8.1 Primary Care Depression, Anxiety & Behavioral Health Screening

ABFM Family Medicine Certification Study Guide Exam

Track your progress as you read

Finished sections get a check mark.

1 Chapter 1: Exam Structure, Blueprint & Clinical Decision-Making

1.1 Exam Blueprint, FMCLA vs. One-Day Exam & Board Scoring 1.2 Clinical Reasoning, Test-Taking Strategy & Ambiguity Management 1.3 Evidence-Based Medicine & Clinical Practice Guidelines in Primary Care

2 Chapter 2: Healthcare Systems, Practice Management & Quality

2.1 Practice Management, Billing, Coding & Documentation 2.2 Quality Improvement, Patient Safety & Diagnostic Stewardship 2.3 Interprofessional Team-Based Care & Care Coordination

3 Chapter 3: Ethics, Law, Biostatistics & Health Equity

3.1 Medical Ethics, Informed Consent & Surrogate Decision-Making 3.2 Biostatistics, Clinical Epidemiology & Diagnostic Test Interpretation 3.3 Social Determinants of Health, Health Equity & Cultural Humility 3.4 Physician Wellness, Burnout Prevention & Professionalism

4 Chapter 4: Lifestyle Counseling & Behavior Change

4.1 Alcohol Use Screening & Brief Intervention 4.2 Illicit Drug & Cannabis Counseling 4.3 Tobacco & Vaping Cessation Counseling

5 Chapter 5: Nutrition, Physical Activity & Chronic Disease Prevention

5.1 Dietary Counseling for Obesity & Chronic Disease Prevention 5.2 Exercise Prescription & Physical Activity Counseling 5.3 Genetic Risk Assessment & Family History Counseling

6 Chapter 6: Routine Adult Immunizations

6.1 ACIP Adult Respiratory Vaccines: Influenza, COVID-19, RSV & Pneumococcal 6.2 ACIP Adult Non-Respiratory Vaccines: Tdap, Shingrix, HPV & Hep B 6.3 Immunizations in Special Populations: Pregnancy, Asplenia & Immunocompromise

7 Chapter 7: Pediatric Health Maintenance & Surveillance

7.1 Newborn Examination & Early Postnatal Care 7.2 Well-Child Care, Developmental Surveillance & Milestones 7.3 Pediatric & Adolescent Screening: Vision, Hearing, Anemia & Lead 7.4 Pediatric Oral Health, Dental Screening & Fluoride

8 Chapter 8: Behavioral Health & Safety Screening

8.1 Primary Care Depression, Anxiety & Behavioral Health Screening 8.2 Domestic Violence, Intimate Partner Violence & Firearm Safety 8.3 Occupational Health & Recreational Safety Counseling

9 Chapter 9: Adult Preventive Screening: Cardiovascular & Metabolic

9.1 Cardiovascular Disease & Hypertension Screening 9.2 Type 2 Diabetes Screening & Prediabetes Risk Stratification 9.3 Abdominal Aortic Aneurysm & Osteoporosis Screening

10 Chapter 10: Adult Cancer Screening: Breast & Gynecologic

10.1 Breast Cancer Screening & Risk-Assessment 10.2 Cervical Cancer Screening & ASCCP Algorithms 10.3 Skin Cancer Clinical Assessment & Counseling

11 Chapter 11: Adult Cancer Screening: Colorectal, Lung & Prostate

11.1 Colorectal Cancer Screening Modalities & Intervals 11.2 Lung Cancer Screening with Low-Dose CT 11.3 Prostate Cancer Screening & Shared Decision-Making

12 Chapter 12: Sexual Health, Infectious Disease Screening & Contraception

12.1 Sexual Health Counseling & Risk-Reduction Strategies 12.2 STI Screening: Chlamydia, Gonorrhea, Syphilis & Trichomoniasis 12.3 Bloodborne Infectious Disease Screening: HIV & Hepatitis C

13 Chapter 13: Reproductive Life Planning, Lactation & Preoperative Care

13.1 Preconception Planning & Comprehensive Contraception Management 13.2 Lactation Support & Breastfeeding Counseling 13.3 Preoperative Medical Evaluation & Pre-Participation Sports Exam

14 Chapter 14: Emergent Cardiovascular Conditions

14.1 Acute Coronary Syndromes & Myocardial Infarction 14.2 Acute Chest Pain Risk Stratification & Triage 14.3 Acute or Critical Valvular Heart Emergencies

15 Chapter 15: Cardiac Arrhythmias, Heart Failure & Hypertensive Crises

15.1 Acute Atrial & Ventricular Arrhythmias 15.2 Acute Decompensated Heart Failure & Cardiogenic Shock 15.3 Hypertensive Emergency & Urgency Management

16 Chapter 16: Vascular & Thromboembolic Emergencies

16.1 Pulmonary Embolism & Deep Vein Thrombosis 16.2 Acute Aortic Syndromes & Peripheral Vascular Emergencies 16.3 Critical Limb Ischemia & Acute Arterial Occlusion

17 Chapter 17: Neurologic Emergencies: Stroke & Altered Consciousness

17.1 Acute Ischemic Stroke & Intracranial Hemorrhage 17.2 Syncope Evaluation & Status Epilepticus 17.3 Acute Delirium, Encephalopathy & Severe Confusion

18 Chapter 18: Neurologic Trauma & Acute Cranial Emergencies

18.1 Concussion, Moderate-to-Severe TBI & Intracranial Injury 18.2 Thunderclap & Acute Severe Secondary Headaches 18.3 Acute Ophthalmologic Emergencies

19 Chapter 19: Acute Abdominal, Pelvic & Gastrointestinal Emergencies

19.1 Acute Abdominal & Pelvic Pain Triage 19.2 Upper & Lower Gastrointestinal Bleeding 19.3 Acute Hepatic Failure, Cholangitis & Severe Jaundice

20 Chapter 20: Acute Pulmonary & Airway Emergencies

20.1 Acute Hypoxic Respiratory Failure & ARDS 20.2 Severe Community-Acquired Pneumonia & Empyema 20.3 Acute Severe Epistaxis & Airway Obstruction

21 Chapter 21: Acute Traumatic Injuries & Wound Care

21.1 Major Trauma Resuscitation & Initial Assessment 21.2 Burn Assessment, Inhalation Injury & Resuscitation 21.3 Laceration Management, Complex Wounds & Animal Bites

22 Chapter 22: Acute Orthopedic & Musculoskeletal Emergencies

22.1 Acute Ambulatory Fractures & Initial Splinting 22.2 Compartment Syndrome & Major Orthopedic Trauma 22.3 Septic Arthritis & Acute Microcrystalline Crises

23 Chapter 23: Severe Infections, Sepsis & Systemic Emergencies

23.1 Sepsis, Septic Shock & Initial Fluid Resuscitation 23.2 Necrotizing Soft Tissue Infections & Severe CNS Infections 23.3 Anaphylaxis Diagnosis, Epinephrine Dosing & Airway Protection

24 Chapter 24: Metabolic, Endocrine & Electrolyte Emergencies

24.1 Diabetic Ketoacidosis & Hyperosmolar Hyperglycemic State 24.2 Critical Electrolyte Emergencies: Dyskalemias & Dysnatremias 24.3 Severe Calcium Abnormalities & Acute Adrenal Crisis

25 Chapter 25: Hematologic, Urologic & Dental Emergencies

25.1 Severe Symptomatic Anemias & Coagulopathic Emergencies 25.2 Testicular Torsion, Priapism & Acute Urinary Retention 25.3 Urgent Odontogenic Infections & Dental Trauma

26 Chapter 26: Psychiatric, Behavioral & Obstetric/Gynecologic Emergencies

26.1 Suicidal Ideation, Acute Agitation & Behavioral Emergencies 26.2 Acute Physical & Sexual Assault Care 26.3 Life-Threatening Vaginal Bleeding & Ectopic Pregnancy 26.4 Environmental Heat Stroke & Severe Hypothermia

27 Chapter 27: Acute Head, Neck & Neurologic Symptoms

27.1 Primary Acute Headaches: Migraine, Tension & Cluster 27.2 Concussion & Minor Closed Head Injury Evaluation 27.3 Transient Ischemic Attack Evaluation & ABCD2 Risk Scoring

28 Chapter 28: Acute Cranial Nerves, Hearing & Sensory Symptoms

28.1 Peripheral Neuropathies: Bell's Palsy, Carpal Tunnel & Radiculopathy 28.2 Acute Tinnitus, Sudden Sensorineural Hearing Loss & Cerumen Impaction 28.3 Acute Dizziness, Benign Paroxysmal Positional Vertigo & Vestibular Neuritis

29 Chapter 29: Acute Upper Respiratory Tract Infections

29.1 Acute Viral Rhinosinusitis vs. Bacterial Rhinosinusitis 29.2 Acute Pharyngitis: Group A Streptococcus & Centor Criteria 29.3 Acute Otitis Media, Otitis Externa & Serous Effusion

30 Chapter 30: Acute Lower Respiratory Infections & Cough

30.1 Influenza, COVID-19 & Viral Respiratory Syndromes 30.2 Acute Bronchitis & Lower Respiratory Tract Infections 30.3 Ambulatory Community-Acquired Pneumonia

31 Chapter 31: Allergic, Nasal & Non-Infectious Pulmonary Conditions

31.1 Allergic Rhinitis & Acute Non-Anaphylactic Allergic Reactions 31.2 Acute Dyspnea in Ambulatory Care 31.3 Interstitial Lung Diseases & Sarcoidosis Presentation

32 Chapter 32: Acute Chest, Cardiac & Vascular Symptoms

32.1 Palpitations Evaluation & Arrhythmia Triage in Primary Care 32.2 Deep Vein Thrombosis & Superficial Thrombophlebitis 32.3 Ambulatory Hypotension & Orthostasis Evaluation

33 Chapter 33: Acute Upper Gastrointestinal Conditions

33.1 Peptic Ulcer Disease & Gastritis 33.2 Dysphagia, Esophagitis & Acute Esophageal Disorders 33.3 Acute Nausea, Vomiting & Foodborne Illness

34 Chapter 34: Acute Lower Gastrointestinal Conditions

34.1 Acute Infectious Diarrhea & Gastroenteritis 34.2 Acute Constipation & Functional Bowel Changes 34.3 Ano-Rectal Disorders: Hemorrhoids, Fissures, Abscesses & Pruritus Ani

35 Chapter 35: Inflammatory, Functional & Malabsorptive GI Disorders

35.1 Acute Flares of Inflammatory Bowel Disease 35.2 Irritable Bowel Syndrome: Diagnosis, Subtyping & Management 35.3 Celiac Disease & Malabsorption Syndromes

36 Chapter 36: Acute Abdominal, Hepatic & Biliary Disorders

36.1 Ambulatory Abdominal & Pelvic Pain Triage 36.2 Acute Cholecystitis, Biliary Colic & Pancreatitis 36.3 Acute Liver Injury & Viral Hepatitis

37 Chapter 37: Acute Abdominal Wall, Hernias & Dental Conditions

37.1 Abdominal Wall, Inguinal & Ventral Hernias 37.2 Acute Dental Pain, Odontogenic Abscess & Aphthous Ulcers 37.3 Acute Edema: Unilateral vs. Bilateral Diagnostic Evaluation

38 Chapter 38: Acute Infectious Dermatoses

38.1 Bacterial Skin Infections: Impetigo, Cellulitis & Cutaneous Abscesses 38.2 Fungal Skin Infections: Tinea Corporis, Cruris, Pedis & Onychomycosis 38.3 Viral Cutaneous Infections: Herpes Simplex, Zoster & Molluscum Contagiosum

39 Chapter 39: Inflammatory, Allergic & Autoimmune Dermatoses

39.1 Atopic Dermatitis, Contact Dermatitis & Eczematous Flares 39.2 Non-Infectious Rashes: Urticaria, Drug Eruptions & Erythema Multiforme 39.3 Cutaneous Malignancies & Premalignant Lesions: AK, BCC, SCC & Melanoma

