Screening For Depression In Primary Care Research Articles

Preferences and experiences of pediatricians on implementing national guidelines on universal routine screening of adolescents for major depressive disorder: A qualitative study

BackgroundTo explore the preferences of pediatricians for key factors around the implementation of universal routine screening guidelines for major depressive disorder in adolescent patients in a primary care setting. MethodSemi-structured qualitative interviews were conducted with U.S. pediatricians. Participants were recruited by convenience sampling and snowball sampling. Qualitive data were summarized using thematic analysis to identify themes relevant to preferences around implementing screening strategies for adolescent patients. Recruitment ended upon reaching thematic saturation when no new themes were revealed. ResultsOf the 14 participants, 11 identified as female, 3 male, 10 white, and 4 Asian. Top themes among pediatrician participants were around the screening modality (14/14 participants), screening validity (14/14), time barriers (14/14), and confidentiality barriers (12/14). Less frequently mentioned themes by pediatricians were workplace coordination and logistics (7/14), alternative starting ages for screening (7/14), more frequent screenings than annual screenings (3/14), and additional clinical training regarding depression diagnosis and treatment (2/14). LimitationsPool of interviewed participants was limited by diversity in terms of geography, race/ethnicity, or practice settings. ConclusionsTo promote the uptake of universal routine screening of adolescent major depression, pediatricians expressed it was important to address key implementation factors regarding the screening modality, screening validity, time constraints, and confidential care concerns in a primary care delivery context. Findings could be used to inform the development of implementation strategies to facilitate depression screening in primary care. Future research is needed to quantitively assess decisions and tradeoffs that pediatricians make when implementing universal screening to support adolescent mental health.

Beyond Clinical Care: The Role of Pediatric Psychology in Supporting Postpartum Depression Screening in Primary Care.

Maternal health is a critical component of optimal child health and development. Consequently, the American Academy of Pediatrics added postpartum depression (PPD) screening to their psychosocial screening guidelines in 2017. The Healthy Mothers, Healthy Children Project (HMHCP) was an interprofessional initiative aimed at preparing for, then implementing and maintaining pediatrician-completed PPD screening at 1-month well visits in a pediatric primary care clinic. Roles of pediatric psychology and rates of PPD screening were examined. Pediatric psychologists actively participated as leaders and collaborators in a variety of non-clinical roles from HMHCP preparation through maintenance. The clinic achieved high and continuously improving PPD screening rates following HMHCP implementation. Importantly, PPD screening rates were equitable across race and gender. The current study outlines feasible non-clinical roles that pediatric psychologists can fulfill in support of routine PPD screening within pediatric primary care. It also highlights associated benefits and outcomes for the clinic, providers, and patients.

Equitability of Depression Screening After Implementation of General Adult Screening in Primary Care

Depression is a debilitating and costly medical condition that is often undertreated. Men, racial and ethnic minority individuals, older adults, and those with language barriers are at increased risk for undertreatment of depression. Disparities in screening may contribute to undertreatment. To examine depression screening rates among populations at risk for undertreatment of depression during and after rollout of general screening. This cohort study from September 1, 2017, to December 31, 2019, of electronic health record data from 52 944 adult patients at 6 University of California, San Francisco, primary care facilities assessed depression screening rates after implementation of a general screening policy. Patients were excluded if they had a baseline diagnosis of depression, bipolar disorder, schizophrenia, schizoaffective disorder, or dementia. Screening year, including rollout (September 1, 2017, to December 31, 2017) and each subsequent calendar year (January 1 to December 31, 2018, and January 1 to December 31, 2019). Rates of depression screening performed by medical assistants using the Patient Health Questionnaire-2. Data collected included age, sex, race and ethnicity, and language preference (English vs non-English); to compare English and non-English language preference groups and also assess depression screening by race and ethnicity within the English-speaking group, a single language-race-ethnicity variable with non-English language preference and English language preference categories was created. In multivariable analyses, the likelihood of being screened was evaluated using annual logistic regression models for 2018 and 2019, examining sex, age, language-race-ethnicity, and comorbidities, with adjustment for primary care site. There were 52 944 unique, eligible patients with 1 or more visits in one of the 6 primary care practices during the entire study period (59% female; mean [SD] age, 48.9 [17.6] years; 178 [0.3%] American Indian/Alaska Native, 13 241 [25.0%] English-speaking Asian, 3588 [6.8%] English-speaking Black/African American, 4744 [9.0%] English-speaking Latino/Latina/Latinx, 760 [1.4%] Pacific Islander, 22 689 [42.9%] English-speaking White, 4857 [9.0%] English-speaking other [including individuals who indicated race and ethnicity as other and individuals for whom race and ethnicity data were missing or unknown], and 2887 [5.5%] with language barriers [non-English language preference]). Depression screening increased from 40.5% at rollout (2017) to 88.8% (2019). In 2018, the likelihood of being screened decreased with increasing age (adusted odds ratio [aOR], 0.89 [95% CI, 0.82-0.98] for ages 45-54 and aOR, 0.75 [95% CI, 0.65-0.85] for ages 75 and older compared with ages 18-30); and, except for Spanish-speaking patients, patients with limited English proficiency were less likely to be screened for depression than English-speaking White patients (Chinese language preference: aOR, 0.59 [95% CI, 0.51-0.67]; other non-English language preference: aOR, 0.55 [95% CI, 0.47-0.64]). By 2019, depression screening had increased dramatically for all at-risk groups, and for most, disparities had disappeared; the odds of screening were only still significantly lower for men compared with women (aOR, 0.87 [95% CI, 0.81 to 0.93]). In this cohort study in a large academic health system, full implementation of depression screening was associated with a substantial increase in screening rates among groups at risk for undertreatment of depression. In addition, depression screening disparities narrowed over time for most groups, suggesting that routine depression screening in primary care may reduce screening disparities and improve recognition and appropriate treatment of depression for all patients.

