Quality Over Quantity: Integrating Mental Health Assessment Tools into Primary Care Practice


Darrell L Hudson, PhD, MPH

Perm J 2016 Summer;20(3):15-148 [Full Citation]

E-pub: 06/17/2016


Depression is one of the most common, costly, and debilitating psychiatric disorders in the US. There are also strong associations between depression and physical health outcomes, particularly chronic diseases such as diabetes mellitus. Yet, mental health services are underutilized throughout the US. Recent policy changes have encouraged depression screening in primary care settings. However, there is not much guidance about how depression screeners are administered. There are people suffering from depression who are not getting the treatment they need. It is important to consider whether enough care is being taken when administering depression screeners in primary care settings.


I was at the doctor’s office, a family medicine practice for a routine check-up.

“I have to ask you these questions about mental health,” the nurse said sheepishly after recording my heart rate and blood pressure.

The preface immediately put me on guard and I tensed up. On the one hand, I thought, does anyone suspect that something is wrong with me? Could they tell I was anxious because I forgot to get cash and would have to dive for quarters in my glove box to get out of their parking deck? On the other hand, I conduct mental health research, so I knew the nurse was probably going to ask me questions from the Patient Health Questionnaire (PHQ). I was encouraged that mental health was being integrated into a medical visit in a primary care setting.

During the past two weeks, have you found little interest or pleasure in doing things?

Have you felt down, depressed, or hopeless?

The answer to both of these questions was no. But the opening statement from the nurse about her obligation to ask questions about mental health set me on edge a bit. The nurse’s demeanor changed from when she was taking my blood pressure and recording my weight. In one sentence, she made it abundantly clear that she was asking only because of obligation, she was not comfortable asking, and she was not particularly interested in hearing my answers to the questions. I wondered, if I was feeling down or losing interest in doing things I had previously enjoyed, would I feel comfortable telling her? Considering her apparent disinterest, did she even care? Would I believe that she would do anything about my feelings?

Depression is one of the most common, costly, and debilitating conditions in the US, affecting millions of Americans each year.1-5 Disability from depression is associated with lower educational attainment and income earned as well as increased days off work.6-10 Depression is also associated with suicide11-13 in addition to a wide range of chronic diseases such as heart disease and diabetes mellitus.14-18 Recent national policy changes related to mental health coverage, namely the Patient Protection and Affordable Care Act of 201019 and the Mental Health Parity and Addiction Equity Act,20 have promoted the integration of mental health screening and treatment into primary care settings. Indeed, most patients are initially diagnosed and treated for mental health problems within primary care settings.21,22 Many practices and health care systems, such as Kaiser Permanente, use the PHQ to screen for mental health problems. Results from numerous studies indicate that this measure is effective in screening for mental health problems in primary care settings; even versions with fewer items do a good job of identifying depression.23-25

Although there are numerous resources that describe different versions of the PHQ as well as information about reliability and validity, in addition to steps on how to score the screener, there are no clear guidelines about how clinicians should go about asking patients questions about their mental health. However, the manner in which questions are asked and by whom have a profound effect on the answers that patients provide.26,27 This is especially true when asking about sensitive information.27 Race/ethnicity, sex, social class, and sexual orientation are additional considerations that mental health service clinicians must contend with and which make recognition and treatment of depression even more challenging. Further, mental health conditions remain highly stigmatized. This seems to be an important factor that should be addressed at the individual clinician level as well as at the system level.

Practices and health care plans should be applauded for taking steps to integrate mental health and primary care. Despite the efficacy and effectiveness of the PHQ, I wondered how probable someone suffering from depression would be to share such feelings during a similar clinical interaction. I wondered if the nurse’s preface and, more importantly, her demeanor would affect the comfort of patients who do suffer from mental health problems and give them pause about answering the questions honestly.

Is it enough to simply ask questions, especially if the person asking the question does not seem the least bit interested or enthused about doing so? If the goal is to screen patients who may be suffering from depression and other mental health problems, there must be better care in the administration of the PHQ within primary care settings. If patients are anxious about their answers or fear judgment, they might give biased answers. And that will not help anyone. If the nurse’s preface to the questions put me on guard, I wondered how other primary care patients might feel.

A search of the literature for best practices in administering the PHQ or other depression screeners did not produce any specific guidelines to help clinicians to most effectively administer these instruments. However, clinicians could help to mitigate stigma by establishing rapport and asking about patients’ overall well-being, whether they are feeling very stressed, and whether there have been any substantial changes in their lives. It may also help to have physicians incorporate these questions into their general physical examination so that patients understand that mental health is essential to overall well-being. Furthermore, there should be clinician continuity in who administers depression screeners. In my case, a nurse with whom I do not recall interacting before my visit administered the PHQ before I saw my regular physician. I did not have a relationship with her and would have found the screener questions less obtrusive if they were incorporated into time with the physician, whom I have been seeing for several years. The PHQ and other depression screeners avoid psychiatric terms that may be stigmatized or confusing to patients. Similarly, clinicians should avoid these terms. Additionally, once clinicians ask questions about mental health, they must be prepared to discuss the challenges that patients are facing and be ready to provide referrals and resources to help patients with mental health conditions.

There are probably many missed opportunities to address the mental health needs of Americans. It is no secret that mental health services are underutilized in the US.28-30 Fewer than half of the people who have a mental health problem ever seek services.31 Even in highly vulnerable populations, like those who have diabetes, depression recognition (eg, diagnosis, medication, referral to mental health specialty care) can be poor.32 It is probable that there are patients suffering from mental health problems who do not seek treatment or who are not being recognized with these problems when they interact with clinicians for medical concerns. It is important to consider whether enough care is being taken when administering depression screeners in primary care settings. Furthermore, it may be important to alert patients that they should expect to be screened for mental health issues even if they are visiting for their physical examinations.

Disclosure Statement

This work was supported by the Barnes-Jewish Hospital Foundation in addition to Grant Number 1P30DK092950 from the National Institute of Diabetes and Digestive and Kidney Diseases, and its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institute of Diabetes and Digestive and Kidney Diseases. The funding agreement ensured the authors’ independence in designing the study, collecting and interpreting the data, writing, and publishing the results.
The author(s) have no other conflicts of interest to disclose.


Mary Corrado, ELS, provided editorial assistance.

How to Cite this Article

Hudson DL. Quality over quantity: integrating mental health assessment tools into primary care practice. Perm J 2016 Summer;20(3):15-148. DOI: https://doi.org/10.7812/TPP/15-148

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