Screening For Depression in Adults

11/4/2021 Screening for depression in adults - UpToDate
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Screening for depression in adults

Authors: John Williams, MD, Jason Nieuwsma, PhD
Section Editors: Joann G Elmore, MD, MPH, Peter P Roy-Byrne, MD
Deputy Editor: Lisa Kunins, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Mar 2021. | This topic last updated: Jun 26, 2020.
INTRODUCTION
Depression is the most common psychiatric disorder in the general population [1] and the most common
mental health condition in patients seen in primary care [2-5]. Although symptoms of depression are prevalent
among primary care patients, few patients discuss these symptoms directly with their primary care clinicians.
Instead, two-thirds of primary care patients with depression present with somatic symptoms (eg, headache,
back problems, or chronic pain), making detection of depression more difficult [6,7].
In the absence of screening, it is estimated that only 50 percent of patients with major depression are
identified [8]. Unless directly asked about their mood, patients omit information about depressive symptoms
for a variety of reasons, including fear of stigmatization, belief that depression falls outside the purview of
primary care, belief that depression isn't a "real" illness but rather a personal flaw, concerns about medical
record confidentiality, and concerns about being prescribed antidepressant medication or being referred to a
psychiatrist [9].
Systematic screening carries the potential for substantial benefit. Untreated depression is associated with
decreased quality of life [10], increased risk of suicide [11], and poor physiological outcomes when depression
co-occurs with chronic medical conditions [12]. Compared with non-depressed persons, patients with
depression have an increased risk of mortality (relative risk [RR] 1.52) [13]. Each year lived with depression has
been calculated to detract approximately 20 to 40 percent from a quality-adjusted life year (QALY) [14-17].
Furthermore, depression imposes a significant economic burden, accounting for billions of dollars annually in
the United States [18]. The effects of depression extend beyond the individual patient, with negative impact on
patients' employers [19], spouses [20,21], and children [22,23]. (See "Unipolar depression in adults: Assessment
and diagnosis".)
This topic will review evidence of the effectiveness of screening adults and recommendations for screening for
depression in primary care.
Depression screening in pregnant and postpartum women, new fathers, children and adolescents, older
adults, and oncology patients is discussed in detail separately.
https://www-uptodate-com.pbidi.unam.mx:2443/contents/screening-for-depression-in-adults/print?search=depression&source=search_result&selecte… 1/23
● (See "Unipolar major depression during pregnancy: Epidemiology, clinical features, assessment, and
diagnosis", section on 'Screening'.)
● (See "Postpartum unipolar major depression: Epidemiology, clinical features, assessment, and diagnosis",
section on 'Screening'.)
● (See "Bipolar disorder in postpartum women: Epidemiology, clinical features, assessment, and diagnosis",
section on 'Screening'.)
● (See "Postpartum paternal depression", section on 'Screening'.)
● (See "Pediatric unipolar depression: Epidemiology, clinical features, assessment, and diagnosis", section on
'Screening'.)
● (See "Diagnosis and management of late-life unipolar depression".)
● (See "Clinical features, assessment, and diagnosis of unipolar depressive disorders in patients with
cancer", section on 'Screening'.)
DEFINITIONS
Depressive syndromes are defined in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition
(DSM-5) [24]. The term "major depression" in this topic refers to unipolar depression.
A major depressive syndrome or episode manifests with five or more of the following symptoms, present most
of the day nearly every day for a minimum of two consecutive weeks ( table 1). At least one symptom is
either depressed mood or loss of interest or pleasure.
● Depressed mood
● Loss of interest or pleasure in most or all activities
● Insomnia or hypersomnia
● Change in appetite or weight
● Psychomotor retardation or agitation
● Low energy
● Poor concentration
● Thoughts of worthlessness or guilt
● Recurrent thoughts about death or suicide
The symptoms cause substantial distress or impair psychosocial functioning, and they are not the direct result
of the physiological effect of a substance or general medical disorder. Further, the symptoms cannot be
explained by response to significant loss, though the clinician should still carefully consider the possibility of
depression if symptoms extend beyond what is normative following a loss. (See "Complicated grief in adults:
Epidemiology, clinical features, assessment, and diagnosis".)
Persistent depressive disorder (dysthymia), a related condition, is characterized by depressive symptoms that
last for at least two years, with depressed mood present for most of the day and for more days than not. The
depressed mood is accompanied by two or more of the following symptoms (see "Unipolar depression in
adults: Assessment and diagnosis", section on 'Diagnostic criteria and classification'):
● Decreased or increased appetite

● Insomnia or hypersomnia
● Low energy
● Poor self-esteem
● Poor concentration
● Hopelessness
EPIDEMIOLOGY AND RISK FACTORS
Depression is highly prevalent throughout the world, and the prevalence appears to be increasing. Community
surveys of adults living in 10 countries (Brazil, Canada, Chile, Czech Republic, Germany, Japan, Mexico,
Netherlands, Turkey, and the United States) found that the lifetime prevalence of major depression varied from
3 percent in Japan to 17 percent in the United States, with most rates in the range of 8 to 12 percent [25].
Reasons for the lower prevalence of depression in some countries may reflect true variation in the
determinants of depression due to cultural or genetic factors, sample selection biases, and problems with the
cross-cultural portability of diagnostic criteria [26,27]. Depression is more difficult to detect in cultures where
patients are more likely to present with somatic symptoms rather than emotional symptoms [28]. (See
"Unipolar depression in adults: Epidemiology", section on 'Prevalence'.)
In the United States, the National Epidemiologic Survey on Alcohol and Related Conditions III identified an
annual major depressive disorder (MDD) prevalence rate of 10 percent and a lifetime rate of 21 percent [29].
Among patients with chronic medical illness, the annual prevalence rate is significantly higher, approximately
25 percent [30]. Rates of depression may be particularly high in diseases of the central nervous system (eg,
stroke, traumatic brain injury, Parkinson disease) [31-33], cardiovascular disorders [34-36], cancer [37], and
conditions involving immune and inflammatory mechanisms (eg, systemic lupus erythematosus [38]).
Risk factors for depression involve genetic, medical, environmental, and social influences and include [29] (see
"Unipolar depression in adults: Epidemiology", section on 'Demographic risk factors'):
● Younger age
● Prior depressive episode
● Family history
● Female gender
● Childbirth (ie, postpartum depression)
● Childhood trauma
● Stressful life events
● Lower income
● Poor social support
● Serious medical illness
● Dementia
● Substance use disorder
Although knowledge of risk factors can be clinically helpful, it is not sufficient to guide clinical practice or the
decision to screen for depression.
PRESENTATION, NATURAL HISTORY, AND COURSE OF ILLNESS

