Patient information: See related handout on depression and a handout from familydoctor. The U. Additionally, the USPSTF recommends screening children and adolescents 12 to 18 years of age for major depressive disorder.
All screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. In older adults, the Geriatric Depression Scale is also an appropriate screening tool for depression. If screening is positive for possible depression, the diagnosis should be confirmed using Diagnostic and Statistical Manual of Mental Disorders , 5th ed.
Major depression is one of the most common mental health disorders in the United States.
Depression: Screening and Diagnosis
Depression is a major risk factor for suicide in older men, with suicide rates increasing with age in this population.
A recent study showed that men older than 75 years had the highest annual incidence of suicide. A systematic review including three randomized trials with more than 6, women found a lower prevalence of postpartum depression at follow-up for those screened four to eight weeks after delivery.
Screening must be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. The PHQ-2 is accepted as an initial screening instrument for depression in all age groups. The USPSTF recommends screening adolescents 12 to 18 years of age for major depressive disorder in the primary care setting.
Pregnant women should be screened for depression at least once during the perinatal period using a validated screening instrument such as the Edinburgh Postnatal Depression Scale or the PHQ Consider screening at least once during pregnancy and again four to eight weeks after delivery.
When screening is positive for possible depression, the diagnosis should be confirmed using criteria from the Diagnostic and Statistical Manual of Mental Disorders , 5th ed. If left untreated, depression may lead to suicide. Persons with an affective disorder have a 0.
Screening for depression is the cornerstone of early recognition, diagnosis, and management. The risk factors for depression are multifactorial but can be split into the three broad categories of internal factors, external factors, and adverse life events Table 1. Information from references 7 through 9. Risk factors for late-life depression include female sex, social isolation, death of a spouse, being divorced or separated, lower socioeconomic status, comorbid general medical conditions, uncontrolled pain, insomnia, and cognitive and functional impairments.
A study showed that men older than 75 years have the highest annual incidence of suicide at 39 deaths per , men, compared with four deaths per , women older than 75 years. There are numerous medical conditions associated with depression, as mimics of depression or coexisting conditions.
Associated neurologic conditions include epilepsy, multiple sclerosis, Alzheimer disease, Parkinson disease, cerebrovascular disease, and traumatic brain injury. Other associated conditions include human immunodeficiency virus infection or AIDS, neurosyphilis, cardiomyopathy, ischemic heart disease, heart failure, hypothyroidism, diabetes mellitus, vitamin deficiencies, parathyroid disorders, irritable bowel syndrome, collagen vascular diseases, and chronic liver disorders.
Symptoms of depression are commonly known by the SIGECAPS mnemonic: sleep disorders either increased or decreased sleep ; interest deficit anhedonia ; guilt worthlessness, hopelessness, regret ; energy deficit; concentration deficit; appetite disorder either decreased or increased ; psychomotor retardation or agitation; and suicidality.
Depressed mood and anhedonia are the two cardinal symptoms of depression. Depression may manifest differently between men and women.
PHQ-9 Depression Screening Tool
Women with depression are more likely to report physical ailments such as headaches, myalgias, or gastrointestinal problems.
They are also more likely to exhibit emotional effects such as stress and crying easily. Preventive Services Task Force USPSTF and American Academy of Family Physicians recommend screening for depression in the general adult population, and screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.
There is a lack of evidence to suggest a specific screening interval.
The USPSTF suggests a pragmatic approach of screening all adults who have not been previously screened, and using clinical judgment in consideration of risk factors, comorbid conditions, and life events to determine if additional screening of high-risk patients is warranted. There is a lack of evidence to recommend one screening instrument over another. If depression is identified, the PHQ-9 or a clinical interview should be completed.
Scoring: A score of 3 or more is considered a positive result. The PHQ-9 Table 3 or a clinical interview should be completed for patients who screen positive.
Accessed February 8, Feeling bad about yourself—or that you are a failure or have let yourself or your family down. Trouble concentrating on things, such as reading the newspaper or watching television. Moving or speaking so slowly that other people could have noticed; or the opposite—being so fidgety or restless that you have been moving around a lot more than usual. The USPSTF recommends screening adolescents 12 to 18 years of age for major depressive disorder in the primary care setting when systems are in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.
