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

Algorithm Steps

1. ▶

   Start

   Depression Screening

   USPSTF recommends screening all adults for depression

   1. ●

      Action

      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
      1. ✓

         Outcome

         PHQ-2 Negative (<3)

         Rescreen annually or if symptoms develop

      2. ●

         Action

         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
         1. ◆

            Decision

            Question 9 Positive?

            Suicidal ideation assessment

            • Q9: Thoughts of being better off dead or hurting yourself?
            • Any positive response requires immediate safety assessment
            1. ⚠

               Warning

               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
               1. ◆

                  Decision

                  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
                  1. ●

                     Action

                     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
                     1. ●

                        Action

                        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
                        1. ●

                           Action

                           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
                           1. ●

                              Action

                              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
                              1. ✓

                                 Outcome

                                 Remission Achieved

                                 Continue maintenance, monitor for relapse

                              2. ⚠

                                 Warning

                                 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
                  2. ●

                     Action

                     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
                  3. ⚠

                     Warning

                     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