I have recently been asked to do the PHQ-9 questionnaire. It’s the second time I did a depression scale and also this time the experience was fairly bizarre. So, it’s time write about it. For good measure, I will add a few remarks about the questionnaire itself.
So, I’ve been asked to engage with depression questionnaires twice. The first time, long time ago, it was with the BDI (Beck Depression Inventory), the second time, a few days ago, it was the PHQ-9. Both times I informed the clinicians that I couldn’t possibly do the questionnaires as I had written about the BDI. Basically, I reject the BDI as a meaningful gauge of how I feel. I also know the BDI (PHQ-9 is small beer in comparison) inside out and I just cannot seriously engage with a depression measure.
The responses were extraordinary. Apparently, it all doesn’t matter. The two instruments somehow penetrate my mind surreptitiously and it doesn’t matter at all whether I studied depression measures. I simply cannot possibly be aware of their measuring power. Somehow, reflecting on the questionnaire and its questions is just impossible, as it is covered with a veil of mystery removing it from human (or simply non-clinical) experience.
Now, I’ll tell you what I often tell students about such questionnaires. I talk about bilberries. In Poland if you are a (semi-)commercial bilberry gatherer, you use a special device, which we call a comb. It’s like a drawer, with its bottom cut into teeth, like in a comb, so when you run it through a bilberry bush, the fruit stay in the ‘drawer’, while the bush remains undamaged. I think this is what the depression questionnaires (and others too) are constructed to be. The clinician simply runs the questionnaire ‘through me’ and I, helpless to resist it, simply exude clinically significant information; in this case information of whether I am depressed or not.
Does it make sense? Of course, it doesn’t. Of course, I was aware of the PHQ-9 and the problems it posed. And as I answered the questions, of course, I gave answers which I wanted the clinician to have. To say they were ‘true’ makes no sense at all; it’s just funny. My responses were strategic, while the exercise was completely pointless. Well, it was in the sense of gauging my depression. Surprisingly, the two clinicians took it my responses quite seriously. I cannot offer any more comment while remaining polite.
So, let’s talk about PHQ-9 (there are many links to the text, if you google it, here is one). To be honest, I find the assumptions behind it difficult to deal with. As often is the case with psychometric instruments, it simply assumes that I have a (special) experience monitoring device which records what I have felt. In the case of depression, obviously, it had to record my experiences of the last two weeks. Hence the main question:
Over the last 2 weeks, how often have you been bothered by any of the following problems
(no, I am not going to unpick the verb ‘bothered’). Incidentally, the British NHS is providing us with a useful mood assessment tool, which includes explanation of some of the concepts (#facepalm?).
But before I consider a couple of questions, let me comment on the timeframe offered by the questionnaire. It asks me whether I have been ‘bothered’ by the various problems
- Not at all
- Several days
- More than half the days
- Nearly every day
And I started wondering. What if I have been bothered ‘all the time’. Which option do I choose? I suspect you think that I should tell you that the last one, but it hardly offers an option reflecting my experience. Moreover, I must admit that I find it difficult to differentiate between the last two options. When does ‘more than half the days’ become ‘nearly every day’?
Consider. We’re talking about 14 days. More than half is 8 days, which means we are left with another 6. Do you just divide 6 by 2? It’s not obvious at all, but let’s assume that we do. In such a case. more than half becomes anything up to 11. And when you experienced the ‘symptoms’ for 12 days or more then you choose option 4. And I challenge anyone to be able to make such distinctions. I doubt very much that I am the only person that simply cannot estimate how often I felt something. For me, if I must decide, it’s
- not at all
- a little or a bit more
- all the time
and of course, I don’t speak of any real ‘all the time’, I speak of what I want to throw at you. The idea that I can just access the experiential data and make an approximation is just silly. Sorry.
Let’s now consider a couple of questions. Number 6 is the following:
Feeling bad about yourself – or that you are a failure or have let yourself or your family down?
What does it mean?! I mean, really, what does it mean?? The ‘feeling bad about myself’ can mean so many complex things that my head is spinning. Do you mean drinking a bottle of Coke last night or do you mean that I fell guilty about not taking out rubbish? Or being a bad father or generally feeling guilty about the world (do recall Beck’s triad). The notion of ‘being a failure’ (incidentally, occurring in the BDI as the ‘most depressed’ option) is equally nebulous. Moreover, why focus on letting down my family (ambiguous in its right) and not my friends? Bloody hell, I just want to forget about this question.
As I was considering whether I was a failure or not (gosh, external funding did register here!), I came to the suicidal ideation question. Number 8:
Thoughts that you would be better off dead or of hurting yourself in some way?
The author of this wonder-instrument did not think that I might actually no be bothered by my suicidal ideation. It’s not only that it might be protective (there is, actually, research suggesting that), but that I might be so depressed that it no longer worries me that my ‘suicidal thoughts’ might no longer ‘bother me’. Moreover, ‘suicidal thoughts‘ are more than likely to mean all sorts of different things.
In fact, I might simply accept that all of those ‘symptoms’ do not ‘bother’ me anymore. I simply accept that this is the way I am. Yes, I suffer, but because I accept that this is part of life I accept my suffering and it does not ‘bother’ me. In their, I’m sorry, primitive simplicity, the PHQ-9 questions just miss what I feel as I take them literally.
Right, perhaps I shouldn’t take them literally then and I simply should report the ‘symptoms of depression’ as they appear in me. Oh, well, for that I need to be a much more professional patient knowing exactly what I must do to please you, doctor. I mean, to exactly account for my experience. So you can make your diagnosis based on, obviously, objective data you collected with your wonderful instrument. I despair, to be honest.
Just in case you wonder, no, in neither case the results of the ‘instrument’ were discussed. There was no ‘follow-up’ interview with which I am often challenged when I talk about ‘bilberry questionnaires’. It’s like: the results of the PHQ-9 don’t really count (it’s always a mystery why you do things which don’t count), clinicians unpick them with interviews. Well, no, they didn’t. The results were taken at face value as the ‘true’ rendering of my mood. I must admit that in both cases this became a source of some jollity for me. Depression or not.