40 Chapter 40: Acute Shoulder, Elbow & Upper Extremity Injuries

40.1 Rotator Cuff Pathology, Tendinopathy & Shoulder Impingement 40.2 Lateral & Medial Epicondylitis, Olecranon Bursitis & Elbow Sprains 40.3 Wrist & Hand Soft-Tissue Injuries: De Quervain, TFCC & Finger Sprains

41 Chapter 41: Acute Knee, Ankle & Lower Extremity Injuries

41.1 Meniscal Tears, Ligamentous Knee Injuries & Patellofemoral Pain 41.2 Ankle Sprains, Ottawa Ankle Rules & Achilles Tendinopathy 41.3 Plantar Fasciitis, Shin Splints & Overuse Syndromes

42 Chapter 42: Acute Ambulatory Fractures & Dislocations

42.1 Distal Radius, Scaphoid & Common Upper Extremity Fractures 42.2 Metatarsal, Clavicle & Common Lower Extremity Fractures 42.3 Joint Dislocation Management: Nursemaid's Elbow & Shoulder Subluxation

43 Chapter 43: Acute Axial Musculoskeletal Pain & Falls

43.1 Acute Low Back Pain: Red Flags, Strain & Disc Herniation 43.2 Acute Cervical Strain, Whiplash & Axial Neck Pain 43.3 Evaluation of Falls in Ambulatory & Older Patients

44 Chapter 44: Acute Inflammatory Arthropathies & Generalized Pain

44.1 Acute Inflammatory Arthritis & Spondyloarthropathies 44.2 Myalgias, Rhabdomyolysis & Post-Viral Pain Syndromes 44.3 Acute Non-Headache Pain Management Strategies

45 Chapter 45: Acute Renal, Urinary & Genitourinary Conditions

45.1 Uncomplicated UTI, Pyelonephritis & Acute Urethritis 45.2 Hematuria Workup & Glomerulonephritis 45.3 Nephrolithiasis & Acute Urinary Tract Obstruction

46 Chapter 46: Acute Male Genitourinary & Prostatic Conditions

46.1 Acute Prostatitis, Epididymitis & Orchitis 46.2 Acute Scrotal Pain: Torsion vs Appendage, BPH & Male Genital Emergencies 46.3 Acute Urinary Retention & Incontinence Evaluation

47 Chapter 47: Acute Women's Health & Early Pregnancy Care

47.1 Early Pregnancy Diagnosis, Dating & Initial Complications 47.2 Abnormal Uterine Bleeding & Acute Menstrual Disorders 47.3 Premenstrual Syndrome & Premenstrual Dysphoric Disorder

48 Chapter 48: Breast Disorders, STIs & Pediatric Elimination

48.1 Palpable Breast Mass, Mastitis & Nipple Discharge 48.2 Sexually Transmitted Infections: Diagnosis, Staging & CDC Guidelines 48.3 Pediatric Enuresis & Encopresis

49 Chapter 49: Systemic Signs, Metabolic Dysregulation & Miscellaneous Infections

49.1 Acute Fever, Sepsis Screening & FUO in Primary Care 49.2 Acute Hyperglycemia & Symptomatic Hypoglycemia 49.3 Electrolyte Abnormalities: Mild-to-Moderate Disturbances 49.4 Vector-Borne, Tick-Borne & Rickettsial Illnesses

50 Chapter 50: Chronic Cardiovascular Diseases: Hypertension & Ischemia

50.1 Essential Hypertension Management: 2025 AHA/ACC Guideline & JNC Strategies 50.2 Chronic Coronary Artery Disease & Post-MI Secondary Prevention 50.3 Chronic Heart Failure: HFrEF, HFpEF & Quadruple GDMT

51 Chapter 51: Chronic Vascular, Valvular & Dyslipidemic Diseases

51.1 Peripheral Arterial Disease & Claudication 51.2 Chronic Valvular Heart Disease & Murmur Evaluation 51.3 Lipid Disorders & ASCVD Risk-Based Statin Therapy

52 Chapter 52: Chronic Respiratory Diseases: Asthma & COPD

52.1 Chronic Asthma Management: GINA Stepwise SMART Therapy 52.2 Chronic Obstructive Pulmonary Disease: GOLD Recommendations 52.3 Solitary Pulmonary Nodule Evaluation & Fleischner Society Criteria

