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Describe the evaluation tool and explain why this tool is essential in the care of the adolescent patient population.

The PHQ-9 is a psychometrically sound screening tool for use by pediatricians in a primary care setting. Because it is a short, simple, easy to administer questionnaire, the PHQ-9 has tremendous potential in helping to tackle the growing problem of depression among adolescents (Ganguly et al., 2013). The PHQ-9 was originally developed for adults in primary care, with 9 items directly related to each of the criteria listed in the DSM-IV-TR for major depression. It consists of nine questions and each question has the same four answer choices. They are not at all, several days, more than half the days, and nearly every day. The patient is scored depending on what they answer. A score of 0-4 suggests that the patient is not depressed. Score of 5-9 suggests mild depression, 10-14 suggests moderate depression, score of 15-19 suggests moderately severe depression, and score of 20-27 suggests severe depression. The PHQ-9 has been strongly supported for its applicability as a screening tool for adolescent depression in primary care as well as in pediatric hospital settings. The PHQ-9 takes approximately 5 to 10 minutes to complete. The optimal PHQ-9 cutoff score for adolescents is 11 or higher; it has been shown to have a sensitivity of 89.5% and specificity of 77.5% compared with a diagnosis of major depression on a structured mental health interview. There are also algorithms to use to determine if the adolescent meets diagnostic criteria for major depressive disorder or dysthymia (Corona, McCarty, & Richardson, 2013).

Apply the findings of the scholarly research articles to the use of this evaluation tool and describe its validity and reliability.

The study by Zhang et al (2013) examined the validity and reliability of the Patient Health Questionnaire-9 (PHQ-9) and Patient Health Questionnaire-2 (PHQ-2). The concurrent validity was tested by examining associations between PHQ-9 and Beck Depression Inventory (BDI). The sensitivity and specificity, as well as the positive and negative predictive values, were calculated for different cutoff scores of PHQ-9 and PHQ-2. The test- retest reliability values of PHQ-9 and PHQ-2 were 0.873 and 0.829, respectively. PHQ-9 had an optimal cutoff score of 11, which indicated a sensitivity of 0.89 and a specificity of 0.97 (Zhang et al., 2013).

Apply this evaluation tool to a patient situation and summarize your opinion of the results.

In case of our patient in the case, Angela scored 19 on the PHQ-9 case which means that she has moderately severe depression. She did not have any suicidal thoughts or behavior. But with a score suggesting that she is moderately depressed, she will need psychotherapy and medications to control her symptoms.

Describe a plan of care for the patient, depending upon the results.

Angela will be referred to a psychiatrist for initiation of both psychotherapy and pharmacotherapy in treatment of adolescent depression. She will be started on fluoxetine, a selective serotonin reuptake inhibitor (SSRI), with upward dosage adjustment over several weeks. SSRIs plus cognitive-behavioral therapy (CBT) have been demonstrated to be effective in treating adolescent depression. Currently fluoxetine and escitalopram are the only SSRIs with U.S. Food and Drug Administration approval for use in children 12 years and older (Burns et al., 2013).

The initial management plan also includes the following actions:

·Review common side effects (nausea, vomiting, decreased appetite, sleep disturbance) with patient and parent. Review black box warning and risk of suicidality with patient and parent.

·Review and document assessment of patient’s suicide risk. Establish an oral no-suicide contract and a safety plan should suicidal thoughts develop while on medication. Clinician should ask about availability of firearms and other dangerous items in the home and request that they be removed.

·Educate patient and parent by providing verbal and written information about the prevalence, symptoms, and treatment of depression.

·Refer to a nutritionist to assess the patient’s nutritional risk factors for recent weight gain, and to assist the patient in setting goals to reduce BMI (dietary modification, behavioral modification, increased physical activity).

·Schedule follow-up appointment with primary care physician to assess response to therapy.

References:

Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., & Blosser, C. G. (2013). Pediatric primary care (5th ed.). Philadelphia, PA: Elsevier Saunders.

Corona, M., McCarty, C., & Richardson, L. (2013). Screening adolescents for depression. Retrieved from http://contemporarypediatrics.modernmedicine.com/c…

Ganguly, S., Samanta, M., Roy, P., Chatterjee, S., Kaplan, D. W., & Basu, B. (2013). Original article: Patient Health Questionnaire-9 as an effective tool for screening of depression among Indian adolescents. Journal of Adolescent Health, 52 (5), 546-551. doi:10.1016/j.jadohealth.2012.09.012

Zhang, Y., Liang, W., Chen, Z., Zhang, H., Zhang, J., Weng, X., & … Zhang, Y. (2013). Validity and reliability of Patient Health Questionnaire-9 and Patient Health Questionnaire-2 to screen for depression among college students in China. Asia-Pacific Psychiatry, 5(4), 268-275. doi:10.1111/appy.12103

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