D0150: Resident Mood Interview (PHQ-2 to 9©)

Item Rationale

Health-related Quality of Life

• It is important to note that coding the presence of clinical signs and symptoms of depressed mood does not automatically mean that the resident has a diagnosis of depression or other mood disorder. Assessors do not make or assign a diagnosis based on these findings; they simply record the presence or absence of specific clinical signs and symptoms of depressed mood. Facility staff should recognize these signs and symptoms and consider them when developing the resident’s individualized care plan.

• Depression can be associated with:

— psychological and physical distress,

— decreased participation in therapy and activities,

— decreased functional status, and

— poorer outcomes.

• Mood disorders are common in nursing homes and are often underdiagnosed and undertreated.

Planning for Care

• Findings suggesting mood distress could lead to:

— identifying causes and contributing factors for symptoms and

— identifying interventions (treatment, personal support, or environmental modifications) that could address symptoms.

Steps for Assessment

1. Interview any resident when D0100 = 1.

2. Conduct the interview in a private setting.

3. If an interpreter is used during resident interviews, the interpreter should not attempt to determine the intent behind what is being translated, the outcome of the interview, or the meaning or significance of the resident’s responses.

4. Sit so that the resident can see your face. Minimize glare by directing light sources awayfrom the resident’s face.

5. Be sure the resident can hear you.

• Residents with a hearing impairment should be interviewed using their usual communication devices/techniques, as applicable, during the interview.

• Try an external assistive device (headphones or hearing amplifier) if you have any doubt about hearing ability.

• Minimize background noise.

6. If you are administering the PHQ-2 to 9© in paper form, be sure that the resident can see the print. Provide large print or assistive device (e.g., page magnifier) if necessary.

7. Explain the reason for the interview before beginning.

Suggested language: “I am going to ask you some questions about your mood and feelings over the past 2 weeks. I will also ask about some common problems that are known to go along with feeling down. Some of the questions might seem personal, but everyone is asked to answer them. This will help us provide you with better care.”

8. Explain and /or show the interview response choices. A cue card with the response choices clearly written in large print might help the resident comprehend the response choices.

Suggested language: “I am going to ask you how often you have been bothered by a particular problem over the last 2 weeks. I will give you the choices that you see on this card.” (Say while pointing to cue card): “0-1 days—never or 1 day, 2-6 days—several days, 7-11 days—half or more of the days, or 12-14 days—nearly every day.”

9. Ask the first two questions of the Resident Mood Interview (PHQ-2 to 9©). Suggested language: “Over the last 2 weeks, have you been bothered by any of the following problems?”

For each of the questions:

• Read the item as it is written.

• Do not provide definitions because the meaning must be based on the resident’s interpretation. For example, the resident defines for themself what “tired” means; the item should be scored based on the resident’s interpretation.

• Each question must be asked in sequence to assess Symptom Presence (column 1) and Symptom Frequency (column 2) before proceeding to the next question.

• Enter code 9 in Column 1 and leave Column 2 blank if the resident was unable or chose not to complete the assessment or responded nonsensically. A nonsensical response is onethat is unrelated, incomprehensible, or incoherent or if the resident’s response is not informative with respect to the item being rated (e.g., when asked the question about “poor appetite or overeating,” the resident answers, “I always win at poker.”).

• For a yes response, ask the resident to tell you how often they were bothered by the symptom over the last 2 weeks. Use the response choices in D0150 Column 2, Symptom Frequency. Start by asking the resident the number of days that they were bothered by the symptom and read and show cue card with frequency categories/descriptions (0-1 days—never or 1 day, 2-6 days—several days, 7-11 days—half or more of the days, or 12-14 days—nearly every day).

10. Determine whether to ask the remaining seven questions (D0150C to D0150I) of the Resident Mood Interview (PHQ-2 to 9©). Whether or not further evaluation of a resident’s mood is needed depends on the resident’s responses to the first two questions (D0150A and D0150B) of the Resident Mood Interview.

• If both D0150A1 and D0150B1 are coded 9, OR both D0150A2 and D0150B2 are coded 0 or 1, end the PHQ interview; otherwise continue.

— If both D0150A1 and D0150B1 are coded 9, leave D0150A2 and D0150B2 blank,then end the PHQ-2© and leave D0160, Total Severity Score blank.

