10/11/19

1

Handling depression/anxiety in primary care settings – How well

is PHQ9 used? Tools for providers

Tammy Duong, MDClinical Assistant Professor

UCSF Department of PsychiatryAsian Health Symposium, October 11th, 2019

1

Disclosures

• None

2

Objectives

Following this talks, participants will be able to:• Discuss barriers to mental health access for Asian

Americans • Select appropriate depression screening tools for

primary care settings• Recognizes benefits and drawbacks of using

depression screening tools

3

Mental health worldwide

• Worldwide, anxiety disorders are the most prevalent mental health disorders

• Depressive disorders are the second most prevalent group of mental disorders

• By 2020, major depression will be the most disabling disease behind cardiovascular disease

4

10/11/19

2

Primary care

• Prevalence major depressive disorder (MDD) in primary care settings: 5-13%

• Primary care providers deliver majority of treatment for MDD– 1/3 – ½ adult patients– 2/3 geriatric patients

• Majority patients go undiagnosed– Training, time constraints, non-specific somatic

complaints

5

Asian Americans

• 2010: 18.2 million Asian Americans in the US population

• 2050: estimated 40.6 million, 9.2% total population

• 2nd highest risk of suicide risk in females 18-24 = Asian American women

• Incidence suicide among Asian Americans grew 100% between 2000-2009

6

Barriers to access

• Lack appropriate mental health providers• Turning to religious leaders, family, peers for help• Public stigma• Language barriers (English vs non-English)• Generational– 1st, 2nd generation vs 3rd generation– Asian American college students highest rate stigma

• Self-help books, hotlines

7

Barriers to access

• Augsberger (2015): 701 Asian American female participants– Chinese > Korean > Vietnamese > mixed– Factors influencing under utilization of mental health

services• Family, community stigma– Dismissive, saving face

• Culturally appropriate treatments– Dual culture providers

8

10/11/19

3

Screening for depression

• US Preventative Task Force (JAMA 2016):– Recommends screening depression in the general adult

population

• Only ~half (48.6%) of adults are assessed for depression within primary care– Often not screened unless symptom complaint

• Asian Americans less likely to be screened (OR 0.35, 95% CI 0.19 – 0.67) compared to Hispanic or African American populations

9

Ideal screening tool

• Valid• Reliable• Brief• Easy to administer• Low cost/free• Effective clinical outcomes

• No single screening tool recommended over another • Selection based on setting, population

10

Screening tools for depression

• Beck Depression Inventory (BDI)• Zung Self-Assessment Depression Scale (ZSDS)• General Health Questionnaire (GHQ)• Patient Health Questionnaire 9 (PHQ-9)• Patient Health Questionnaire 2 (PHQ-2)• Center for Epidemiologic Study Depression Scale

(CES-D)• Geriatric Depression Scale (GDS)

11

Center for Epidemiologic Study Depression Scale (CES-D)

• 20-item questionnaire• Most commonly used in studies with Asian

Americans (versus clinic populations?)• Accounts for somatic symptoms more commonly

found in Asian American patients– Changes in appetite, headache, stomach aches, insomnia,

fatigue• Can also be used in adolescents

12

10/11/19

4

13

Geriatric Depression Scale (GDS)

• 15-item and 30-item versions• 15-item GDS sensitivity (82-100%) (72-87%)• Recommended for easy yes/no format

14

Geriatric Depression Scale (GDS)

15

PHQ-2

• 2-item questions asks about depressed mood and anhedonia

• May be administered verbally, takes < 2 minutes to administer

• Validated, may be as effective as more extensive instruments

• Can be used as a first step screener

16

10/11/19

5

PHQ-9

• Cut-off score varies between countries, settings (primary care, community care, non-primary care)

• Sometimes considered the “gold standard” for depression screening

• Cut-off score >10, less sensitive but more specific (74%, 86%)

17

PHQ-9

18

PHQ-9: will it work for Asian populations?

• Reliability and validity confirmed in Asian populations– Korean, including geriatric– Chinese, including adolescents– Thai– Indian adolescents– English speaking Singaporean residents

• Available in Mandarin, Hindi, Punjabi, Gujarti, Japanese, Korean, Thai

19

Disclosures

20

10/11/19

6

Screening tool drawbacks

• Not diagnostic!• Higher scores do not necessarily correlate with

severity• Short item questionnaires (2-3 items) have high false

positive rates• Varying degrees of sensitivity, specificities among

screening tools• Varying cut-off values• Confounding co-morbid disease• Must have adequate treatment and follow-up

21

Summary

• Depression is a major cause of morbidity worldwide• Asian American populations are less likely to be

screened than other populations• Ideal screening tools should be cost-effective, easy

to administer, accurate• Variety of screening tools available; no evidence that

one is more effective than others• Screening should be followed with interview and

appropriate treatment, follow up

22

References• Augsberger A, Yeung A, Dougher M, Hahm HC. Factors influencing the underutilization of mental

health services among Asian American women with a history of depression and suicide. BMC Health Services Research. 2015;15:542.

• Coleman KJ et al. Predicting Suicide Attempts for Racial and Ethnic Groups of Patients During Routine Clinical Care. Suicide and Life-Threatening Behavior. 2019;49(3):724-734. Doi: 10.1111/sltb.12454

• Kato E, Borsky AE, Zuvekas SH, Soni A, Ngo-Metzger Q. Missed Opportunities for Depression Screening and Treatment in the United States. J Am Board Fam Med. 2018;31:389-397. doi: 10.3122/jabfm.2018.03.170406

• Kim HJ, Park E, Storr CL, Tran K, Juon HS. Depression among Asian-American Adults in the Community: Systematic Review and Meta-Analysis. PLoS One. 2015;10(6): e0127760. doi:10.1371/journal.pone.0127760

• Lakkis NA, Mahmassani DM. Screening instruments for depression in primary care: a concise review for clinicians. Postgraduate Medicine. 2015:127(1):99-106. Doi: 0.1080/00325481.2015.992721

• Lotrakul M, Sumrithe S, Saipanish. Reliability and validity of the Thai version of the PHQ-9. BMC Psychiatry. 2008;8(46). doi:10.1186/1471-244X-8-46

• Na PJ, Kim KB, Lee-Tauler SY, Han HR, Kim MT, Lee HB. Predictors of suicidal ideation in Korean American older adults: analysis of the Memory and Aging Study of Koreans (MASK). Int J Geriatr Psychiatry. 2017;32:1272-1279. doi: 10.1002/gps.4608

•

23

References• Siu AL, and the US Preventive Services Task Force (USPSTF). Screening for Depression in

Adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2016;315(4):380–387. doi:10.1001/jama.2015.18392

• Tsai FJ, Huang YS, Liu HC, Huang KY, Huang YH, Liu SI. Patient Health Questionnaire for School-Based Depression Screening Among Chinese Adolescents. Pediatrics. 2014;133(2):e402-e409. doi: 10.1542/peds.2013-0204

• Wang W, et al. Reliability and validity of the Chinese version of the Patient Health Questionnaire (PHQ-9) in the general population. General Hospital Psychiatry. 2014;36:539-544

24