What is the management approach for a patient with a positive PHQ2 (Patient Health Questionnaire 2) screen, using the PHQ9 (Patient Health Questionnaire 9)?

Management Approach for a Patient with a Positive PHQ-2 Screen Using the PHQ-9

When a patient screens positive on the PHQ-2, the clinician should administer the full PHQ-9 to assess the severity of depression and determine appropriate management based on the score, with immediate referral to mental health specialists for severe cases or suicidal ideation.

Screening Process and Interpretation

Initial Screening with PHQ-2

• The PHQ-2 is a rapid, self-administered screen that inquires about the frequency of depressed mood and anhedonia over the past 2 weeks, with each item scored from 0 ("not at all") to 3 ("nearly every day") 1
• A PHQ-2 score of ≥3 is generally considered the optimal cutoff for depression screening with a sensitivity of 83% and specificity of 92% for major depression 1
• Some clinical settings may use a lower threshold of ≥2 to minimize missed cases, as this threshold misses only about 2% of possible depression cases 2

Follow-up Assessment with PHQ-9

• When a patient screens positive on the PHQ-2 (score ≥3 or ≥2 depending on clinical setting), the next step is to administer the full PHQ-9 3
• The PHQ-9 includes all nine DSM criteria for depression, with each item scored from 0-3 based on symptom frequency over the past two weeks 3
• Traditional cutoff for the PHQ-9 is ≥10, though some guidelines recommend a cutoff score of ≥8 based on studies of diagnostic accuracy in specific populations 3

Management Algorithm Based on PHQ-9 Score

None/Mild Symptomatology (PHQ-9 score 1-7)

• Provide education about depression and normal stress responses 3
• Ensure patient has adequate coping skills and access to resources 3
• Consider reassessment at future visits, especially during times of transition or stress 3

Moderate Symptomatology (PHQ-9 score 8-14)

• Evaluate for pertinent history and specific risk factors for depression:
  • Prior mood disorder with/without treatment
  • Comorbid mood/anxiety disorders
  • Presence of chronic illnesses
  • Social factors (being single, unemployed, lower education)
  • Disease status (recurrent, advanced, or progressive disease) 3
• Consider referral to psychology or psychiatry for diagnostic evaluation 3
• Offer low-intensity intervention options:
  • Psychosocial group support
  • Individual psychological interventions (cognitive behavioral therapy)
  • Pharmacologic treatment with antidepressants when appropriate 3

Moderate to Severe/Severe Symptomatology (PHQ-9 score 15-27)

• Make immediate referral to psychology and/or psychiatry for diagnosis and treatment 3
• Assess for risk of harm to self or others, which requires immediate psychiatric referral 3
• Evaluate for medical or substance-induced causes of depressive symptoms 3
• Implement close follow-up to monitor symptoms and treatment response 3

Special Considerations

Suicide Risk Assessment

• Pay particular attention to item 9 of the PHQ-9, which assesses thoughts of self-harm 3
• The frequency and specificity of self-harm thoughts are important for risk assessment 3
• Some clinicians may choose to omit this item from the PHQ-9, but doing so may artificially lower the score and weaken predictive validity 3
• Immediate referral is required for patients with specific plans or intent for self-harm 3

Implementation Challenges

• Despite recommendations, studies show only about 5% of patients with positive PHQ-2 scores are administered the full PHQ-9 in primary care settings 4
• Common barriers include time constraints, competing demands, and reliance on clinical judgment 4
• Systematic implementation requires clear protocols and designated responsibilities among the clinical team 3

Special Populations

• Consider cultural sensitivity in assessment and treatment planning 3
• Tailor assessment for patients with learning disabilities or cognitive impairments 3
• Be aware of the difficulty of detecting depression in older adults 3
• For adolescents, the PHQ-9 may be more sensitive than PHQ-2 for detecting school-related stress 5

By following this structured approach to depression screening and management, clinicians can effectively identify and address depression in their patients, leading to improved outcomes and quality of life.