53 Chapter 53: Chronic Metabolic Diseases: Diabetes Mellitus

53.1 Type 2 Diabetes Management: ADA Pharmacotherapy Algorithms 53.2 Type 1 Diabetes: Basal-Bolus Insulin, CGMs & Diabetic Complications 53.3 Diabetic Microvascular & Macrovascular Disease Surveillance

54 Chapter 54: Obesity, Nutrition & Metabolic Bone Diseases

54.1 Medical & Behavioral Management of Obesity & Incretin Mimetics 54.2 Osteoporosis & Metabolic Bone Disease: DEXA, FRAX & Antiresorptives 54.3 Nutritional Deficiencies: Vitamin D, B12, Iron & Malnutrition

55 Chapter 55: Chronic Endocrine Disorders

55.1 Primary & Subclinical Hypothyroidism, Hyperthyroidism & Nodules 55.2 Adrenal Disorders: Addison's Disease & Cushing's Syndrome 55.3 Hypercalcemia, Hyperparathyroidism & Pituitary Disorders

56 Chapter 56: Chronic Kidney Disease & Venous Disorders

56.1 Chronic Kidney Disease: KDIGO Staging & Renoprotective Therapy 56.2 Chronic Venous Insufficiency, Stasis Dermatitis & Lymphedema 56.3 Chronic Electrolyte & Acid-Base Management in CKD

57 Chapter 57: Chronic Gastrointestinal & Hepatic Diseases

57.1 Gastroesophageal Reflux Disease, Barrett's Esophagus & Dyspepsia 57.2 Chronic Liver Disease: MASLD/NAFLD, Cirrhosis & Portal Hypertension 57.3 Viral Hepatitis B & C: Long-Term Monitoring & DAA Therapy

58 Chapter 58: Colorectal Surveillance & Chronic Pancreaticobiliary Care

58.1 Post-Polypectomy Colorectal Polyp Surveillance Guidelines 58.2 Chronic Pancreatitis & Exocrine Pancreatic Insufficiency 58.3 Chronic Nausea, Gastroparesis & Functional GI Disorders

59 Chapter 59: Chronic Musculoskeletal & Rheumatologic Disorders

59.1 Osteoarthritis: Hip, Knee & Hand Management 59.2 Spinal Conditions: Spinal Stenosis, Spondylolisthesis & Compression Fractures 59.3 Chronic Myopathies & Fibromyalgia Syndrome

60 Chapter 60: Chronic Neurologic & Neurodegenerative Disorders

60.1 Dementia: Alzheimer's, Vascular & Lewy Body Disease 60.2 Parkinson's Disease & Essential Tremor 60.3 Epilepsy: Chronic Antiseizure Medications & Post-Stroke Care

61 Chapter 61: Chronic Peripheral Nerves, Pain & Sensory Disorders

61.1 Diabetic & Chronic Peripheral Neuropathies 61.2 Chronic Pain Syndromes & Chronic Daily Headaches 61.3 Chronic Tinnitus, Presbycusis & Persistent Dizziness

62 Chapter 62: Chronic Psychiatric Disorders

62.1 Major Depressive Disorder & Generalized Anxiety Disorder 62.2 Bipolar Disorder: Maintenance Pharmacotherapy & Lithium Monitoring 62.3 Adult & Pediatric Attention-Deficit/Hyperactivity Disorder

63 Chapter 63: Chronic Behavioral Health & Neurodevelopmental Conditions

63.1 Chronic Behavioral Conditions: PTSD, OCD & Somatization 63.2 Autism Spectrum Disorder & Intellectual Disabilities 63.3 Eating Disorders: Anorexia Nervosa, Bulimia & Binge Eating

64 Chapter 64: Chronic Substance Use Disorders & Tobacco Cessation

64.1 Alcohol Use Disorder: Pharmacotherapy & Relapse Prevention 64.2 Opioid & Stimulant Use Disorders: MOUD & Harm Reduction 64.3 Longitudinal Tobacco Cessation Pharmacotherapy

