Appendix 114-I Assessment Instruments for Non-Medicaid Home and Community Based Services: Patient Health Questionnaire-9 Item Scale (PHQ-9) | HCBS-5300-MANUAL

The Primary Care Evaluation of Mental Disorders (PRIME-MD) was an instrument developed and validated in the early 1990s to efficiently diagnose five of the most common types of mental disorders presenting in medical populations: depressive, anxiety, somatoform, alcohol, and eating disorders. The 27-item test was found to be a barrier to use in busy clinical settings. In two large studies, a self-administered version of the PRIME-MD called the Patient Health Questionnaire (PHQ) was developed and validated.

Based on the Depression and Anxiety section of the Risk Assessment Tool (Section G) using the PHQ-2 and GAD-2 screens, or based on professional judgement, staff may complete the PHQ-9 assessment tool.

Before using the PHQ-9, staff must complete webinar #24 entitled “Assessment for Depression in Older Adults” on the Rosalynn Carter Institute website.

The PHQ-9 consists of nine questions, each with the following answer options:

Ask the client each question, preceded by the statement “Over the last 2 weeks, how often have you been bothered by any of the following problems.” Record the answer by selecting the correct item in the dropdown menu. Alternately, the questionnaire can be printed out and given to the client to complete, then entered into the system.

The first two questions of the PHQ-9 are the same as the two questions asked on the Risk Assessment Tool (the PHQ-2). Depending on the time lapse from when the Risk Assessment Tool was conducted, the first two questions can be scored without repeating those questions. However, it is certainly appropriate to ask all nine questions, in case anything has changed in the client’s situation.

The system automatically computes a Total Score based on the answers provided by client.

The additional question helps you to identify how significantly the person’s level of depression is impacting their daily routines and help them develop strategies to improve his/her quality of life. The response to this question will give an indication of how urgent further evaluation may be and may indicate that a manual “override” of the Risk Level may be appropriate, with input from supervisory staff.

A score of 10 or higher is considered a positive screen for depression and should prompt intervention. It is suggested that staff print out the PHQ-9 for the client and ask him/her to take it to a health care provider or mental health provider. Depending on the severity of the depression as indicated by the score, immediate action may be appropriate. The following are appropriate emergency treatment options:

For non-emergency treatment, the following represent appropriate options: