Brief Report: Opioid-Involved Overdose Mortality in United States Veterans.

BACKGROUND AND OBJECTIVES: The purpose of this study is to assess trends in opioid-involved overdose mortality among US Veterans. METHODS: Age-adjusted drug overdose mortality rates, overall and by opioid subtype, were assessed from National Death Index data for US Veterans; statistical significance of trends was assessed for 2010 to 2015 and 2015 to 2016. RESULTS: Veteran age-adjusted overdose mortality rates increased 23.7% from 2010 to 2015 (19.7-24.4 of 100 000) and a further 20.4% through 2016 (29.3 of 100 000). Opioid involvement increased from 51.3% in 2010 to 62.1% in 2016, as opioid overdose rates increased from 10.9 to 19.5 of 100 000. Overdose mortality varied substantially by opioid subtype and demographics. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: This report provides the first-ever description of trends and characteristics of overdose mortality and opioid-involved deaths among US Veterans of military service for the period 2010 to 2016. With the exception of female Veterans and Veterans in Western States, it has been found that trends in Veteran overdose mortality paralleled rising rates of drug overdose observed in the United States more broadly. Published 2020. This article is a U.S. Government work and is in the public domain in the USA. (Am J Addict 2020;00:00-00).

Predictive Modeling and Concentration of the Risk of Suicide: Implications for Preventive Interventions in the US Department of Veterans Affairs.

OBJECTIVES: The Veterans Health Administration (VHA) evaluated the use of predictive modeling to identify patients at risk for suicide and to supplement ongoing care with risk-stratified interventions. METHODS: Suicide data came from the National Death Index. Predictors were measures from VHA clinical records incorporating patient-months from October 1, 2008, to September 30, 2011, for all suicide decedents and 1% of living patients, divided randomly into development and validation samples. We used data on all patients alive on September 30, 2010, to evaluate predictions of suicide risk over 1 year. RESULTS: Modeling demonstrated that suicide rates were 82 and 60 times greater than the rate in the overall sample in the highest 0.01% stratum for calculated risk for the development and validation samples, respectively; 39 and 30 times greater in the highest 0.10%; 14 and 12 times greater in the highest 1.00%; and 6.3 and 5.7 times greater in the highest 5.00%. CONCLUSIONS: Predictive modeling can identify high-risk patients who were not identified on clinical grounds. VHA is developing modeling to enhance clinical care and to guide the delivery of preventive interventions.

Impact of Implementation Facilitation on the REACH VET Clinical Program for Veterans at Risk for Suicide.

OBJECTIVE: In 2017, the Veterans Health Administration (VHA) implemented a national suicide prevention program, called Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment (REACH VET), that uses a predictive algorithm to identify, attempt to reach, assess, and care for patients at the highest risk for suicide. The authors aimed to evaluate whether facilitation enhanced implementation of REACH VET at VHA facilities not meeting target completion rates. METHODS: In this hybrid effectiveness-implementation type 2 program evaluation, a quasi-experimental pre-post design was used to assess changes in implementation outcome measures evaluated 6 months before and 6 months after onset of facilitation of REACH VET implementation at 23 VHA facilities. Measures included percentages of patients with documented coordinator and provider acknowledgment of receipt, care evaluation, and outreach attempt. Generalized estimating equations were used to compare differences in REACH VET outcome measures before and after facilitation. Qualitative interviews were conducted with personnel and were explored via template analysis. RESULTS: Time had a significant effect in all outcomes models (p<0.001). An effect of facilitation was significant only for the outcome of attempted outreach. Patients identified by REACH VET had significantly higher odds of having a documented outreach attempt after facilitation of REACH VET implementation, compared with before facilitation. Site personnel felt supported and reported that the external facilitators were helpful and responsive. CONCLUSIONS: Facilitation of REACH VET implementation was associated with an improvement in outreach attempts to veterans identified as being at increased risk for suicide. Outreach is critical for engaging veterans in care.

Suicide mortality following nursing home discharge in the Department of Veterans Affairs health system.

