Annals of Clinical Psychiatry

Transcription

So Section D, Mood. We're going to spend the next few minutes just going through the items in this section. We'll see one of the scenario interviews at the end as well. We're going to talk about the intent of the section, the purposes and benefits of the PHQ-9. And we're going to talk about effective interviewing techniques, although we've talked about some of those already. Describe how to conduct the assessment and then how to code the section right. So, why is there a lot of emphasis in the instrument on mood? It's a serious condition. And study after study has shown us that it is underdiagnosed and undertreated in nursing homes. Nursing homes aren't the only settings where mood disorder is underdiagnosed and undertreated. It's a problem in outpatient, it's a problem in hospital, and it's a problem in rehab. But we're in nursing homes, and we're there to take care of the patients that are there. It's associated with significant morbidity. We actually see poor outcomes in rehab. We see poor outcomes in response to therapy for diabetes in patients who have an untreated mood disorder. And actually a major mood disorder can cause biochemical imbalances that affect your body's ability to regulate in terms of insulin and fighting infection. The signs and symptoms of a mood disorder are treatable. We can do something about it for a significant number of our patients and really address their suffering and help get better outcomes. As I said, it's associated with psychological and physical distress. We see these folks have decreased participation in the important therapies that we're trying to provide for them and their activities. They have poorer functional status overall and poorer health outcomes. So, if our findings suggest that there may be a mood disorder, then we should be thinking about what the causes and contributing factors could be for the symptoms. Identifying interventions that could address their symptoms and trying to ensure resident safety. If you code that these are present, if you're coding the PHQ-9, the staff version or the resident version, you're not making a diagnosis of depression. That still is up to the primary care provider (PCP) and/ or the mental health specialist at your facility to actually look at these signs and symptoms and say yes, this is related to a mood disorder, or no, these signs and symptoms are something else. To be honest, there are lots of times when we can't tell, and we end up treating sort of empirically to see if we get some improvement. But again, that's not what you're being asked to do here. What you're being asked to do is to be the watchdog, to sort of go out there and look for these signs and symptoms and report them back to your care planning teams including the PCP and the mental health specialist. The Section D now uses the PHQ-9 resident mood interview. It is basically based on the resident's voice and their own report of how they're doing. You're only going to do the staff assessment for those residents who are unable to make themselves understood at least some of the time or who are unable to complete the PHQ-9 despite your best efforts to work with them to get through it. You do not have to do, you do not do both the resident mood interview and the staff assessment. The only exception to that is that you get through the resident interview, and they haven't met the minimum number of answered items to be considered complete. So the first item is D0100. This is part of that skip pattern thing that we talked about before. This is just basically asking whether you need to do the mood interview. Why is it there? We want you to try these interviews. Most residents are capable of communicating and can answer ů.most residents who are capable of communicating can answer questions about how they feel. It is more reliable and accurate than observation alone for identifying a mood disorder. In our trial, we actually compared staff observations to resident self-report to a gold standard measure. The resident self-report was closer to the gold standard measure than were staff observations. So the residents -- I know that people are concerned that maybe if the resident's not the sharpest tool in the shed or they've got a little bit of cognitive impairment that they don't know their mood as well as I know their mood. They really can tell us more accurately than we're going to gestalt by looking at them. So, basically, the question is should the resident mood interview be conducted and this item is saying attempt to conduct it with all residents. If the resident is rarely or never understood, then you answerůyou code zero and then you move on to D0500, the Staff Assessment of Resident Mood. It's right there on the form for you so you don't have to remember it. If they can be ů make themselves understood at least some of the time, then you go on to try the PHQ-9. They can respond by pointing to answers on the cue card. They can write out their answers. You can do the PHQ-9 in writing. In fact the original version of the PHQ-9 was in writing. I wouldn't suggest handing them the 3.0 form because it's something only those of us in the 3.0 world can make out, but you can give them a written version of the PHQ-9. The other thing to tell you again to do it in a language that's preferred by the patient. This is a very commonly used, as I said yesterday, very commonly used approach for mood assessment and it's been translated - and validated into multiple languages and you can find this on the web if you just