Spotting Depression in Medicare Patients

The PHQ-9 patient intervew for depression affects the nursing component of PDPM and directly relates to the categories of special care high, special care low, and clinically complex. Not completing the PHQ-9 can result in a loss of over $40 dollars a day and there are no allowances for when the interview is missed due to unexpected resident discharge from the facility.

Clinically, depression can decrease the resident’s motivation to engage in therapy and lead to poor patient outcomes. Untreated depression complicates care by leading to poor appetite, changes in sleep, and increased confusion. Depression also increases the resident’s overall risk of hospitalization.

Over a year after the start of the COVID 19 pandemic, preliminary studies find that PHQ-9 scores continue to remain low – despite COVID-19, increased isolation,  and rising mental illness in the general population.

Why Are PHQ-9 Scores Low?

Low scores could result from lack of interviewer training or the stigma that still surrounds depression, suicidality, and psychiatric illness. These factors may impair the facilities ability to capture depression symptoms, and can lead to poor patient outcomes.

We recommend you complete the PHQ-9 early in each admission to enable prompt treatment. Use these recommendations to ensure your interviewers complete an effective PHQ-9:

Effective PHQ-9 Interviewing Techniques

  • Interview in a quiet, private place
  • Sit facing the resident, so that they can see your face
  • Provide written questions if that may improve the resident’s communication and understanding
  • Ensure that all adaptive equipment for communication is in use
  • If the resident is between two answers, document the most severe answer on the PHQ-9 and on the MDS
  • Break longer questions into part by disentangling them
  • Clarify resident answers that are confusing or do not match the RAI manual wording
  • Code what the resident said, not what the interviewer thinks that they should have said

 Avoid Conveying Any Social Stigma

  • Use a nonjudgmental tone when interviewing the resident
  • Ensure the resident that the same questions are asked of everyone and it is not unusual for patients to feel depressed after injury and illness.
  • Protect resident confidentiality from others listening to interview.
  • Establish rapport with the resident prior to the interview.
  • Respond with empathy.

Once the interview has been conducted to thoroughly screen for depression symptoms, the treatment can begin.  Remember that the PHQ-9 interview does not diagnose a patient with depression. Any symptoms should be brought to the attention of the medical provider and nursing for any clinical interventions. Nursing can initiate non-pharmacological treatment and document the patient’s response to inform the physician’s decision regarding the use of medication – if needed.

Is your facility using these techniques to correctly capture and treat depression symptoms? Or could you be missing out on addressing this pertinent patient concern?

Additional Resources

For the BIMS and PHQ-9 tools, see: