Creyos Health has been updated to allow you to easily administer standard questionnaires alongside existing cognitive assessments, beginning with the Patient Health Questionnaire (PHQ-9). Further details are provided below for your reference.

Note: The purpose of a PHQ-9 is to assist the clinician in quantifying depressive symptoms and monitoring the severity of these symptoms over time. Any conclusions drawn from the PHQ-9 should be paired with clinical interviews and observations, other mental health examinations or assessments administered, and evaluations of the patient’s level of distress, functional impairment, and/or family history. Please refer to the official PHQ-9 instruction manual for additional details.

What is the PHQ-9 assessment?

Released in 2010 by Pfizer, the PHQ-9 is a simple 9-question instrument for screening, diagnosing, monitoring and measuring the severity of depression. In less than 10 years, it has become one of the most commonly used depression screens by clinicians as well as researchers alike, and is endorsed by a number of organizations, such as the American Psychological Association (APA), the National Institute for Health and Care Excellence, and the American Psychiatric Association. While the PHQ-9 is most commonly used by mental health providers, a wide array of other healthcare providers (such as Primary Care Physicians, for example) have also adopted this questionnaire as part of their standard practices for screening depression symptoms.

How it works

At the beginning of the PHQ-9, patients are prompted with the following question: “How often have you been bothered by the following over the past 2 weeks?” Patients then fill out the following questionnaire:

Once these questions are answered by the patient, the assessment is scored and the severity of the depressive symptoms are categorized according to the following rules:

In the example responses above, the final score would be: 3 + 1 + 2 + 3 + 1 + 2 + 3 + 0 + 1 = 16 / 27, which would classify the depressive symptoms as being “moderately severe”.

Note: The purpose of a PHQ-9 is to assist the clinician in quantifying depressive symptoms and monitoring the severity of these symptoms over time. Any conclusions drawn from the PHQ-9 should be paired with clinical interviews and observations, other mental health examinations or assessments administered, and evaluations of the patient’s level of distress, functional impairment, and/or family history. Please refer to the official PHQ-9 instruction manual for additional details.

How is depression related to cognitive function?

In this year, more than ever, mental health is becoming a larger and larger component of patient care plans. The COVID-19 pandemic has led to an unprecedented increase in stress among communities and individuals, worsening or triggering mental health conditions such as depression (see the CDC’s pandemic stress guide for more information). Research shows that the effects go beyond depression itself—mental health is closely linked with cognitive function, and collecting information about both together can have important clinical implications, as referenced by the following literature:

One new study (Desai et al., 2020) showed that depression, as measured by the PHQ-9, predicted both current and future scores on Creyos tasks like Token Search, Grammatical Reasoning, and Paired Associates. The reverse was also true—poor cognitive functioning is a risk factor for future depression. For those treating mental health, both PHQ-9 scores and cognitive task scores are key measures that can identify baseline risk, refine treatments, and demonstrate the wide-ranging success of your care.

Studies show that even if your focus is not mental health, a quick measure of depression may be beneficial. A wide variety of mental and physical illnesses are closely linked with depression and cognition. For example, one study published in JAMA Psychiatry (Sullivan et al., 2013) found that among patients with type 2 diabetes, depression was associated with accelerated cognitive decline. The greatest decline occurred in patients with a PHQ-9 score of 10 or more at both baseline and 20 months later. The researchers propose that depression could be causing or worsening the risk of dementia.

Another study (Hawkins et al., 2016) involved patients with heart failure, who have high rates of both depression and cognitive impairment. The researchers found that certain PHQ-9 scores predicted performance in multiple cognitive domains. They suggest that treatments known to affect both depression and cognition, such as cognitive behavioural therapy and physical exercise, may be most impactful on this population.

With Creyos Health's questionnaire features, you can begin to answer the questions addressed by studies like this with your individual patients. Is successfully treating depression potentially slowing the rate of cognitive decline? Is a patient's subjective "brain fog" a result of objective cognitive impairment, or is it a biased perception caused by a mood disorder? After quick Creyos Health assessments, you will have additional supplementary information that helps answer these questions, and that can be combined with other assessments you are completing today. Ultimately, these assessments can help guide your treatment plans and provide quantifiable evidence.

Challenges associated with administering the PHQ-9 through existing methods

Before determining the administration, patient and reporting experiences for the PHQ-9 in Creyos Health, we interviewed customers who regularly administer the PHQ-9 as part of their clinical practices today. These interviews helped shed light on the many problems providers face in this regard, and ensured that our implementation addressed these pain points:

• PHQ-9 assessments take significant manual effort and time to administer and score
• Patient experiences are inconsistent, disjointed, and often confusing, creating unnecessary back-and-forth communications that waste time
• Collecting and analyzing results trends (both for overall PHQ-9 scores and individual responses to the PHQ-9 questions) are difficult and time consuming

To illustrate these challenges, here is an example from a healthcare provider we interviewed:

