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Depression Screening & Initial Management (PHQ-9/USPSTF)

Depression Screening & Initial Management (PHQ-9/USPSTF): Depression Screening in Adults → PHQ-2 Screen → PHQ-2 Below 3 and No Clinical Concern? → PHQ-2...

Pathway Overview

22 steps

Algorithm Steps

22 total

  1. 01Start

    Depression Screening in Adults

    Adults 18 and over, including pregnant, postpartum and older adults (USPSTF grade B). Under 18: use an adolescent pathway. Low mood, suicidal thoughts or clinician concern: go straight to the full PHQ-9 and a clinical interview.

  2. 02Action

    PHQ-2 Screen

    Two questions about the last 2 weeks. Pregnant or postpartum: the EPDS is an alternative.

    • 1. Little interest or pleasure in doing things
    • 2. Feeling down, depressed or hopeless
    • Score each 0-3: not at all 0; several days 1; more than half the days 2; nearly every day 3
    • Positive: total 3 or more. A cut-off of 2 finds more cases but gives more false positives
  3. 03Decision

    PHQ-2 Below 3 and No Clinical Concern?

    Concern includes low mood, suicidal thoughts or self-harm, even with a low score.

  4. If Yes
    1. PHQ-2 below 3, no concern
    2. 04Outcome

      PHQ-2 Negative: No Further Screening Now

      No screening interval is proven. Rescreen when risk factors, life events, pregnancy or postpartum, or symptoms arise.

    If No
    1. PHQ-2 3 or more, or concern
    2. 05Action

      PHQ-2 Positive or Concern: Full PHQ-9 and Interview

      The PHQ-9 measures severity. It does not make the diagnosis.

      • Add 7 items: sleep, tiredness, appetite, feeling a failure or guilty, concentration, slowed or restless movement, thoughts of death or self-harm (item 9)
      • Total 0-27. A score of 10 or more detects major depression with about 85% sensitivity and 85% specificity
      • Confirm major depression by clinical interview (DSM-5 criteria)
    3. 06Decision

      Item 9 Positive, or Any Suicidal Thoughts or Self-Harm?

      Ask about suicidal thoughts directly, whatever the total score.

    4. If Yes
      1. 07Warning

        Item 9 Positive: Same-Day Safety Assessment

        Ask directly. Assess the person's needs and safety. Do not rely on a scale.

        • Ask about thoughts, intent, plan, access to means, past attempts, alcohol and drugs
        • Do not use scales or low/medium/high risk ratings to decide treatment or discharge
        • Remove or restrict access to means (medicines, firearms); involve family or carers with consent
      2. 08Decision

        Immediate Danger or Cannot Stay Safe?

        Clinical judgement. For example: intent or a plan, a recent attempt, psychosis, or no safety plan can be agreed.

      3. If Yes
        1. Immediate danger
        2. 09Outcome

          Immediate Danger: Emergency Mental Health Care Now

          Same-day mental health crisis team or emergency department. Do not leave the person alone. Call emergency services if there is immediate danger. Australia: 000, state or territory mental health line, Lifeline 13 11 14.

        If No
        1. Can stay safe
        2. 10Action

          Can Stay Safe: Safety Plan and Close Follow-Up

          Then continue with the steps below (confirm the diagnosis, then treat by severity).

          • Write a safety plan with the person: warning signs, coping steps, people to contact, means restriction
          • Give crisis contacts. Australia: Lifeline 13 11 14; 000 in an emergency
          • Refer to mental health services as a priority if distress or suicidal intent is rising, or you are concerned; agree the next review date
      If No

      No branch defined.

    5. All patients continue
    6. 11Warning

      Before Treatment: Confirm Diagnosis and Exclude Bipolar Disorder

      Check every patient before any antidepressant is started. Bipolar disorder in a first-degree relative: higher risk of switching to mania; warn the person and watch for hypomania.

      • Past mania or hypomania, or known bipolar disorder: no antidepressant alone; get psychiatric advice
      • Psychotic symptoms, catatonia, or not eating or drinking: urgent psychiatric referral
      • Look for medical, medicine, alcohol and drug causes of the symptoms
    7. 12Decision

      PHQ-9 Total Score?

      0-4 minimal; 5-9 mild; 10-14 moderate; 15-19 moderately severe; 20-27 severe. Use with clinical judgement.

    8. 0-9
    9. 13Action

      PHQ-9 0-9: Minimal or Mild Symptoms

      Support and active monitoring. No antidepressant as routine first-line treatment. If treated: the review step below applies.

      • Explain depression; advise physical activity, a regular sleep routine and less alcohol
      • Mild symptoms: offer guided self-help, digital CBT or brief psychological therapy
      • Do not routinely start an antidepressant unless the person prefers it after discussion
      • Reassess with the PHQ-9 in 2-4 weeks. If 10 or more, or worse: treat as moderate
    10. 10-14
    11. 14Action

      PHQ-9 10-14: Moderate

      Offer treatment. Decide together with the person.

      • Offer psychological therapy (CBT, IPT or behavioural activation) or an SSRI
      • Many people prefer psychological therapy; combined treatment works better than either alone
      • Next: the SSRI step if an antidepressant is chosen, then the review step
    12. 15-19
    13. 15Action

      PHQ-9 15-19: Moderately Severe

      Offer an antidepressant and psychological therapy together.

