Managing Depression Screening

---
name: managing-depression-screening
language: en
description: Administers and interprets PHQ-9 with severity-based treatment pathways and safety assessment. Use when screening for depression, interpreting PHQ scores, or initiating mental health treatment.
tags:
  - management
  - primary-care
  - treatment
metadata:
  author: casemark
  practice_areas:
    - Family Medicine
    - Internal Medicine
    - Primary Care
  document_types:
    - Management Report
  skill_modes:
    - Management
    - Coordination
---

# Managing Depression Screening

Administers and interprets PHQ-9 with severity-based treatment pathways and safety assessment.

## Why This Skill Exists

Major depressive disorder (MDD) affects approximately 21 million U.S. adults annually, yet only 35% receive treatment. The USPSTF issues a Grade B recommendation for depression screening in all adults (≥18) when adequate systems are in place for diagnosis, treatment, and follow-up. The PHQ-9 (Patient Health Questionnaire-9) is the most widely validated screening and monitoring tool in primary care, with sensitivity of 88% and specificity of 88% at a cutoff score of ≥10 for major depression.

Primary care clinicians diagnose and manage the majority of depression cases. However, common failures include screening without follow-up, missing suicidal ideation on Question 9, failing to distinguish adjustment disorders from MDD, and underutilizing measurement-based care (serial PHQ-9 tracking). This skill enforces a complete workflow from screening through treatment initiation and response monitoring, with mandatory safety assessment at every encounter.

---

## Checkpoint A: Pre-Draft Intake (Mandatory)

1. What screening tool was used (PHQ-2, PHQ-9, Edinburgh Postnatal if perinatal)? **Default: PHQ-2 → PHQ-9 if positive**
2. What is the PHQ-9 total score? **Default: [REQUIRED if screening positive]**
3. What is the response to Question 9 (thoughts of self-harm or suicide)? **Default: [REQUIRED - document exact response]**
4. Is this an initial screen or follow-up monitoring score? **Default: initial**
5. Does the patient have prior history of depression, psychiatric hospitalization, or suicide attempts? **Default: per history**
6. Is the patient currently on antidepressant medication? If so, agent, dose, and duration? **Default: none**
7. Has the patient had prior therapy (CBT, interpersonal, other)? **Default: unknown**
8. Are there comorbid conditions affecting treatment selection (substance use, chronic pain, insomnia, anxiety)? **Default: per problem list**

### Documents to Request

- Completed PHQ-9 questionnaire with individual item scores
- Prior PHQ-9 scores for trend analysis
- Current medication list (antidepressants, anxiolytics, sleep aids)
- Behavioral health records (therapist notes, psychiatric evaluations)
- Substance use screening results (AUDIT-C, DAST-10)
- Columbia Suicide Severity Rating Scale (C-SSRS) if suicidal ideation identified
- Medical history affecting antidepressant selection (cardiac, hepatic, renal, seizure history)
- GAD-7 score if anxiety symptoms co-occurring

---

## Step 1: PHQ-9 Score Interpretation and Severity Classification

| PHQ-9 Score | Severity | Treatment Recommendation |
|---|---|---|
| 0-4 | Minimal/none | No treatment; rescreen at next annual visit |
| 5-9 | Mild | Watchful waiting; rescreen in 2-4 weeks; consider psychotherapy |
| 10-14 | Moderate | Antidepressant OR psychotherapy; patient preference guides choice |
| 15-19 | Moderately severe | Antidepressant AND psychotherapy recommended; consider psychiatry referral |
| 20-27 | Severe | Antidepressant + psychotherapy; psychiatry referral; assess for hospitalization |

**Question 9 response protocol** (critical safety assessment):
- Score 0 ("not at all"): Document as screened negative for SI; no further action required for safety
- Score 1 ("several days"): Administer C-SSRS or equivalent; assess passive vs. active ideation
- Score 2 ("more than half the days"): C-SSRS mandatory; assess plan, intent, means, timeline
- Score 3 ("nearly every day"): C-SSRS mandatory; same-day safety evaluation; consider crisis intervention

If ANY active suicidal ideation with plan or intent: do NOT release patient; contact crisis team, 988 Suicide and Crisis Lifeline, or arrange emergency psychiatric evaluation.