put in PHQ-9 and the language that you're looking for. Asian languages, Middle Eastern languages, Latin languages, There are available validated versions of that. And, of course, make every effort to have an interpreter available if needed. So basically this is just a review I think of what we already said. So D0200 is the actual interview itself. It's a validated interview, it screens for symptoms of depression. It gives us a standardized severity score at the end of the day, provides a rating for evidence of a depressive disorder. So it's both looking at presence and frequency of each symptom. These are things we've talked about already -- that you're going to try to make the environment as conducive for revealing information as possible. Make sure they can hear you. Explain what you're doing. You know, you're just asking them some questions about how they've been feeling over the past two weeks. And then you're going to explain the response choices. Now you do that up front in part because sometimes with patients we've talked about those, the GDS, the Geriatric Depression Scale, makes them pick an absolute yes or no answer that's tough for people. But, if they know going into this, if they're first going to tell you if they had it at all and then they're going to be able to tell you how much they've had it, it makes it a lot easier for them to tell you the yes/no to begin with. And then you can go into the, you know, how often they had it. Show their responses in a large font. Allow them to write as necessary. We talked about those things. So you're going to ask if they've been bothered by any of the symptoms over the last two weeks. Read it as it's written. Don't try to define terms because this has really been validated with the resident responding to how they interpret sleep or how they interpret appetite. That doesn't mean as you saw in the video earlier you can't redirect them when they're not answering your question or they're answering but they're giving you a very long narrative that's not directly responsive to the question. But what you're not doing is telling them what you think a sleep problem is. That you think sleep is sleeping less than 8 hours a night. What they're doing is telling you whether they think they have they're sleeping too much or too little. And I don't know how many of you have had the experience with interpreters, but the interpreter comes in and you tell the interpreter your question. They ask it and it seems probably about the right rephrasing of what you've said. Then the patient gives you back a five-minute answer in their language, and the interpreter looks at you and says, "They said yes." So try to be sure your interpreter understands this concept as well. (Laughter) Ask each question in the sequence to assess the presence and frequency of a symptom. Determine the presence, which is basically have they had it in the last two weeks, yes or no. And then if they say yes, you're going to go on and ask about the frequency of that symptom, while you're on that symptom. It just makes more sense. You don't have to review it and it's less -- it's more time efficient as well. Neither the staff nor residents have found that the PHQ-9 was burdensome and intrusive. Yes, people were worried about doing it initially. But again, this has been used in countless settings and our national trial. The feedback that we got was that patients were fine with it. They were actually glad that somebody was asking them how they were doing and going through it in a very systematic and clinical way. Multiple interviews have led to improved symptom identification. So one of the concerns has been whether or not, you know, we're going to be asking these a lot for some patients depending on when they're scheduled for their assessments. And we've gone back and looked at studies where they've actually where that's been part of the research protocol -- to ask frequently. And actually in one particular study, they were just following people over time to see how their mood changed. And it was very interesting, and it was sort of a little bit different result than I would have expected. What they found was that the people who got asked frequently at the end of the study actually had fewer psychiatric diagnoses and had better physical functional status as well as better mental health status than the people who were not asked frequently about their PHQ-9 symptoms. So I would have expected you're asking people all the time, you're going to get a lot more reports and a lot more diagnoses by asking all the time. But it seemed to have sort of almost this therapeutic effect of having of being asked and being comfortable with being able to reveal what was up. It was a very interesting finding, I found. There was just an article last week in JAMA, Journal of the American Medical Association where they did this with cancer patients. They did PHQ-9 in pain. And pain interviews. They did a slightly different approach. These were people with terminal diagnoses. They actually had them interviewed by telephone -- computer and telephone -- and had much better responses, much better outcomes in the group that was randomized to get the frequent follow-up and interviews along the way. All right. Interviewing techniques: So you can repeat a question here. Like the BIMS, we told you they didn't get it right if they had to repeat it. This is different. You can repeat questions as needed. You can ask to clarify. We talked about unfolding frequency responses and interview technique and you'll see Rena doing the interview again. You can probe to explore noncommittal responses, echo to summarize long answers as you saw. And disentangle the items to help the resident. Again, some residents like to talk about what's going on and they may stray from the topic a bit. And that's okay. But you also need to be sure that you've assessed everything in this form. And it's not to be cavalier, but it's that to get a full picture of what can happen very easily, especially with our patients who have such rich life experiences, is you can get off on a tangent, and before you know it, you've not gotten the fundamental information you need to get to piece together everything that's going on. So you can always say I'd love to come back and let's talk, I'm going to come back today at lunch and we'll talk about it, or somebody from our team will come back and talk to you more about that. Or you can follow up at the end of the interview with things you want to talk about. But you do need to try to be sure that are able to get the full picture of what's going on with that resident so you can understand, you know, is pain affecting their mood, all the other things that might be going on. So, anyway, that's interesting now I need to know.., let's get back to.., I understand you know, that you're having this experience. Can you tell me more about Validate your understanding of what the resident is saying: I think what I hear you saying to me is that, Let's see if I understood you correctly. You said whatever, is that right? So these are just some phrases that help with the situation. Unfolding, I think we talked about it. It's just if they have difficulty selecting a frequency. You can pick a mid-point and then have them move up or down. Probing is that you can ask, you know, What do you mean? Tell me what you have in mind. Tell me more about that. Please be more specific. Can you give me an example. Sometimes the examples are interesting. Echoing is basically, again, like we said this morning, just a way to get -- if someone gives you a very long answer, you summarize their answer and then try to bring them back to the question and try to pick from the response choices that are there. So we talked about you saw an example of the poor appetite item and this is just another example. I mean, I'm sure you guys know that that's probably when you go in to talk to your residents, that's probably the biggest issue that comes up. That and not liking their roommate. So disentangling, separate the item into shorter parts and providing them an opportunity to respond to each part. You're going to end up coding for the one that's most severe response. So you're going to code both the symptom presence. And, if they don't have the symptom present, you're going to enter zero and move down to the next item. If they do have the symptom present, then you're going to ask them to tell you the frequency. For frequency, you have some choices here. You can either give them the verbal descriptor scale and by that that's the never, several days, half or more than half the days or nearly every day. Or you can give them the days. The actual day count. It's been tested both ways. CDC, the Centers for Disease Control, in their national surveys use the numerical approach. The original developers of the PHQ-9 used the verbal descriptor approach. Either one works. Some patients do better with the numbers some patients do better with the verbal. And As you can see in the video, Rena will sort of switch back and forth between the two depending on what's working for that resident. So you've got both of them there that you can use. And when we make the cue cards or write it out, we usually just put them together on that card to help them. You're going to give one frequency response per item. You're going to code the higher frequency if they have difficulty selecting between two options. So let's say they can't decide you know how whether they have it more than half the days or nearly every day. You're going to go ahead and code it as nearly every day. Why is that? Well, you're screening. You're not diagnosing. You're screening. So it's better to be over-vigilant in picking up something that may be problematic for the resident and coding it than to sort of underestimate the signs and symptoms that are going on. The same happens code 9 for nonsensical response and then, of course, you can't answer column 2 if in the frequent -- if in the presence they had a 9. So let's turn to -- is that all we have in that section? Let's see. Okay. Yeah. So we're just going to watch the video. So, if you guys will turn to the section in your handouts for the mood interview, the PHQ-9. We're going to listen to the interview and code it as we're listening. Now, Mr. Royce I'm going to ask you some questions about your mood and your feelings over the past two weeks. And, I'm also going to ask you about some common problems that are known to go along with feeling down. I know that some of these questions are going to sound pretty personal, but we really ask everybody to answer them because they can really help us provide you with better care. So, the first thing I'm going to do is I'm going to ask you if you've been bothered over the past two weeks by a particular problem. And, if you tell me yes, that you have been, then I'm going to ask you to tell me the number of days that you've had the problem in the last two weeks. And, I'm going to give you the choices that you see on this card. So, that would be 0 to 1 days, which would be not at all, 2 to 6 days which would be several