OBJECTIVES: We assessed suicide rates up to 6 months following discharge from US Department of Veterans Affairs (VA) nursing homes. METHODS: In VA Minimum Data Set (MDS) records, we identified 281 066 live discharges from the 137 VA nursing homes during fiscal years 2002 to 2008. We used MDS and administrative data to assess resident age, gender, behaviors, pain, and indications of psychoses, bipolar disorder, dementia, and depression. We identified vital status and suicide mortality within 6 months of discharge through National Death Index searches. RESULTS: Suicide rates within 6 months of discharge were 88.0 per 100 000 person-years for men and 89.4 overall. Standardized mortality ratios relative to age- and gender-matched individuals in the VA patient population were 2.3 for men (95% confidence interval [CI] = 1.9, 2.8) and 2.4 overall (95% CI = 2.0, 2.9). In multivariable proportional hazards regression analyses, resident characteristics, diagnoses, behaviors, and pain were not significantly associated with suicide risk. CONCLUSIONS: Suicide risk was elevated following nursing home discharge. This underscores the importance of ongoing VA efforts to enhance discharge planning and timely postdischarge follow-up.

Outcomes for treatment of depression in the Veterans Health Administration: Rates of response and remission calculated from clinical and survey data.

Healthcare Effectiveness Data and Information Set (HEDIS) quality measures for depression treatment aggregate Patient Health Questionnaire (PHQ)-9 data from routine clinical assessments recorded in electronic health records (EHR). To determine whether aggregated PHQ-9 data in US Veterans Health Administration (VHA) EHRs should be used to characterize the organization's performance, we compared rates for depression response and remission calculated from EHRs with rates calculated with data representing the underlying Veteran patient population estimated using Veterans Outcome Assessment (VOA) survey data. We analyzed data from initial assessments and 3-month follow-up for Veterans beginning treatment for depression. EHR data were available for only a minority of Veteran patients, and the group of Veterans with EHR data differed from the underlying Veteran patient population with respect to demographic and clinical characteristics. Aggregated rates of response and remission from EHR data were significantly different from estimates based on representative VOA data. The findings suggest that until patient-reported outcome from EHRs are available for a substantial majority of patients receiving care, aggregated measures of patient outcomes derived from these data cannot be assumed to be representative of the outcomes for the overall population, and they should not be used as outcome-based measures of quality or performance.

Suicide risk following a new cancer diagnosis among Veterans in Veterans Health Administration care.

BACKGROUND: Cancer diagnoses are associated with an increased risk for suicide. The aim of this study was to evaluate this association among Veterans receiving Veterans Health Administration (VHA) care, a population that has an especially high suicide risk. METHODS: Among 4,926,373 Veterans with VHA use in 2011 and in 2012 or 2013, and without VHA cancer diagnoses in 2011, we assessed suicide risk following incident cancer diagnoses. Risk time was from initial VHA use in 2012-2013 to 12/31/2018 or death, whichever came first. Cox proportional hazards regression models evaluated associations between new cancer diagnoses and suicide risk, adjusting for age, sex, VHA regional network, and mental health comorbidities. Suicide rates were calculated among Veterans with new cancer diagnoses through 84 months following diagnosis. RESULTS: A new cancer diagnosis corresponded to a 47% higher suicide risk (Adjusted Hazard Ratio [aHR] = 1.47, 95% CI: 1.33-1.63). The cancer subtype associated with the highest suicide risk was esophageal cancer (aHR = 6.01, 95% CI: 3.73-9.68), and other significant subtypes included head and neck (aHR = 3.55, 95% CI: 2.74-4.62) and lung cancer (aHR = 2.35, 95% CI: 1.85-3.00). Cancer stages 3 (aHR = 2.36, 95% CI: 1.80-3.11) and 4 (aHR = 3.53, 95% CI: 2.81-4.43) at diagnosis were positively associated with suicide risk. Suicide rates were highest within 3 months following diagnosis and remained elevated in the 3-6- and 6-12-month periods following diagnosis. CONCLUSION: Among Veteran VHA users, suicide risk was elevated following new cancer diagnoses. Risk was particularly high in the first 3 months. Additional screening and suicide prevention efforts may be warranted for VHA Veterans newly diagnosed with cancer.

Estimating the per-protocol effect of lithium on suicidality in a randomized trial of individuals with depression or bipolar disorder.

