Screening for Anxiety and Depression in your Office

Why is this important? In 2016 the U.S. The Preventive Services Task Force encouraged primary care providers to screen every adolescent and adult patient for anxiety and depression symptoms. Screenings like this not only help capture patients who may not speak up about their mental health concerns during a routine visit, but can also help improve their overall health outcomes. For example, patients struggling with untreated depression may not maintain healthy habits, such as taking medication or exercising consistently, and may be more likely to become physically ill as a result. Offering a questionnaire is one way to determine if mental health may be contributing to a patients’ overall well being. If you do find your patient is struggling with mental health, you can improve their health outcomes and reduce stigma by offering alternative professional supports such as referring them to a licensed therapist or support group.

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Depression Screening

One commonly used depression questionnaire is the Patient Health Questionnaire 9 (PHQ-9). It is a nine-item questionnaire that is one of the most validated tools in mental health. The questions are designed to address levels of symptoms that could be related to depression. This self-administered survey reviews loss of interest, changes to energy or sleep, feelings of hopelessness or worthlessness and decreased levels of pleasure. At the end of this article, we’ve included a link to the PHQ-9 and a short guide on how to interpret scores, as well as what to do if a patient reports elevated levels of depression on the PHQ-9.

Screening for Anxiety

The Generalized Anxiety Disorder 7 (GAD-7) is a tool to screen for symptoms of anxiety. It is a 7-item questionnaire that is one of the most validated tools in mental health. This survey assesses symptom categories associated with stress or anxiety and is helpful in understanding intensity and frequency of overall anxiety. You can also use it as a way to baseline your patient in order to assess changes in each visit. A short guide on how to interpret scores and what to do if a patient reports elevated levels of anxiety on the GAD-7 is included below.

Assessing for Suicidality

If your patient does indicate that they are experiencing suicidal thoughts, completing a suicide risk assessment is the next step to ensuring their safety. The Columbia Suicide Severity Rating Scale measures the severity and immediacy of an individuals risk as well as what support is needed as follow up. It can help determine if the patient requires emergency services to intervene. A short guide on how to interpret scores and what to do if a patient reports elevated risk levels for suicide on the C-SSRS is included below.

While these questionnaires are some of the more commonly used assessments available for screening depression and anxiety, there are several other well-validated questionnaires that may be more specific to your patient population. For example, there are assessments that are pediatric or geriatric specific. The American Psychological Association has compiled a comprehensive guide for depression measures and can be found here. The association of clinical psychologists created a similar resource for anxiety symptoms that can be found here. 

PHQ-9

PHQ9 overview 

1. Patient Health Questionnaire (PHQ9) is a 9 item questionnaire that is one of the most validated tools in mental health
2. This is a tool to understand overall level of depressive symptoms, a view of one’s baseline in order to assess future levels, and an indicator for when self-reported symptoms may reach a significant impact.
3. It assesses symptom categories that can be associated with depression to understand frequency, intensity and impact of functioning
4. Can be used as a tool to determine if your patient requires behavioral health resources.

Scoring

1. 0-3 item rating assessing presence of symptoms over the past 2 weeks

     a. 0= not at all
     b. 1= several days
     c. 2= more than half the days
     d. 3= nearly everyday 

2. Total score- 0-27 point scale

     a. 0-4= no notable depressive symptoms
     b. 5-9= mild
     c. 10-14= moderate
     d. 15-19= moderately severe
     e. 20+= severe

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Positive risk score (question 9)

1. Question 9: Thoughts that you would be better off dead or hurting yourself in some way
2. A score higher than 0 indicates that an individual has reported these thoughts at least some of the days
3. A response offers an opportunity to complete a clinical risk assessment (such as the C-SSRS), determine if further safety action needed, and develop a safety plan 

Treatment considerations based on score

Resources: 

PHQ-9 adapted from PRIME MD TODAY, developed by Dr. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, made possible by Pfizer, Inc. Used with permission from Pfizer, Inc. PRIME MD TODAY is a trademark of Pfizer, Inc
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Instruction Manual: Instructions for Patient Health Questionnaire (PHQ) and GAD-7 Measures. Available here. Published December 2014

GAD 7

GAD7 overview 

1. Generalized Anxiety Disorder 7 (GAD-7) is a 7 item questionnaire that is one of the most validated tools in mental health
2. This survey assesses symptom categories associated with stress or anxiety 
3. This tool helps to understand intensity and frequency of overall anxiety as well as specific symptom categories, a glance of one’s baseline in order to assess changes, and any indicators for when self-reported symptoms may reach a significant impact
4. Can be used as a tool to determine if your patient requires behavioral health resources.

Scoring

1. 0-3 item rating

     a. 0= not at all
     b. 1= several days
     c. 2= more than half the days
     d. 3= nearly everyday 

2. Total score- 0-21 point scale

     a. 0-4= no notable anxiety symptoms
     b. 5-9= mild
     c. 10-14= moderate
     d. 15+ = severe

Treatment considerations based on score

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Resources: Source: Spitzer RL, Kroenke K, Williams JB, et al; A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006 May 22;166(10):1092-7. GAD-7 

C-SSRS

C-SSRS overview 

1. The Columbia Suicide Severity Rating Scale (C-SSRS) is a 6-item questionaire that can help clinicians determine suicide risk in their patients.
2. This survey assesses suicide risk by using plain, direct language.
3. This tool helps to understand the intensity and frequency of suicidal thoughts and also assesses any steps the patient has taken to end their own life.
4. Can be used as a tool to determine if your patient requires behavioral health resources and/or immediate help.

Scoring 

1. Yes/No item rating
2. ‘Yes’ to any item is considered a positive risk

Positive risk score (question 4, 5, 6)

1. Question 4: Have you had any intention of acting on these thoughts of killing yourself, as opposed to you having the thoughts but definitely would not act on them?
2. Question 5: Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?
3. Question 6: Have you done anything, started to do anything, or prepared to do anything to end your life?
4. A score ‘yes’ to any of these questions indicates that the individual is high risk and should be escorted to the emergency room as soon as possible.

Treatment considerations based on Answer

Resources: https://cssrs.columbia.edu/