8.1 Primary Care Depression, Anxiety & Behavioral Health Screening

Universal Adult Depression Screening in Primary Care

Major depressive disorder (MDD) is among the leading causes of disability worldwide, affecting approximately 8% to 10% of primary care patients at any given time. Because over 50% of depressed patients present to primary care exclusively with somatic complaints (such as chronic fatigue, insomnia, non-specific musculoskeletal pain, or digestive disturbances) rather than overt psychological distress, routine universal screening is essential for timely detection and intervention.

Clinical Guidelines and Recommendations

• U.S. Preventive Services Task Force (USPSTF): Recommends universal screening for depression in the general adult population, including pregnant and postpartum individuals, as well as older adults (Grade B recommendation). Screening should be implemented in clinical practices with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate longitudinal follow-up.
• American College of Obstetricians and Gynecologists (ACOG): Recommends universal depression screening in perinatal patients at the initial prenatal visit, later in pregnancy, and at postpartum visits.
• American Academy of Family Physicians (AAFP): Endorses the USPSTF Grade B recommendation, underscoring that screening must be linked to integrated collaborative behavioral health workflows or established referral pathways.

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The Two-Step Screening Algorithm: PHQ-2 to PHQ-9

Universal depression screening is most efficiently conducted using a validated two-step stepped-screening protocol. This framework conserves clinical resources while preserving high diagnostic sensitivity and specificity.

+-----------------------------------------------------------------------------------------+
|                               TWO-STEP SCREENING WORKFLOW                               |
|                                                                                         |
|  [General Adult Patient] ---> Step 1: Administer PHQ-2 (2 Questions, Score 0–6)         |
|                                     |                                                   |
|                                     +---> Score 0–2: Negative screen; rescreen annually |
|                                     |                                                   |
|                                     +---> Score ≥3: POSITIVE SCREEN (Sens 83%, Spec 92%)|
|                                                  |                                      |
|                                                  v                                      |
|                               Step 2: Reflex Full PHQ-9 (9 Criteria, Score 0–27)        |
|                                     |                                                   |
|                                     +---> Score 0–4: Minimal/No depression              |
|                                     +---> Score 5–9: Mild depression                    |
|                                     +---> Score 10–14: Moderate depression              |
|                                     +---> Score 15–19: Moderately severe depression     |
|                                     +---> Score 20–27: Severe depression                |
|                                     |                                                   |
|                                     +---> Question 9 > 0: Immediate Suicide Risk Strat. |
+-----------------------------------------------------------------------------------------+

Step 1: The Patient Health Questionnaire-2 (PHQ-2)

The PHQ-2 comprises the first two cardinal DSM-5 diagnostic criteria for major depressive disorder, assessing symptoms over the preceding 2 weeks:

1. "Little interest or pleasure in doing things" (Anhedonia)
2. "Feeling down, depressed, or hopeless" (Depressed mood)

Each question is scored on a 4-point Likert scale:

• 0 = Not at all
• 1 = Several days
• 2 = More than half the days
• 3 = Nearly every day

Clinical Interpretation: The total PHQ-2 score ranges from 0 to 6. A score of ≥3 is the standard validated cutoff, yielding a sensitivity of 83% and specificity of 92% for major depressive disorder. A score ≥3 constitutes a positive screen and mandates immediate reflex administration of the full 9-item Patient Health Questionnaire (PHQ-9). A score <3 has a high negative predictive value (>98%), allowing routine annual rescreening unless clinical suspicion remains elevated.

Step 2: The Patient Health Questionnaire-9 (PHQ-9)

The PHQ-9 maps directly to the nine DSM-5 diagnostic criteria for a major depressive episode. Each item is scored 0 to 3 based on frequency over the past 2 weeks, generating a total score between 0 and 27:

1. Anhedonia (diminished interest/pleasure)
2. Depressed, down, or hopeless mood
3. Sleep disturbances (insomnia or hypersomnia)
4. Fatigue or loss of energy
5. Appetite changes (weight loss or weight gain)
6. Feelings of worthlessness, self-reproach, or excessive guilt
7. Diminished concentration, indecisiveness, or executive slowing
8. Psychomotor agitation or retardation (observable by others)
9. Suicidal ideation (thoughts of being better off dead or hurting oneself)

