eMeasure Title

Depression Utilization of the PHQ-9 Tool

eMeasure Identifier (Measure Authoring Tool) 160 eMeasure Version number 6.1.000
NQF Number 0712 GUID a4b9763c-847e-4e02-bb7e-acc596e90e2c
Measurement Period January 1, 20XX through December 31, 20XX
Measure Steward MN Community Measurement
Measure Developer MN Community Measurement
Endorsed By National Quality Forum
The percentage of patients age 18 and older with the diagnosis of major depression or dysthymia who have a completed PHQ-9 during each applicable 4 month period in which there was a qualifying visit
Copyright MN Community Measurement, 2017. All rights reserved.
This measure is "re-tooled" from the existing NQF # 712 measure. eMeasure development was a collaboration between MN Community Measurement and Telligen with technical assistance provided by Telligen.
Measure Scoring Proportion
Measure Type Process
Risk Adjustment
Rate Aggregation
Depression is a common and treatable mental disorder. The Centers for Disease Control and Prevention states that an estimated 6.6% of the U.S. adult population (14.8 million people) experiences a major depressive disorder during any given 12-month period. Additionally, dysthymia accounts for an additional 3.3 million Americans. In 2006 and 2008, an estimated 9.1% of U.S. adults reported symptoms for current depression (Centers for Disease Control and Prevention, 2010).

Persons with a current diagnosis of depression and a lifetime diagnosis of depression or anxiety were significantly more likely than persons without these conditions to have cardiovascular disease, diabetes, asthma and obesity and to be a current smoker, to be physically inactive and to drink heavily (Strine, 2008).
People who suffer from depression have lower incomes, lower educational attainment and fewer days working each year, leading to seven fewer weeks of work per year, a loss of 20% in potential income and a lifetime loss for each family who has a depressed family member of $300,000 (Smith, 2010). 

The cost of depression (lost productivity and increased medical expense) in the United States is $83 billion each year (Greenberg, 2003). 

Please note that this process measure for administration of the PHQ-9 depression tool, a PROM that is validated for both the assessment and diagnosis of depression as well as for monitoring ongoing outcomes of treatment, is a PAIRED process measure with RELATED measures of depression remission (PHQ-9 < 5) and depression response (PHQ-9 is improved by > 50%) at six and twelve months.  To quote a NQF Behavioral Steering Committee member as these measures were initially endorsed "the best way to avoid being measured is to never give the PHQ-9".  This process measure allows an understanding of the use of the tool in the target population, promotes frequent and follow-up contact with patients whose score indicates a need for treatment and serves as a catalyst in a collaborative care model for patients with major depression or dysthymia.  It is estimated that up to 90% of patients diagnosed with depression and anxiety are treated solely in primary care (National Institute for Health and Care Excellence, 2011).
Clinical Recommendation Statement
Source: Institute for Clinical Systems Improvement (ICSI) Health Care Guideline for Adult Depression in Primary Care (Trangle, 2016)

Major depression is a treatable cause of pain, suffering, disability and death, yet primary care clinicians detect major depression in only one-third to one-half of their patients with major depression (Williams Jr, 2002; Schonfeld, 1997).

Usual care for depression in the primary care setting has resulted in only about half of depressed adults getting treated (Kessler, 2005) and only 20-40% showing substantial improvement over 12 months (Unutzer, 2002; Katon, 1999).

Recommendations and algorithm notations supporting depression assessment and monitoring of depression outcomes according to ICSI's Health Care Guideline:

Recommendation:  Clinicians should establish and maintain follow-up with patients.  Appropriate, reliable follow-up is highly correlated with improved response and remission scores.  It is also correlated with the improved safety and efficacy of medications and helps prevent relapse. 

Proactive follow-up contacts (in person, telephone) based on the collaborative care model have been shown to significantly lower depression severity (Unutzer, 2002).  In the available clinical effectiveness trials conducted in real clinical practice settings, even the addition of a care manager leads to modest remission rates (Trivedi, 2006-; Unutzer, 2002).  Interventions are critical to educating the patient regarding the importance of preventing relapse, safety and efficacy of medications, and management of potential side effects.  Establish and maintain initial follow-up contact intervals (office, phone, other) (Hunkeler, 2000; Simon, 2000).
PHQ-9 as monitor and management tool.  The PHQ-9 is an effective management tool, as well, and should be used routinely for subsequent visits to monitor treatment outcomes and severity. It can also help the clinician decide if/how to modify the treatment plan (Duffy, 2008; Lowe, 2004).  Using a measurement-based approach to depression care, PHQ-9 results and side effect evaluation should be combined with treatment algorithms to drive patients toward remission.  A five-point drop in PHQ-9 score is considered the minimal clinically significant difference (Trivedi, 2009). 

Every time that the PHQ-9 is assessed, suicidality is assessed, as well. If the suicidality was indeed of high risk, urgent referral to crisis specialty health care is advised. In case of low suicide risk, the patient can proceed with treatment in the primary care practice (Huijbregts, 2013).

