A study just published by Na et al (2018) in the Journal of Affective Disorders* suggests that item 9 of the PHQ-9 is an insufficient assessment tool for suicide risk and suicide ideation, creating large numbers of false positives. Yet within IAPT, GP’s may be informed that either there are no risk issues on the basis of a ‘not at all’ response to item 9, ‘thoughts that you would be better off dead or of hurting yourself’ or that there are risk issues on the basis that they have been bothered by these thoughts for at least several days in the last 2 weeks. The message is usually communicated to the GP following a telephone assessment conducted by the most junior members of staff a Psychological Wellbeing Practitioner. The GP then feels obliged to call the patient in for an assessment which turns out to be invariably pointless, not good for the patient or for the GP who may be seeing 40 patients that day!
A (2012) paper on IAPT by Vail et al ** stated ‘that IAPT clinicians did not have set procedures or questions for assessing mental health risk, and were flexible in the approaches they adopted. They often relied upon their own clinical judgement and experience about how to approach the topic of mental health risk’. This chimes with what I found in an analysis of 90 cases going through IAPT, Scott (2018) in only three cases was there mention of risk in the documentation. Inspection of item 9 on the PHQ-9 shows that it confounds passive suicidal ideation with active planning making it unclear what the frequency response refers to, creating many false positives.
More direct questionning based on the C-SSRS * is probably more appropriate:
Have you started to work out or worked out details of how to kill yourself? Do you intend to carry out this plan ?
Have you made a suicide attempt- purposely tried to harm yourself with at least some intention to end your life?
Have you taken any steps to prepare to kill yourself or actually started to do something to end your life or were stopped before you actually did anything?
A none response to either of the 3 questions would indicate no suicide risk.
* Na, P.J et al (2018) The PHQ-9 item 9 based screening f or suicide risk: a validation study of the Patient Health Questionnaire (PHQ) – 9 item 9 with the Columbia Suicide Severity Rating Scale (C-SSRS) Journal of Affective Disorders, 232, 34-40.
** Vail, L (2012) Investigating mental health risk assessment in primary care and the potential role of a structured decision support tool, GRIST. Mental Health in Family Medicine, 9, 57-67
Dr Mike Scott