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PHQ-9 Severity Stratification and Stepped-Care Management Protocols

The total PHQ-9 score guides the clinical treatment tier in family medicine:

Monitoring Treatment Response and Remission

• Baseline Assessment: Measure PHQ-9 prior to starting or modifying therapy.
• Treatment Response: Defined as a ≥50% reduction in total PHQ-9 score from baseline after an adequate therapeutic trial (typically 6 to 8 weeks at therapeutic dosages).
• Remission: Defined as a PHQ-9 score <5. The primary goal of acute depression treatment is full remission, as residual depressive symptoms (PHQ-9 score 5–9) predict high rates of early relapse, persistent functional disability, and chronic recurrence.
• Continuation Phase: Once full remission is achieved, antidepressant pharmacotherapy must be continued for a minimum of 6 to 9 months at the same remission-inducing dose to prevent relapse. For patients with recurrent depression (≥3 prior episodes), severe depression, or chronic dysthymia, maintenance therapy for 2 or more years (or lifelong) is recommended.

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Managing PHQ-9 Question 9: Suicidal Ideation & Safety Planning

Question 9 on the PHQ-9 asks: "Thoughts that you would be better off dead, or of hurting yourself in some way?"

[!CRITICAL] Any non-zero score on Question 9 (1 = several days, 2 = more than half the days, 3 = nearly every day) requires immediate, same-day face-to-face suicide risk evaluation prior to the patient leaving the clinical facility. An automated EHR alert or standardized clinic workflow must trigger clinician notification.

Columbia-Suicide Severity Rating Scale (C-SSRS) Risk Triage

The clinician must immediately clarify the nature, severity, and chronicity of the suicidal ideation:

1. Passive Suicidal Ideation: A non-specific wish to be dead (e.g., "I wish I could fall asleep and not wake up") without thoughts of killing oneself, intent, or plan.
2. Active Suicidal Ideation without Intent/Plan: Thoughts of killing oneself without a specific method, plan, or intent (e.g., "I think about killing myself, but I would never actually do it").
3. Active Suicidal Ideation with Method/Plan but No Intent: Detailed contemplation of a specific mechanism (e.g., overdose, firearm) without active intent to carry it out.
4. Active Suicidal Ideation with Intent and Specific Plan: Explicit desire and preparation to end one's life (e.g., "I have saved up 60 oxycodone pills and plan to take them tonight when my family leaves").

Risk Stratification and Action Matrix

• Low Imminent Risk (Passive ideation, no plan, no intent, strong protective factors, cooperative, reliable support system):
  • Outpatient management; establish treatment for underlying mood disorder.
  • Formulate a collaborative Stanley-Brown Safety Plan.
  • Conduct lethal means counseling (secure firearms, lock away medications).
  • Schedule in-person or telehealth follow-up within 24 to 48 hours.
• Moderate Imminent Risk (Active ideation, non-specific plan, no active intent, ambivalence, identified protective factors):
  • Involve primary care behavioral health care manager or on-site crisis counselor.
  • Complete structured safety plan with identified emergency contacts and crisis resources.
  • Engage family or support persons (with patient consent) to assist with home monitoring and environmental lethal means removal.
  • In-person clinical re-evaluation within 24 to 48 hours; provide 24/7 crisis numbers.
• High Imminent Risk (Active ideation with intent, lethal plan, preparatory behavior, acute agitation, severe hopelessness, psychosis, substance intoxication, or refusal to participate in safety planning):
  • Emergency psychiatric evaluation.
  • Do NOT leave the patient unattended in the examination room.
  • Arrange immediate transfer to an emergency department or crisis stabilization unit via emergency medical services (EMS). Involuntary psychiatric hold (e.g., state-specific emergency detention) is indicated only if the patient refuses voluntary evaluation and poses an imminent danger to self.