The traditional PHQ-2 may also be used in adolescents; a positive screening score of 3 or more should prompt additional assessment for major depressive disorder.
Postpartum depression has significant effects on the entire family. It is associated with abnormal development, cognitive impairment, and psychopathology in children. Postpartum depression is not listed as its own diagnosis in the Diagnostic and Statistical Manual of Mental Disorders , 5th ed.
Patient Health Questionnaire (PHQ-9)
DSM-5 , but rather as a qualifier to the diagnosis of major depressive disorder. The EPDS is the most commonly used tool, is simple to score, and is available in more than 50 languages. Screening for postpartum depression appears to be effective. A systematic review including three randomized trials and more than 6, women found a lower prevalence of postpartum depression at follow-up for those screened four to eight weeks after delivery.
The American College of Obstetricians and Gynecologists does not include guidance on the specific timing and frequency of screening.
One approach is to screen at least once during pregnancy and again four to eight weeks after delivery. The American Academy of Pediatrics recommends that physicians screen mothers for postpartum depression at the infant's one-, two-, and four-month visits. Family physicians practicing full-spectrum care have other opportunities to screen for postpartum depression. Screening during infant hospitalizations can identify previously unscreened mothers.
A prospective observational study of mothers screened during infant hospitalizations showed that only However, few positive screening results were diagnostically confirmed, partly because of the high number of women lost to follow-up. Multiple screening tests have been developed to address the confounding factors that make depression screening and diagnosis more challenging later in life. The Geriatric Depression Scale is a five-, , or item questionnaire that screens for depression in older patients without dementia.
Notably, it does not assess for somatic issues because this is thought to interfere with the diagnosis. Scoring: Bolded answers receive 1 point. A score of 2 or more is considered a positive result.
Adapted with permission from Maurer DM.
Screening for depression [published correction appears in Am Fam Physician. Am Fam Physician. A score of more than 5 suggests depression that should be further evaluated clinically. In: Brink TL, ed. It retains its validity when used in patients with dementia, unlike the Geriatric Depression Scale. The PHQ-2 can be used in the older population and may have similar effectiveness with greater brevity and ease of use than other instruments. The performance of the PHQ-2 is comparable to that of other instruments, including clinician-rated scales, in noninstitutionalized older persons 42 and nursing home residents.
The incidence of depression is higher in patients with chronic medical conditions. A Canadian study demonstrated a 1. Physicians should also be mindful that many symptoms commonly attributed to chronic medical conditions are also symptoms of underlying depression. When screening is positive for possible depression, the diagnosis should be confirmed using DSM-5 criteria, which are presented in Table 6.
Phq 9 depression screening tool pdf995
A major depressive episode must not be better explained by schizoaffective disorder, schizophrenia, or schizophreniform disorder. Bipolar disorder must also be excluded, especially if the patient has ever had a manic or hypomanic episode.
Physicians should familiarize themselves with basic screening tools for bipolar disorder. Five or more of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either 1 depressed mood or 2 loss of interest or pleasure. Note: Do not include symptoms that are clearly attributable to another medical condition.
Depressed mood most of the day, nearly every day, as indicated by either subjective report e.
Note: In children and adolescents, can be irritable mood. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day as indicated by either subjective account or observation.
Note about credits
Significant weight loss when not dieting or weight gain e. Note: In children, consider failure to make expected weight gain. Insomnia or hypersomnia nearly every day. Psychomotor agitation or retardation nearly every day observable by others, not merely subjective feelings of restlessness or being slowed down. Fatigue or loss of energy nearly every day. Feelings of worthlessness or excessive or inappropriate guilt which may be delusional nearly every day not merely self-reproach or guilt about being sick.
Diminished ability to think or concentrate, or indecisiveness, nearly every day either by subjective account or as observed by others. Recurrent thoughts of death not just fear of dying , recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The episode is not attributable to the physiological effects of a substance or to another medical condition. Note: Criteria A—C represent a major depressive episode. Note: Responses to a significant loss e.
Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual's history and the cultural norms for the expression of distress in the context of loss.
The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders. There has never been a manic episode or a hypomanic episode.