Patients with depressive syndromes may present with mood, cognitive, neurovegetative, or somatic symptoms.
Mood manifestations include sadness, emotional distress, emotional numbness, or sometimes anxiety or
irritability. Neurovegetative symptoms include loss of energy, changes in sleep, appetite, or weight. Certain
patient populations are more likely to present with somatic symptoms (headache, abdominal or pelvic pain,
back pain, or other physical complaints), which can impede the diagnosis of depression. Populations in which
somatic symptoms often predominate include pregnant women, older adults, incarcerated individuals, some
cultural ethnicities, patients with low incomes, and patients with coexisting medical conditions [6].
Most individuals with depressive syndromes eventually remit, such that approximately half will be in remission
after one year [39] and three-quarters after two years [40]. However, subsyndromal symptoms of depression
often persist even after full criteria for depression are no longer met. The most common symptom to persist
after remission is insomnia, followed by sad mood and decreased concentration [41]. Persistence of such
symptoms heightens the risk for recurrence of the full depressive syndrome. (See "Unipolar depression in
adults: Course of illness".)
Individuals who have suffered from one episode of depression frequently have recurrences; among patients
with a history of depression, 72 percent report having more than one episode [42]. The average age of onset
for unipolar major depression among patients seen in clinical settings is in the thirties, with earlier age of
onset associated with a range of negative biopsychosocial outcomes [43].
Effective treatments for depression include pharmacotherapy and psychotherapy. Chronic depression is
associated with poorer treatment response [44], underscoring the importance of early identification and
treatment. (See "Unipolar major depression in adults: Choosing initial treatment" and "Unipolar depression in
adults: Choosing treatment for resistant depression".)
RATIONALE FOR SCREENING
Several factors related to depression would seem to lead to a cogent argument for population screening:
● Depression is often difficult to detect since patients often present with a variety of somatic symptoms and
may be reluctant to acknowledge symptoms of depression.
● Untreated depression is associated with decreased quality of life, increased mortality, and increased
economic burden.
● Depression can be successfully treated and treatment is more effective when started early in the course.
However, the true test of whether or not screening is effective is a trial in which patients are randomly assigned
to a screening group or to a non-screened control group, and the two groups compared over time for
outcomes related to the condition being screened. Only two relatively short-term randomized trials have
evaluated screening alone without additional supports for the treatment of depression [45,46]. These studies
found conflicting results. Thus, there is disagreement among experts on how best to interpret the available
evidence.
EFFECTIVENESS OF SCREENING
The effectiveness of screening depends upon multiple factors [47,48]:
● Whether a condition is sufficiently common in the general population to merit screening
● Whether there is an asymptomatic or early phase of the condition that can be detected by screening and
for which treatment is more effective than if started at a later and more symptomatic time
● Whether there is a screening test with acceptable performance characteristics (high sensitivity and
relatively high specificity)
● Whether the screening test is easily administered, inexpensive, and well tolerated by the patient
● Whether outcomes of screening result in clinically meaningful benefits that outweigh potential harms to
the patient
In considering screening for depression in primary care, there is good evidence that depression is both a
common condition and frequently undetected in the absence of screening. There is evidence that response
rates to treatment are better if treatment is initiated earlier in the course of depression. Screening instruments
are available that are relatively easy to administer and have been validated for use in primary care. Less well
confirmed, however, is whether screening leads to improved patient outcomes that outweigh the potential
harms of false-positive test results and unnecessary treatment.
Several high-quality systematic reviews address the effects of depression screening in primary care settings for
a broad range of clinically relevant outcomes [49-52]. A review completed for the US Preventive Services Task
Force (USPSTF) found that screening in adults, without other practice enhancements to improve depression
care, increases the rate of depression diagnosis (absolute increase 10 to 47 percent) [49,53]. A subsequent
meta-analysis of 16 studies with 7576 patients found the use of depression screening or case-finding
instruments in primary care or other non-mental health settings was associated with a modest increase in
clinicians' recognition of depression (relative risk [RR] 1.27, 95% CI 1.02-1.59) and a nonsignificant impact on
the initiation of any treatment (RR 1.30; CI 0.97-1.76), with no influence on the prescription of antidepressants
(RR 1.20, CI 0.87-1.66) [50]. The seven studies that provided data on clinical outcomes, however, found no
