How a depression test devised by a Zoloft marketer became a crutch for a failing mental health system

“The PHQ-9 became a means for time-crunched primary care doctors, under pressure to see more and more patients in shorter appointments, to dole out prescriptions with barely a conversation. Despite its prevalence, data suggesting that PHQ-9 has actually improved outcomes is ambiguous at best. Meanwhile, mental health outcomes for patients are dismal and only getting worse, with depressive symptoms and suicide climbing ever higher.

A combination of good intentions and straightforward business savvy lies behind the PHQ-9. Pfizer invested hundreds of thousands of dollars in its development [..]. The company naturally hoped its investment would pay off with increased Zoloft prescriptions — which it ultimately did. And yet those who created the PHQ-9 were also hoping to fill a need: Patients were depressed, there weren’t enough psychiatrists, and the tool would allow them to get help from primary care doctors.

Today, depression is all too often treated like a strep infection, said Tom Insel, former head of the National Institute of Mental Health, with prescriptions churned out by primary care doctors with little training in mental health. “There’s more to treating depression than writing a prescription,” he said. “Primary care isn’t really set up to do more than that.” [..]

Whether a patient is experiencing ADHD, addiction, an eating disorder, or trauma, they’re likely to get a PHQ-9 score that will classify them as depressed. A SSRI alone, though, isn’t effective for these other disorders, so patients can spend years being pushed around the health care system without being properly diagnosed or treated. [..]

This widespread misuse [..] has had far-reaching consequences and deserves heightened scrutiny. For those who are depressed, the quick and shallow interaction with their doctor generally has poor long-term results. For other patients, the form elevates depression above all other mental health conditions. [..]

The creators of the PHQ-9 all had good intentions, said Duke’s [professor emeritus of psychiatry and behavioral sciences Allen] Frances. But they didn’t consider the “disastrous unintended consequences.” Namely, the tool has a high false positive rate, which suited Pfizer’s interests, but not those of patients. [..]

Researchers and mental health experts are quick to emphasize the PHQ-9 is not intended for diagnosis — rather, it’s a screening tool, intended to flag patients who might have depression for further evaluation. [..]

Time-strapped primary care doctors now often use the PHQ-9 in place of a careful and comprehensive mental health evaluation, leading to both misdiagnosis, as in Callie Williams’ case, and inappropriate treatment. “You’re above a certain score, you’re going to get an antidepressant,” said Wesley Boyd, professor of psychiatry and medical ethics at Baylor College of Medicine, who said he’s heard this complaint from both patients and primary care physicians. [..]

Today, common mental health conditions continue to suffer from a lack of recognition and diagnosis. Eating disorders affect roughly 9% of the population, but the vast majority go undiagnosed. ADHD is overdiagnosed in boys but underdiagnosed in women and girls. And of the 21 million Americans suffering from addiction, 90% never receive treatment.

Conversely, anxiety diagnoses have become more prevalent in recent years. Crucially, anxiety is also treated with SSRIs including Zoloft, and with Pfizer funding, Spitzer, Williams, and Kroenke created a separate screening tool to assist in its diagnosis, the Generalized Anxiety Disorder Scale-7, which was released in 2006. [..]

PHQ-9 screening is associated with overuse of SSRIs. Although antidepressants are helpful for some, a study published last year found no overall improvement in mental or physical quality of life among patients who took them for two years. These drugs have no benefit over placebo for those with minor depression, and yet those same patients, who likely would have gotten better on their own with time, may well credit their recovery to the drugs they were prescribed. And so screening results in more SSRI sales. [..]

Both the United Kingdom and Canada opted not to recommend such widespread depression screening, as the research didn’t present direct evidence that screening helped depressed patients. Studies have repeatedly questioned the data behind the U.S. Preventive Services Task Force decision, with one meta-analysis finding that screening for depression doesn’t improve outcomes. These results point to the larger paradox around the PHQ-9: It was designed to help doctors engage with depression and, above all, to help patients. But mental health outcomes for the overall population keep getting worse. [..]

There are also calls to consider other mental health treatments, such as exercise and therapy, rather than reflexively writing a prescription based on a PHQ-9 score. Non-pharmacological approaches are critically important, said Kroenke, but they’re time-consuming and lack industry support, limiting their adoption. “Let’s say we have effective psychotherapies. Who’s promoting them? Who’s paying for them?” he asked.

Both [chief medical officer of the National Alliance on Mental Illness Ken] Duckworth and Insel — who co-founded a startup, Vanna Health, focused on connecting patients with behavioral health and community care — advocate for a collaborative care model developed by researchers at the University of Washington. In this approach, primary care doctors have access to a behavioral health care manager and psychiatric consultant. The primary care physician is guided in how to respond to mental health conditions, and research suggests this model creates far more effective responses to behavioral health conditions such as depression, anxiety, and substance misuse. The PHQ-9 still plays a crucial role, but in monitoring patients’ response to treatment over time rather than being relied upon as a diagnostic tool.”

Full article, O Goldhill, 2023.2.21