days, 7 to 11 days which would be more than half of the days and 12 to 14 days which would be nearly every day. So, are you ready? Yeah, go ahead. Over the past two weeks, have you been bothered by little interest or pleasure in doing things? The past two weeksů let's see. I don't know. I'm not interested in doing anything. I don't know. I just don't feel like it. I used to like talking to friends, you know, other people. But, I, I don't do that much anymore. I don't talk. I I don't visit anymore. It would help me to understand how often you felt that way in the last two weeks. So, do you think it was 0 to 1 days, 2 to 6 days, 7 to 11 days 7 to 11 days. Thank you. Over the last two weeks have you been bothered by feeling down, depressed or hopeless? It's not a big deal. I just don't want to bother anybody. You are not bothering me when you tell me how you feel. It's really important for me to know if you're feeling down, depressed or hopeless. I want to know. Well, actually, I Frankly I I have. I've been feeling down I've Can you tell me how often in the last two weeks you've been bothered by feeling down. Everyday. I feel sad I feel sad every day. But I don't want to bother people. Thank you. I really appreciate your telling me about how you feel Mr. Royce. It's important, and I know that it's difficult. But I want to know, so we can help. Do you think that you can continue with some more questions? Yeah, sure sure. Over the last two weeks have you been bothered by trouble falling asleep or staying asleep? No, no. How about the opposite sleeping too much? Ah, no. I don't sleep too much. Ok, so sleep hasn't been a problem. Over the last two weeks have you been bothered by feeling tired? Well tired yes, uh, yes sometimes. Can you tell me how often you've been bothered by feeling tired? 0 to 1 days, 2 to 6 days Oh, I don't I don't think I could count the days. Well, would you say that it's been more than half the days or less than half the days? Oh, more than half the days for sure. Ok well, do you think that it's been nearly every day? Not every day. Yeah, more than half the days. Ok, so you've been tired more than half the days. I also want to know about your appetite. Over the past two weeks have you been bothered with poor appetite? Have you ever had to eat any of the food here, huh? I wouldn't feed it to a dog. Now, I got my doctor put me on a low salt, anti-diabetic diet or something like that. The food tastes terrible. I can't stand it. It's awful. So you don't like the food you're being served. I'm going to make a note and talk with the dietician so that she can get together with you and work on that. Oh, that's good. But, knowing that you don't like the food, it's also important for me to understand if you have not felt hungry. So, over the last two weeks have you been bothered by a poor appetite? No I'm hungry. Have you been bothered by overeating? With this food, overeating, are you kidding? No, no overeating. The food is the problem. I understand, and we're going to work on that with you. Okay. I do have a few other questions. Over the last two weeks, have you been bothered by feeling bad about yourself? Well yeah. Yeah, I feel bad about myself, because I can't take care of myself. I can't even go to the bathroom by myself. How often would you say that you've been bothered by feeling bad about yourself? Well, 7 to 11 days, yeah. Ok Over the last two weeks, have you had trouble concentrating on things such as reading the newspaper or watching television? Uh, television, the news, hah. I used to like to watch television and the news, I can't. I can't concentrate on that stuff anymore. Well I'd like to understand how often you've been bothered by not being able to concentrate. Do you think that it was 12 to 14 days actually. So it was nearly every day. Over the past two weeks, have you been bothered by moving or speaking so slowly that other people could've noticed? So slowly, no. Well, how about the opposite, being so fidgety or restless that you've been moving around a lot more than usual? No, I wouldn't consider myself fidgety, no. Ok one more question about mood. Over the last two weeks, have you had thoughts that you would be better off dead or of hurting yourself in some way? No, not that. I just I just want to get better, that's all. All right. I know that some of this has been difficult, and I appreciate your talking with me about your feelings. Our care team is going to work with you to address some of the issues that you talked about that bother you. Is there anything else you want to tell me about your mood? No. No I think that about ůthat about covers everything. Ok, we can stop there. So basically, let's go through the scoring on that. As you saw, I mean, Rena stayed pretty cool. She was there. She was engaged. She was sympathetic, but she didn't overreact to any of the things that he was telling her. And we learned a whole lot about him that will help us with care planning and trying to set up some routines for him around the facility. So let's go around the scoring for him in this. 1A, little interest or pleasure in doing things. Column 1. Present, yes, 1. And then Column 2? 2. 2, right. B, column 1. B, present. And for column 2? 3. 