Depression Screening with PHQ-9: Starting Age
Begin universal depression screening with the PHQ-9 at age 12 years, as endorsed by the U.S. Preventive Services Task Force (USPSTF) and supported by the American Academy of Pediatrics GLAD-PC guidelines. 1
Recommended Screening Age
- The USPSTF clearly recommends universal adolescent depression screening starting at age 12 years and continuing through age 18 years. 1
- This recommendation is based on evidence that validated depression screening tools exist for this age group and that effective treatments are available for identified patients. 1
- The American Academy of Family Physicians and American Academy of Pediatrics align with this age 12 starting point. 2
Evidence Supporting Age 12 as the Starting Point
- The PHQ-9 has been validated in adolescent primary care populations with a sensitivity of 89.5% and specificity of 77.5% at a cutoff score of 11 for detecting major depressive disorder. 1, 3
- Most treatment trials demonstrating efficacy of SSRIs and psychotherapy were restricted to adolescents aged 12-14 years or older, providing the evidence base for intervention effectiveness in this age group. 1
- The mean age of onset for major depressive disorder in childhood and adolescence is approximately 14-15 years, with onset earlier in girls than boys. 1
Considerations for Younger Children
- Evidence for screening children younger than age 12 is insufficient, and the USPSTF does not recommend for or against screening in children aged 7-11 years. 4
- Studies examining depression screening in younger populations (ages 8-14 years) typically include depression as part of broader psychosocial screening rather than focused depression screening. 1
- No screening studies included children younger than age 11 years when the USPSTF evaluated the evidence. 1
- The literature shows starting ages ranging from 8 to 14 years across various studies, but most depression-specific screening focuses on older age ranges. 1
Implementation Requirements
- Screening should only be implemented when adequate systems are in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. 2, 4
- The PHQ-9 Modified for Teens may be more appropriate when screening adolescents specifically. 3
- Immediate referral to mental health specialists is required for severe cases (PHQ-9 score 15-27) or any indication of suicidal ideation on item 9. 3
Clinical Pitfalls to Avoid
- Do not screen without having a clear protocol for managing positive screens, as screening alone without intervention does not improve outcomes. 1
- Pay particular attention to item 9 of the PHQ-9, which assesses thoughts of self-harm, as this requires immediate action regardless of total score. 3
- Consider using the PHQ-2 as an initial brief screen (cutoff ≥3), followed by the full PHQ-9 if positive, though this two-stage approach may miss some cases of suicidality that would be detected by the PHQ-9. 1, 5