evidence of an effect on depressive symptoms [54]. This suggests that although screening is important for
detecting depression, it is insufficient to improve clinical outcomes.
Other systematic reviews, including the 2009 review for the USPSTF [51], included studies that evaluated
screening in combination with additional staff support for activities, such as symptom monitoring, self-
management plans, or facilitated referral [55]. The USPSTF review identified eight randomized controlled trials
and found that intervention patients were more likely to show significant improvement in depressive
symptoms than control patients (RR 1.78), improvements that persisted for up to five years [51,53]. Although
the independent contribution of screening in these complex interventions is impossible to determine, these
data support the conclusion that depression screening, coupled with appropriate follow-up and effective
treatment supported by staff in addition to the primary care clinician, is beneficial. Effective treatment requires
careful monitoring of treatment adherence and clinical response together with changes in treatment if the
clinical response is poor [56]. This is no different from the approach to patients with chronic medical
conditions. For example, when a screening blood glucose test reveals diabetes and treatment is initiated, that
patient will need subsequent glucose monitoring, titration of therapy, and involvement of a health care team to
optimize clinical outcomes.
The 2016 USPSTF systematic review found one trial in the general adult population that reported no adverse
events attributed to screening [52]. There were no other trials that reported on the potential harms of
screening. Potential harms include false-positive diagnoses with subsequent labeling effects and unnecessary
treatment, including the medication costs and adverse effects of medication, as well as opportunity costs (time
taken from a patient encounter to screen for depression might be spent on other preventive or therapeutic
activities). Depression screening is highly accepted, with few patients finding the process burdensome or
upsetting [57-59].
Cost-effectiveness — Data on the cost-effectiveness of depression screening are limited and come from two
sources, simulation approaches and randomized trials of enhanced care models that utilized depression
screening to identify patients. Limited evidence suggests that depression screening may be cost-effective when
conducted in general medical settings with a high prevalence of depression (eg, serving patients with chronic
medical conditions) coupled with access to enhanced models of care.
The modeling approach used a sophisticated Markov model to estimate the costs of screening and found high
costs for annual screening (USD $192,444 per quality-adjusted life year [QALY]) but lower costs for screening
every five years ($85,679/QALY) [60]. Screening was cost-effective only under the optimistic conditions of high
prevalence (≥13 percent) and high treatment and remission rates. Cost-effectiveness analyses were reported in
two of the seven trials included in USPSTF’s review of depression screening. Costs per QALY were within the
proposed threshold of ≤$50,000 per QALY for interventions considered to be cost-effective, ranging from $9478
to $36,467 per QALY [61,62].
An evidence synthesis evaluating the cost-effectiveness of depression screening for postnatal depression
found no adequate primary data, and a simulation model did not suggest cost-effectiveness using
conventional thresholds [63,64].
SCREENING OPTIONS
Targeted versus general population screening — One approach, recommended by the US Preventive
Services Task Force (USPSTF), is to screen all patients during routine visits and then further evaluate those who
score above a specified threshold [52]. A more selective approach, known as case-finding, is to evaluate only
those patients whose clinical presentation triggers a suspicion of depression. Clinical red flags for depression
include [65]:
● Insomnia
● Fatigue
● Chronic pain
● Recent life changes or stressors
● Fair or poor self-rated health
● Unexplained physical symptoms
Although the likelihood of a depressive disorder increases by 1.5 to 3.5 times if a patient reports any of these
symptoms, this targeted approach is only moderately more efficient than routine screening and misses more
patients who have a depressive disorder [66,67]. Compared with screening all adults, case-finding increases
specificity but decreases sensitivity (eg, false-positive findings are decreased but fewer patients suffering from
clinical depression are identified). Rates of false positives are lower for screening in specialty settings than in
primary care because of the increased prevalence of depression in patients with chronic illness (eg, chronic
heart disease, chronic obstructive pulmonary disease [COPD], diabetes mellitus).
Regardless of the approach, further evaluation following screening is essential to confirm a diagnosis of
depression. Trials show that screening is associated with improved clinical outcomes when it is coupled with
careful diagnostic assessment and treatment [51,53,55,56]. (See "Unipolar depression in adults: Assessment
and diagnosis", section on 'Assessment' and "Unipolar major depression in adults: Choosing initial treatment",
section on 'Overview of treatment'.)
Screening instruments — A number of attributes should be considered in choosing a questionnaire to screen