BACKGROUND: The CSP590 randomized trial was designed to estimate the effect of lithium on suicidality. After a third of the intended number of participants were enrolled, the hazard ratio of suicidality was 1.10 (95% CI: 0.77, 1.55). Based on this, the trial was stopped for futility. However, only 17% of patients adhered to the specified protocol. AIMS: The objective was to estimate the per-protocol effect of lithium on suicidality, that is, the effect of adhering to the treatment strategies as specified in the protocol. METHODS: We stopped individuals' follow-up if/when they showed evidence of nonadherence. We then conducted the analysis in the restricted sample, adjusting for prognostic factors that predict adherence via inverse probability weighting. The primary outcome was the 12-month risk of suicidality (including death from suicide, suicide attempt, interrupted attempt, hospitalization specifically to prevent suicide). RESULTS: The estimated 12-month risk of suicidality was 18.8% for lithium, and 24.3% for placebo. The risk ratio was 0.78 (95% CI: 0.43, 1.37) and the risk difference -5.5 percentage points (95% CI: -17.5, 5.5). Results were consistent across sensitivity analyses. CONCLUSIONS: With one-third of the targeted sample size, lithium effects (compared with placebo) ranging between a 17.5% reduction and a 5.5% increase in the risk of suicidality were highly compatible with the data. Thus, a protective effect of lithium on suicidality among patients with bipolar disorder or major depressive disorder cannot be ruled out. Trials should incorporate adequate per-protocol analyses into the decision-making processes for stopping trials for futility.

The Veterans Health Administration REACH VET Program: Suicide Predictive Modeling in Practice.

The U.S. Veterans Health Administration developed a suicide prediction statistical model and implemented a novel clinical program, Recovery Engagement and Coordination for Health-Veterans Enhanced Treatment (REACH VET). This high-value suicide prevention program aims to efficiently identify patients at risk and connect them with care. Starting in April 2017, national REACH VET metric data were collected from electronic health records to evaluate required task completion. By October 2020, 98% of veterans identified (N=6,579) were contacted by providers and had their care evaluated. In the nation's largest health care system, it was feasible to implement a clinical program based on a suicide prediction model.

Suicide among veterans in 16 states, 2005 to 2008: comparisons between utilizers and nonutilizers of Veterans Health Administration (VHA) services based on data from the National Death Index, the National Violent Death Reporting System, and VHA administrative records.

OBJECTIVES: We sought to compare suicide rates among veterans utilizing Veterans Health Administration (VHA) services versus those who did not. METHODS: Suicide rates from 2005 to 2008 were estimated for veterans in the 16 states that fully participated in the National Violent Death Reporting System (NVDRS), using data from the National Death Index, NVDRS, and VHA records. RESULTS: Between 2005 and 2008, veteran suicide rates differed by age and VHA utilization status. Among men aged 30 years and older, suicide rates were consistently higher among VHA utilizers. However, among men younger than 30 years, rates declined significantly among VHA utilizers while increasing among nonutilizers. Over these years, an increasing proportion of male veterans younger than 30 years received VHA services, and these individuals had a rising prevalence of diagnosed mental health conditions. CONCLUSIONS: The higher rates of suicide for utilizers of VHA among veteran men aged 30 and older were consistent with previous reports about which veterans utilize VHA services. The increasing rates of mental health conditions in utilizers younger than 30 years suggested that the decreasing relative rates in this group were related to the care provided, rather than to selective enrollment of those at lower risk for suicide.

Implementation and early utilization of a Suicide Hotline for veterans.

Suicide crisis lines have a respected history as a strategy for reducing deaths from suicide and suicidal behaviors. Until recently, however, evidence of the effectiveness of these crisis lines has been sparse. Studies published during the past decade suggest that crisis lines offer an alternative to populations who may not be willing to engage in treatment through traditional mental health settings. Given this promising evidence, in 2007, the Department of Veterans Affairs in collaboration with the Department of Health and Human Services' Substance Abuse and Mental Health Administration implemented a National Suicide Hotline that is staffed 24 hours a day, 7 days a week, by Veterans Affairs clinical staff. We report here on the implementation of this suicide hotline and our early observations of its utilization in a largely male population.

Prevalence and characteristics of suicide ideation and attempts among active military and veteran participants in a national health survey.

The relationships between military service and suicide are not clear, and comparatively little is known about the characteristics and correlates of suicide ideation and attempts among those with history of military service. We used data from a national health survey to estimate the prevalence and correlates of suicidal behaviors among veterans and service members in 2 states. The prevalence of suicidal behaviors among Veterans was similar to previous estimates of ideation and attempts among adults in the US general population.

Risk for PTSD symptom worsening during new PTSD treatment episode in a nationally representative sample of treatment-seeking U.S. veterans with subthreshold PTSD.

