With an Adverse Childhood Experiences (ACE) score of 8 and a Patient Health Questionnaire‑9 (PHQ‑9) score of 15, does the patient need emergency department evaluation, or what is the next appropriate step?

Emergency Evaluation Not Required, But Immediate Mental Health Referral Is Mandatory

A PHQ-9 score of 15 indicates moderately severe depression requiring immediate referral to psychology and/or psychiatry for diagnosis and treatment, but does not automatically necessitate emergency department evaluation unless the patient endorses specific suicidal intent or plan on item 9 of the PHQ-9. 1, 2

Immediate Next Steps

1. Assess Item 9 for Suicidal Ideation

• Immediately review the patient's response to PHQ-9 item 9, which specifically assesses thoughts of self-harm ("thoughts that you would be better off dead or of hurting yourself in some way"). 1, 2
• If the patient endorses any suicidal ideation with specific plan or intent, immediate emergency evaluation is required regardless of the total PHQ-9 score. 1, 2
• Any positive response on item 9 triggers immediate safety assessment and referral for emergency evaluation by a licensed mental health professional to prevent suicide attempts. 1

2. Make Immediate Mental Health Referral

• For PHQ-9 scores of 15-27 (moderately severe to severe depression), make immediate referral to psychology and/or psychiatry for diagnostic confirmation and treatment initiation. 1, 2
• This severity level mandates specialist involvement to prevent the substantial functional impairment and mortality risk associated with untreated severe depression. 1
• Do not delay referral for "watchful waiting"—moderate-to-severe symptoms require active intervention to prevent progression. 1

3. Evaluate for Medical or Substance-Induced Causes

• Screen for bipolar disorder before initiating or increasing antidepressants, as undiagnosed bipolar disorder can lead to manic episodes, rapid cycling, or mixed states when treated with antidepressants alone. 1
• Assess for medical conditions (thyroid dysfunction, anemia, neurological disorders) or substance effects (alcohol, stimulants, sedatives) that may mimic or exacerbate depressive symptoms. 2

4. Assess Risk of Harm to Self or Others

• Conduct a thorough safety assessment beyond item 9, including access to lethal means, history of prior attempts, current stressors, and protective factors. 2
• The ACE score of 8 significantly elevates risk: adults with high ACE scores have markedly increased odds of depression, anxiety, PTSD, and substance-use disorders. 3

Understanding the ACE Score of 8

Significance of Severe Childhood Adversity

• An ACE score of 8 denotes severe cumulative childhood adversity and markedly raises the risk for mental illness, substance-use disorders, and risky health behaviors across the lifespan. 3
• The dose-response relationship means higher ACE scores correspond to exponentially greater risk for poor mental health outcomes. 3
• In adults with treatment-resistant depression, greater ACE exposure (3+ ACEs) is associated with more severe symptomatology, and the subtypes of sexual trauma and violence uniquely predict lifetime suicide attempts. 4

Clinical Implications for This Patient

• Mental health screening is essential: The combination of ACE score 8 and PHQ-9 of 15 indicates this patient is at substantially elevated risk for depression, anxiety, PTSD, and substance-use disorders. 3
• Evaluate current symptoms of trauma-related distress beyond depression, as high ACE scores predict psychiatric comorbidity. 3
• Assess for substance use (tobacco, alcohol, illicit drugs), as these mediate the relationship between ACE exposure and other adverse health outcomes. 3

Trauma-Informed Care Approach

• Apply trauma-informed approaches rather than trauma-focused interventions that rely solely on the ACE score, as the ACE score alone is insufficient for individual clinical decision-making. 3
• The standard ACE questionnaire does not capture frequency, intensity, chronicity, developmental timing, or protective factors. 3
• Prioritize safe, stable, nurturing relationships as the primary buffer against toxic-stress effects. 3

Common Pitfalls to Avoid

Do Not Screen Without Intervention Protocols

• Never screen with PHQ-9 or ACE questionnaires without established protocols for managing positive screens, as screening alone without intervention pathways does not improve outcomes and wastes resources. 1
• This patient has already been screened—the priority now is immediate action, not further assessment. 1

Do Not Use ACE Score as Deterministic Predictor

• The ACE score reflects population-level risk, not personal destiny—it should inform clinical vigilance but not replace individualized assessment. 3
• The ACE score may underestimate total adversity because it omits experiences such as racism, bullying, community violence, and poverty-related stressors. 3

Do Not Delay Specialist Referral

• Moderate-to-severe depression (PHQ-9 15-27) requires immediate specialist involvement—primary care management alone is insufficient at this severity level. 1, 2
• Persistent moderate scores after 4-6 weeks of treatment indicate need for dose optimization or treatment modification. 1

Monitoring and Follow-Up

Repeat PHQ-9 Administration

• Administer the PHQ-9 at 3,6, and 12 months after treatment initiation to detect inadequate response or relapse, with a minimal clinically important difference of 5 points indicating meaningful change. 1
• If scores remain moderate (8-14) after 4-6 weeks of treatment, this indicates need for treatment modification to prevent prolonged inadequate treatment. 1

Build Protective Factors

• Strengthen protective relationships with caregivers, mentors, or other supportive adults to buffer against toxic-stress effects. 3
• Connect to trauma-informed behavioral health services for evidence-based treatment of psychiatric symptoms. 3
• Build self-regulation skills to help the patient manage stress responses, as executive dysfunction mediates the relationship between childhood adversity and mental health concerns. 5