Depression Screening
USPSTF recommends screening all adults for depression
All Pathways
Family MedicineDiagnostic
Depression Screening & Initial Management (PHQ-9/USPSTF)
Depression Screening & Initial Management (PHQ-9/USPSTF): Depression Screening → PHQ-2 Initial Screen → PHQ-2 Negative (<3).
Pathway Overview
15 steps
Algorithm Steps
15 total
01Start 02Action PHQ-2 Initial Screen
2-question screening tool
- Over last 2 weeks, how often have you:
- 1. Little interest or pleasure in doing things?
- 2. Feeling down, depressed, or hopeless?
- Score 0-3 for each (Not at all=0, Several days=1, More than half=2, Nearly every day=3)
- Positive screen: Total ≥3
03Outcome PHQ-2 Negative (<3)
Rescreen annually or if symptoms develop
04Action Complete PHQ-9
Full 9-item depression severity assessment
- Add 7 more questions covering:
- Sleep disturbance, fatigue, appetite changes
- Concentration, psychomotor changes
- Worthlessness/guilt, suicidal ideation
- Total score 0-27
05Decision Question 9 Positive?
Suicidal ideation assessment
- Q9: Thoughts of being better off dead or hurting yourself?
- Any positive response requires immediate safety assessment
06Warning Immediate Safety Assessment
Columbia Suicide Severity Rating Scale (C-SSRS)
- Assess suicidal ideation, intent, plan, means
- Determine if safe to go home
- Consider emergency psychiatric evaluation
- Document safety plan if appropriate
- Consider hospitalization if high risk
07Decision PHQ-9 Severity Score
Determine depression severity
- 0-4: Minimal depression
- 5-9: Mild depression
- 10-14: Moderate depression
- 15-19: Moderately severe depression
- 20-27: Severe depression
08Action Minimal/Mild (0-9)
Watchful waiting with active support
- Patient education about depression
- Lifestyle modifications (exercise, sleep hygiene)
- Consider brief counseling
- Reassess PHQ-9 in 2-4 weeks
- Treatment if persistent >2 weeks or worsening
09Action Moderate (10-14)
Initiate treatment
- Offer choice: antidepressant OR psychotherapy
- First-line SSRI: sertraline, escitalopram, fluoxetine
- Psychotherapy: CBT or IPT (8-16 sessions)
- Patient preference should guide choice
- Follow up in 2-4 weeks
10Action SSRI Selection & Dosing
First-line antidepressant options
- Sertraline: Start 50mg daily, max 200mg
- Escitalopram: Start 10mg daily, max 20mg
- Fluoxetine: Start 20mg daily, max 80mg
- Avoid paroxetine in young adults (discontinuation)
- Consider comorbidities in selection
11Action Treatment Follow-Up
Monitor response and adjust
- Repeat PHQ-9 at each visit
- Response: ≥50% reduction in PHQ-9
- Remission: PHQ-9 <5
- If no response by 4-6 weeks: increase dose or switch
- Continue effective treatment 6-12 months minimum
12Outcome Remission Achieved
Continue maintenance, monitor for relapse
13Warning Treatment-Resistant
Inadequate response to 2+ adequate trials
- Refer to psychiatry
- Consider augmentation strategies
- Rule out bipolar disorder, substance use
- Consider TMS or ECT referral for severe cases
- Path rejoins step 09Shared downstream outcome
14Action Moderately Severe (15-19)
Combination therapy recommended
- Antidepressant + psychotherapy preferred
- Start SSRI at standard dose
- Refer for CBT/IPT concurrently
- Follow up in 1-2 weeks initially
- Consider psychiatric referral if complex
- Path rejoins step 10Shared downstream outcome
15Warning Severe (20-27)
Urgent psychiatric involvement
- Combination antidepressant + psychotherapy
- Consider psychiatric consultation
- Weekly follow-up initially
- Assess for hospitalization if functional impairment severe
- Safety planning mandatory
- Path rejoins step 10Shared downstream outcome
- Path rejoins step 07Shared downstream outcome
Guideline Source
USPSTF Screening for Depression and Suicide Risk in Adults
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- PHQ-9 is a screening tool, not diagnostic - clinical interview required
- Does not replace psychiatric evaluation for complex cases
- Suicide risk assessment requires immediate safety evaluation
- Does not address bipolar disorder screening (use MDQ separately)
- Cultural and language factors may affect scoring validity
Contraindicated Populations
pediatric
Applicable Regions
USAUUKEU
AU: RACGP endorses PHQ-9 for depression screening in primary care
UK: NICE recommends PHQ-9 for case-finding and severity assessment
US: USPSTF Grade B recommendation for adult screening
Version 1Next review: 2028-01-01
Next steps
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Related Resources
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.
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 (DOI: 10.1001/jama.2022.21680).
What are the limitations of the Depression Screening & Initial Management (PHQ-9/USPSTF)?
Known limitations include: PHQ-9 is a screening tool, not diagnostic - clinical interview required; Does not replace psychiatric evaluation for complex cases; Suicide risk assessment requires immediate safety evaluation; Does not address bipolar disorder screening (use MDQ separately); Cultural and language factors may affect scoring validity. Individual patient factors may require deviation from these recommendations.
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