Previous research has examined risk factors associated with poorer treatment outcomes for military Veterans with PTSD. However, work has not examined risk for symptom worsening among Veterans with subthreshold PTSD. The aim of this study was to examine demographic, psychiatric, physical health, and pre-treatment PTSD symptom clusters associated with clinically significant worsening of PTSD among a nationally representative sample of United States (U.S.) Veterans with subthreshold PTSD. Participants were Veterans (weighted N = 3162; unweighted N = 236) with subthreshold PTSD entering a new episode of treatment at U.S. Veterans Affairs PTSD specialty clinics during fiscal years 2018 and 2019. Data was collected as part of the Veterans Outcome Assessment, a yearly baseline and 3-month follow-up telephone survey. Analyses used weighted calculations to support the use of VOA data to draw inferences about all eligible Veterans, and binary logistic regression was used to examine risk factors for symptom worsening. Over 1/3 (37.7%) of Veterans with subthreshold PTSD experienced clinically significant symptom worsening from baseline to follow-up. Adjusted analyses revealed several risk factors for symptom worsening, including demographic (e.g., male sex, White race), psychiatric (personality and anxiety disorders), health care utilization (e.g., more primary care encounters in the previous year), physical health disability, and specific baseline PTSD symptom clusters (negative affect and anxious arousal). Findings suggest that Veterans with subthreshold symptoms seeking treatment for PTSD are at risk for symptom worsening, and highlight the importance of assessment, prevention, and treatment in targeting veterans with PTSD symptoms below the diagnostic threshold.

Interpreting patient reports of perceived change during treatment for depression: Findings from the Veterans Outcome Assessment survey.

This study addressed ongoing questions about the meaning of patients' perceptions of change during treatment. The study used data from the Veterans Outcome Assessment survey for patients with a depressive disorder, without mental health comorbidities, treated in Department of Veterans Affairs general mental health clinics (n = 694). Perceived changes in problems/symptoms, other domains, and the quality of communication with providers were evaluated with items from the Experience of Care & Health Outcomes (ECHO) survey. Depressive symptoms were measured with the Patient Health Questionnaire-9 (PHQ-9). Linear regression models evaluated associations of perceived change at 3-months post-baseline with observed change in PHQ-9 scores, scores on other patient-reported outcome measures (PROMs), and ratings of communication with providers. Patients' reports of their clinical condition at follow-up together with ratings of communication accounted for approximately one-third of the variance in patients' perceptions of change. Adding change-scores based on baseline and follow-up scores on the PHQ-9 and other PROMs did not improve model fit. The findings suggest that patient reports of perceived change during treatment reflect their current clinical state and their experience of care more closely than actual changes in the PHQ-9 or other PROMs.

Associations between patient experience and clinical outcomes in substance use disorder clinics: Findings from the veterans outcomes assessment survey.

BACKGROUND: Patient-centeredness is a cornerstone of substance use disorder (SUD) treatment. Patient-experience measures are potential tools for the routine assessment of patient-centered SUD care and may be valuable measures to inform quality monitoring improvement efforts. Little research exists on the predictive validity of patient-experience measures in SUD care. PURPOSE: We report on findings from the Veterans Outcome Assessment (VOA) survey that provides information on Veterans Health Administration SUD specialty care at treatment initiation and approximately 3-months post-initiation. METHODS: The VOA includes patient-reported outcomes across multiple domains, including the Brief Addiction Monitor (BAM-R), the Short-Form-12 (SF-12) and the Experience of Care and Health Outcome Survey (ECHO), and provides patient reports of the quality of provider communication and overall quality of SUD care. RESULTS: Nearly 40% of veterans in SUD care gave the highest possible ratings for communication and quality at both baseline and follow-up. Ratings of communication at 3-months were associated with treatment discontinuation and both ratings of communication and quality at 3-months and were independently associated with SUD symptoms and with mental well-being at 3-months. CONCLUSIONS: This study provides preliminary support for the inclusion of patient experience measures, particularly ratings of provider communication, as part of routine assessment in SUD care. However, further work on the validity of ratings of provider communication using additional methodologies is likely important before piloting the inclusion of such measures in routine assessment, such as in measurement base care.

Progress toward a performance measure for mental health based on a generic patient- reported outcome measure: Findings from the Veterans Outcome Assessment survey.

