Three lessons from 10 years of PHQ-9s in one practice

Zenara Team December 23, 2025

Real-world insights on what happens when you actually measure every visit.

If you’ve ever finished a visit thinking, “Are they actually better?” you know the cost of flying blind. A single story from the room can mislead. Memory is selective. Risk hides in the quiet.Ten years ago I committed to a simple rule in my San Francisco practice: every patient with depression completes a PHQ‑9 at every visit, and at key touchpoints between visits. Over ~400 patients, that discipline changed my day, my outcomes, and my sleep at night.

Here are the three clearest lessons—practical, repeatable, and grounded in what the evidence says should happen when you measure and adjust care on purpose.

Lesson 1: When you measure every visit, the room changes
Before measurement, the first minutes of the visit were story-catching and guesswork. With a current PHQ‑9 on the chart, the first minute is medicine. We see the trend together, set a target (remission: PHQ‑9 < 5), and decide what needs to change now.What this looks like in practice:

  • A patient starts at 18 (moderately severe). Two weeks later, still 18. That’s not “let’s wait and see.” That’s “what did we miss?”—medication adherence, dose, side effects, sleep, alcohol, pain, thyroid, therapy fit. We adjust in the room.
  • Another patient drops from 16 to 9 over four weeks. We don’t declare victory; we agree to drive the last mile to remission. Response without remission leaves people suffering and relapse risk high.

Why this works:

  • Measurement-based care (MBC) improves outcomes and speeds decisions. Trials and guidance are consistent: when you track, share, and treat‑to‑target, patients do better, faster. You also make fewer blind adjustments and catch non-response earlier.
  • Clear thresholds reduce ambiguity. PHQ‑9 categories (5, 10, 15, 20) align your language with the patient’s experience. Targets and timelines become shared, concrete goals—not vague hopes.

What changes in the room:

  • Patients see their own progress. Motivation rises because the mountain looks climbable.
  • Conversations get cleaner. “You’re at a 12. We’re aiming for <5. Here are the three levers we can pull today.”

Lesson 2: Trends beat snapshots—and early non‑response is your cue
A single score can lie; a trajectory rarely does. The most useful signal in my practice is early slope. By week 4–6, if we haven’t seen meaningful movement, we change something. Doing nothing is the riskiest move.How the trend guides action:

  • By 4–6 weeks, a 20–50% reduction is a reasonable expectation when the plan fits. If it’s not happening, we escalate: adjust dose, switch or augment, tighten psychotherapy cadence, treat sleep, address substance use, or close a medical gap that’s sabotaging mood.
  • Flat or worsening scores trigger a structured checklist. In my workflow, that includes adherence, side effects, life events, sleep disorders, pain, thyroid and B12, alcohol/cannabis, bipolar spectrum red flags, PTSD symptoms, and therapy engagement.

Why this matters:

  • The evidence base behind MBC shows better remission and response when you use systematic measurement to trigger timely adjustments. You don’t wait months to discover that “it never really got better.”
  • Response without remission is not the finish line. People who stop at “better” often bounce back. Driving to remission reduces relapse and restores function.

What it feels like day-to-day:

  • Fewer emergencies, more steady course corrections.
  • Less “let’s hope this works,” more “we know what to do next.”

Lesson 3: Item 9 is a radar, not a verdict—build a pathway around it
Item 9 (suicidal thoughts) is a gift and a trap. It’s a sensitive early warning, but it’s neither a diagnosis nor a complete risk assessment. A “0” doesn’t mean no risk. A “1” or higher demands context, not panic.What’s proven:

  • Reporting any frequency of suicidal thoughts on item 9 is associated with elevated risk of attempts in subsequent weeks to months. That signal deserves your full attention.
  • But item 9 alone can’t sort imminent risk from passing thoughts. It’s a screen—use it to start the right conversation, then assess.

How to operationalize safely (what we do every time):

  • If item 9 > 0: pause the plan and assess intent, plan, means, past attempts, substance use, agitation, protective factors, and willingness to accept help.
  • Update the safety plan in the chart. Document means reduction, crisis contacts, who knows, and the next touchpoint.
  • Increase contact frequency and set a concrete follow‑up window (often 24–72 hours). Use portal check‑ins and a brief PHQ‑9 (or even just item 9) in between.
  • If risk is unclear or rising, escalate: same‑day consult, family involvement with consent, or a higher level of care as indicated.

The net effect:

  • Fewer “missed” deteriorations. More visible, defensible safety work.
  • Patients feel held, not surveilled. The measure opens a caring conversation; it doesn’t replace it.

What improved—clinically and operationally

  • Faster time to right care: Measurement revealed when to escalate and when to keep going. We changed course weeks earlier than we used to.
  • More complete remission: Targets and trends kept us from stopping at “good enough.”
  • Cleaner documentation and billing: MBC supports quality measures and underpins monthly care models (BHI, CoCM, CCM) because the work is visible, time‑stamped, and tied to a plan.
  • Calmer days: Less reactivity, more predictable follow‑through. Nothing falls through because the system won’t let it.

A 14‑day quick start any practice can run

  • Decide your instruments and cadence: PHQ‑9 at every BH‑relevant visit; GAD‑7 alongside when anxiety is present; weekly check‑ins early in treatment via portal.
  • Set targets upfront: Define response (≥50% drop) and remission (PHQ‑9 < 5). Put the target on the care plan.
  • Embed the workflow: Intake sends PHQ‑9 automatically before the visit; MAs or care managers cue completion in room; scores flow into the note; trendline shows up where you work.
  • Define the item‑9 pathway: Write the exact steps for >0 (assessment, safety plan, follow‑up window, escalation criteria). Train the team. Use a template.
  • Create the “no‑movement” rule: If PHQ‑9 hasn’t improved by week 4–6, require a plan change and a brief case review.
  • Close the loop: Send a concise PCP letter when scores cross key thresholds (e.g., new episode, response, remission, relapse). Patients get a simple handout reflecting the plan and target.

Common pitfalls to avoid

  • Treating the score as the diagnosis. PHQ‑9 supports clinical judgment; it doesn’t replace it. Screen for bipolarity and trauma when indicated.
  • Measuring without acting. A score should change the plan or reinforce it—document which and why.
  • Letting “ghost work” disappear. If a nurse calls to check side effects and logs nothing, it didn’t happen. Build easy, audit‑ready documentation into the workflow.
  • Ignoring function. Ask and track “How is this affecting your day?” alongside the score. Recovery is symptom and function.

A light note on infrastructure
I’ve run “mental vitals” in my practice for a decade: PHQ‑9, GAD‑7, labs, vitals—trends surfaced where I work, with treat‑to‑target as the default. That same backbone is what we’re rolling out for partner practices: measurement that runs itself, shows up cleanly in your workflow, and supports both care quality and compliant billing. If you want to see how it fits your reality, request a practice assessment or join the waitlist.

If you’d like the 14‑day PHQ‑9/GAD‑7 rollout checklist, templates for item‑9 workflows, and a treat‑to‑target note structure, request a practice assessment or join the waitlist. We’ll fit it to your current stack so you can see the same gains—quickly and cleanly.



References
Measurement-based care guidance

PHQ‑9 instrument and psychometrics

Clinical utility of MBC

Suicide risk and PHQ‑9 item 9

Quality measures and policy context

Complementary measure

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