---

## Step 2: Differential Diagnosis and Medical Workup

Before diagnosing MDD, rule out medical and substance-related causes:

| Condition | Screening Test | When to Suspect |
|---|---|---|
| Hypothyroidism | TSH | Fatigue, weight gain, cold intolerance with depressive symptoms |
| Anemia | CBC | Fatigue, weakness, pallor |
| Vitamin B12/folate deficiency | B12, folate | Elderly, vegans, post-bariatric, metformin use |
| Substance use disorder | AUDIT-C, DAST-10, UDS | Heavy alcohol use, recreational drug use |
| Bipolar disorder | MDQ (Mood Disorder Questionnaire) | History of manic/hypomanic episodes, family history, antidepressant-induced mania |
| Obstructive sleep apnea | STOP-BANG | Excessive daytime sleepiness, obesity, snoring |
| Medication-induced depression | Med review | Beta-blockers, corticosteroids, interferons, hormonal contraceptives, opioids |
| Grief/adjustment disorder | Clinical interview | Recent loss, clear precipitant, <6 months duration |

Confirm MDD diagnosis meets DSM-5 criteria: ≥5 of 9 symptoms for ≥2 weeks, including depressed mood or anhedonia, causing functional impairment.

---

## Step 3: First-Line Antidepressant Selection

| Agent | Starting Dose | Target Dose | Advantages | Key Risks |
|---|---|---|---|---|
| Sertraline (Zoloft) | 50mg daily | 100-200mg daily | Best evidence in cardiac patients; safe in pregnancy | GI side effects, sexual dysfunction |
| Escitalopram (Lexapro) | 5-10mg daily | 10-20mg daily | Fewest drug interactions; well-tolerated | QTc prolongation at high doses |
| Fluoxetine (Prozac) | 20mg daily | 20-80mg daily | Long half-life; good for adherence issues | CYP2D6 inhibitor; drug interactions |
| Bupropion (Wellbutrin) | 150mg XL daily | 300-450mg XL daily | No sexual dysfunction; helps smoking cessation, ADHD | Seizure risk (avoid if eating disorder, seizure history) |
| Duloxetine (Cymbalta) | 30mg daily × 1 week, then 60mg | 60-120mg daily | Comorbid pain, fibromyalgia, neuropathy | Nausea; hepatic impairment risk; discontinuation syndrome |
| Mirtazapine (Remeron) | 7.5-15mg QHS | 15-45mg QHS | Insomnia, poor appetite, weight loss | Sedation, weight gain; less sexual dysfunction |
| Venlafaxine (Effexor XR) | 37.5-75mg daily | 150-225mg daily | Comorbid anxiety (GAD); pain | BP elevation at higher doses; severe discontinuation syndrome |

**Selection principles:**
- Match side effect profile to patient needs (insomnia → mirtazapine; pain → duloxetine; weight concern → bupropion)
- Prior response: restart previously effective agent at previously effective dose
- Family response: consider agent that worked for first-degree relative
- Pregnancy: sertraline is preferred first-line per ACOG
- Avoid TCAs and MAOIs as first-line in primary care

---

## Step 4: Measurement-Based Care and Follow-Up

| Timepoint | Action | Expected Response |
|---|---|---|
| Week 0 | Start medication at initial dose; provide safety plan if SI | Baseline PHQ-9 documented |
| Week 2 | Phone/portal check-in; assess side effects and adherence | Early side effects may appear; antidepressant effect not yet expected |
| Week 4 | Office visit; repeat PHQ-9; titrate dose if inadequate response | ≥20% reduction in PHQ-9 = early response |
| Week 8 | Repeat PHQ-9; assess functional improvement | ≥50% reduction = response; <50% = consider dose increase or augmentation |
| Week 12 | Full assessment; determine if remission achieved | PHQ-9 <5 = remission; if not remitting, switch or augment |
| Ongoing | PHQ-9 every 4-8 weeks until remission; then every 3-6 months | Maintain remission for ≥6-12 months before considering taper |