• Provider sends patient a Word document with the PHQ-9 template embedded
• Patient opens that document, fills in the responses, and sends it back to the provider
• Provider then opens the document, manually tallies the score, prints the document for her records and stores it in a file drawer. Sometimes, the formatting of the questionnaire responses breaks, or the file doesn’t open properly on the patient’s computer, and the provider resorts to spending time resolving the issues
• When it comes time to reassess the patient, the provider follows the same process as above—except, to gauge progress, she must pull out the previous report from the file drawer, and physically compare it side-by-side to the newly printed report

In most other cases, we found that providers are collecting this information through pen and paper, and during COVID-19, have not been able to find suitable solutions to facilitate the assessment remotely. Others have resorted to setting up custom surveys through online survey tools as a stop-gap measure. In all of these cases, the patient experience suffers, as patients often have to follow a tedious set of instructions to complete the assessments. This ultimately hurts compliance rates, and places a burden on administrative staff to follow-up with patients to ensure that assessments are completed in a timely manner.

How can the PHQ-9 assessment be administered in Creyos Health?

The Creyos Health implementation aims to solve these problems. Here’s a step-by-step guide illustrating how the PHQ-9, and other future questionnaires, will be incorporated into the Creyos Health platform.

1. Simple, easy, and fast administration

As with any assessment administered through Creyos Health, the first step is to select a patient, click on “Start Assessment”, and choose the administration path—that is, you may administer the assessment on the device you are on, via email through the Creyos Health platform, or by copying a link out of Creyos Health to paste in your own communication channel. For this example, let’s select “Send by Email”.

On the next page, you’ll notice a familiar prompt, except that instead of choosing assessments, you’re now going to choose the protocol. Much like how you currently have various built-in cognitive assessments, each made up of a different combination of individual tasks, you will have the opportunity to have built-in protocols, each made up of a combination of different assessment types. When combining assessments, patients will complete each in a single sequence based on the order you define. Aside from built-in protocols, you may also build your own custom protocols to administer on the spot by selecting “+Administer Custom Protocol” as illustrated below:

Upon selecting “+Administer Custom Protocol”, you’ll see a new panel that allows you to select assessments from multiple assessment types, allowing you to combine questionnaires with cognitive assessments, or administer them separately.

As an example, let’s say you wish to combine a custom 2-task cognitive battery consisting of Working Memory and Episodic Memory, and administer it alongside a PHQ-9. In this case, you would first click on the “Individual” tab within the “Cognition” main menu

Next, you would check off the Working Memory and Episodic Memory options.

Then, you’d click on the “Depression” main menu item on the left-hand side, and select “PHQ-9”. You’ll see the right side of the screen populate with your choices as you select them:

Once the protocol is defined, the remaining steps remain the same—you may set a reminder schedule, modify the email message, and finally, send the protocol for your patient to complete.

2. Elegant and effortless patient experience

As soon as your patient receives the email, they will click on the “Start Now” link, much like how they complete cognitive assessments sent via email today. The patient experience when completing questionnaires is fast and simple. At the beginning of every questionnaire, the patient will receive high-level instructions. Here is the example from the PHQ-9:

Clicking “Start” will then reveal the first question of the PHQ-9:

As the patient clicks on each response, they are automatically shown the next question:

When the questionnaire is complete, the patient is then shown the introduction page of the next assessment in the series:

One more addition that you may notice is that cognitive assessments now have progress bars such that the patient can see exactly how far they’ve progressed and how many more tasks are left to complete:

3. Automated and insightful reporting

Once the patient completes each assessment in the protocol, reports will be automatically scored, generated, and stored in your account in PDF format. To access a report, click on the patient. You’ll see two different rows: one containing a link to the PHQ-9 assessment results, and the other, the cognitive assessment:

Clicking on the PHQ-9 row will open a PDF of the report. The first time a patient completes the PHQ-9, the report will consist of the following:

On future questionnaire completions, trends will automatically be displayed:

PHQ-9 billing procedures in the United States

Please note: Please note that Creyos can not determine your eligibility for reimbursement and does not assume responsibility over the outcome of any claims. The CPT code(s) noted below to report the services provided will depend on other procedures performed, associated CCI edits, and other factors. Please contact your local payer to determine whether you qualify for these codes, and if any additional coding and coverage guidelines exist, such as which providers can perform the service, limits on billable time, or if the use of a modifier is required or allowed.

Providers utilizing the PHQ-9 may be eligible for reimbursement through CPT code 96127, described as the following by the Centre for Medicare and Medicaid Services (CMS): Brief emotional/behavioral assessment, with scoring and documentation, per standardized instrument.

As per the latest guidelines from the American Medical Association, this code is also telehealth-approved. Usage limits and reimbursement amounts vary by state, payer types, and potentially other factors, though the average reimbursement value can range anywhere from $4-$8. For further information, please contact your local payer.

Future questionnaires are coming soon

Stay tuned, as this is the first of many other standard assessments that will be made available in our platform. Quickly following the PHQ-9, the GAD-7 will be released, which assesses the severity of anxiety symptoms.

Finally, if there are any questionnaires you are using today as part of your practice that you would like to have available in Creyos Health—or if you have other feedback or comments for the Creyos team—please do not hesitate to let us know by commenting on this blog or contacting us directly via email. We always look forward to hearing from you.

Thanks as always,
— The Creyos Team