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

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.KEY WORDS: suicidal ideation; primary health care; community health centers; mental health services; disease management.

Health Care Contacts in the Year Before Suicide Death

“…36,37 Positive suicide screens can initiate conversations about suicidality between the health provider and patient, and should prompt psychiatric evaluation and follow-up. 38 Another important finding from this study is that a mental health diagnosis was absent in over half of all individuals in the year before death and approximately 75 % in the 4 weeks before death. Mental health diagnosis was even less common among disadvantaged groups with lower levels of education and income.…”

Implications of two-stage depression screening for identifying persons with thoughts of self-harm

“…Another study, based in a mental health services program for “safety-net” populations, found an even higher percentage, 90.1% of persons with thoughts of self-harm were identified by a PHQ-2 cutoff of three. Everyone in this population, however, had been identified as having psychiatric illness, and the prevalence of thoughts of self-harm was 45% [21]. …”

“…Most studies that describe the characteristics of persons who endorse the ninth question of the PHQ-9 describe special populations: persons with cancer [18] or congestive heart failure [19], older recipients of home delivered meals [20] or primary care patients already identified as having psychiatric illness [21]. The National Health and Nutrition Examination Survey (NHANES) provides the opportunity to describe persons in the general population who answer the ninth question of the PHQ-9 positively.…”

Change in Suicidal Ideation After Interdisciplinary Treatment of Chronic Pain

“…[55][56][57] This single item was found to be sensitive to change in thoughts of self-harm after treatment for depression, 57 but its validity as a sole measure of serious suicidality has been questioned. 58 In studies that have conducted follow-up interviews with individuals who scored >0 on the self-reported PHQ SI item, 20% to 35% were considered to be actually suicidal on interview [58][59][60] and an additional 39% confirmed thoughts of being better off dead.…”