Recognising symptoms

Patients and practitioners described how using the PHQ-9 could help patients recognise that the range of different symptoms they were experiencing, in the context often of adverse life events and difficulties, could be understood better as occurring together as part of the recognised syndrome of depression. The PHQ-9 was described as helpful in identifying the severity categories, particularly for patients having a first episode of depression. Patients’ accounts and researchers’ diaries suggested that seeing each item and the infographic helped to validate experiences of depressive symptoms and provide a way to understand them together as depression:

Patient PT03037-03:

I didn’t realise half of the symptoms and I’m guessing other people don’t either, unless you know or you have an inkling that you are depressed, you probably aren’t going to – look into it. It’s probably not something you want to look into either; so having that there is really useful.

Patient PT02024-03:

As I was reading [the items] I was thinking to myself – yes, that is me, that is me and I kind of understood it bit more

Both groups described how the PHQ-9 provided a global assessment and explicit marker of the severity of patients’ difficulties, but also provided insight into the areas with which individual patients needed help:

Practitioner GP01056-01:

It’s like another little bit of a jigsaw really … You’ve got someone who is coming in and you’re like, you’re in the severe zone, I know that … Gosh, you really are struggling.

Patient PT03037-03:

It made me realise I’m apparently more depressed than I thought I was. There are a few points here that I didn’t realise meant you’re depressed, like concentration.

Some patients found that the PHQ-9 score and infographic were complementary and helped them to understand how they were doing. These could be reassuring if the severity level was not too high. However, they could also be distressing if there was dissonance, making patients feel judged by the severity category when the PHQ-9 outcome did not align with their own expectations. For some individuals this was a sharp ‘wake-up call’ to seek support but also gave them solace that they were not alone in their struggles:

Patient PT01023-02:

It reassured me that I wasn’t going mad, that it is an illness, and it does affect a lot of other people as well.

Patient PT01026-02:

I guess when you’re feeling really rubbish and then you look at it and you’re like actually, well, I haven’t got all of these things on here, so it’s not as bad as it could be [laughter].

However, others did not necessarily feel that the PHQ-9 score accurately reflected how they were feeling. Some found the score difficult to accept, and the infographic could invoke feelings of fear and anxiety:

Patient PT03059-01:

I wouldn’t necessarily describe myself as seriously depressed but maybe I am … That was difficult to process … Let’s say on your way to work, you see 100 people. Oh, I’m one of two people.

Monitoring over time

The PHQ-9 was reported to be a useful tool for GPs to monitor their patients’ depressive symptoms over time. Follow-up scores provided an opportunity for reflection and to identify improvements or deteriorations and relative progress:

Practitioner GP02013-01:

I used to just say it’s working or it’s not. So if the PHQ-9 score was decreasing, then I would congratulate the patient and say – maybe, you know, you’re not feeling that to an extent, but look at the number that you scored some time ago because they’ve forgotten what the number was, but they’ve come with this new number, which could be 13 and it would be 24 in the past. So I say, well, that’s great progress

Symptoms were being monitored, and there was relief if things were getting better, although sometimes the scores were felt not to be nuanced enough:

Patient PT01002-04:

There have been times where it has gone back up a little bit but then it comes back down again. It is one of those things – sometimes it’s a mixture. If it goes back up slightly you do sometimes feel a little bit disappointed but it’s definitely helpful to see what areas you need to focus on and where to get better.

Practitioner GP03044-01:

I could see patients improving and patients didn’t realise they were improving until they saw the scores and that was quite a pleasant discovery for them and that motivated them … Especially when they’re depressed, they can’t really see a way out and can’t see the progress that they’re making, but it was a nice way for the patient to see that they’ve actually made progress.

Patient PT01002-04:

Looking at the questionnaire my score had gone down … I left [the appointment] with that sense of relief that stuff was helping and I was starting to feel a bit better

Many patients reported that recognising changes in their depressive symptoms was difficult without the ‘physical’ scores on the questionnaire. The PHQ-9 also enabled patients to progressively ‘map out’ necessary steps and areas of improvement:

Patient PT03037-03:

It’s mainly mapping to see which bits needed to be improved and which bits could be not focused on for a little while, what to work on or how to make yourself feel better

Motivation and hope

Using the PHQ-9 initially and realising the severity of their depression motivated some patients to actively seek support and address their problems.

Patient PT01002-04I:

I don’t think it made me feel worse. If anything, it put things into perspective as to how bad I was feeling and how much – I was grateful that I was able to see that because I knew then how much I needed that help and how important it was.