for depression, including its diagnostic accuracy in the population being screened and the feasibility of its
administration. Factors impacting feasibility include the number of questions, scoring and ease of
interpretation, and reading level required. These characteristics are summarized in a table about
recommended questionnaires ( table 2) [68,69].
The diagnostic accuracy of screening questions for depression is validated against structured diagnostic
interviews that use consensus criteria, such as the Diagnostic and Statistical Manual of Mental Disorders, 5th
Edition (DSM-5). Systematic reviews evaluating the performance of screening questionnaires in primary care
settings found that the sensitivity is too low (32 percent) if only a single question about depression is posed
[70]. However, short questionnaires that range from 2 to 10 questions perform well ( table 2) [68,70]. In a
meta-analysis of screening instruments in primary care, the median sensitivity and specificity of instruments
was 85 and 74 percent respectively, with no significant difference in performance between instruments [69].
Short screening instruments include the Patient Health Questionnaire-9 (PHQ-9), the Patient Health
Questionnaire-2 (PHQ-2), the Beck Depression Inventory for Primary Care (BDI-PC), and the 5-Item World
Health Organization Well-Being Index (WHO-5). These can be self-administered by patients preceding their
meeting with a clinician or while in the waiting area.
PHQ-9 — The PHQ-9 ( table 3) is somewhat more accurate than other screens (sensitivity 88 percent;
specificity 85 percent [71]) and is useful for monitoring a patient's response to treatment [72-75]. The PHQ-9 is
scored 0 to 27, with scores ≥10 indicating a possible depressive disorder. It also includes a question to assess
whether depressive symptoms are impairing function, a key criterion to establish a DSM-based diagnosis [24].
Similar to other screening questionnaires, the PHQ-9 is not sufficiently accurate to establish a definitive
diagnosis for depression [71]. Scores exceeding the threshold for a positive screen should prompt a careful
diagnostic assessment. The PHQ-9 can be used to monitor treatment response. (See "Unipolar depression in
adults: Assessment and diagnosis", section on 'Unipolar major depression' and "Using scales to monitor
symptoms and treat depression (measurement based care)".)
Using a prevalence of 10 percent for major depressive disorder or dysthymia, a score of 10 or higher on the
PHQ-9 yields a positive predictive value of 45 percent. Some false-positive screens may lead to other diagnoses
that share symptoms with major depressive disorder (MDD), such as anxiety disorder, at-risk alcohol use, or
subsyndromal depression, a condition defined by lower-level depressive symptoms that increases the risk for
MDD. A score less than 10 on the PHQ-9 yields a negative predictive value of 99 percent.
The Spanish-language version of the PHQ-9 is available from the National Immigrant Women’s Advocacy
Project [76].
PHQ-2 — The PHQ-2, also called the “Two-Question Screen,” is comprised of the first two questions from the
PHQ-9 ( table 4):
● During the past two weeks, have you often been bothered by feeling down, depressed, or hopeless?
● During the past two weeks, have you often been bothered by having little interest or pleasure in doing
things?
The PHQ-2 has the advantage of being brief and easy to administer verbally. Responses may be dichotomous
(yes/no), or scaled (0 to 3). A single "yes" response, or a score ≥3 (out of a possible score of 0 to 6) indicates
possible clinically significant depression. The PHQ-2 has a sensitivity of 76 percent and a specificity of 87
percent [77].
The PHQ-2 is often used as a "pre-screening" exam, and, if positive, followed up with a more detailed screening
such as the PHQ-9. In a meta-analyses including over 44,000 participants, administration of the PHQ-2 using a
cutoff score of ≥2, followed by a PHQ-9 for those who screened positive, reduced the need for a follow-up PHQ-
9 by 57 percent compared with screening all patients with a PHQ-9 alone [78]. The sensitivity and specificity of
this more efficient two-step strategy was similar to screening all individuals with a PHQ-9. (See 'Screening
implementation' below.)
Beck Depression Inventory for Primary Care — The BDI-PC is a seven-item scale [79] adapted from the
extensively validated 21-item Beck Depression Inventory (BDI-II) [80,81]. The 21-item BDI-II is useful for
monitoring treatment response. In primary care outpatients, the BDI-PC with a cutoff of four points had 97
percent sensitivity and 99 percent specificity for identifying major depression [82]. However, the BDI is
available only by license requiring a fee and thus has limited use for screening, since other instruments are
available in the public domain.
WHO-5 — The WHO-5 ( form 1) has excellent sensitivity but is somewhat less specific than other
instruments [83].
Instruments for special populations — Specialized depression questionnaires are available for some
patient populations.
● Pregnant women (see "Unipolar major depression during pregnancy: Epidemiology, clinical features,
assessment, and diagnosis", section on 'Screening')
● Postpartum women (see "Postpartum unipolar major depression: Epidemiology, clinical features,
assessment, and diagnosis", section on 'Screening' and "Bipolar disorder in postpartum women:
Epidemiology, clinical features, assessment, and diagnosis", section on 'Screening')
● Men who have recently become fathers (see "Postpartum paternal depression", section on 'Screening')
SCREENING IMPLEMENTATION
Based on our interpretation of the available evidence, we suggest general population screening for depression,
when the practice setting has adequate systems to ensure accurate diagnosis, effective treatment, and
appropriate follow-up. The optimal frequency of screening is not established by evidence. To facilitate ease of
implementation, we support screening at the time of a routine health visit.
When personnel or systems are available to assure appropriate follow-up and management of patients who
screen positive, screening all adults for depression at the time of a routine visit perhaps is the simplest
approach, particularly when using an electronic medical record (EMR) that incorporates clinical reminders.
Practices may wish to distribute questionnaires at check-in for patients to complete, or have staff distribute or
verbally administer questionnaires along with assessment of vital signs. When using the latter approach, many
practices find it most efficient to administer the Patient Health Questionnaire-2 (PHQ-2) verbally and, when
positive, distribute a longer questionnaire, such as the Patient Health Questionnaire-9 (PHQ-9), to be
completed in the examination room while the patient is waiting for the clinician.
Use of pre-visit videos or interactive computer programs to engage patients in recognition of depression
symptoms has also been explored. In one randomized trial, patients with depressive symptoms who used a
tailored interactive computer program in the waiting area prior to their clinician visit were more likely to be
treated for depression (by antidepressant prescription and/or referral) than control patients; viewing a
noninteractive video did not increase treatment [84]. However, there was no difference between groups in
mental health outcomes at 12 weeks.
Regardless of the screening approach chosen, changing practice routines can be challenging [85]. To facilitate
implementation of depression screening, everyone on staff should understand the following:
● Why depression screening is important

