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10/11/19 Disclosures Handling depression/anxiety in None primary care settings How well is PHQ9 used? Tools for providers Tammy Duong, MD Clinical Assistant Professor UCSF Department of Psychiatry Asian Health Symposium, October 11

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10/11/19 1

Handling depression/anxiety in primary care settings – How well is PHQ9 used? Tools for providers

Tammy Duong, MD Clinical Assistant Professor UCSF Department of Psychiatry Asian Health Symposium, October 11th, 2019

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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

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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

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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

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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

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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)

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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

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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

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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

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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

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

appropriate treatment, follow up

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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

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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

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