— If both D0150A2 and D0150B2 are coded 0 or 1, then end the PHQ-2© and enter the total score from D0150A2 and D0150B2 in D0160, Total Severity Score.

• For all other scenarios, proceed to ask the remaining seven questions (D0150C to D0150I of the PHQ-9©) and complete D0160, Total Severity Score.

Coding Instructions for Column 1. Symptom Presence

• Code 0, no: if resident indicates symptoms listed are not present. Enter 0 in Column 2 as well.

• Code 1, yes: if resident indicates symptoms listed are present. Enter 0, 1, 2, or 3 in Column 2, Symptom Frequency.

• Code 9, no response: if the resident was unable or chose not to complete the assessment or responded nonsensically. Leave Column 2, Symptom Frequency, blank.

• Enter a Dash in Column 1 if the symptom presence was not assessed.

Coding Instructions for Column 2. Symptom Frequency

Record the resident’s responses as they are stated, regardless of whether the resident or the assessor attributes the symptom to something other than mood. Further evaluation of the clinical relevance of reported symptoms should be explored by the responsible clinician.

• Code 0, never or 1 day: if the resident indicates that during the past 2 weeks they have never been bothered by the symptom or have only been bothered by the symptom on 1 day.

• Code 1, 2-6 days (several days): if the resident indicates that during the past 2 weeks they have been bothered by the symptom for 2-6 days.

• Code 2, 7-11 days (half or more of the days): if the resident indicates during the past 2 weeks they have been bothered by the symptom for 7-11 days.

• Code 3, 12-14 days (nearly every day): if the resident indicates during the past 2 weeks they have been bothered by the symptom for 12-14 days.

Coding Tips and Special Populations

• Attempt to conduct the interview with ALL residents.

• If both D0150A1 and D0150B1 are coded 9, leave D0150A2 and D0150B2 blank, then end the PHQ-2© and leave D0160 Total Severity Score blank.

• If Column 1 equals 0, enter 0 in Column 2.

• If Column 1 equals 9 or dash, leave Column 2 blank.

• For question D0150I, Thoughts That You Would Be Better Off Dead or of Hurting Yourself in Some Way:

— Beginning interviewers may feel uncomfortable asking this item because they may fear upsetting the resident or may feel that the question is too personal. Others may worry that it will give the resident inappropriate ideas. However,

○ Experienced interviewers have found that most residents who are having this feeling appreciate the opportunity to express it.

○ Asking about thoughts of self-harm does not give the person the idea. It does letthe provider better understand what the resident is already feeling.

○ The best interviewing approach is to ask the question openly and without hesitation.

• If the resident uses their own words to describe a symptom, this should be brieflyexplored. If you determine that the resident is reporting the intended symptom but using their own words, ask them to tell you how often they were bothered by that symptom.

• Select only one frequency response per item.

• If the resident has difficulty selecting between two frequency responses, code for the higher frequency.

• Some items (e.g., item D0150F) contain more than one phrase. If a resident gives different frequencies for the different parts of a single item, select the highest frequency as the score for that item.

• Residents may respond to questions:

— verbally,

— by pointing to their answers on the cue card, OR

— by writing out their answers.

Interviewing Tips and Techniques

• Repeat a question if you think that it has been misunderstood or misinterpreted.

• Some residents may be eager to talk with you and will stray from the topic at hand. Whena person strays, you should gently guide the conversation back to the topic.

— Example: Say, “That’s interesting, now I need to know…”; “Let’s get back to…”; “I understand, can you tell me about….”

• Validate your understanding of what the resident is saying by asking for clarification.

— Example: Say, “I think I hear you saying that…”; “Let’s see if I understood you correctly.”; “You said…. Is that right?”

• If the resident has difficulty selecting a frequency response, start by offering a single frequency response and follow with a sequence of more specific questions. This is known as unfolding.

— Example: Say, “Would you say [name symptom] bothered you more than half the days in the past 2 weeks?”

○ If the resident says “yes,” show the cue card and ask whether it bothered them nearly every day (12-14 days) or on half or more of the days (7-11 days).

○ If the resident says “no,” show the cue card and ask whether it bothered themseveral days (2-6 days) or never or 1 day (0-1 day).

• Noncommittal responses such as “not really” should be explored. Residents may be reluctant to report symptoms and should be gently encouraged to tell you if the symptom bothered them, even if it was only some of the time. This is known as probing. Probe by asking neutral or nondirective questions such as:

— “What do you mean?”