3, right. Are the answers up there? Am I reading you what you can already see. I won't be quite so redundant. So on C, trouble following or staying asleep or sleeping too much? Was a zero in column one. For D feeling tired or having little energy in column one it was symptom present, 1. And in column 2 it was 2. Right? For poor appetite or overeating, zero. And zero in column 2. In column F -- I mean for item F in column one it was a 1. And in column 2 it was a 2. Now here he said he felt bad about himself, and some of us think that's a hard question to ask people. But again, we now know that. That he really feels bad about having to get help from us, and so we can talk about that within our interdisciplinary care team, with the nurse aides, with the therapists that are working with him, to help us be sure we are approaching him in a way that provides that reassurance and helps him feel moreůhave more dignity. Hopefully, of course, we are doing that with everyone but knowing this is a particularly difficult thing for him may help us do a better job of sort of care planning around that. Trouble concentrating-- G. The column one was a 1. Column 2 was a 3. H zero and zero. And I zero and zero. Perfect and then what you'll do in the end for the severity score, and we'll get back to that in the end, is you're going to add up those values in column 2. Not column one, column 2. You're going to add up the values and enter them into D0300. Now, we call this the hard question because every time we start to get new providers to use the PHQ-9 for the first time, people have trouble with I Thoughts that you would be better off dead or of hurting yourself in some way. People feel like -- some people feel like that's a harsh question. Some people feel like that's not a good thing to ask people. Some people are actually even worried you're going to make someone feel like harming themselves by asking that question. You cannot make somebody depressed by asking them about how they're feeling in a structured way, and you do not make folks have thoughts of suicide by asking them about it. If they don't have it, they're going to tell you no. You're not going to make them feel that way. And the way that, you know, you approach it, it is just part of your clinical assessment. It's part of the questions. They see you reading off a form. You didn't design this item just for them. They really accept this a lot more than what you think they're going to going into it. Why do we have it there? The highest risk group for successful suicide in the United States are men over the age of 65. The highest successful population group in the U.S. for successful suicide is men over the age of 65. Many of those people were seen by a healthcare provider in the month prior to them killing themselves. And it was not picked up. It's an important thing to know so that we can help people. We'll show you some different ways that he could have responded to this question and ways to respond to that. But it's really an important part of knowing where your people -- where your patients and residents are along the way. Residents appreciate having the opportunity to express it. If it is something they're feeling, they feel they wish they were better off dead. Often people feel they wish they were better off dead, but they still haven't thought about harming themselves. But just being able to express that is actually a relief for the person who is feeling that way. It does not give residents ideas towards self harm. Being asked, we do not see this big spike in people who have gone through the PHQ-9 or any spike in attempts. But now you know and you can sort of help them figure out a way to get help when they're feeling that despondent. And, if you didn't ask, they would have no recourse or resource for getting help from you and would not people don't just when you walk in the door volunteer this kind of information. So you do have to systematically go through it. You just ask it openly without hesitation. If they sense that you're freaked out about asking it, it's going to interfere with their ability to report to you how they're really feeling. So doing it as if this is just part of your routine assessment, it's one of these questions that you're asking. They get through it just fine. So we're going to show a couple of clips now of different ways where he could have given a more abnormal response to the PHQ-9. Let me say just one thing before you do cue that up, sorry, guys. What we're showing with you this PHQ-9 interview with this particular patient is a much more severe interview than the majority of interviews. Because we wanted you to see a harder interview rather than an easier interview. What we heard back from staff is that they would get more out of being taught and shown a tough interview to get through because that's what they're worried about than being shown the more typical 60% who don't have a mood disorder. So you're going to see a much tougher set of responses not to worry you but just to help you see some of the techniques and skills to help you do successful and accurate interviews. Okay, thanks. You'll notice the last question in the Moods section asks about thoughts of being better off dead or of self-harm. The overwhelming majority of residents will not have these feelings. And, don't worry. You won't make anyone have these thoughts or feelings by asking this question in a calm, matter-of-fact way. On a rare occasion, a resident may indicate that he or she wishes they were dead. Although this is rare, it is important for you to know that someone feels this way. We will show you how to appropriately handle this situation should it arise. Mr. Royce, over the last two weeks, have you been bothered by thoughts that you would be better off dead or of hurting yourself in some way? I feel my family would be better off if I weren't here. I think they'd