Adult Depression in Primary Care - Guideline Aims 
- Increase the percentage of patients with major depression or persistent depressive disorder who have improvement in outcomes from treatment for major depression or persistent depressive disorder. 
- Increase the percentage of patients with major depression or persistent depressive disorder who have follow-up to assess for outcomes from treatment.
- Improve communication between the primary care physician and the mental health care clinician (if patient is co-managed).
Improvement Notation
Higher scores indicate better quality
Trangle M, Gursky J, Haight R, Hardwig J, Hinnenkamp T, Kessler D, Mack N, Myszkowski M. Institute for Clinical Systems Improvement. Adult Depression in Primary Care. Updated March 2016. https://www.icsi.org/_asset/fnhdm3/Depr.pdf
Centers for Disease Control and Prevention. Current Depression Among Adults United States, 2006 and 2008. MMWR 2010;59(38);1229-1235. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5938a2.htm
Strine TW, Mokdad AH, Balluz LS, et al. Depression and anxiety in the United States: findings from the 2006 Behavioral Risk Factor Surveillance System. Psychiatr Serv 2008;59:1383-90. http://ps.psychiatryonline.org/doi/abs/10.1176/ps.2008.59.12.1383
Smith JP, Smith GC. Long-term economic costs of psychological problems during childhood. Soc Sci Med 2010;71:110-115. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2887689/
Greenberg PE, Kessler RC, Birnbaum HG, et al. The economic burden of depression in the United States: how did it change between 1990 and 2000? J Clin Psychiatry 2003;64(10):1465-1475.
National Institute for Health and Care Excellence. Clinical guideline CG123. Common mental health problems; identification and pathways to care. May 2011. https://www.nice.org.uk/guidance/cg123/chapter/introduction
Williams Jr JW, Noel PH, Cordes JA, et al. Is this patient clinically depressed? JAMA 2002;287:1160-70.
Schonfeld WH, Verboncoeur CJ, Fifer SK, et al. The functioning and well-being of patients with unrecognized anxiety disorders and major depressive disorder. J Affect Disord 1997;43:105-19.
Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the national comorbidity survey replication. Arch Gen Psychiatry 2005;62:617-27.
Unutzer J, Katon W, Callahan CM, et al. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA 2002;288:2836-45.
Katon W, Von Korff M, Lin E, et al. Stepped collaborative care for primary care patients with persistent symptoms of depression: a randomized trial. Arch Gen Psychiatry 1999;56:1109-15.
Trivedi MH, Rush AJ, Wisniewski SR, et al. Evaluation of outcomes with citalopram for depression using measurement-based care in STAR*D: implications for clinical practice. Am J Psychiatry 2006;163:28-40.
Hunkeler EM, Meresman JF, Hargreaves WA, et al. Efficacy of nurse telehealth care and peer support in augmenting treatment of depression in primary care. Arch Fam Med 2000;9:700-08.
Simon GE, Van Korff M, Rutter C, Wagner E. Randomised trial of monitoring, feedback, and management of care by telephone to improve treatment of depression in primary care. BMJ 2000;320:550-54.
Duffy FF, Chung H, Trivedi M, et al. Systematic use of patient-rated depression severity monitoring: is it helpful and feasible in clinical psychiatry? Psychiatric Serv 2008;59:1148-54.
Lowe B, Unutzer J, Callahan CM, et al. Monitoring depression treatment outcomes with the patient health questionnaire-9. Med Care 2004;42:1194-1201.
Trivedi MH. Tools and strategies for ongoing assessment of depression: a measurement-based approach to remission. J Clin Psychiatry 2009;70:26-31.
Huijbregts KML, de Jong FJ, van Marwijk HWJ, et al. A target-driven collaborative care model for major depressive disorder is effective in primary care in the Netherlands: a randomized clinical trial from the depression initiative. J Affect Dis 2013;146:328-37.
Kroenke K, Spitzer RL, Williams JBW. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001;16:606-13. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495268/
Completed PHQ-9 - The patient must answer ALL nine questions for the score to be valid.
If a patient has a qualifying diagnosis and encounter in more than one of the 4 month periods within the measurement year, the patient must be counted (denominator and numerator) in each qualifying 4 month period.  For example, a patient could be counted in the first and third 4 month periods.
Transmission Format
Initial Population
Patients age 18 and older with an office visit and the diagnosis of major depression or dysthymia during the four month period
Equals Initial Population
Denominator Exclusions
1: Patients who died
2: Patients who received hospice or palliative care services
3: Patients who were permanent nursing home residents 
4: Patients with a diagnosis of bipolar disorder
5: Patients with a diagnosis of personality disorder
Patients who have a PHQ-9 tool administered at least once during the four-month period
Numerator Exclusions
Not applicable
Denominator Exceptions
Supplemental Data Elements
For every patient evaluated by this measure also identify payer, race, ethnicity and sex

Table of Contents

Population Criteria

Data Criteria (QDM Variables)

Data Criteria (QDM Data Elements)

Supplemental Data Elements

Risk Adjustment Variables

Measure Set