J Public Health. 2012;102(6):e41–5.
Feldman MD, Franks P, Duberstein PR, Vannoy S, Epstein R, Kravitz RL. Let's not talk about it: suicide inquiry in primary care. Ann Fam Med. 2007;5(5):412–8.
Vannoy SD, Robins LS. Suicide-related discussions with depressed primary care patients in the USA: gender and quality gaps. A mixed methods analysis. BMJ Open. 2011;1(2):e000198.
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.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
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
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11606-012-2194-2