— “Tell me what you have in mind.”

— “Tell me more about that.”

— “Please be more specific.”

— “Give me an example.”

• Sometimes respondents give a long answer to interview items. To narrow the answer to the response choices available, it can be useful to summarize their longer answer and then ask them which response option best applies. This is known as echoing.

— Example: Item D0150E, Poor Appetite or Overeating. The resident responds “the food is always cold and it just doesn’t taste like it does at home. The doctor won’t let me have any salt.”

○ Possible interviewer response: “You’re telling me the food isn’t what you eat at home and you can’t add salt. How often would you say that you were bothered by poor appetite or over-eating during the last 2 weeks?”

— Example: Item D0150A, Little Interest or Pleasure in Doing Things. The resident, when asked how often they have been bothered by little interest or pleasure in doing things, responds, “There’s nothing to do here, all you do is eat, bathe, and sleep. They don’t do anything I like to do.”

○ Possible interview response: “You’re saying there isn’t much to do here and I want to come back later to talk about some things you like to do. Thinking about how you’ve been feeling over the past 2 weeks, how often have you been bothered by little interest or pleasure in doing things.”

— Example: Item D0150B, Feeling Down, Depressed, or Hopeless. The resident, when asked how often they have been bothered by feeling down, depressed, or hopeless, responds: “How would you feel if you were here?”

○ Possible interview response: “You asked how I would feel, but it is important that I understand your feelings right now. How often would you say that you have been bothered by feeling down, depressed, or hopeless during the last 2 weeks?”

• If the resident has difficulty with longer items, separate the item into shorter parts, and provide a chance to respond after each part. This method, known as disentangling, is helpful if a resident has moderate cognitive impairment but can respond to simple, direct questions.

— Example: Item D0150E, Poor Appetite or Overeating.

○ You can simplify this item by asking: “In the last 2 weeks, how often have you been bothered by poor appetite?” (pause for a response) “Or overeating?”

— Example: Item D0150C, Trouble Falling or Staying Asleep, or Sleeping Too Much.

○ You can break the item down as follows: “How often are you having problems falling asleep?” (pause for response) “How often are you having problems staying asleep?” (pause for response) “How often do you feel you are sleeping too much?”

— Example: Item D0150H, Moving or Speaking So Slowly That Other People Could Have Noticed. Or the Opposite—Being So Fidgety or Restless That You Have Been Moving Around a Lot More than Usual.

○ You can simplify this item by asking: “How often are you having problems with moving or speaking so slowly that other people could have noticed?” (pause for response) “How often have you felt so fidgety or restless that you move around a lot more than usual?”

Examples

1. Assessor: “Over the past 2 weeks, have you been bothered by any of the following problems? Little interest or pleasure in doing things?”

Resident: “I’m not interested in doing much. I just don’t feel like it. I used to enjoy visiting with friends, but I don’t do that much anymore. I’m just not interested.”

Assessor: “In the past 2 weeks, how often would you say you have been bothered by this? Would you say never or 1 day, 2-6 days, 7-11 days, or 12-14 days?

Resident: “7-11 days.”

Coding: D0150A1 (Symptom Presence) would be coded 1, yes and D0150A2 (Symptom Frequency) would be coded 2, 7-11 days.

Rationale: The resident indicates that they have lost interest in activities that theypreviously enjoyed. The resident indicates that the symptom has bothered them 7-11 days in the past 2 weeks.

2. Assessor: “Over the past 2 weeks, have you had trouble concentrating on things, such as reading the newspaper or watching television?”

Resident: “Television? I used to like watching the news. I can’t concentrate on that anymore.”

Assessor: “In the past 2 weeks, how often have you been bothered by having difficulty concentrating on things like television? Would you say never or 1 day, 2-6 days, 7-11 days, or 12-14 days?

Resident: “I’d say every day. It bothers me every day.”

Coding: D0150G1 (Symptom Presence) would be coded 1, yes and D0150G2 (Symptom Frequency) would be coded 3, 12-14 days.

Rationale: The resident states that they have trouble concentrating and that this bothers them every day.

DEFINITION

PATIENT HEALTH QUESTIONNAIRE (PHQ-2 to 9©)

A validated interview that screens for symptoms of depression. It provides a standardized severity score and a rating for evidence of a depressive disorder.