Screening and Screening Tools

Routine screening for depressive disorders is an important mechanism for reducing morbidity and mortality. Screening and follow-up of a positive screen should be standard clinical practice.[ Reference 1 ] Most depressed patients receive their health care through primary care physicians, and screening is a component of integrated care programs that are effective models for managing these patients in primary care settings.[ Reference 2 ]

Current guidelines for VA and DoD recommend annual screening for depression, with more frequent screening for several high-risk populations, such as those with congestive heart failure, significant losses, and chronic medical illness, or pregnant or postpartum women.[ Reference 3 ] There are several validated instruments for screening of depression, though the Patient Health Questionnaire-2 (PHQ-2) is widely used and recommended within the VA and DoD.[ Reference 4 ]

Patient Health Questionnaire

The Patient Health Questionnaire (PHQ) tools are designed to facilitate recognition and diagnosis of depression in primary care patients.[ Reference 5 ] The PHQ-2 is the recommended screening tool and patients who screen positive on the PHQ-2 should have a further assessment of symptoms and risk.[ Reference 6 ]PHQ scales are available in the public domain and free to use without permission. They can also be found in the VA/DoD Clinical Practice Guideline for the Management of Major Depressive Disorder.

PHQ-2

VA/DoD Clinical Practie Guideline for the Management of Major Depressive Disorder (PHQ-2)

The PHQ-2 is a two-item self-report that inquires about the frequency of depressed mood and anhedonia over the last two weeks.[ Reference 7 ] All patients not currently receiving treatment for depression should be screened for depression using this tool. Patients who screen positive (score ≥3) should be further assessed. Providers should complete assessment for acute safety risks (e.g., harm to self or others, psychotic features, etc.) for all patients with suspected depression.[ Reference 8 ]

PHQ-9

VA/DoD Clinical Practie Guideline for the Management of Major Depressive Disorder (PHQ-9)

The PHQ-9 is a validated, nine-item questionnaire that can be self- or interviewer- administered to screen for the presence of depressive symptoms and symptom severity within the previous two weeks. It is readily available in the VA and DoD and takes as little as two minutes to complete. While the PHQ-2 is used as a screening tool for depression, the PHQ-9 can be used to obtain information on depression severity or response to treatment for patients with a depressive disorder.[ Reference 9 ] It should not, though, be used in isolation to make a diagnosis without considering other aspects of the assessment, such as whether the symptoms may be better accounted for by another disorder (e.g., PTSD, hypothyroidism, etc.). For patients with a diagnosis of MDD, the PHQ-9 can be used as a quantitative measure of depression severity in the initial treatment planning and to monitor treatment progress. Use of the PHQ-9 alone does not replace the need for a clinical interview and full assessment to establish a diagnosis of MDD.[ Reference 10 ]  Providers should review a patient’s response to the last item (“Thoughts that you would be better off dead or of hurting yourself in some way?”), as it has been associated with increased risk for a suicide attempt.[ Reference 11 ] The PHQ-9 should be used at least monthly to track progress, particularly as systematic measurement of treatment response has been found to increase the likelihood of response to treatment.[ Reference 12 ]


PHQ-9 Score Table

Severity Level

  • Mild
  • Moderate
  • Severe

PHQ-9 Total Score

  • 10-14
  • 15-19
  • ≥20

DSM-5 Symptoms

  • 2
  • 3
  • 4 or 5

Functional Impairment

  • Mild
  • Moderate
  • Severe
Table adapted from the VA/DoD Clinical Practice Guideline for the Management of Major Depressive Disorder (2016)
 
  1. Step 1: Identification

    • Patient identified as suspected depression based on clinical suspicion or positive screen on PHQ-2
    • Complete a risk assessment and diagnostic work-up that may include:
      • Administration of PHQ-9
      • Review of medical history, past treatment history and relevant family history
      • Evaluation of suicidal and homicidal ideation, history of suicide attempts, and presence of suicidal features
      • Evaluation to rule-out secondary causes of depression, such as medical issues
      • Determination of functional status
  2. Step 2: Assessment and Triage

    • If there is a possible acute safety risk, patient should be referred for inpatient or emergent care to stabilize
    • Otherwise, patient should be evaluated to determine whether he/she meets criteria for Major Depressive Disorder (MDD)
      • If patient meets criteria, a provider should determine whether the depressive disorder is mild to moderate or more severe/chronic/recurrent in severity to guide appropriate course of treatment
  3. Step 3: Management (Treatment)

*adapted from the VA/DoD Clinical Practice Guideline for the Management of Major Depressive Disorder (2016)

Screening for Depression in Pregnancy and in the Postpartum Period

Women that are pregnant or postpartum are at elevated risk for depression and if untreated, this depression can have adverse impacts on mother and child.[ Reference 13 ]VA/DoD clinical practice guidelines recommend screening for depression at first contact with a health care provider in the antenatal and postnatal periods, as well as at 4-6 weeks and then at 3-4 months in the postpartum period using the PHQ-2 or the Edinburgh Postnatal Depression Scale (EDPS).