all be better off if I were dead. I know this is hard for you. I mean I always used to take care of myself. I used to take care of my family. And now I have to rely on other people. I feel so helpless. I hear how you're feeling, and I want to thank you for sharing this important but difficult information with me. It's important that I understand how often you're feeling this way. Would it be 0 to 1 days or 2 to 6" Well, there, at least 2 to 6 days. 2 to 6 days, ok. And I need to ask you if you've been bothered by thoughts of hurting yourself in some way? Hurting myself no, not hurting myself. I just don't want to bother other people, that's all. Well, we need to work together to help you to feel better. So I'm going to talk to the charge nurse and let her know how you're feeling, and it's also important that we talk to the doctor to develop a plan to help you feel better. OK. In order for that plan to be as helpful as it can be, there are some other questions that I'd like to ask you about things that are important to you and about whether you're in physical pain. Would that be ok with you? UH, yeah, yeah that would be all right. Actually it's kind of it's kind of a relief to be able to talk these things out, you know? We'll pause there and then we'll go back. I noticed nervous laughter when Rena asked about the frequency. Again, this is a clinical item and like all the other items in this section, you're going to ask how often they've had it. When you're reporting this back to the mental health specialist or physician, you need to be able to provide them with that information. So she just responded to it as she did to all the other items in the section. She didn't jump up and say, "Oh, my God, what am I going to do?" She responded to as if it were any of the other items in the section. And that's really important. I know it seems awkward. Sometimes when you hear it you think well, why did she respond that way? But it's part of the standard part of the assessment to respond in the same way and figure out how much quantity of the symptom that they're having. So we're going to go on to an even more severe answer from the resident. It's extremely uncommon for residents to have suicide ideation. It is important that we identify the rare resident who is thinking in this way. Let's watch one way to handle thoughts of self-harm should it arise. Mr. Royce, over the last two weeks, have you been bothered by thoughts that you would be better off dead or of hurting yourself in some way? I tell you, I can't do this anymore. I can't live like this. Like, I ought to do something to end it all. I know this is a difficult time for you, but it's important for me to understand how often you feel this way. Would you say that it has been not at all, several days, more than half the days... Oh, ohů this, several days, several days. 2 to 6 days, several days, ok. I know that this is a tough time for you, and what you've told me makes me even more concerned. It's important that we help you to develop a plan to protect yourself and to get help when you feel this way. And, part of that plan is going to be for us to talk with your doctor about developing a plan to help you feel better. But, before I do that, I'd like to ask you some questions about things that are important to you to help you be more comfortable in the facility. And, I'd also like to be sure that you're not in any physical pain. So, how are you doing? Do you feel like you could answer some questions about your daily care and comfort? Yeah I think that it'll help actually. I can I can answer some more questions. Ok. And then after we've done all that I'll ask the charge nurse to come in, and we can talk with her about how to help you with those feelings of not wanting to live like this anymore. All right. Thank you. So again, in that facility, their protocol for responding to the self-harm item was to bring in the charge nurse to help sort things out once someone did indicate thoughts of self-harm. And, again, you don't have to stop the interview immediately to do that. You can continue on. Again, it's a clinical assessment you've done, and you're doing your assessment. You go on to talk about things that are important to them and about their levels of physical pain because obviously care planning for this patient is going to be trying to give them things that are important to them and helping to address any pain that's present in addition to taking care of the mood disorder that's present. All right. So total severity score: So the summary of the frequency scores on the PHQ-9 question will go down in D0300. It indicates the extent of potential depression symptoms, and it can be useful for requesting additional assessment by providers and mental health specialists. So increasingly, this instrument is being used in other settings. Some of your medical care providers may not be familiar with it. Your medical director may not be familiar with it. But there's tons -- hundreds of articles about this instrument. It's available on the web. And a lot of providers are increasingly aware of it so that when you call them with a PHQ-9 score of 17, they know they've got somebody with a potential major issue on their hands. And you can sort of be using these scores to communicate across healthcare settings. It -- we're not asking you to diagnose a mood disorder or depression. Somebody still has got to go back and figure out what the source of the symptoms are. It does give you a standardized score which can be communicated. And the other thing that's very useful