Patient PT01096-04:

It was a bit of a shock at first … but it certainly did help, I have to say. It is fairly bad, so you’ve just got to try and get on with it and get better.

Over time, seeing improvements motivated patients to continue their efforts to try to get better and emphasised that there was worth in their perseverance. It also gave them hope that progress was taking place.

Patient PT01002-04:

When I see it go down, you’re relieved. You’re like, oh, it’s working; it’s worth getting help.

Being pigeonholed

GPs and patients described the response options on the PHQ-9 as pushing patients to be pigeonholed into arbitrary categories. Patients perceived this as difficult to do, inaccurate in reflecting their actual problems, and an oversimplification of their complex experiences:

Patient PT01002-06:

You just get judged by these 9 questions, to assess how severe you are and how ill you are and that becomes […] people are worried about becoming numbers and becoming just data. […]. It can almost feel like an efficient method to judge something that’s almost impossible to understand fully, which I guess it is

Some GPs reported that the items were not clear, which resulted in the loss of nuanced understanding of their patients’ difficulties; for example, daily changes were not identified or items unhelpfully captured both ends of a spectrum at once. This affected the quality of symptom-specific care, which required GPs to gather more information beyond the pre-ordained symptom categories and scales, which could work to conflate or even ‘lump together’ different types of concern:

Practitioner GP01002-01:

I just got a score for the symptoms and need to discuss: Do they comfort eat? Do they skip meals? All these things are not separated. The PHQ-9 asks are you overeating or are you skipping meals? Well, what is it? It’s not clear, it could be either … Maybe they need a referral to an eating disorder clinic or maybe they need to see a dietitian.

Some patients echoed this but also said that the PHQ-9 only considers the frequency of symptoms over the period of 2 weeks. This was important for patients for whom frequency of symptoms did not necessarily change but the impact and severity of symptoms did. Not being able to reflect tiny but meaningful triumphs was disappointing and ultimately worked to obfuscate rather than illuminate changes that were meaningful to the patient and potentially helpful for the GP:

Patient PT01096-05:

It only had three points and I felt like it wasn’t enough for me to say, ‘I am improving, but actually I’m not improving enough to go to the next point on the scale’ … The frequency of symptoms remained the same, but the intensity has decreased … I was disappointed that I couldn’t reflect my progress.

Cognitive aspects

General practitioners and patients found the PHQ-9 easy to fill in and the visuals of the infographic understandable. The brevity of the questionnaire was reported to be a relief, especially for those patients whose scores indicated moderate to severe depressive symptoms and for whom concentration may be a problem:

Patient PT01096-04:

If someone would have just said to me, ‘this is your score, this is what it means,’ I would have been a little bit confused but having something to look at and analyse, for me it gave me a lot better of an understanding.

Patient PT03037-03:

Nine questions is easy compared to other questionnaires I had to do … My head was in a very odd place, it felt easy to focus on a small document … Especially if you do come under like severe or moderate, you probably don’t want to read a large bulk of information straightaway.

Practitioner GP03044-01:

I think it was quite quick and easy and patients didn’t struggle to fill it in; it was quite you know, patient-centred. They understood the terminology, there weren’t any queries about, you know, clarifying anything; I think it was quite good

However, a minority of patients found various aspects difficult. One patient found themselves overthinking their response to each item when completing the PHQ-9 independently, which made the process time-consuming. Another also reported that their answers differed hugely depending on their mood at the time of completing the PHQ-9. Reflecting on their week was sometimes helpful.

Patient PT03059-01:

If I was filling it in thinking, I’ve had such a shit week, blah … and then I looked back through my diary and hang on a minute. I really enjoyed that day and that day and they were all within the week … How I’m feeling on the particular day that I’m filling it in is reflected on the whole week, rather than just that day … Looking in my diary I did feel okay that day, why have I said that it was awful?

Accessibility

Both patients and GPs had mixed perceptions of the accessibility of the PHQ-9. Some preferred to be able to complete it independently at home online or over the telephone, whereas others wanted to complete it on paper. GPs found that some patients needed help from their doctor to complete it:

Practitioner GP01002-01:

The PHQ-9 was developed as a self-assessment but some patients, when they’re feeling depressed, they find it difficult to focus on what the questions mean. You have to interpret things, so I often did it for [them].

