What are the best inpatient pediatric screeners for mood disorder, anxiety, and depression?

Best Inpatient Pediatric Screeners for Mood Disorder, Anxiety, and Depression

Primary Recommendation

For inpatient pediatric depression screening, use the Patient Health Questionnaire Modified for Adolescents (PHQ-9 Modified for Teens) starting at age 12 years, with a cutoff score of 10 or higher warranting immediate referral to mental health specialists. 1, 2

Depression Screening Tools by Age Group

Adolescents (Ages 12-18 Years)

• PHQ-9 Modified for Adolescents is the preferred tool for this age group, with demonstrated sensitivity of 89.5% and specificity of 77.5% at a cutoff score of 11 1
• The standard PHQ-9 can also be used, covering all nine DSM criteria for depression with each item scored 0-3 based on symptom frequency over the past two weeks 1
• A cutoff score of 10 or higher requires immediate referral to psychology and/or psychiatry in the inpatient setting 2
• The Patient Health Questionnaire for Adolescents (PHQ-A) has been most extensively studied and shows the highest positive predictive value among adolescent screening tools, with sensitivity of 73% and specificity of 94% 3

Children (Ages 8-11 Years)

• Evidence for depression screening tools in children under age 12 is insufficient, with no screening studies including children younger than age 11 3, 1
• The USPSTF found inadequate evidence on the accuracy and reliability of screening tests in this age group 3
• For children ages 8-11, focus on anxiety screening rather than depression-specific screening, as anxiety screening is recommended starting at age 8 4, 5

Children Under Age 8

• Do not perform routine depression screening in children under age 8, as the balance of benefits and harms cannot be determined 3
• Maintain clinical vigilance for signs of depression but avoid formal screening tools 3

Anxiety Screening

Recommended Tool and Age

• The Generalized Anxiety Disorder scale (GAD-7) should be used for anxiety screening starting at age 8 years 5, 6
• A cutoff score of 6 on the GAD-7 provides the best balance of sensitivity, specificity, and predictive power in pediatric populations 6
• The GAD-7 demonstrates excellent internal consistency and good convergent validity 6
• The USPSTF recommends screening for anxiety in children and adolescents aged 8 to 18 years with moderate certainty of net benefit 5

Brief Screening Alternative

• The GAD-2 (two-item version) with a cutoff score of 2 may have similar clinical utility as the full GAD-7 measure, particularly useful in busy inpatient settings 6

Critical Implementation Considerations for Inpatient Settings

Immediate Action Protocols

• Pay particular attention to item 9 of the PHQ-9, which assesses thoughts of self-harm—any positive response requires immediate referral regardless of total score 1
• For PHQ-9 scores of 15-27 (moderate to severe/severe symptomatology), make immediate referral to psychology and/or psychiatry and assess for risk of harm to self or others 1
• Never screen without having clear protocols for managing positive screens, as screening alone without intervention does not improve outcomes 1

Score-Based Management Algorithm

• PHQ-9 score 1-7 (none/mild): Provide education about depression, ensure adequate coping skills and access to resources, consider reassessment at future visits 1
• PHQ-9 score 8-14 (moderate): Evaluate for pertinent history and specific risk factors, consider referral to psychology or psychiatry for diagnostic evaluation 1
• PHQ-9 score 15-27 (moderate to severe/severe): Immediate referral to psychology and/or psychiatry, assess for self-harm risk, evaluate for medical or substance-induced causes 1

Common Pitfalls to Avoid

• Do not assume absence of suicidal ideation means low risk in patients with previous suicide attempts, as they remain at elevated risk if underlying factors remain unchanged 1
• Recognize that irritability, not sadness, may be the primary manifestation of depression in adolescents—look for cranky mood, oppositional behavior, and loss of interest in previously enjoyed activities 1
• Self-administered scales are preferable because adolescents may disclose suicidality on self-report that they deny in person 1
• The positive predictive value of screening tests is lower in children and adolescents than in adults, so all positive screens must trigger full diagnostic interviews using DSM criteria 3

Alternative Screening Tools (Lower Quality Evidence)

• The Beck Depression Inventory (BDI) shows sensitivity of 84-90% and specificity of 81-86% at a cutoff score of 11, though it has been less extensively studied than the PHQ-A in adolescents 3
• The Center for Epidemiologic Studies Depression Scale (CES-D) has inconsistent performance with sensitivity ranging from 18-84% depending on cutoff score used 3
• These alternative tools are not recommended over the PHQ-9/PHQ-A given the superior evidence base for the PHQ instruments 3, 1