We report on studies conducted to develop outcome-based performance measures (PROM-PMs) based on generic patient-reported outcome measures (PROMs) that could support strategies for quality improvement applicable to all patients in a mental health system. Data were from the Veterans Outcome Assessment Survey at baseline and three months for the Mental Component Score (MCS-12), a widely used measure of mental health-related quality of life, for 15,540 outpatients beginning treatment in General Mental Health clinics in 140 Veterans Affairs (VA) facilities. Mental health diagnoses from medical records were coded using hierarchical categories. Mental health staffing levels and quality measures were from administrative data. Changes in MCS-12 scores were associated with demographics, baseline scores, and diagnostic categories; in fully adjusted models, differences between facilities accounted for only 0.5% of the total variance between patients. There were small but significant associations of both baseline and changes in MCS-12 scores with staffing levels and administrative measures of the quality of care that support the potential value of adjusted measures of changes in MCS-12 as a PROM-PM. Remaining issues include the low proportion of variability that can be attributed to differences between facilities and the associations of staffing and quality with possible case-mix adjustment variables.

Comparative risks of all-cause mortality for Veterans with schizophrenia with ongoing receipt of clozapine and other antipsychotic medications.

To guide care for patients with schizophrenia, the Veterans Health Administration (VHA) evaluated the associations between current or recent use of clozapine and all-cause mortality and explored associations for other antipsychotic medications. Using a case-control design, patients with schizophrenia who died in fiscal years 2014-2018 were matched on age, sex, race, and VHA facility to up to 10 controls who were alive on the case's date of death (index date). Medication coverage during the 91 days before the index date was classified as none, partial (1-44 days), and consistent (45-91 days). Medication coverage patterns during the index period were compared to coverage patterns during the period of 92-182 days prior to index date with each medication coverage classified as no change, no coverage, increased, or decreased. Conditional logistic regression analyses controlling for patient characteristics identified no associations of consistent or increasing clozapine coverage with mortality; partial and decreasing coverage were associated with greater mortality and these effects did not differ from those of other the medications considered. Exploratory analyses considering non-clozapine antipsychotic agents suggest that consistent coverage by olanzapine may be associated with increased mortality, that mortality associated with olanzapine may be greater than aripiprazole, and that this effect can be attributed primarily to patients with diabetes. Further study of this topic is needed.

Lithium Treatment in the Prevention of Repeat Suicide-Related Outcomes in Veterans With Major Depression or Bipolar Disorder: A Randomized Clinical Trial.

Importance: Suicide and suicide attempts are persistent and increasing public health problems. Observational studies and meta-analyses of randomized clinical trials have suggested that lithium may prevent suicide in patients with bipolar disorder or depression. Objective: To assess whether lithium augmentation of usual care reduces the rate of repeated episodes of suicide-related events (repeated suicide attempts, interrupted attempts, hospitalizations to prevent suicide, and deaths from suicide) in participants with bipolar disorder or depression who have survived a recent event. Design, Setting, and Participants: This double-blind, placebo-controlled randomized clinical trial assessed lithium vs placebo augmentation of usual care in veterans with bipolar disorder or depression who had survived a recent suicide-related event. Veterans at 29 VA medical centers who had an episode of suicidal behavior or an inpatient admission to prevent suicide within 6 months were screened between July 1, 2015, and March 31, 2019. Interventions: Participants were randomized to receive extended-release lithium carbonate beginning at 600 mg/d or placebo. Main Outcomes and Measures: Time to the first repeated suicide-related event, including suicide attempts, interrupted attempts, hospitalizations specifically to prevent suicide, and deaths from suicide. Results: The trial was stopped for futility after 519 veterans (mean [SD] age, 42.8 [12.4] years; 437 [84.2%] male) were randomized: 255 to lithium and 264 to placebo. Mean lithium concentrations at 3 months were 0.54 mEq/L for patients with bipolar disorder and 0.46 mEq/L for patients with major depressive disorder. No overall difference in repeated suicide-related events between treatments was found (hazard ratio, 1.10; 95% CI, 0.77-1.55). No unanticipated safety concerns were observed. A total of 127 participants (24.5%) had suicide-related outcomes: 65 in the lithium group and 62 in the placebo group. One death occurred in the lithium group and 3 in the placebo group. Conclusions and Relevance: In this randomized clinical trial, the addition of lithium to usual Veterans Affairs mental health care did not reduce the incidence of suicide-related events in veterans with major depression or bipolar disorders who experienced a recent suicide event. Therefore, simply adding lithium to existing medication regimens is unlikely to be effective for preventing a broad range of suicide-related events in patients who are actively being treated for mood disorders and substantial comorbidities. Trial Registration: ClinicalTrials.gov Identifier: NCT01928446.