65 Chapter 65: Chronic Dermatologic Conditions

65.1 Acne Vulgaris, Rosacea & Seborrheic Dermatitis 65.2 Chronic Plaque Psoriasis & Biologic Therapies 65.3 Chronic Eczema, Hidradenitis Suppurativa & Cutaneous Lupus

66 Chapter 66: Chronic Reproductive, Infectious & Geriatric Special Care

66.1 Chronic Menstrual Disorders, Infertility & Sexual Dysfunction 66.2 Menopause Management & Hormone Replacement Therapy 66.3 Chronic HIV Infection Management & Primary Care Integration 66.4 Gender-Affirming Primary Care & Hormone Therapy 66.5 Advance Care Planning, Palliative Care & End-of-Life Symptom Control

67 Chapter 67: Continuity Care: Sleep, Fatigue, Cancer, Pregnancy & the Adult Preventive Visit

67.1 Chronic Insomnia & Obstructive Sleep Apnea 67.2 Chronic Malaise, Fatigue & ME/CFS 67.3 Primary Care During Cancer Treatment & Survivorship 67.4 Routine Prenatal Care & Longitudinal Pregnancy Management 67.5 The Periodic Adult Health Examination & Medicare Annual Wellness Visit

8.1 Primary Care Depression, Anxiety & Behavioral Health Screening

Key Takeaways Explain This Topic AI

Universal adult depression screening (USPSTF Grade B, age ≥18, PHQ-2 score ≥3 reflexing to PHQ-9) and universal anxiety screening (USPSTF Grade B, ages 19–64, GAD-2 score ≥3 reflexing to GAD-7) establish standard stepped-care behavioral screening in primary care.

PHQ-9 score stratification guides stepped-care clinical management: 5–9 represents mild depression (watchful waiting, lifestyle counseling, repeat in 4–6 weeks); 10–14 indicates moderate depression (first-line psychotherapy and/or SSRIs); 15–19 indicates moderately severe depression (pharmacotherapy ± psychotherapy); and ≥20 indicates severe depression (combined pharmacotherapy and structured psychotherapy ± urgent psychiatric consultation).

Any affirmative response to PHQ-9 Question 9 requires immediate clinical suicide risk stratification using the Columbia-Suicide Severity Rating Scale (C-SSRS) and collaborative development of a Stanley-Brown Safety Planning Intervention with lethal means restriction.

Prior to initiating antidepressant monotherapy, all patients must be screened for bipolar disorder using the Mood Disorder Questionnaire (MDQ; ≥7 co-occurring symptoms with moderate-to-severe impairment) to prevent antidepressant-induced manic or hypomanic switches, mixed states, and rapid cycling.

Perinatal depression screening using the Edinburgh Postnatal Depression Scale (EPDS) is recommended during pregnancy and at 1-, 2-, 4-, and 6-month well-child visits; a cutoff score ≥10 (or any affirmative response to Question 10 regarding self-harm) mandates same-day clinical safety assessment, with sertraline representing the preferred first-line agent during lactation.

Last updated: September 2026

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.

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 :

• "Little interest or pleasure in doing things" (Anhedonia)
• "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 :

• Anhedonia (diminished interest/pleasure)
• Depressed, down, or hopeless mood
• Sleep disturbances (insomnia or hypersomnia)
• Fatigue or loss of energy
• Appetite changes (weight loss or weight gain)
• Feelings of worthlessness, self-reproach, or excessive guilt
• Diminished concentration, indecisiveness, or executive slowing
• Psychomotor agitation or retardation (observable by others)
• Suicidal ideation (thoughts of being better off dead or hurting oneself)
• PHQ-9 Severity Stratification and Stepped-Care Management Protocols

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

PHQ-9 Score Depression Severity Clinical Action & Management Protocol

0–4 Minimal or None Reassurance and psychoeducation; repeat routine universal screening in 12 months.