**If inadequate response at 8 weeks on adequate dose:**
1. Optimize: increase to maximum tolerated dose
2. Switch: try different SSRI or different class (SNRI, bupropion)
3. Augment: add bupropion to SSRI, or add low-dose aripiprazole (2-5mg) or lithium (for specialist co-management)
4. Refer: psychiatry referral for treatment-resistant depression (failed ≥2 adequate trials)

---

## Step 5: Safety Planning and Crisis Resources

For all patients scoring ≥10 or with any endorsement of Question 9:

- Complete a safety plan (Stanley-Brown template): warning signs, coping strategies, social contacts, professionals to call, means restriction
- Provide crisis resources: 988 Suicide and Crisis Lifeline (call or text), Crisis Text Line (text HOME to 741741)
- Assess access to lethal means (firearms, medications); counsel on safe storage or temporary removal
- Document safety plan in EHR and provide patient with written copy
- Schedule follow-up within 1-2 weeks for patients with any suicidal ideation
- Coordinate with behavioral health for co-management when available

---

## Checkpoint B: Post-Draft Alignment (Mandatory)

1. Is the PHQ-9 score documented with individual item scores including Question 9?
2. Has the severity classification been matched to the appropriate treatment pathway?
3. Has a medical workup been ordered or documented to rule out secondary causes?
4. Is the follow-up schedule documented with specific PHQ-9 monitoring intervals?
5. Has safety assessment been performed and documented for all patients with PHQ-9 ≥10?

---

## Quality Audit

- [ ] PHQ-2 administered as initial screen; PHQ-9 completed if PHQ-2 ≥3
- [ ] PHQ-9 total score calculated correctly and documented
- [ ] Question 9 response individually documented with safety assessment
- [ ] Severity classification matches PHQ-9 score range
- [ ] DSM-5 criteria confirmed before MDD diagnosis
- [ ] Medical workup ordered (TSH, CBC, B12 minimum) for new depression diagnosis
- [ ] Bipolar screening performed (MDQ) before starting antidepressant
- [ ] Antidepressant selection rationale documented (comorbidities, side effect profile, patient preference)
- [ ] Black box warning discussed for patients age 18-24 (increased suicidality risk in early treatment)
- [ ] Follow-up appointment scheduled within 2-4 weeks of medication initiation
- [ ] Safety plan completed and documented for patients with suicidal ideation
- [ ] Crisis resources provided in writing
- [ ] Measurement-based care plan documented with PHQ-9 tracking schedule
- [ ] Psychotherapy referral offered for moderate-severe depression

---

## Guidelines

- Never prescribe antidepressants without a follow-up plan; unmonitored antidepressant prescribing is a leading cause of treatment failure and adverse outcomes
- The FDA black box warning for suicidality applies to patients under 25; counsel patients and families about monitoring for worsening mood, agitation, or suicidal thoughts during the first 1-2 months of treatment
- PHQ-9 is a screening and monitoring tool, NOT a diagnostic instrument; DSM-5 criteria must be confirmed through clinical interview
- Bipolar disorder must be screened before starting antidepressants; antidepressant monotherapy in bipolar depression can trigger mania or rapid cycling
- SSRIs require 4-6 weeks at therapeutic dose for full effect; do not switch agents before adequate trial duration
- Discontinuation syndrome can occur with abrupt cessation of SSRIs (especially paroxetine, venlafaxine); taper over 2-4 weeks minimum
- Serotonin syndrome risk increases with SSRI + tramadol, SSRI + triptan, or SSRI + MAOI combinations; maintain 14-day washout between MAOIs and SSRIs
- Document all shared decision-making discussions including patient preference for medication vs. psychotherapy vs. combination treatment