Depression — Depression Screening Tools & Assessment Rating Scales — Clinical Pathway: Outpatient Behavioral Health and Primary Care

Depression Clinical Pathway — Outpatient Behavioral Health and Primary Care

Depression Screening Tools & Assessment Rating Scales

Screening tools are used as a starting point in diagnosis whereas assessment rating scales are used to diagnose, estimate severity (mild, moderate, or severe) and monitor treatment response. Examples of screening and assessment tools are listed below.

  • For younger patients or patients with substantial developmental delays and/or communication challenges, screening and assessment may need to rely more on information obtained from parents/caregivers than the patient.
  • Assessment tools can be used for initial assessment as well as for ongoing assessment to monitor response.
Tool Screening or Assessment Tool Concerns related to sad or irritable mood or anhedonia (loss of interest in everyday activities)
Clinical Screen Screening
  • Concerns related to sad or irritable mood or anhedonia (loss of interest in everyday activities)
View PHQ-2 Questionnaire Screening
  • Score of 3 or higher is positive screen
Patient Health Questionnaire (PHQ-9) Both
  • Score of 10 or Higher is positive screen
  • 0-4: no or minimal depression
  • 5-9: mild depression
  • 10-14: moderate depression
  • 15-19: moderately severe depression
  • 20-27: severe depression
  • Or
  • 5-10: subthreshold (mild)
  • 11-27: threshold (moderate to severe)
Patient Health Questionnaire- Modified for Teens (PHQ-A) Both
  • Score of 10 or Higher
  • 0-4: no minimal depression
  • 5-9: mild depression
  • 10-14: moderate depression
  • 15-19: moderately severe depression
  • 20-27: severe depression
  • Or
  • 5-10: subthreshold (mild)
  • 11-27: threshold (moderate to severe)
Behavioral Health Screen (BHS) Screening
  • 0-0.36: Not Significant
  • 0.37-1.28: Mild Depression
  • 1.29-1.61: Moderate Depression
  • 1.62-4: Severe Depression
DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure—Child Age 11–17   Screening Score of “mild (2)” or greater on Question 5 and/or 6 is positive screen
DSM-5 Self-Rated Level 2- Depression- Child Age 11-17   Assessment
  • T Score Less than 55 = None to slight
  • 55.0—59.9: mild
  • 60.0—69.9: moderate
  • 70 and over: severe
Beck Depression Inventory, 2nd edition (BDI-II) Assessment
  • 0-13: minimal depression
  • 14-19: mild depression
  • 20-28: moderate depression
  • 29-63: severe depression
Children’s Depression Inventory, 2nd edition (CDI-2) Assessment
  • T-score above 65 is elevated
Children's Depression Rating Scale, Revised (CDRS-R) Assessment
  • T Score 39 or lower: possibly invalid
  • T Score 40-54: depressive disorder unlikely
  • T Score 55-64: depressive disorder possible
  • T Score 65-74: depressive disorder likely
  • T Score 75-84: depressive disorder very likely
  • T Score 85 or higher: depressive disorder certain
Montgomery-Asberg Depression Scale (MADRS) Assessment
  • 0-6: symptoms absent
  • 7-19: mild depression
  • 30-34: moderate depression
  • 35-60: severe depression