The Stanley-Brown Safety Planning Intervention

"Contracts for safety" (e.g., having a patient sign a document promising not to commit suicide) are ineffective, non-evidence-based, and legally unprotective. In contrast, the Stanley-Brown Safety Planning Intervention is an evidence-based, collaborative protocol comprising six sequential, prioritized steps recorded on a pocket card or mobile app:

1. Step 1: Recognizing Personal Warning Signs: Identify individualized triggers, catastrophic thoughts, mood changes, and behaviors that signal a developing suicidal crisis.
2. Step 2: Internal Coping Strategies: Identify solitary relaxation, cognitive reframing, or behavioral activities that distract from suicidal thoughts without contacting others (e.g., walking, listening to music, exercise, meditation).
3. Step 3: Social Contacts and Settings for Distraction: Identify trusted people and safe public environments that provide healthy distraction (e.g., calling a friend to chat about sports, visiting a library or coffee shop).
4. Step 4: Family Members or Friends for Crisis Help: Identify specific individuals the patient can openly confide in during a crisis.
5. Step 5: Professionals and Agencies to Contact: Document exact names and 24/7 phone numbers for:
   • Primary care physician / clinic phone
   • Outpatient therapist or psychiatrist
   • 988 Suicide & Crisis Lifeline: Call or text 988 (available 24/7/365 across the US)
   • The Crisis Text Line: Text HOME to 741741
   • Local emergency department address and contact
6. Step 6: Making the Environment Safe (Lethal Means Restriction): Collaborative identification and elimination of lethal means: surrendering firearms to a licensed dealer, trusted third-party, or locking in a biometric gun safe with keys held by a relative; locking up lethal prescription and over-the-counter medications.

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Adult Anxiety Screening: GAD-2 and GAD-7

Anxiety disorders represent the most prevalent psychiatric conditions in the United States, with a lifetime prevalence exceeding 30%. Symptoms frequently present as somatic complaints, including palpitations, trembling, diaphoresis, chronic muscle tension, irritable bowel symptoms, and chronic headaches.

USPSTF Screening Recommendations (2022/2023 Update)

• Adults Aged 19 to 64 Years: The USPSTF recommends screening for anxiety disorders in asymptomatic non-pregnant adults aged 19 to 64 (Grade B recommendation).
• Older Adults (Aged 65 and Older): The USPSTF concludes that current evidence is insufficient to assess the balance of benefits and harms of screening for anxiety in adults aged 65 and older (Grade I statement), largely due to overlapping physical comorbidities, medication side effects, and cognitive impairment that confound screening accuracy.
• Screening Frequency: Optimal intervals are not strictly established; pragmatic clinical guidance supports screening every 1 to 2 years during preventive health visits or when risk factors/symptoms arise.

The Generalized Anxiety Disorder 2-Item (GAD-2) and 7-Item (GAD-7) Scales

Similar to depression screening, anxiety screening employs a stepped protocol:

• The GAD-2: Assesses core symptoms over the past 2 weeks:
  1. "Feeling nervous, anxious, or on edge"
  2. "Not being able to stop or control worrying"
  • Scored 0 to 3 each (total score 0 to 6). A cutoff score of ≥3 is positive, demonstrating a sensitivity of 86% and specificity of 83% for Generalized Anxiety Disorder (GAD).
• The GAD-7: Reflexively administered when GAD-2 is ≥3. Total score ranges from 0 to 21:
  • 0–4: Minimal anxiety (monitoring)
  • 5–9: Mild anxiety (psychoeducation, sleep hygiene, caffeine reduction, relaxation techniques)
  • 10–14: Moderate anxiety (evidence-based psychotherapy [CBT] and/or pharmacotherapy [SSRI/SNRI])
  • 15–21: Severe anxiety (combined CBT and pharmacotherapy; psychiatric consultation)
  • A cutoff score of ≥10 has 89% sensitivity and 82% specificity for identifying GAD, and also serves as a sensitive screen for Panic Disorder, Social Anxiety Disorder, and Post-Traumatic Stress Disorder (PTSD).

Evidence-Based Pharmacotherapy for Anxiety Disorders

• First-Line Pharmacotherapy: SSRIs (escitalopram, sertraline, paroxetine) and SNRIs (venlafaxine XR, duloxetine). In anxiety disorders, initial dosing should start at half the standard starting dose used for depression (e.g., escitalopram 5 mg daily or sertraline 25 mg daily) to avoid transient activation syndrome (paradoxical early agitation, jitteriness, and worsening anxiety during the first 1 to 2 weeks).
• Second-Line / Adjunctive Options: Buspirone (5-HT1A partial agonist; non-sedating, non-addictive; requires 2 to 4 weeks for efficacy; dosed 7.5–15 mg BID/TID; ineffective as PRN), pregabalin/gabapentin, hydroxyzine (PRN for acute somatic symptoms).
• Benzodiazepine Safety Warning: Routine long-term use of benzodiazepines (e.g., alprazolam, clonazepam, lorazepam) is strongly discouraged due to risks of physical dependence, tolerance, cognitive blunting, withdrawal seizures, fall-related fractures in older adults, and accidental overdose death (particularly when co-prescribed with opioids or alcohol). If used acutely for severe, disabling panic, treatment should be strictly limited to short-term bridge therapy (<2 to 4 weeks) while awaiting SSRI/SNRI onset.

