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July 15, 2008 Table of Contents

Point-of-Care Guides

Screening Instruments for Depression

MARK H. EBELL, MD, MS, Athens, Georgia

Clinical Question
In the primary care setting, what is the best way to identify patients with depression?

Evidence Summary
Although depression is common in the primary care setting, accurate identification of these patients is
challenging. A variety of screening instruments for depression have been developed and validated.
They range from relatively lengthy and complex instruments, such as the 21-item Beck Depression
Inventory,1 to brief one- or two-item instruments.2 This article includes the brief screening
instruments that are most widely used in the primary care setting.

Some instruments are well validated and accurate, but too long for routine use in the primary care
setting, especially as screening tools. They are more appropriate in the research setting or to monitor
patient response to treatment, particularly by subspecialists. These instruments include the Beck
Depression Inventory, the Hamilton Depression Rating Scale (HAM-D),3 and the Zung self-rating
depression scale.4

A study of 164 outpatients with depression showed that a six-item version of the HAM-D scale has
comparable sensitivity to the longer version, but has somewhat lower specificity.5 Another validation
study found comparable accuracy between the six- and 21-item scales in a group of patients with
Parkinson's disease, as measured by the area under the receiver operating characteristic curve.6
However, the six-item scale has not been validated in larger or more general primary care
populations.

The four-item Brief Case-Find for Depression instrument is short enough for use in the primary care
setting, but has not been broadly validated.7 Similarly, the Hospital Anxiety and Depression Scale has
been validated primarily in more specialized populations and has limited accuracy (80 percent
sensitivity, 69 percent specificity) in the primary care setting.8 A recent comparison of the five-item

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World Health Organization Well-Being Index (WBI-5) and the nine-item Patient Health
Questionnaire (PHQ-9; Figure 1) found that the WBI-5 was slightly more sensitive, but significantly
less specific than the PHQ-9.9

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Figure 1. Patient Health Questionnaire screening tool for depression.

Copyright © Pfizer Inc. All rights reserved.

The most widely used and best-validated instruments in the primary care setting are the PHQ-9 and

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its two-item version, the PHQ-2 (Table 1). A meta-analysis of 14 studies found that the PHQ-9 is 81
percent sensitive and 92 percent specific for major depressive disorder in the primary care setting.10
Given a 10 percent pretest probability, a patient with a positive screen result has a 53 percent posttest
probability of depression, and a patient with a negative result only has a 2.2 percent probability. In a
higher-risk patient with a 30 percent pretest probability, the posttest probabilities of depression are 81
percent with a positive screen result and 8.1 percent with a negative result. The PHQ-9 had variable
sensitivity in more specialized populations, ranging from 54 percent in a cardiology service to 92
percent in a dialysis service; specificity was stable across settings.10

Table 1. PHQ-2 Questionnaire for Major Depressive Disorder

During the past month:
Have you often been bothered by feeling down, depressed, or hopeless?
Have you often been bothered by little interest or pleasure in doing things?

NOTE: An affirmative answer to either question is a positive test result; a negative answer to both
questions is a negative test result.
PHQ = Patient Health Questionnaire.
Copyright © Pfizer Inc. All rights reserved

The PHQ-2 has been evaluated in two large studies. The first, which included 1,419 outpatients,
found the instrument to be 87 percent sensitive and 78 percent specific for major depressive
disorder.11 The second, which included 6,000 primary care and obstetrics/gynecology outpatients,
found it to be 83 percent sensitive and 92 percent specific.12 Thus, the two-question version is similar
in accuracy to the longer version, but does not allow for the evaluation of severity or impact on daily
activities.

A single-item screening question (Have you felt depressed or sad much of the time in the past year?)
was evaluated in a study of outpatients at a Veterans Affairs hospital, but was shown to be less
sensitive than the PHQ-2.2 The one-item version of the Yale-Brown Obsessive Compulsive Scale
("Do you often feel sad or depressed?"), which is similar to the PHQ-2, was 86 percent sensitive and
84 percent specific in a series of 122 patients hospitalized with stroke,13 and was 65 percent sensitive
and 87 percent specific in a series of 120 patients with multiple sclerosis.14 There are no large
validation studies in the primary care setting.