5–9 Mild Depression Watchful waiting ; lifestyle modifications (sleep hygiene, structured aerobic exercise [150 min/wk], alcohol reduction); social support engagement; re-evaluate with repeat PHQ-9 in 4 to 6 weeks . If persistent or causing functional impairment, initiate brief psychotherapy (e.g., behavioral activation, problem-solving therapy). Pharmacotherapy is generally not indicated as first-line for uncomplicated mild depression.

10–14 Moderate Depression Shared decision-making : Evidence-based psychotherapy (Cognitive Behavioral Therapy [CBT] or Interpersonal Psychotherapy [IPT]) and/or first-line pharmacotherapy (Selective Serotonin Reuptake Inhibitors [SSRIs] or Serotonin-Norepinephrine Reuptake Inhibitors [SNRIs]); screen for bipolar disorder (MDQ) prior to medication initiation; follow-up within 2 to 4 weeks .

15–19 Moderately Severe Depression Active pharmacotherapy (SSRI/SNRI) combined with structured psychotherapy (CBT/IPT); screen for bipolar disorder with MDQ; evaluate suicide risk (Question 9); follow-up in 1 to 2 weeks ; consider behavioral health care manager involvement.

20–27 Severe Depression Combined intensive pharmacotherapy plus specialized psychotherapy ; mandatory suicide risk stratification and safety planning; urgent psychiatric consultation or referral; close monitoring every 1 to 2 weeks until clinical response is established.

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.

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:

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.

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" ).

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.

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:

Step 1: Recognizing Personal Warning Signs : Identify individualized triggers, catastrophic thoughts, mood changes, and behaviors that signal a developing suicidal crisis.

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).

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).

Step 4: Family Members or Friends for Crisis Help : Identify specific individuals the patient can openly confide in during a crisis.

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

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.

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:

• "Feeling nervous, anxious, or on edge"
• "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.

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:

Antidepressant-Induced Manic or Hypomanic Switch : Acute emergence of euphoria, irritability, grandiosity, flight of ideas, extreme impulsivity, reckless spending, or hypersexuality.

Mixed Affective States : A highly volatile combination of depressive hopelessness with severe psychomotor agitation and racing thoughts, dramatically escalating suicide attempt lethality .

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:

• ≥7 positive items out of the 13 symptom questions in Part 1
• An affirmative ( "Yes" ) response to Part 2 confirming symptom co-occurrence
• 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.

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

• Feature Postpartum Blues ("Baby Blues") Perinatal / Postpartum Depression (PPD) Postpartum Psychosis
• Incidence 50% to 80% of delivering women 10% to 15% of mothers 0.1% to 0.2% (1–2 per 1,000 deliveries)

Onset Days 2 to 3 postpartum ; peaks around day 5 Typically weeks 4 to 8 postpartum ; can occur anytime in pregnancy or first year Rapid onset; typically within the first 1 to 2 weeks postpartum

Duration Spontaneously resolves within 10 to 14 days Persistent; lasts months to years if untreated Medical emergency; lasts until treated aggressively

Clinical Features Emotional lability, tearfulness, mild dysphoria, anxiety, fatigue; maternal functioning remains intact ; patient bonds normally with baby Intense sadness, severe anhedonia, excessive maternal guilt, feelings of incompetence, profound fatigue, insomnia (waking even when infant is asleep), impaired mother-infant bonding Delusions (frequently involving the infant being possessed, defective, or condemned), auditory/visual hallucinations, delirium, confusion, rapid mood swings, bizarre behavior

Risk of Harm No thoughts of harming infant or self Passive thoughts of death; maternal self-harm risk; infant neglect; active infanticidal thoughts are absent Extreme psychiatric emergency ; high risk of infanticide (up to 4%) and maternal suicide (up to 5%)

Management Reassurance, emotional support, sleep optimization, partner involvement; no medication indicated Evidence-based psychotherapy (CBT/IPT); pharmacotherapy (SSRIs: sertraline preferred ); brexanolone / zuranolone Immediate inpatient psychiatric hospitalization ; urgent antipsychotic + mood stabilizer therapy; electroconvulsive therapy (ECT); strict physical separation from infant until safe

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.

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

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.

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.

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.

Loading diagram... Primary Care Behavioral Health Triage: Depression, Anxiety, Suicide & Bipolar Screening