      • Combined SSRI and psychological therapy works better than either alone
      • Either alone if the person prefers
      • Get psychiatric advice if complex, poor response or rising suicide concern
      • Next: the SSRI step, then the review step
    14. 20-27
    15. 16Warning

      PHQ-9 20-27: Severe - Involve Psychiatry

      Start combined treatment and arrange psychiatric assessment. Next: the SSRI step, then the review step.

      • Reassess suicidal thoughts and the safety plan at every contact
      • Psychotic features, not eating or drinking, or cannot care for self: urgent psychiatry or admission
      • Offer an SSRI plus psychological therapy; review weekly at first
    16. Antidepressant chosen
    17. 17Action

      If Antidepressant Chosen: Start an SSRI (Adult Doses)

      Bipolar screen first. Age 18-25: warn about early suicidal thinking; review 1 week after starting or a dose increase. Never with an MAOI or moclobemide, or within 14 days of stopping one. Never with pimozide. Pregnant, planning pregnancy or breastfeeding: get perinatal mental health advice first.

      • Sertraline 50 mg once daily; max 200 mg/day. Hepatic impairment: lower or less frequent dose
      • Escitalopram 10 mg once daily; max 20 mg/day. Over 65: max 10 mg/day. Hepatic impairment: 5 mg daily for 2 weeks, then up to 10 mg. Long QT or other QT-prolonging drugs: avoid escitalopram
      • Fluoxetine 20 mg each morning; max 80 mg/day. Hepatic impairment: lower or less frequent dose. Taking tamoxifen: use another antidepressant (CYP2D6). Wait at least 5 weeks after stopping fluoxetine before an MAOI
      • Serotonin syndrome risk: tramadol, triptans, linezolid; avoid St John's wort. Bleeding risk: anticoagulants, antiplatelets, NSAIDs. Hyponatraemia risk: older adults
    18. 18Action

      Review and Monitor: All Treated Patients (Therapy or SSRI)

      First review within 2 weeks. Age 18-25 or concern about suicide: review 1 week after starting or after a dose increase.

      • At each review: PHQ-9, suicidal thoughts, side effects and adherence
      • Response: PHQ-9 falls by 50% or more. Remission: PHQ-9 below 5
      • SSRI with no improvement after 3 weeks at a standard dose: consider a dose increase
    19. 19Decision

      In Remission (PHQ-9 Below 5)?

    20. If Yes
      1. PHQ-9 below 5
      2. 20Outcome

        Remission: Continue Treatment to Prevent Relapse

        On an antidepressant: continue the same dose for at least 6 months after remission; review at 1 year. Reduce slowly when stopping; do not stop suddenly. Offer CBT to prevent relapse.

      If No
      1. Not in remission
      2. 21Action

        Not in Remission: Review and Step Up

        Find the reason, then change treatment.

        • Check adherence, dose, side effects and the diagnosis (bipolar disorder, substance use, medical causes)
        • Options: increase the dose, switch antidepressant, or add psychological therapy
        • Rising PHQ-9 or new suicidal thoughts: reassess safety the same day
      3. 22Warning

        No Response to 2 Adequate Trials: Refer to Psychiatry

        Treatment-resistant depression.

        • Specialist options include augmentation (for example lithium), rTMS and ECT
        • Re-check for bipolar disorder, substance use and medical causes

Guideline Source

USPSTF Screening for Depression and Suicide Risk in Adults (2023)

DOI: 10.1001/jama.2023.9297View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Screening tool only: confirm major depression by clinical interview before treatment
  • Any suicidal thoughts need same-day clinical assessment; scores and scales do not predict suicide
  • Adults only; bipolar, psychotic and perinatal depression need specialist pathways
  • Culture, language and literacy can affect PHQ scores

Contraindicated Populations

Children and adolescents under 18 yearsKnown or suspected bipolar disorder (antidepressant steps)

Applicable Regions

USAUUKEU

AU: Treatment follows the RANZCP 2020 mood disorders guideline. Crisis: 000, Lifeline 13 11 14, state or territory mental health line. Medicare-subsidised psychological therapy via a GP mental health treatment plan (Better Access).

UK: NICE NG222 defines less severe depression as PHQ-9 below 16 and advises against antidepressants as routine first-line treatment for it. Crisis: 999 in an emergency; NHS 111 (mental health option).

US: USPSTF 2023: screen adults for depression (grade B). Evidence is insufficient for suicide-risk screening in adults without symptoms (I statement). Crisis: 988 Suicide and Crisis Lifeline; 911 in an emergency.

Version 2Next review: 2027-09-30

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Frequently Asked Questions

What is the Depression Screening & Initial Management (PHQ-9/USPSTF)?

The Depression Screening & Initial Management (PHQ-9/USPSTF) is a diagnostic clinical algorithm for Family Medicine. It provides a structured decision tree to guide clinical decision-making, based on USPSTF Screening for Depression and Suicide Risk in Adults (2023).

What guideline is the Depression Screening & Initial Management (PHQ-9/USPSTF) based on?

This algorithm is based on USPSTF Screening for Depression and Suicide Risk in Adults (2023) (DOI: 10.1001/jama.2023.9297).

What are the limitations of the Depression Screening & Initial Management (PHQ-9/USPSTF)?

Known limitations include: Screening tool only: confirm major depression by clinical interview before treatment; Any suicidal thoughts need same-day clinical assessment; scores and scales do not predict suicide; Adults only; bipolar, psychotic and perinatal depression need specialist pathways; Culture, language and literacy can affect PHQ scores. Individual patient factors may require deviation from these recommendations.

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