Patient PT03037-03:

It was different doing it on my own because the first time I did it with [researcher] and I guess doing on my own … I would say – it’s really hard because I know when you answer things, you’re supposed to just kind of like tick whatever one you feel like initially or – like – just – whichever one you thought – not put too much thought into it, but when you’re on your own, it’s harder to do that. I spent a bit longer – like – thinking about each point and being – like – and also focusing on the last two weeks rather than how I’m feeling at that moment, and I think it’s easier when you’re – when someone else is doing it with you.

Some GPs also highlighted potential populations in whom accessibility may be reduced, such as older adults who may be less ‘tech-savvy’, people with sight impairments or patients without fluent English:

Practitioner GP02013-01:

We should try [the PHQ-9] in different languages as well … If they can’t read or they can read but they can’t understand English very well – it’s like merely ticking the boxes. We don’t know whether that’s accurate.

Some GPs suggested that patients should complete the questionnaire in the waiting room before their appointment, and that staff in reception could support those who needed help filling it in. However, issues around confidentiality needed to be considered. Relying on patients to independently complete the PHQ-9 at home was not considered ‘bulletproof’ as some patients may struggle to complete it as asked:

Practitioner GP01056-01:

I would probably be more inclined to give someone it to take away or to fill out in the waiting room and hand in rather than doing it there and then because, you know, it’s time-consuming.

Practitioner GP02013-01:

The receptionist used to be well trained to just hand over the PHQ 9 while they were waiting to be called … We’ve got a text messaging system on our EMIS, so if we have a link to the PHQ-9, we can just text them the PHQ-9 link and they can fill it out. Or if it comes in the form of an app, let’s say a PHQ-9 app, that can be sent through so we can ask them to do the score once a month and they can send the whole stuff to, you know, text it to the surgery or e-mail it to the surgery and we could just – it gets automatically downloaded on the patient notes.

Practitioner GP01026-01:

It’s fine if someone’s going to your house and doing the PHQ-9 with you or in the surgery there and then … Someone who’s depressed and can’t motivate themselves to get out of bed … They may not get that motivation to do the form.

Driver of discussion

The PHQ-9 could act as a guide for practitioners to discuss patients’ difficulties, needs and care. It facilitated productive conversations as both parties had more information on the problem as assessed using the PHQ-9. It also removed perceived pressure on some patients to formulate what they wished to discuss in the consultation:

Patient PT01002-04:

It sometimes is really difficult to explain how you’re feeling. Being able to put it down on paper like that both yourself and your GP can see how you have been feeling and what areas are a bit worse than others. I think it’s very helpful.

It could also help those who found it hard to talk about their depression for various reasons, including stigma, or found it hard to articulate their difficulties and experiences and felt that the GP practice was not a legitimate place to talk about mental health:

Patient PT03059-01:

So it has been helpful in that way to – be able to quiz him from a medical perspective about certain things, to try to understand why – some of the stuff might be going on where, in the past, I would never ever have gone to the doctor really to talk about depression because you feel like you’re wasting their time, where there are other places like talking therapies that you can actually talk to a therapist about it

As each item highlighted a specific symptom, some GPs felt that the tool helped them clarify with patients each of their difficulties and its individual impact. Many GPs found the final item, which asks patients about whether they have thought about self-harm and suicide, a helpful reminder to conduct necessary risk assessments, as this may not happen routinely in a less structured consultation. This worked as a safety net for the patient, it could be helpful for onward referral to mental health services, and it could also ensure that GPs covered key risks to minimise legal and medical consequences:

Practitioner GP01002-01:

The good thing is the safety aspect. You are forced to ask the question about the self-harm … I think a big plus of this tool, you can’t just do the score without asking the question and medically and legally, of course it’s indefensible if things happen … In a consultation where you have other things to discuss with them, it can be easy to forget.

Patients sometimes reported feeling that using the PHQ-9 was beneficial in bringing structure to the consultation and as a way to compare how they were doing from one consultation to the next:

Interviewer:

in terms of the conversation, what were you mainly discussing in that [second] appointment?

Patient PT03037-03:

I think it was the second PHQ-9; yes, because we talked how about they were the same score. Then she wanted to know other stuff about what had been happening over the last few months and before that and I know that we talked about things that I hadn’t talked about in the first one […] It was mainly the PHQ-9 score and seeing – like – which – because she had two of them in front of her so she could see which questions had changed and she kind of just went through which ones had gone up and which ones had gone down and stuff like that

The patient–GP relationship

The PHQ-9 could facilitate GPs’ engagement with and support for patients through validation, praise, monitoring and evidence of improvement:

Practitioner GP02013-01:

If the PHQ 9 score was decreasing, then I would congratulate the patient and say – you’re not feeling that to an extent but look at the number that you scored some time ago, but they’ve [come] with this new number, which could be [13] and it would be 24 in the past. I say, that’s great progress.