Ultimately, the PHQ-2 is the best brief screening instrument for use during a routine intake or annual
physical examination survey. In patients with a positive screen result, the PHQ-9 or HAM-D
instrument should be performed to confirm the diagnosis and assess severity. These scales can then be
used prospectively to monitor response to therapy.

Address correspondence to Mark Ebell, MD, MS, at ebell@uga.edu. Reprints are not available from the author.

Author disclosure: Nothing to disclose.

REFERENCES
1. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression.

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Arch Gen Psychiatry. 1961;4:561-571.

2. Corson K, Gerrity MS, Dobscha SK. Screening for depression and suicidality in a VA primary care
setting: 2 items are better than 1 item. Am J Manag Care. 2004;10(11 pt 2):839-845.
3. Bagby RM, Ryder AG, Schuller DR, Marshall MB. The Hamilton Depression Rating Scale: has the
gold standard become a lead weight? Am J Psychiatry. 2004;161(12):2163-2177.
4. Romera I, Delgado-Cohen H, Perez T, Caballero L, Gilaberte I. Factor analysis of the Zung
self-rating depression scale in a large sample of patients with major depressive disorder in primary
care. BMC Psychiatry. 2008;8:4.
5. O'Sullivan RL, Fava M, Agustin C, Baer L, Rosenbaum JF. Sensitivity of the six-item Hamilton
Depression Rating Scale. Acta Psychiatr Scand. 1997;95(5):379-384.
6. Serrano-Dueñas M, Soledad Serrano M. Concurrent validation of the 21-item and 6-item Hamilton
Depression Rating Scale versus the DSM-IV diagnostic criteria to assess depression in patients
with Parkinson's disease: an exploratory analysis. Parkinsonism Relat Disord.
2008;14(3):233-238.
7. Jefford M, Mileshkin L, Richards K, et al. Rapid screening for depression-validation of the Brief
Case-Find for Depression (BCD) in medical oncology and palliative care patients. Br J Cancer.
2004;91(5):900-906.
8. Bunevicius A, Peceliuniene J, Mickuviene N, Valius L, Bunevicius R. Screening for depression and
anxiety disorders in primary care patients. Depress Anxiety. 2007; 24(7):455-460.
9. Henkel V, Mergl R, Kohnen R, Maier W, Möller HJ, Hegerl U. Identifying depression in primary
care: a comparison of different methods in a prospective cohort study. BMJ.
2003;326(7382):200-201.
10. Gilbody S, Richards D, Brealey S, Hewitt C. Screening for depression in medical settings with the
Patient Health Questionnaire (PHQ): a diagnostic meta-analysis. J Gen Intern Med.
2007;22(11):1596-1602.
11. Löwe B, Kroenke K, Gräfe K. Detecting and monitoring depression with a two-item questionnaire
(PHQ-2). J Psychosom Res. 2005;58(2):163-171.
12. Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: validity of a two-item
depression screener. Med Care. 2003;41(11):1284-1292.
13. Watkins CL, Lightbody CE, Sutton CJ, et al. Evaluation of a single-item screening tool for
depression after stroke: a cohort study. Clin Rehabil. 2007;21(9):846-852.
14. Avasarala JR, Cross AH, Trinkaus K. Comparative assessment of Yale Single Question and Beck
Depression Inventory Scale in screening for depression in multiple sclerosis. Mult Scler.
2003;9(3):307-310.

This guide is one in a series that offers evidence-based tools to assist family physicians in improving their
decision making at the point of care.

A collection of Point-of-Care Guides published in AFP is available at http://www.aafp.org/afp/poc.

Copyright © 2008 by the American Academy of Family Physicians.

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