to this. One of the things that we're seeing a lot in nursing homes is that a lot of people are on psychotropic medications. There's a lot of use of Zoloft, Prozac, whatever out there. But people still have mood disorder present. And it's sort of like they.. it gets picked up, and they get started on something and then follow-up assessment doesn't get done. It's just assumed they're treated. So what we've really wanted to do with the MDS is have something that allowed us to be better at tracking change over time and being able to pick up where that person is getting better or not with their symptoms. And that's one of the things that your severity score on your PHQ-9 can help your team do and help feed back to providers. You add the numeric score across all the frequency items. You only total the frequency items. Do not add the column 1 items. You don't add up the score during the interview. I actually would have a hard time doing it during the interview, but don't do it during the interview. Afterwards go back and sit down and add it up. And the score is going to be a 2-digit number. You see two boxes on the form. So it's going to be a zero -- anything from 00 to 27. So 27 would be someone that had all of the -- all 9 symptoms and had them nearly every day. Obviously very extreme presentation. Again, you've got that leading -- yeah, you have that leading box there. So, if it's a 9, say, for example, you'd write in a 09 to complete that item. The interview is complete if the resident provides frequency responses for at least 7 of the 9 items, and by saying 7 of the 9 that includes a zero if they say they didn't have the symptom that's included. That's considered a frequency response. If the frequency column is blank for three or more items, then the interview isn't complete. You're going to code 9 if you've put in a 9 for more than three symptoms, then you're going to end up putting -- for the presence of three or more symptoms, then you're going to end up putting in a total severity score of 99 for incomplete and going on to do the staff assessment of the resident's mood. There is a D0350 safety notification item that's in here. You complete it only if I was answered as present. And it just says that a responsible staff or provider was informed that there was a potential of resident self-harm. Although rates of suicide are lower in nursing homes, indirect self-harm and life threatening behaviors are common and something that commonly occurs in -- or are seen in nursing homes, and recognizing and treating depression can be life saving. And it's also very important in our post acute care patients who are going to be going home only to recognize if we're sending folks home with a high level of risk. You're only going to only complete this if column 1 for item I was coded as a 1. You're going to say no, you -- hopefully, no one's going to answer no to this item. But whether or not someone was informed. So hopefully you'll be coding this one as a yes, that someone was. Let's see if there's anything else to cover. I think that pretty much gets it. In the manual, there's an actual correlation between the different severity scores on the PHQ-9 and levels of mood disorder. So it's right there in the manual for you to give to your providers in the instruction manual. There's also a way of doing categorical coding of probably not depressed, probable minor depression or probable major depression. And those scoring things are right there in your manual to do with that. So there are some residents who end up needing to have a staff assessment of mood because they're unable to complete the PHQ-9. They can still have a mood disorder even if they're not able to make themselves understood some of the time. Or if they were unable to complete the PHQ-9. And so - but you've learned something from the interview for those people that you've attempted it with. If they become hostile and unwilling to answer questions, you've learned something in that -- about that defensive -- with observing that defensiveness. So even attempted interviews that aren't successful have still given you some information that you wouldn't have had if you wouldn't have set down with sort of concrete, systematic interviews with that resident. So you haven't wasted your time, but you do need to go back and do the staff assessment. But you've met that requirement that you've tried to talk to them. So we developed the PHQ-9 observational version so that we would have something that could be used to pick up the DSM-IV criteria for these patients who still may have a mood disorder. And this ensures that information about their mood is not overlooked. Remember that just because you're coding presence doesn't mean that you're being asked to diagnose mood disorder or depression. You're going to be asked in this section for those limited number of persons who can't do the PHQ-9 interview, you're going to be asked to actually really talk to staff across all shifts that know the resident best. You're going to use the same interviewing techniques basically that we talked about with the residents. some staffer is distracted as the residents being interviewed. So you're going to use the same techniques in trying to probe and echo and get information. You're going to ask them to report the symptom frequency and ask them to report them even if they don't think it's related to depression. If they're unclear, try to focus it, try to explore them. If they've been in the facility for less than 14 days when you're doing this assessment, then you're going