How a depression test devised by a Zoloft marketer became a crutch for a failing mental health system

A bedrock of the U.S. mental health system — a nine-item questionnaire used to spot depression — began not with a doctor, but with a marketing man. Howard Kroplick, now 73 years old and living on Long Island, is obsessed with antique racing cars and, in his storied career in the pharmaceutical industry, crucially urged Pfizer to avoid the word “impotence” when promoting Viagra.

More than two decades ago, he had the brainstorm to give primary care doctors a simple form to help them identify depressed patients. His key client, Pfizer, had recently released Zoloft, one of a new generation of antidepressants called SSRIs. Although the drug was safe enough to be prescribed by primary care doctors, most were uncomfortable treating mental illness, meaning these patients were going untreated and Pfizer was missing a huge potential market. Kroplick, speaking for the first time publicly about how he came up with the idea, told STAT he pitched the concept to both its scientific creators and to Pfizer, which funded their work: “It wouldn’t have happened if it wasn’t for me,” he said.

What came next, though, was beyond what he imagined. The resulting tool — called the PHQ-9 — took on a life of its own. It has become omnipresent, cited in more than 11,000 scientific papers and routinely handed to patients during primary care checkups and OB-GYN visits, regardless of whether they voice mental health concerns.

This marketing origin story, revealed in detail here for the first time, is not merely a historical footnote. In an overstretched health care system warped by business interests, STAT’s investigation shows how this simple tool has become a crutch — used in place of, rather than as a gateway to, thoughtful mental health care. The PHQ-9 became a means for time-crunched primary care doctors, under pressure to see more and more patients in shorter appointments, to dole out prescriptions with barely a conversation. Despite its prevalence, data suggesting that PHQ-9 has actually improved outcomes is ambiguous at best. Meanwhile, mental health outcomes for patients are dismal and only getting worse, with depressive symptoms and suicide climbing ever higher.

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