Many GPs felt that the PHQ-9 was appropriate only for use with patients with whom they had an established relationship. If stepping in for a colleague with a patient they had never seen, they might be reluctant to use the PHQ-9, as no comparisons could be made with that person’s previous level of depression.

Practitioner GP01002-01:

If I see the patient only once, in between the doctor who normally sees them, I would not feel inclined to use this tool, because what am I going to compare it against, and what am I going to do with this information?

Involvement in the trial encouraged practices to offer patients follow-up consultations with the same GP, which patients found could make it easier to develop a trusting relationship and open up about their depression. Continuity of care was voiced as paramount by patients, who felt that it made a huge difference as they could build rapport with their doctor, feel comfortable, and not need to start again from scratch and repeatedly present their problem or concern to another practitioner:

Patient PT03059-01:

It was good that I could then go and see my doctor quickly after [completing the first PHQ-9], because then it was nice to be able to talk it through with him. He was able to explain a few things in more depth and talk to me about what I wanted to focus on and try and work on and things. […] I mean I felt more – I guess – safe in a way because I knew then that I’d be seeing him in another four weeks and there is something reassuring about that, knowing that you’ve got something booked in, especially when – now I’ve been trying to book an appointment just for a general appointment – oh, we don’t have anything, we don’t have anything, we don’t have anything; that’s been going on for three months now and I’m just like – oh my God. It’s so ridiculous, like seriously – I don’t understand. So yes, in that sense I feel like I’ve got a bit of a safety net in being able to see him once a month.

Patient PT01002-04:

It’s someone who you’re already comfortable with. You’ve already opened up and [the GP] knows what’s going on so you don’t have to talk about some of the more difficult things again. It’s just a carry on the conversation from the last appointment sort of thing. I definitely preferred having the same doctor.

Patient PT03044-04:

It was good knowing that there’s somebody there to monitor that progress. I think that’s reassuring.

Person-centred care

Patients very much valued having trust in the GP and feeling that the GP cared, listened to them and was interested in them, and being viewed holistically as a person in context rather than reduced to simply a person with depression. Patients described feeling that the GP cared when they seemed excited or disappointed about the impact of treatments. Patients also valued flexibility, including discussions around what they wanted, scheduling follow-ups depending on their needs and choice, and flexible treatment plans:

Patient PT02139-04:

I know it’s silly because it’s not, really, it’s just procedure, I know that, but it’s just the way that they called and had time for you […] we’re trying to ring the GP, we’re almost impossible to speak with them. They were always busy, and the fact that they’d taken the time out to speak with you. I think he’d rung and spoke with me for half-an-hour, which is a lot, when you consider how busy they are. So it was nice to have that, and it made you feel like you did matter. I know that’s daft. It is daft, it was just a phone call, but it’s amazing how that can change your mood.

Patient PT03036-04:

She’s really great, asking questions; it felt like she really made the time. She asked me certain questions about – like – my day-to-day and my – well first just how am I feeling, am I feeling any better than the last appointment or not? How do I feel the meds are doing for me and just – am I – I don’t know, just like day-to-day stuff

The PHQ-9 helped GPs and patients to understand individual symptoms and the impact these had on different patients:

Practitioner GP01002-01:

You actually ask about individual symptoms, which maybe are not widely recognised as symptoms of depression … I think it’s a more holistic assessment than you would do if you’re left to your own devices and you ask just three random questions, which might not actually show you the whole extent of how things affect you.

Having their complex and individual experiences understood made patients feel listened to and appeared to instil a sense of agency as they were enabled to play an active part in the decision-making about their symptoms and appropriate care:

Patient PT01094-04:

I felt quite positive that he had listened to me and my views on it. Whether he did or not, I don’t know, but I felt like he did.

However, some GPs thought that the PHQ-9 training did not necessarily reflect the idiosyncratic approach that they should take in clinical practice. They said that the PHQ-9 should be a stepping stone to deeper conversations about patients’ problems, which the training did not fully elucidate:

Practitioner GP02024-01:

The training was a bit too black and white for my taste … Normally the answer was, talk to the patient and listen to them a bit more and see what they wanted, and that was never an option. It was always you had to do this, if antidepressants were appropriate, you’d offer them, and they may or may not take them … I wouldn’t be pushing any particular course of action so that training wasn’t that realistic.