to need to talk to the family or significant other. You're going to need to review their transfer records. The look-back period for this item is different from other items; it's 14 days. That's the same for the interview and that's just because that's part of the DSM-IV standard for diagnosing a mood disorder. It needs to have been present and fairly persistent for two weeks in order for it to be considered a mood disorder. Sometimes what people say is, of course, they feel bad. They're in a nursing home. How would you feel? But again, 60% of people don't screen in positive with this instrument. So we need to know if they're having a transitional problem. And transitioning into the nursing home, it's something we need to know about so that we can start trying to address it and take care of it. There's also been an increasing shift in this thought about bereavement and life change and mood disorder. In the field, traditionally there's been a lot of thought that you give people months to be unhappy before you do something about it if you think it's a transition thing or if it's bereavement. There's increasing recognition that that's maybe not the best way to do this, that what we need to be is understanding people who are struggling with these things and really trying to help them get the supports and help that they need. Even though it may be a quote "normal" response, it's not a good quality of life for people. And so trying to help think through what some approaches and solutions are for someone who's feeling this way is really important and not to be just written off as something that would be expected because they've lost a loved one or they've had a life transition. Doesn't mean we have to, you know, medicate everybody. But that's where your mental health providers and your PCPs come in and your whole care team comes in trying to think through what the most thoughtful way is to address this person who's suffering so much and to help them start to feel better. All right. So anyway you're going to select the higher frequencies. Let's say you talked to a lot of different staff members and some of them are saying not very much and others are saying more. You're going to select the higher frequency response because, again, you're screening to identify people in need. You're going to do very much what you did with the interview. You're going to code the presence of the symptom in column one and in column two, if they've answered that yes the symptom is present, you're going to be coding how often it's present. If column one they said it's not present, then 2 you're just entering the zero. Again, it's the same response categories. Never, several days, more than half the days or nearly every day. Or the number of days, 1, 2-6, 7-11, and 12-14. You'll also get a severity code for the observational version. The one thing that's different on the observational version is that we added an irritability item. If you look at J, being short tempered or easily annoyed, we worked with the developer in doing that. We recognize in our cognitively impaired residents or folks that don't have the ability to communicate easily, irritability may be the one thing that's easiest to pick up on and that people really see. We added this in, and it did improve the detection and mood disorder to have the irritability item in the observational version. So you're going to basically do the same thing that we did before. You're going to add up the symptom frequency from column 2 and that's what's going to go in D0600 for reporting a total severity score. When we do both in residents, the staff score is systematically lower than what the residents are self-reporting. Again, consistent with our experience with other mood screening approaches that we tend to pick up less if we're just using our observations and gestalt. But it's more accurate and closer than the old way that we had of trying to pick up the mood disorder by focusing in on specific, more observable behaviors and signs and symptoms. You don't put -- just like with the resident interview, for the total severity score, you don't add in the values from column one, you're only adding up the values from column 2. It's a 2-digit number, same thing. But because we have an additional item, the score can be as high as 30. So instead of going from 00 to 27, it can go from 00 to 30. Same thing with the leading digit. Iif it's a 9 or 7, you just put a 09 or 07. Again, this is the same thing, the safety notification and sort of the self-harm. So sometimes what you're going to hear from these patients is more stuff like God should have taken me already. People aren't meant to live like this. You'll hear those kinds of things, and those may be the clues that your staff should be looking for that this person in extreme distress and may be having thoughts of self-harm. Again, you're only going to code that, the D0650 safety notification hopefully again if you think there's a problem you've notified someone. Everyone's facilities should have protocols that address this. All right. So we have time for questions. I think - how many people in this room have done a geriatric depression scale? Great. Wonderful. And if you remember the first time you asked that, it was a little tough, right, to do it? Of course, for me the 100th time I did it was a little tough. So it's hard because some of those questions in they are sort of tough to ask -- about hopelessness, for example. How many of you have done a PHQ-9? Pretty new. There's only a handful of people who have actually done it.