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Cover  |  Table of Contents  |  Step 1. - Recognition & Diagnosis


Recognizing that a patient is depressed can be challenging, as often patients are concerned about social stigma when told their symptoms suggest a depression diagnosis. To aid with identification of depression, astute clinicians look for red flags and selectively use a two-question-screen.

Recognition may occur over several visits, especially with somatic presentation. This step may occur during one visit but may require several if history is complex or the patient is reluctant to accept a depression disgnosis or active treament.

Step 1a: Red flags:
Does the patient present with any of the following?
  • History of depression

  • Multiple unexplained somatic symptoms

  • Recent major stressor or loss

  • High healthcare utilizer

  • Chronic pain

  • Chronic illness(es)

  • Chief complaint of sleep disturbance, fatigue, appetite or weight change

STEP 1b: Ask screening questions
Whenever you suspect depression, ask the patient these questions:

During the past month:

1. Have you often been bothered by little interest or pleasure in doing things?

2. Feeling down, depressed or hopeless?

If patient says “yes" to either of these questions, use the PHQ-9 to assist with diagnostic assessment.

STEP 1c: Complete diagnostic assessment & administer the diagnostic assessment tool
               (PHQ-9) at the initial visit
Clinicians should follow their usual diagnostic assessment. In addition, the PHQ-9 is a patient self-administered questionnaire that helps make a depression diagnosis and determine severity. The clinician and/or office staff discusses the reasons for completing the questionnaire and explains how to fill it out.

After the patient has completed the PHQ-9 questionnaire, it is scored by the clinician or office staff. There are two components on the PHQ-9 to be tallied:

    • Number of symptoms          (Follows DSM-IV criteria for depression)

    • Total severity score             (Depression severity)

In addition, the patient will rate the level of functional impairment (impact on their life).

STEP 1d: Assessing suicide risk
If the suicide item is positive on the PHQ-9 (question “i”), the clinician needs to perform a suicide risk assessment.

STEP 1e: Formulating a depression diagnosis
Based on the PHQ-9 number of symptoms present more than half the days in the past 2 weeks, the total severity score, and the level of functional impairment, the clinician can formulate a working depression diagnosis.

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