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Pre-Treatment Bipolar Disorder Screening: The Mood Disorder Questionnaire (MDQ)

A critical clinical safety rule in primary care: Never initiate an antidepressant without first screening for personal and family history of bipolar spectrum disorder.

The Clinical Danger of the "Manic Switch"

Between 20% and 30% of patients who present to primary care complaining of depression actually have an underlying bipolar diathesis (Bipolar I, Bipolar II, or Cyclothymic Disorder). Initiating unopposed antidepressant monotherapy (SSRIs, SNRIs, or tricyclics) in a patient with bipolar disorder can precipitate catastrophic adverse psychiatric events:

1. Antidepressant-Induced Manic or Hypomanic Switch: Acute emergence of euphoria, irritability, grandiosity, flight of ideas, extreme impulsivity, reckless spending, or hypersexuality.
2. Mixed Affective States: A highly volatile combination of depressive hopelessness with severe psychomotor agitation and racing thoughts, dramatically escalating suicide attempt lethality.
3. Rapid Cycling Induction: Acceleration of mood episodes to four or more distinct episodes per year, resulting in progressive treatment resistance.

The Mood Disorder Questionnaire (MDQ)

The MDQ is a brief, validated 3-part self-report instrument:

• Part 1: 13 yes/no questions evaluating lifetime manic or hypomanic symptoms (hyperactivity, decreased need for sleep, elevated self-confidence, excessive talking, racing thoughts, distractibility, spending sprees, risky sexual behaviors).
• Part 2: Evaluates symptom co-occurrence: "Have several of these things happened during the same period of time?" (Yes/No)
• Part 3: Assesses functional impairment: "How much of a problem did any of these cause you?" (No problem, minor problem, moderate problem, serious problem)

Diagnostic Threshold for a Positive MDQ Screen

A positive MDQ screen requires meeting ALL THREE of the following criteria:

1. ≥7 positive items out of the 13 symptom questions in Part 1
2. An affirmative ("Yes") response to Part 2 confirming symptom co-occurrence
3. An endorsement of "Moderate problem" or "Serious problem" in Part 3

Clinical Action upon a Positive MDQ Screen

• Withhold Antidepressant Monotherapy: Do not start an SSRI, SNRI, or bupropion as a solitary agent.
• Comprehensive Evaluation: Screen for family history of bipolar disorder, suicide attempts, and psychiatric hospitalizations; gather collateral history from family members (who often recognize hypomanic episodes that patients perceive as periods of high productivity).
• Initiate First-Line Bipolar Depression Pharmacotherapy: Mood stabilizers (lithium, lamotrigine, divalproex sodium) or second-generation atypical antipsychotics specifically FDA-approved for bipolar depression:
  • Quetiapine (300 mg daily at bedtime)
  • Lurasidone (20–120 mg daily with food ≥350 calories)
  • Cariprazine (1.5–3.0 mg daily)
  • Lumateperone (42 mg daily)
  • Olanzapine-fluoxetine combination (Symbyax)
• Psychiatric Referral: Secure prompt referral to a psychiatrist for diagnostic confirmation and long-term mood stabilization.

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Perinatal Mood Disorders & the Edinburgh Postnatal Depression Scale (EPDS)

Perinatal depression (occurring during pregnancy or within the first 12 months postpartum) affects 10% to 15% of women and is a leading cause of maternal morbidity and mortality. Differentiating normal postpartum emotional adjustments from major mood disorders is a classic ABFM clinical challenge.