● How to address patients' concerns about confidentiality
● How to introduce depression screening to patients
● The importance of asking the screening questions verbatim
Adequate systems for depression care refers to the support of staff who provide direct clinical care or
coordinate care for patients with depression. They may provide support with symptom monitoring, self-
management plans, medication adherence, patient education, assessment of patient preferences and goals,
and/or referrals. Medicare and many other health insurers reimburse practices for integrated behavioral health
services [86], facilitating the financial viability of offering such services [87]. Examples of system supports for
depression care include [52,56,88]:
● A nurse who screens patients for depression, informs the clinician of a positive screen, and facilitates
referral for evidence-based behavioral treatment
● Trained care managers who assess patient symptoms at baseline and follow-up, using a standardized
instrument, and who assess treatment adherence
● Collaborative care involving direct coordination between mental health specialists and primary care
Care is also facilitated by inclusion of active self-management support and assuring active follow-up for a
minimum of 16 weeks [56].
There is limited evidence to guide the optimal frequency of routine screening for depression. Although
screening every five years may be more cost-effective than more frequent screening [60], annual screening or
screening at the time of a health maintenance examination may be easier to incorporate into routine practice.
It bears mentioning that the greatest impact of depression derives from insufficient treatment of patients with
known depression, rather than lack of screening to identify depression in less symptomatic patients [51].
Practices should prioritize high-quality treatment, including these practice supports over depression screening.
GUIDELINE RECOMMENDATIONS
Guidelines on depression from several countries vary in their recommendations. Links to society and
government-sponsored guidelines from selected countries and regions around the world are provided
separately. (See 'Society guideline links' below.)
United States — The USPSTF recommends screening for depression in the general adult population, including
pregnant and postpartum women [52]. The USPSTF also states that screening should be implemented with
adequate systems in place to ensure diagnosis, treatment, and appropriate follow-up. The USPSTF notes that
the optimal interval for screening is not known. They suggest a pragmatic approach of screening all adults who
have not been previously screened and using clinical judgement to determine if additional screening in
needed. (See "Postpartum unipolar major depression: Epidemiology, clinical features, assessment, and
diagnosis", section on 'Screening' and "Unipolar major depression during pregnancy: Epidemiology, clinical
features, assessment, and diagnosis", section on 'Screening'.)
The Department of Veterans Affairs recommends that all patients not currently receiving treatment for
depression be screened using the Patient Health Questionnaire (PHQ-2) [89]. The American College of
Physicians (ACP) does not make specific recommendations about screening for depression. However, the ACP
supports the integration of behavioral health care (including screening, diagnosis, brief treatment, and
referral) into primary care and encourages addressing behavioral health issues within the limits of available
resources [90].
Canada — The Canadian Task Force on Preventive Health Care (CTFPHC) recommends not routinely screening
for depression in the primary care setting in adults with no history of depression and no apparent symptoms of
depression, including not screening those who are at average risk or who may be at increased risk of
depression [91,92]. They advise that clinicians remain alert to symptoms of depression (eg, insomnia, low
mood, anhedonia, and suicidal thoughts), especially among patients with characteristics that may increase
depression risk. CTFPHC based their recommendations on the absence of high-quality evidence of the
effectiveness of screening for depression and the concern about false-positive diagnoses leading to
unnecessary treatment. This reverses its previous recommendations to screen adults in primary care settings
that had integrated feedback to the clinician regarding depression status and a system for managing
treatment, and that included access to case management, and/or mental health treatment [49,93].
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United Kingdom — Guidelines from the National Institute for Health and Clinical Excellence (NICE) suggest
being alert to possible depression, particularly if there is a depression history or chronic physical health
problem with functional impairment [94]. They recommend considering asking people who may be depressed
two questions from the PHQ-2:
● During the past two weeks, have you often been bothered by feeling down, depressed, or hopeless?
● During the past two weeks, have you often been bothered by having little interest or pleasure in doing
things?
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions around the world
are provided separately. (See "Society guideline links: Screening for depression".)
SUMMARY AND RECOMMENDATIONS
● Depression is the most common psychiatric disorder and the most common mental health condition
among patients seen in primary care. In the absence of screening, it is estimated that only 50 percent of
patients with major depressive disorder (MDD) are identified. (See 'Introduction' above.)
● Patients with depression may present with mood, cognitive, neurovegetative, or somatic symptoms.
Diagnosis of depression is more challenging in patients who present with somatic symptoms. Effective
treatments for depression include pharmacotherapy and psychotherapy. Chronic depression is associated
with poorer treatment response. (See 'Presentation, natural history, and course of illness' above and
'Rationale for screening' above.)
● Depression screening improves diagnosis rates, but clinical outcomes are only improved if screening is
part of an enhanced care approach in which staff are available to participate in patient management.
There appear to be limited, if any, harms from screening as long as a positive screen is followed by a
careful diagnostic assessment. (See 'Effectiveness of screening' above.)
● For practices choosing to screen, the Patient Health Questionnaire-2 (PHQ-2), either as a verbal or written
screen, is easily administered with reasonable performance characteristics ( table 4). A positive screen
should be followed by a clinical interview, facilitated with the Patient Health Questionnaire-9 (PHQ-9) (
table 3) or a similar instrument, to diagnose depression. (See 'Screening instruments' above.)
● We suggest screening adults for depression when adequate systems are in place to ensure appropriate
diagnosis, treatment, and follow-up (Grade 2C). The optimal frequency of screening is not established by
evidence. To facilitate ease of implementation, we support screening at the time of a routine health visit.
(See 'Screening implementation' above and 'Guideline recommendations' above.)
● Recommendations for screening for depression vary internationally. (See 'Guideline recommendations'
above.)
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9, 2018).
Topic 83887 Version 29.0
GRAPHICS
DSM-5 diagnostic criteria for a major depressive episode
A. Five (or more) of the following symptoms have been present during the same two-week period and represent a change from previous functioning; at
least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
NOTE: Do not include symptoms that are clearly attributable to another medical condition.
1) Depressed mood most of the day, nearly every day, as indicated by either subjective report (eg, feels sad, empty, hopeless) or observations made
by others (eg, appears tearful). (NOTE: In children and adolescents, can be irritable mood.)
2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account
or observation).
3) Significant weight loss when not dieting or weight gain (eg, a change of more than 5% of body weight in a month), or decrease or increase in
appetite nearly every day. (NOTE: In children, consider failure to make expected weight gain.)
4) Insomnia or hypersomnia nearly every day.
5) Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
6) Fatigue or loss of energy nearly every day.
7) Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about
being sick).
8) Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by their subjective account or as observed by others).
9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for
committing suicide.
B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The episode is not attributable to the direct physiological effects of a substance or to another medical condition.
NOTE: Criteria A through C represent a major depressive episode.
NOTE: Responses to a significant loss (eg, bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include
the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a
depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode
in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical
judgement based on the individual's history and the cultural norms for the expression of distress in the context of loss.
D. The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder,
delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.
E. There has never been a manic or hypomanic episode.
NOTE: This exclusion does not apply if all of the manic-like or hypomanic-like episodes are substance-induced or are attributable to the physiological
effects of another medical condition.
Specify:
With anxious distress
With mixed features
With melancholic features
With atypical features
With psychotic features
With catatonia
With peripartum onset
With seasonal pattern
Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright © 2013). American Psychiatric Association. All Rights
Reserved.
Graphic 89994 Version 13.0
Characteristics of depression case-finding instruments validated
Number Monitor
Time to
Sensitivity* Specificity ¶ of Response Score Usual Literacy severity
Instrument administer
(%) (%) items Δ format range cutpoint ◊ level § or
(minutes)
response
BDI 90 79 21, 13, 7 Four statements 0 to 63 10 to 19 mild Easy 2 to 5 Yes