Co-occurring Disorders with Depression

Major depressive disorder frequently occurs with other psychiatric disorders, including substance-related disorders, panic disorder, obsessive-compulsive disorder, anorexia nervosa, bulimia nervosa, and borderline personality disorder.[ Reference 14 ] The diagnostic work-up for depression should include an evaluation for existing or emerging psychological, as well as medical conditions that may exacerbate the depressive symptoms. These conditions may include cardiovascular diseases, chronic pain syndrome, degenerative disorders, immune disorders, metabolic endocrine conditions, neoplasms, or trauma. Psychological conditions that may complicate treatment or put an individual at increased risk for adverse outcomes are bipolar disorder, posttraumatic stress disorder (PTSD), substance use disorder (SUD), suicidality or homicidality, and psychosis.

References

  1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

  2. National Institute of Mental Health (NIMH). (n.d.). NIMH causes of depression. Retrieved from http://www.nimh.nih.gov/health/publications/depression/index.shtml?rf=3247

    Centers for Disease Control. (2015). Depression. Retrieved from http://www.cdc.gov/nchs/fastats/depression.htm (link is external)

    National Quality Management Program - Lockheed Martin Federal Healthcare. (2004). Depression: Detection, management, and comorbidity in the Military Health System. Alexandria, VA: Birch & Davis.

    American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

    Freedland, K.E. & Carney, R.M. (2008). Depression and medical illness. In I. H. Gotlib & C. L. Hammen (Eds.), Handbook of depression, second edition (pp. 113-141). New York, NY: Guilford Press. Management of Major Depressive Disorder Working Group (2016). VA/DoD clinical practice guideline for management of major depressive disorder. Retrieved from https://www.healthquality.va.gov/guidelines/MH/mdd/VADoDMDDCPGFINAL82916... (link is external). Stewart, T., Yusim, A., & Desan, P. (2005). Depression as a risk factor for cardiovascular disease. Primary Psychiatry, 12(5), 36-41.

    American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

  3. Gadermann, A.M., Engel, C.C., Naief, J.A., Nock, M.K., Petukhova, M., Santiago, P.N., Benjamin, W., Zaslavasky, A.M., & Kessler, R. (2012). Prevalence of DSM-IV major depression among U.S. military personnel: Meta-analysis and simulation. Military Medicine, 177(8), 47-59. Kessler, R.C., Heeringa, S.G., Stein, M.B., Colpe, L.J., Fullerton, C.S., Hwang, I., Naifeh, J.A., Nock, M.K., Petukhova, M., Sampson, N.A., Schoenbaum, M., Zaslavsky, A.M., & Ursano, R. Thirty-day prevalence of DSM-IV mental disorders among nondeployed soldiers in the US Army: Results from the army study to assess risk and resilience in servicemembers (Army STARRS). Journal of the American Medical Association Psychiatry, 71(5), 504-513.

  4. Hoge, C.W., Auchterlonie, J.L., & Milliken C.S. (2006). Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. Journal of the American Medical Association, 295(9), 1023-32. Hoge, C.W., Castro, C.A., Messer, S.C., McGurk, D., Cotting, D.I., Koffman, R.L. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 351(1), 13-22.

  5. National Institute of Mental Health (NIMH). (n.d.). NIMH causes of depression. Retrieved from http://www.nimh.nih.gov/health/publications/depression/index.shtml?rf=3247

  6. Trivedi, M.H. (2004). The link between depression and physical symptoms. Primary Care Companion Journal of Clinical Psychiatry, 6(suppl 1), 12–16.

  7. National Collaborating Centre for Mental Health (UK). (2010). Depression: The treatment and management of depression in adults (Updated Edition). Leicester (UK): British Psychological Society. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK63748/.

  8. U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Mental Health. (2015). Depression (NIH Publication No. 15-3561). Bethesda, MD: U.S. Government Printing Office.

  9. Kendler, K.S. & Gardner, C.O. (2011). A longitudinal etiologic model for symptoms of anxiety and depression in women. Psychological Medicine, 41(10), 2035–2045.

  10. Hoge, C.W., Auchterlonie, J.L., & Milliken C.S. (2006). Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. Journal of the American Medical Association, 295(9), 1023-32.

  11. <p>Chapman, D.P., Whitfield, C.L., Felitti, V.J., Dube, S.R., Edwards, V.J., &amp; Anda, R.F. (2004). Adverse childhood experiences and the risk of depressive disorders in adulthood. Journal of Affective Disorders, 82(2), 217-225.</p>

  12. Institute of Medicine. (2014). Preventing psychological disorders in service members and their families. Washington DC: National Academies Press. Retrieved from http://iom.nationalacademies.org/Reports/2014/Preventing-Psychological-Disorders-in-Service-Members-and-Their-Families.aspx.

  13. Department of Veterans Affairs/Department of Defense. (2016). Understanding Depression: A Resource for Providers and Patients. Retrieved from https://www.healthquality.va.gov/guidelines/MH/mdd/MDDTool4Depression4x6BookletNewStyle121516508.pdf.

  14. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.