Associations between patient experience and clinical outcomes in general mental health clinics: Findings from the veterans outcomes assessment survey.

For mental health, evidence linking the patients' experiences of care with treatment outcomes is limited. We report findings from the Veterans Outcome Assessment (VOA) survey of Veterans beginning treatment in Veterans Health Administration (VHA) mental health programs with follow-up after approximately 3 months. In addition to assessments of symptoms and functioning, it includes key components of the Experience of Care and Health Outcomes (ECHO) survey including patient reports of communication with clinicians and of the overall quality of mental health care. For Veterans treated in VHA general mental health clinics, significant associations between ratings of communication and quality at baseline, and both retention in treatment and patient-reported outcomes assessed at follow-up demonstrate that better patient experience predicts more favorable outcomes. Further research is necessary to determine whether including them in measurement-based care could improve outcomes by facilitating the early identification of problems in providing care.

Facility-Level Excess Mortality of VHA Patients With Mental Health or Substance Use Disorder Diagnoses.

OBJECTIVE: Individuals with mental or substance use disorders have higher mortality rates than people in the general population. How excess mortality varies across health care facilities is unknown. The authors sought to investigate facility-level mortality rates among Veterans Health Administration (VHA) patients who had received diagnoses of mental or substance use disorders. METHODS: An electronic medical records-based retrospective cohort study was conducted, encompassing 8,812,373 unique users of 139 VHA facilities from 2011 to 2016. Covariates included age, sex, and past-year diagnoses of serious mental illness, posttraumatic stress disorder, major depressive disorder, other mental health conditions, or substance use disorders. The outcome was all-cause mortality per comprehensive Veterans Affairs/Department of Defense searches of the National Death Index. Proportional hazards regression was used to calculate overall and facility-specific hazard ratios (HRs) for each diagnosis group, adjusted for age, sex, and comorbid medical conditions. RESULTS: Overall, all-cause mortality was statistically significantly elevated among VHA users with mental health diagnoses (HR=1.21, 95% confidence interval=1.20-1.22). HRs varied across facilities consistently over time. At the VHA facility level, diagnostic groups were significantly correlated with the degree of excess mortality. Results were similar in sensitivity analyses that excluded deaths from suicide or drug or alcohol overdose. CONCLUSIONS: VHA users with mental or substance use disorder diagnoses had elevated mortality rates. Correlation in excess mortality across two periods indicated that facility differences in excess mortality were persistent and therefore potentially associated with facility- and community-level factors, which may help inform quality improvement efforts to reduce mortality rates.

Performance of the PHQ-9 across conditions and comorbidities: Findings from the Veterans Outcome Assessment survey.

BACKGROUND: The items of the Patient Health Questionnaire-9 (PHQ-9) represent the criterion symptoms for DSM-IV major depression. This study evaluated the extent to which the PHQ-9 functions as a patient-reported outcome measure (PROM) specific to patients with major depressive disorder. METHOD: Data were from the Veterans Outcome Assessment survey for 8848 patients beginning treatment in VA general mental health clinics, including 5754, re-surveyed after 3 months. The PHQ-9's performance as a PROM was evaluated by comparing rank order correlations between both initial scores and improvements over 3 months between the PHQ-9 and several transdiagnostic PROMs across a range of diagnoses and comorbidities. Performance of PHQ-9-related patient-reported outcome-based performance measures (PROM-PM) were evaluated by comparing rates of response and remission across patient groups. RESULTS: Correlations between the PHQ-9 and transdiagnostic measures were significant and comparable in magnitude across a range of diagnoses and for cases with depression with or without comorbidities. Rates of response and remission were comparable across most patient groups. LIMITATIONS: Limitations include use of clinical diagnoses as recorded in health records, and the relatively short time between assessments. CONCLUSIONS: In these settings, the PHQ-9 functions more as a general measure of symptoms or distress than as a disease-specific scale. This supports its use as a PROM for patients beyond those with major depression, including those with related diagnoses and those with comorbidities, and use of related PROM-PMs in clinical settings where diagnoses may not be precise and comorbidities may be common.