of symptom 20 to 29
severity per moderate
item
≥30 severe
EPDS 82 86 10 Four frequency 0 to 30 ≥10 Easy <2 Yes

ratings
GDS 81 78 15 Yes or no 0 to 15 ≥6 Easy 2 to 5 Yes
PHQ-2 76 87 2 Four frequency 0 to 6 ≥3 Average <1 Limited

ratings
PHQ-9 88 85 9 Four frequency 0 to 9 for For Average <2 Yes

ratings diagnosis diagnosis:
0 to 27 5 symptoms
for For severity:
response 0 to 4 none
5 to 9 mild
10 to 14
moderate
15 to 19
major
20 to 27
severe
WHO-5 93 64 5 Five frequency 0 to 25 ≤12 Easy <2 Unknown

ratings
BDI: Beck Depression Inventory; EPDS: Edinburgh Postnatal Depression Scale; GDS: Geriatric Depression Scale; PHQ: Patient Health Questionnaire; WHO-5:
World Health Organization Well-being Index.
* Sensitivity describes the proportion of patients with major depressive disorder who score below the cutpoint.
¶ Specificity describes the proportion of patients without major depressive disorder who score below the cutpoint.
Δ Numbers refer to different versions of the same instrument and are listed from most to least number of items.
◊ Cutpoint is given for the instrument version with the most number of items.
§ Easy: 3rd to 5th grade reading level; Average: 6th to 9th grade reading level.
Adapted from: Williams JW, Jr. Depression. In: The Rational Clinical Examination: Evidence-Based Clinical Diagnosis, Simel DL, Rennie D (Eds), McGraw-Hill, New York
2009.
PHQ-9 depression questionnaire
Name: Date:
Over the last 2 weeks, how often have you been bothered by any of the following Not at all Several More than Nearly
problems? days half the every day
days
Little interest or pleasure in doing things 0 1 2 3
Feeling down, depressed, or hopeless 0 1 2 3
Trouble falling or staying asleep, or sleeping too much 0 1 2 3
Feeling tired or having little energy 0 1 2 3
Poor appetite or overeating 0 1 2 3
Feeling bad about yourself, or that you are a failure, or that you have let yourself or 0 1 2 3
your family down
Trouble concentrating on things, such as reading the newspaper or watching television 0 1 2 3
Moving or speaking so slowly that other people could have noticed? Or the opposite, 0 1 2 3
being so fidgety or restless that you have been moving around a lot more than usual.
Thoughts that you would be better off dead, or of hurting yourself in some way 0 1 2 3
Total ___ = ___ + ___ + ___ + ___
PHQ-9 score ≥10: Likely major depression
Depression score ranges:
5 to 9: mild
10 to 14: moderate
15 to 19: moderately severe
≥20: severe
If you checked off any problems, how difficult have these problems made it for you Not difficult Somewhat Very difficult Extremely
to do your work, take care of things at home, or get along with other people? at all difficult ___ difficult
___ ___ ___
PHQ: Patient Health Questionnaire.
Developed by Drs. Robert L Spitzer, Janet BW Williams, Kurt Kroenke, and colleagues, with an educational grant from Pﬁzer, Inc. No permission required to reproduce,
translate, display or distribute.
Short Patient Health Questionnaire (PHQ-2)
Name: Date:
Over the past 2 weeks, how often have you Not at all Several days More than half the Nearly every day
been bothered by any of the following days
problems?
Little interest or pleasure in doing things? 0 1 2 3
Feeling down, depressed, or hopeless? 0 1 2 3
Total point score: ____ ____ + ____ + ____ + ____
Score interpretation [1]:

