Jacquelin Esque, MD
photo: Jamie Manser
An annual, universal screening for depression in the primary care setting is recommended by the U.S. Preventative Services Task Force (USPSTF) and the American Academy of Pediatrics (AAP) for ages 12 and older. The AAP also recommends that any patients with depression risk factors – including but not limited to a history of trauma, a family history of depression, and psychosocial adversity – should be identified and monitored over time through targeted screening by using a formal depression instrument or tool. The USPSTF notes there is insufficient evidence to universally recommend screening for depression in those 11 years old and younger. However, as noted by the AAP recommendations, risk factors for depression should be taken into consideration.
There are many different screening tools for depression available with the Patient Health Questionnaire-2 (PHQ-2) and the Patient Health Questionnaire-9 (PHQ-9) being most commonly used. These tools have been validated in a sample against the Diagnostic Interview Schedule for Children-IV. The PHQ9 had a sensitivity of 89.5% and a specificity of 77.5%. The PHQ-2, while quicker to administer given it is only two questions, has the potential to miss out on an important question covered in the PHQ-9 related to suicidal thoughts. This is particularly important because suicide is the second leading cause of death in those 10 to 14 years old and is the third leading cause of death in those 15 to 24 years old. The Patient Health Questionnaire for Adolescents (PHQ-9A) is a modified version of the PHQ9 that is specifically written for adolescents. The patient health questionnaires are free to use and are available in multiple languages.
Other screening tools to consider include: Beck Depression Inventory (BDI), Center for Epidemiological Studies Depression Scale for Children (CES-DC), Short Mood and Feelings Questionnaire (SMFQ), and the Composite International Diagnostic Interview (CIDI). To help determine the most accurate diagnosis prior to beginning treatment, all screening tools should be followed up with clinical interview questions, including gathering collateral information from others – including guardians/parents – and ruling out other potential causes of symptoms.
Use of an adolescent depression screening tool done at well child visits for those 12 to 21 years old can be coded using CPT code 26127.
PHQ-9A and PHQ-9 quick scoring guide:
| 0-4 | no or minimal depression |
| 5-9 | mild depression |
| 10-14 | moderate depression |
| 15-19 | moderately severe depression |
| 20-27 | severe depression |
References
American Academy of Pediatrics. (2021). Depression Coding Fact Sheet for Primary Care Clinicians. https://downloads.aap.org/AAP/PDF/coding_factsheet_depression.pdf
Jin J. Screening for Depression and Suicide Risk in Children and Adolescents. JAMA. 2022 Oct 18;328(15):1570. doi: 10.1001/jama.2022.18187. PMID: 36219439.
Patra KP, Kumar R. Screening for Depression and Suicide in Children. [Updated 2023 Jun 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK576416/
Zuckerbrot RA, Cheung AH, Jensen PS, Stein RE, Laraque D; GLAD-PC Steering Group. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): I. Identification, assessment, and initial management. Pediatrics. 2007 Nov;120(5):e1299-312. doi: 10.1542/peds.2007-1144. PMID: 17974723.