1 Boring Old Man

Validation and Utility of a Self-report Version of PRIME-MD
The PHQ Primary Care Study
^{by Robert L. Spitzer, Kurt Kroenke, Janet B. W. Williams, and the Patient Health Questionnaire Primary Care Study Group}
JAMA. 1999 282[18]:1737-1744.
[full text on-line]

Context The Primary Care Evaluation of Mental Disorders [PRIME-MD] was developed as a screening instrument but its administration time has limited its clinical usefulness.
Objective To determine if the self-administered PRIME-MD Patient Health Questionnaire [PHQ] has validity and utility for diagnosing mental disorders in primary care comparable to the original clinician-administered PRIME-MD.
Design Criterion standard study undertaken between May 1997 and November 1998.
Setting Eight primary care clinics in the United States.
Participants Of a total of 3000 adult patients [selected by site-specific methods to avoid sampling bias] assessed by 62 primary care physicians [21 general internal medicine, 41 family practice], 585 patients had an interview with a mental health professional within 48 hours of completing the PHQ.
Main Outcome Measures Patient Health Questionnaire diagnoses compared with independent diagnoses made by mental health professionals; functional status measures; disability days; health care use; and treatment/referral decisions.
Results A total of 825 [28%] of the 3000 individuals and 170 [29%] of the 585 had a PHQ diagnosis. There was good agreement between PHQ diagnoses and those of independent mental health professionals [for the diagnosis of any 1 or more PHQ disorder, κ = 0.65; overall accuracy, 85%; sensitivity, 75%; specificity, 90%], similar to the original PRIME-MD. Patients with PHQ diagnoses had more functional impairment, disability days, and health care use than did patients without PHQ diagnoses [for all group main effects, P<.001]. The average time required of the physician to review the PHQ was far less than to administer the original PRIME-MD [<3 minutes for 85% vs 16% of the cases]. Although 80% of the physicians reported that routine use of the PHQ would be useful, new management actions were initiated or planned for only 117 [32%] of the 363 patients with 1 or more PHQ diagnoses not previously recognized.
Conclusion Our study suggests that the PHQ has diagnostic validity comparable to the original clinician-administered PRIME-MD, and is more efficient to use.

Funding/Support: The development of the PHQ was underwritten by an educational grant from Pfizer US Pharmaceuticals Inc, New York, NY. PRIME-MD is a trademark of Pfizer Inc. Copyright held by Pfizer Inc.
Financial Disclosure: Drs. Spitzer and Williams receive honoraria and consulting money from Pfizer Inc, which has supported this work.

What Internists do is "work-ups" – gathering the necessary data that allows one to say, "no disease found" with authority. But most of the time, you sort of know when you’re not likely to find anything. You can play it two ways. You can do the work-up and then declare, "nothing to report." Alternatively, you can say up front that you doubt there’s a problem but you’re going to do a thorough evaluation to be sure. In those few cases where you were wrong, you have to eat some humble pie, but I still preferred to do it that way for two reasons. First, if you don’t say anything up front and don’t find anything, many patients conclude "it" is there but you didn’t find "it" and leave still worried. If you are straight up front, that doesn’t happen. But my second reason is that if you’ve been clear from the outset and the work-up is negative as predicted, you’re in a good position to ask, "Anything going on in your life that’s causing stress?" and the patient doesn’t feel discounted. I was awed by how many people answered that question [and the case made a lot more sense].

Most of the time the stresses were marital, or work, or homesickness [overseas base], or a difficult kid – the stresses of life that seem routine [unless they’re something you’re experiencing personally]. Sometimes it was mental illness proper, requiring a referral [certainly not 28%]. And there were a number of such cases where things were of a magnitude for a referral, but the patient would go to mental health because it would be "on the records for promotion," so I got to be an amateur shrink by default. I must’ve liked it because I went on to get to be a pro. I think it was worth the time it took to tell people who were having stress related problems that the physical symptoms were telling them that they needed to pay attention to whatever it was that was bothering them. I think that because a lot of them came back by and thanked me for saying that later.

How would I have felt if the Air Force [my employer at the time] had required that all my new patients fill out a PRIME-MD form in the waiting room and that I go over the results with them? I think I would have been kind of annoyed – another Air Force program – Yuk. I don’t think I would’ve found it very helpful. Would I have written more antidepressant prescriptions? I doubt it. Made more referrals? I don’t know. Probably more than in any other specialty, a referral to psychiatry depended on whom I was referring to – even back then. I run across all kinds of mental illness these days, and I find referral difficult because so many psychiatrists are only psychopharmacology mavens – so my resources are limited. I often refer to other therapists and let them refer to the psychiatrist if medications are necessary. I occasionally feel guilty about that, but it is what it is.

Hat Tip…