PHQ-2 score Probability of major depressive disorder (%) Probability of any depressive disorder (%)
1 15.4 36.9
2 21.1 48.3
3 38.4 75.0
4 45.5 81.2
5 56.4 84.6
6 78.6 92.9
Reference:
1. Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care 2003; 41:1284.
PHQ-2 reproduced with the permission of Pﬁzer Inc.
WHO (Five) Well-Being Index (1998 version)
Scoring:
The raw score is calculated by totalling the figures of the five answers. The raw score ranges from 0 to 25, 0
representing worst possible and 25 representing best possible quality of life.
To obtain a percentage score ranging from 0 to 100, the raw score is multiplied by 4. A percentage score of 0
represents worst possible, whereas a score of 100 represents best possible quality of life.
Interpretation:
It is recommended to administer the Major Depression (ICD-10) Inventory if the raw score is below 13 or if the
patient has answered 0 to 1 to any of the five items. A score below 13 indicates poor wellbeing and is an indication
for testing for depression under ICD-10.
Monitoring change:
In order to monitor possible changes in wellbeing, the percentage score is used. A 10% difference indicates a
significant change.
ICD-10: International Classification of Diseases, Tenth Revision.
Originally published in: World Health Organization Psychiatric Research Unit. Who (Five) Well-Being Index (1998 version). WHO
Collaborating Center for Mental Health 1998. Reprinted with permission from: the World Health Organization. Republished in: Bech P.
Clinical Psychometrics. Wiley-Blackwell, Oxford, 2012.
Contributor Disclosures
John Williams, MD Nothing to disclose Jason Nieuwsma, PhD Nothing to disclose Joann G Elmore, MD, MPH Nothing to
disclose Peter P Roy-Byrne, MD Employment: Mass Medical Society. Lisa Kunins, MD Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by
vetting through a multi-level review process, and through requirements for references to be provided to support the
content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence.
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● Decreased or increased appetite

EPIDEMIOLOGY AND RISK FACTORS

PRESENTATION, NATURAL HISTORY, AND COURSE OF ILLNESS

RATIONALE FOR SCREENING

The effectiveness of screening depends upon multiple factors [47,48]:

● Whether a condition is sufficiently common in the general population to merit screening

Screening instruments — A number of attributes should be considered in choosing a questionnaire to screen

● Why depression screening is important

SOCIETY GUIDELINE LINKS

SUMMARY AND RECOMMENDATIONS

Use of UpToDate is subject to the Subscription and License Agreement.

a.gov/publications/esp/Depression-Interventions-2009.pdf (Accessed on May 16, 2013).

61. Schoenbaum M, Unützer J, Sherbourne C, et al. Cost-effectiveness of practice-initiated quality

92. http://www.cmaj.ca/content/suppl/2013/07/29/cmaj.130403.DC3/depress-update.pdf (Accessed on Septe

DSM-5 diagnostic criteria for a major depressive episode

4) Insomnia or hypersomnia nearly every day.

6) Fatigue or loss of energy nearly every day.

NOTE: Criteria A through C represent a major depressive episode.

E. There has never been a manic or hypomanic episode.

With anxious distress

With mixed features

With melancholic features

With atypical features

With psychotic features

With peripartum onset

With seasonal pattern

Graphic 89994 Version 13.0

Characteristics of depression case-finding instruments validated

BDI 90 79 21, 13, 7 Four statements 0 to 63 10 to 19 mild Easy 2 to 5 Yes

EPDS 82 86 10 Four frequency 0 to 30 ≥10 Easy <2 Yes

GDS 81 78 15 Yes or no 0 to 15 ≥6 Easy 2 to 5 Yes

PHQ-2 76 87 2 Four frequency 0 to 6 ≥3 Average <1 Limited

PHQ-9 88 85 9 Four frequency 0 to 9 for For Average <2 Yes

WHO-5 93 64 5 Five frequency 0 to 25 ≤12 Easy <2 Unknown

Graphic 89929 Version 4.0

PHQ-9 depression questionnaire

Little interest or pleasure in doing things 0 1 2 3

Feeling down, depressed, or hopeless 0 1 2 3

Trouble falling or staying asleep, or sleeping too much 0 1 2 3

Feeling tired or having little energy 0 1 2 3

Poor appetite or overeating 0 1 2 3

Trouble concentrating on things, such as reading the newspaper or watching television 0 1 2 3

Total ___ = ___ + ___ + ___ + ___

PHQ-9 score ≥10: Likely major depression

Depression score ranges:

15 to 19: moderately severe

PHQ: Patient Health Questionnaire.

Graphic 59307 Version 11.0

Short Patient Health Questionnaire (PHQ-2)

Little interest or pleasure in doing things? 0 1 2 3

Feeling down, depressed, or hopeless? 0 1 2 3

Total point score: ____ ____ + ____ + ____ + ____

Score interpretation [1]:

Graphic 89663 Version 3.0

WHO (Five) Well-Being Index (1998 version)

ICD-10: International Classification of Diseases, Tenth Revision.

Graphic 89665 Version 2.0

Conflict of interest policy

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Total _ = _ + _ + _ + ___

Total point score: + + +