Some patients reported feeling that they had more of a say in their own treatment and support and feeling empowered, which increased their hope as a result of more collaborative decision-making about treatment:

Patient PT01096-04:

So the score I got, if I remember rightly, he said to me that he probably would recommend tablets, but he said if I wanted to do, on the side, therapy, then I could, but I decided to see how the tablets would go. He said normally he would recommend the tablets, but he then went through all the side effects with me, and he let me make my own decision. He just recommended and went through all the risks and side-effects they can have and things like that.

Interviewer:

What do you think about the patient’s reaction when you gave them their feedback on their scores?

Practitioner GP01012-01:

I think they were mostly absolutely fine and accepted that, you know, it was – putting it in – in less of a judgemental way; so it gave them a bit of ownership of it. So, yes, I think they liked it

Evidence to inform treatment and management

Most GPs and patients found the PHQ-9 informative for treatment and management plans. They felt that the PHQ-9 solidified decisions about potential treatments to suggest; for example, lower PHQ-9 scores might indicate lifestyle improvements and medication might be more appropriate for those with higher PHQ-9 scores. The strength of GPs’ endorsement of treatment suggestions was also influenced by the PHQ-9 score.

Practitioner GP01056-01:

I perhaps might be more persuasive towards someone who’s dark red saying I actually think we do need to start you on treatment … If someone’s yellow, I might sit more on the fence and just say – this is an option, how do you feel? Would you prefer to have treatment or not have treatment? … I think it does help you knowing where someone is on the severity score in terms of how you emphasise the different treatment.

The utility of completing the questionnaire with the doctor was described by some patients in terms of focusing the discussion on the severity of the depression and the corresponding treatments:

Patient PT01096-04:

I remember we both had the form up on there and we were going through it, and he was explaining to me the diagram and things like that, and we were talking about the category that I fell into, and different ways to help it and things like that. So that’s, again, when he said about the two different types of treatment, which was tablets or therapy. Yes, so it was used to see where I was at, at that current point in time, basically

However, practitioners often felt that a score on the questionnaire was not needed as they already knew the patient and could judge what management/treatment they might need, although having the score could be helpful with patients they did not know:

Practitioner GP03044-01:

I think I’ll probably preserve it for patients that actually need a more formal management plan.

Interviewer:

And how would you identify those patients, as compared to those who don’t – who won’t use the PHQ-9?

Practitioner GP03044-01:

Just because I know the patients quite well and I think the ones who will open up to me and I’ve got a good rapport and history with them, I can probably judge, you know, what I need to do with them, faster. Maybe somebody like new patients, patients who don’t come in [that well], ones I’m not sure about, would be a good place to use that

The PHQ-9 score was also described as indicative of whether or not the treatment plan was working. If scores did not change or increased, this made GPs and patients consider stepping up treatment:

Patient PT01002-04:

Looking at the scores and stuff, [the GP] would make that decision on whether he thought some of the dosage for things needed to be increased or stay the same. We were really looking at the score and seeing where were at and how much it’s gone down.

Practitioner GP03044-01:

You could actually see what the changes were and in patients where there were no changes, if they were worse, then we were going to implement. It helped me decide treatment, you know, plan … It was a nice way for me to see that the medication is or is not working and then for me to refer onwards if need be or start medication.

On the other hand, a few GPs reported that the PHQ-9, although helpful to an extent, was not necessary or influential in treatment decisions:

Practitioner GP02024-01:

The treatment options are unlikely to be that different. Maybe you might be encouraging drugs more if they are more severe, but you don’t necessarily need the PHQ 9 to do that.

Very occasionally, practitioners thought that patients might respond to the questionnaire in a particular way to effect a change in their care (e.g. one patient was described as ‘lying’ about their symptoms in order to be discharged from counselling they were not finding helpful).

Objectivity versus subjectivity

In the presence of uncertainty about patients’ difficulties and needs, some GPs believed that the PHQ-9 could provide objective and clarifying quantitative information that could be helpful, whether in going along with their clinical judgement or contrasting with it. Some saw it as helpful because patients may not always be present with symptoms in the same way, and symptoms may not be overtly visible during consultations:

Practitioner GP01026-01:

Does it make any difference to what I’m going to do? Ninety-nine per cent, no. As I say, I’ve used it literally twice in the last couple of weeks, purely because I was thinking, this patient’s coming in and they’re depressed, but I’m not really sure they are. [The PHQ-9] did reaffirm already what I had thought in my head, that they were mild. That’s the only time I’ve found it beneficial.

