For many years, the standard tool for monitoring depression has been the 9-item Patient Health Questionnaire (PHQ-9), and it has been useful when starting patients on treatment and determining their response to therapy. Patients receive scores ranging from 0 (no depression) to 27 (severe depression). A score ranging between 10 and 14 indicates moderate depression.
Clinical experience, however, has shown that once patients reach scores of about 10 on the PHQ-9, the tool becomes less useful. Typically, a score of 10 would trigger clinicians to continue recommending medication use. Some individuals with this score report that they are feeling better, are back to their daily routines, and feel like their mood has improved. Others with a score of around 5 on the PHQ-9—indicating that their depression has resolved—say they aren’t feeling like their normal selves. Assessment of other depression symptoms may be necessary to further flesh out what patients consider as being back to normal.
A Tool to Assess Depression Remission
My colleagues and I recently developed the Remission Evaluation and Mood Inventory Tool (REMIT). This tool can be used to ask patients with PHQ-9 scores of 12 and under an additional five questions that go beyond the PHQ-9. Specifically, patients are asked how often, over the previous 2 weeks, they felt:
In control of their emotions
That they could bounce back when things went wrong
That the future seemed dark
In a study published in the May/June 2011 issue of General Hospital Psychiatry, my colleagues and I recruited 1,000 patients to test REMIT. Our tool appeared to add to our ability to determine which patients were feeling recovered and which weren’t. The additional questions found that nearly one-third of patients with mild depression were not back to normal despite what findings from the PHQ-9 indicated. REMIT helped discover another one-third of moderately depressed patients who were doing better than PHQ-9 scores indicated. When compared with patients’ sense of own recovery, PHQ-9 was approximately 60% accurate in reflecting remission. The addition of REMIT to PHQ-9 demonstrated an accuracy that was higher than 70%.
Participants in our study provided positive feedback on REMIT, reporting that questions were asked in a way that made sense to them and matched up with their experiences. Also, our clinical experience is that many patients believe the additional questions allow them to give a full-picture account of how they’re feeling. If answers on REMIT deviate from the consistency of answers to other questions on REMIT, clinicians should dig deeper into the patient’s history and target symptoms that are inconsistent with the patient’s general progress.
REMIT Tested Clinical Trials
REMIT is now being incorporated into clinical trials for depression treatment in an effort to assess its performance longitudinally. We’re also determining if REMIT can be administered periodically once patients are in remission to detect early signs of depression recurrence or relapse, potentially allowing for early intervention. The takeaway for physicians is to think about the full range of symptoms associated with depression, not just those that are negative. Using instruments like the PHQ-9 and/or REMIT can help capture signs and symptoms as depression begins to remit or improve.
Readings & Resources (click to view)
Nease D, Aikens J, Klinkman M, et al. Toward a more comprehensive assessment of depression remission: the Remission Evaluation and Mood Inventory Tool (REMIT). Gen Hosp Psychiatry. 2011;33:279-286.
Wallace M, Dombrovski A, Morse J, et al. Coping with health stresses and remission from late-life depression in primary care: a two-year prospective study. Intl JGeriatr Psychiatry. 2011. Mar 30 [Epub ahead of print]. Available at: http://onlinelibrary.wiley.com/doi/10.1002/gps.2706/full.
Jiang W, Kishnan R, Kuchibhatla M, et al. Characteristics of depression remission and its relation with cardiovascular outcome among patients with chronic heart failure (from the SADHART-CHF Study). Am J Cardiol. 2011;107:545-551.
Greenlee A, Karp J, Dew M. Anxiety impairs depression remission in partial responders during extended treatment in late-life. Depression Anxiety. 2010;27:451-456.
Sussman T, Yaffe M, McCusker J, et al. Improving the management of late-life depression in primary care: barriers and facilitators. Depression Res Treat. 2011. May 5 [Epub ahead of print]. Available at: http://www.hindawi.com/journals/drt/2011/326307.