managing-depression-screening

name	managing-depression-screening
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.

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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

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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.

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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.

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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

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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)

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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

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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?

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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

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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