Disability Underwriting: Expanded Use of the Patient Health Questionnaire (PHQ-9)
U.S. underwriters of individual disability policies often struggle making an underwriting decision when a physician has noted subjective symptoms without diagnosis. This is especially true when assessing conditions such as anxiety and depression. It is not uncommon for records to indicate a history of subjective physical complaints, such as fatigue, muscle aches and pain or headaches. Any of these symptoms could be irrelevant to the disability risk or suggestive of a more concerning underlying psychiatric condition. Most underwriters would view these symptoms as “red flags” worthy of further development. But in the absence of the treating physician noting anxiety or depression, the underwriter must make the best decision possible with imperfect data.
The good news is this may be changing due to the recently updated recommendation by the U.S. Preventative Services Task Force stating all individuals aged 18 and older be screened for depression in the primary care setting. The recommendation suggests screening for all patients using tests such as the Patient Health Questionnaire, which is comprised of nine questions with factors for severity.
Alternatively, a simple screening tool that asks only two questions may be used in certain circumstances. These questions are:
1. During the past months, have you often been bothered by feeling down, depressed, or hopeless?
2. During the past months, have you often been bothered by little interest or pleasure in doing things?
A positive score may provide valuable information that may not otherwise have been brought to light.
For Example: Suppose the proposed insured has been to his physician on three separate occasions over the past year. During the first visit, the patient complains of vague flu-like symptoms such as aches and pain, fatigue and headache. Two months later he returns with same symptoms, which have not improved. This time the physician orders a panel of labs to include complete blood count, as well as tests for Epstein Barr and mononucleosis, along with hormone tests. All test results were negative. A few months later he returns with complaints of stress at work, insomnia and generally not feeling well. The underwriter is faced with a number of “red flags” but little concrete actionable information, and there is growing concern of underlying mental or nervous condition. Had the physician conducted the PHQ and asking the nine questions or even the two question screen, the underwriter would be better able to assess the risk and make the most appropriate decisions.
Caution should be used when basing decisions purely on the findings of these mental health questionnaires. Taking adverse action without knowing for sure if there is underlying mental or nervous condition may result in lost business. Conversely, not acting upon this information could result in excess claims as there may be an emerging or undiagnosed impairment.
When we find PHQ-9 assessments in medical records obtained at the time of underwriting, we should view them as another helpful tool, which improves assessment of the subjective symptoms that may (or may not) be associated with anxiety, depression or a number of other mental and nervous conditions that are relevant to the disability insurance risk.