Practitioner GP03044-01:

We stopped using [the PHQ-9] but it’s something we should think about using, especially with something as grey as depression, because people have different emotions. So people could be really, really tearful but not have really bad depression and there could be other people who look quite, you know, which happened with a few patients. They looked quite together with it but actually who were, like severely depressed. So, yes; it’s a helpful, objective tool.

However, several GPs, especially those with more years of experience, preferred to use clinical judgement by itself to identify symptoms and make decisions about patients’ care. They did not like the rigidity of the categories and the associated suggested treatments, which they referred to as ‘tick-box medicine’. These GPs expressed resistance to the continued use of the PHQ-9. However, some suggested that it could be used as a guide for younger GPs with less experience:

Practitioner GP01026-01:

I think if you’re relatively OK at your job, I think you should be able to assess that anyway, without having to do a tick box exercise on a piece of paper; it’s probably not my kind of thing. So I would not be keen for them to come back in. As I say, when I was talking to the GP colleagues about the study, there was lots of moans and groans, ‘Oh, are we going to have to do PHQ-9 again?’ – which gives everybody’s tale of what they think about it, basically.

Practitioner GP01002-01:

Doctors as a rule don’t like tick-box medicine, unless they are starting out as new doctors and haven’t found their feet yet and are glad about any pointers that they can get hold of to do a proper job. As you’re becoming more senior, doctors tend to do less of those things, because they feel they are being patronised and being told what to do and they didn’t become a doctor to be told by an administrator they need to use this or that tool … They’d rather do what they think is right rather than somebody else telling them to do so.

Many among this group of GPs were open to implementing the PHQ-9 if either there were demonstrable data on its effectiveness on patient outcomes or patients stated a preference for its use:

Practitioner GP01026-01:

It’ll be interesting to know from the results of the study, whether they have found that it helped [patients] with their symptoms … It’ll be interesting to know from the patient’s point of view … It may be turned on its head, with all the patients saying, it really is. Then I’m happy to change my mind.

Time restraints

Some GPs stated that they did not have as much time as they would like during their 10-minute consultations to discuss depression with patients and often felt unable to spend time administering or discussing the PHQ-9 on top of that:

Practitioner GP01026-01:

They’ll be given a 10-minute appointment, which is the usual in GP land. We don’t tend to have appointments longer than that which is a bit of a shame when assessing depression, because it clearly takes longer than that, let alone then having to do a PHQ-9. I think most of [the GPs] just found it a complete pain.

However, because the PHQ-9 scores immediately generate specific treatment suggestions, this could sometimes balance out the additional time it took to use the questionnaire during consultations:

Practitioner GP01056-01:

It perhaps helps formulate that decision more quickly … If someone’s coming to their appointment with [the PHQ-9] already done, you’ve got that information in front of you. I think it makes your consultation more efficient.

Patients could also on occasion value shorter, more focused follow-up consultations:

Patient PT01094-04:

(Talking about a follow-up call) It was quite short, which surprised me, I think. When I had spoken to my own GP, I had gone to great lengths to explain about everything that was going on and the family situation. Whereas, when I had the phone call with the second GP, it was much more, ‘Right, you’ve been told. Right, here’s the questions. Give me numbers. Give me answers to this’ Then he gave me a score at the end. Then he was like, ‘Right. So you’ve been on the medication now for a month. What do you think? What are your thoughts? How do you feel? Yes, I agree with what you’re saying. I think that’s a good route to go. Let’s do that’ End of call. So the whole thing was quite short, but it got the job done

Technological integration

Practitioners mentioned that the PHQ-9 was being integrated into GP computer systems to streamline its use in e-consultations ahead of contact with the patient, and some valued being able to text it to patients during remote telephone or video consultations using an integrated messaging system on their computer:

Practitioner GP03044-01:

It’s quite nice if it was integrated into our clinical system, our IT system; so it would be faster to generate – to tick with the patient there, go through it and then they get the results.

Practitioner GP02013-01:

We can just text them the PHQ-9 link and they can fill it out. We can ask them to do the score once a month and they can text it or e-mail it to the surgery. It gets automatically downloaded on the patient notes.

Patient PT03059-01:

It’s so hard, especially in London, to get appointments with doctors. Having my GP apps, things where you can fill it in, and it goes directly to your doctor. If they’re concerned, they send you a message saying, would you like to come in and have an appointment?

Patient PT02024-03:

I just showed him the form and he said he already had some of the results, they’d been e-mailed through to him and just showed him the graph and I told him I didn’t realise that I was that low