Master Comparison: Postpartum Mood Syndromes

The Edinburgh Postnatal Depression Scale (EPDS)

• Structure: 10-item self-administered scale scored 0 to 3 for each item (total score 0 to 30). Crucially, the EPDS emphasizes cognitive and emotional symptoms (guilt, anxiety, despair, lack of humor) while omitting somatic neurovegetative symptoms (fatigue, sleep changes, weight fluctuations), which are ubiquitous in healthy postpartum mothers.
• Diagnostic Cutoff: A score of ≥10 (or ≥12 in some screening protocols) indicates high probability of major depression and warrants comprehensive clinical diagnostic interview.
• Question 10 (Self-Harm Assessment): Question 10 states: "The thought of harming myself has occurred to me." Any score greater than 0 (1, 2, or 3) on Question 10 mandates immediate, same-day safety evaluation, regardless of the total composite EPDS score.

Psychopharmacology in Pregnancy and Lactation

• Antidepressant Selection in Lactation:
  • Sertraline: The first-line SSRI of choice during breastfeeding. Sertraline has high plasma protein binding (98%) and low excretion into human breast milk, yielding infant serum concentrations that are generally undetectable, with a Relative Infant Dose (RID) <1% to 2% (well below the 10% safety threshold).
  • Paroxetine: Also exhibits low breast milk transfer (RID ~1% to 2%), but is less favored in women who may become pregnant again due to historic concerns regarding first-trimester cardiac malformations (ventricular septal defects).
  • Fluoxetine: Has a prolonged parent elimination half-life (1–3 days) and an active metabolite, norfluoxetine (half-life 7–14 days), leading to greater accumulation in breast milk (RID up to 5% to 9%) and potential infant irritability, colic, and loose stools.
• Neuroactive Steroids for Severe Postpartum Depression:
  • Brexanolone: An intravenous formulation of allopregnanolone (positive allosteric modulator of GABA-A receptors); administered as a continuous 60-hour IV infusion under monitored inpatient setting (REMS program) for severe refractory PPD.
  • Zuranolone: An oral GABA-A receptor positive allosteric modulator taken once nightly for 14 days (50 mg orally with a fat-containing meal); provides rapid antidepressant response within days for severe postpartum depression.

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Collaborative Care Models & Integrated Behavioral Health

Traditional primary care referral models ("referral out" to community psychiatrists) suffer from profound fragmentation, leading to referral completion rates <20% and persistent health disparities. The Collaborative Care Model (CoCM), validated in landmark trials such as the IMPACT study, is the gold-standard evidence-based framework for behavioral health integration in family medicine.

The Triad Team Structure of Collaborative Care

1. The Primary Care Physician (Team Leader): Identifies psychiatric conditions through universal screening, initiates medications, manages medical-psychiatric comorbidities, and oversees the overall longitudinal care plan.
2. The Behavioral Health Care Manager (BHCM): A registered nurse, clinical social worker, or psychologist embedded within the primary care clinic. Responsibilities include:
   • Maintaining a computerized disease registry of all enrolled patients.
   • Administering standardized symptom scales (PHQ-9, GAD-7) at every clinical contact to track objective treatment progress (measurement-based care).
   • Delivering brief, evidence-based psychological interventions (Behavioral Activation, Problem-Solving Therapy, Motivational Interviewing).
   • Conducting proactive outreach for patients who miss appointments or fail to achieve treatment targets.
3. The Psychiatric Consultant: A board-certified psychiatrist who conducts weekly systematic registry caseload reviews with the Care Manager. The psychiatrist reviews patients who are not achieving target response (e.g., PHQ-9 not decreasing by ≥50% by 6–8 weeks) and provides structured diagnostic and psychopharmacologic recommendations to the PCP without necessarily conducting a direct face-to-face evaluation.

The Five Core Principles of Effective CoCM

• Patient-Centered Team: Primary care clinicians and behavioral health specialists work in seamless coordination with shared clinical goals.
• Population-Based Care: Clinicians manage an explicit registry panel of patients to ensure no individual "falls through the cracks."
• Measurement-Based Stepped Care: Treatment changes (dose titration, medication switch, therapy augmentation) are driven by quantitative score thresholds on validated rating scales.
• Evidence-Based Practice: Interventions utilize proven modalities (CBT, SSRIs/SNRIs, behavioral activation).
• Accountable Care: Quality metrics, remission rates, and clinical outcomes are routinely measured and audited to guarantee high-value clinical care.