Depression Screening in Primary Care
Recommended Screening Approach
Use brief validated screening instruments that can be administered in less than 5 minutes, with the simplest and most effective approach being two questions about depressed mood and anhedonia. 1
Screening Methods
Primary Screening Tools
Two-question screen (most practical): Ask patients "Over the past 2 weeks, have you felt down, depressed, or hopeless?" and "Over the past 2 weeks, have you felt little interest or pleasure in doing things?" 1
Standardized instruments (if preferred): Several validated tools are available including PHQ-9, Beck Depression Inventory, Geriatric Depression Scale, Zung Self-Rating Depression Scale, Hospital Anxiety and Depression Scale, General Health Questionnaire, and Center for Epidemiologic Study Depression Scale 1
Critical Follow-Up Requirements
Diagnostic Confirmation
A positive screen is NOT a diagnosis and requires full diagnostic evaluation using DSM criteria. 1
- Only 24-40% of patients who screen positive will have major depression in primary care settings with 5-10% prevalence 1
- False-positive screens may represent:
Assessment Components After Positive Screen
- Establish specific diagnosis (major depression, dysthymia, adjustment disorder) using DSM-IV criteria 1
- Assess depression severity 1
- Evaluate for comorbid conditions: anxiety, panic attacks, substance abuse, chronic pain 1
- Screen for bipolar disorder risk before initiating antidepressants, including detailed psychiatric history and family history of suicide, bipolar disorder, and depression 2
Systems Requirements for Effective Screening
Screening programs only improve patient outcomes when integrated with comprehensive management systems. 1
- Screening with feedback alone to clinicians increases depression recognition 2-3 fold but does NOT improve treatment rates or clinical outcomes 1
- Effective programs require:
Screening Frequency
- Optimal screening interval is unknown 1
- Prioritize recurrent screening for high-risk patients:
Special Population Considerations
Children and Adolescents
- Screening performance is more variable (sensitivity 40-100%, specificity 49-100%) 1
- Positive predictive value is lower due to lower prevalence 1
- Routine screening benefits are not established in pediatric primary care 1
- Remain alert for depression signs but recognize limitations of screening tools 1
Treatment Initiation After Diagnosis
Antidepressant Options
- For major depression, both tricyclic antidepressants and SSRIs are more effective than placebo 1
- Newer agents perform similarly to older agents 1
- In adolescents: SSRIs and cognitive-behavioral therapy are effective, but NOT tricyclic antidepressants 1
Monitoring Requirements
All patients started on antidepressants require close monitoring for:
- Clinical worsening 2
- Suicidality 2
- Unusual behavioral changes, particularly in first few months or with dose changes 2
- Agitation, anxiety, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia, hypomania, or mania 2
Common Pitfalls
- Do not rely on screening alone - always confirm diagnosis with full evaluation 1
- Do not screen without treatment capacity - screening without integrated management systems does not improve outcomes 1
- Do not miss bipolar disorder - antidepressant monotherapy may precipitate manic episodes in unrecognized bipolar disorder 2
- Do not assume all positive screens are major depression - many represent other conditions requiring different management 1