Improving Depression Screening in Primary Care.

Depression is a serious problem in the United States. It not only impacts chronic illness and healthcare utilization, but it can also result in death, intentional or unintentional. Despite the seriousness associated with depression, it continues to be underdiagnosed and undertreated. The primary care setting provides an ideal location to screen and initiate treatment for depression in individuals who would otherwise not be screened. The objective of this evidence-based practice project was to improve the diagnosis and treatment of depression in an adult primary care office. An intervention consisting of a HealthWatcher reminder for depression screening, the administration of the PHQ-9 instrument, and a treatment algorithm was incorporated into the office workflow. The charts of a pre-intervention random sample were compared to a post-intervention random sample to test for significant differences in depression screening and treatment rates. Using the chi-squared test, the post-intervention sample screening rate was significantly higher than pre-intervention sample rate (90% vs 23.3%; χ2 = 54.3, df = 1, P < .000). It is feasible to improve the diagnosis and treatment of depression for adult primary care patients by modifying office protocols and using the PHQ-9 screening instrument and a treatment algorithm.

Improving Depression Screening in Primary Care.

Depression is a serious problem in the United States. It not only impacts chronic illness and healthcare utilization, but it can also result in death, intentional or unintentional.Despite the seriousness associated with depression, it continues to be underdiagnosed and undertreated. The primary care setting provides an ideal location to screen and initiate treatment for depression in individuals who would otherwise not be screened. The objective of this evidence-based practice project was to improve the diagnosis and treatment of depression in an adult primary care office. An intervention consisting of a HealthWatcher reminder for depression screening, the administration of the PHQ-9 instrument, and a treatment algorithm was incorporated into the office workflow. The charts of a pre-intervention random sample were compared to a post-intervention random sample to test for significant differences in depression screening and treatment rates. Using the chi-squared test, the post-intervention sample screening rate was significantly higher than pre-intervention sample rate (90% vs 23.3%; χ2 = 54.3, df = 1, P < .000). It is feasible to improve the diagnosis and treatment of depression for adult primary care patients by modifying office protocols and using the PHQ-9 screening instrument and a treatment algorithm.

Improving Depression Screening in Primary Care: A Quality Improvement Initiative.

The increase in depression during the COVID-19 pandemic underscores the importance of systematic approaches to identify individuals with mental health concerns. Primary care is often underutilized for depression screening, and it is not clear how practices can successfully increase screening rates. This study describes a quality improvement initiative to increase depression screening in five Family Medicine clinics. The initiative included four Plan-Do-Study-Act cycles that resulted in implementing a standardized workflow for depression screening, collaborative efforts with health information technology to prompt providers to perform screening via the medical record, delivering educational materials for providers and clinic staff and conducting follow-up education. Between September 2020 and April 2021 there were 23,745 clinic encounters with adult patients that were analyzed to determine whether patients were up-to-date on depression screening following their visit. A multi-level logistic regression model was constructed to determine the changes in likelihood of a patient being up-to-date on screening over the study period, while controlling for patient demographics and comorbidities. The average proportion of up-to-date patients increased from 61.03% in September 2020 to 82.33% in April 2021. Patients aged 65+ and patients with comorbidities were more likely to be up-to-date on screening; patients with telemedicine visits had lower odds of being up-to-date on depression screening. Overall, this paper describes a feasible, effective intervention to increase depression screening in a primary care setting. Additionally, we discuss lessons learned and recommendations to inform the design of future interventions.

Adolescent depression screening in primary care: Who is screened and who is at risk?

BackgroundLimited research has simultaneously focused on sociodemographic differences in who receives recommended adolescent depression screening in primary care and who endorses elevated depression and suicide risk on these screeners. We describe screening and risk rates in a large pediatric primary care network in the United States after the network expanded its universal depression screening guideline to cover all well-visits (i.e., annual medical checkups) for adolescents ages 12 and older. MethodsBetween November 15, 2017 and February 1, 2020, there were 122,682 well-visits for adolescents ages 12–17 (82,531 unique patients). The Patient Health Questionnaire – Modified for Teens (PHQ-9-M) was administered to screen for depression. ResultsA total of 99,961 PHQ-9-Ms were administered (screening rate=81.48%). The likelihood of screening was higher among adolescents who were female, 12–14 years of age at their first well-visit during the study, White, Hispanic/Latino, or publicly-insured (i.e., Medicaid-insured). Additionally, 5.92% of adolescents scored in the threshold range for depression symptoms and 7.19% endorsed suicidality. Heightened depression and suicide risk were observed among adolescents who were female, 15–17 years of age at their first well-visit during the study, Black, Hispanic/Latino, attending urban primary care practices, or Medicaid-insured. Odds of endorsing suicidality were also higher among teens who identified as other races. LimitationsLimitations related to data available in the electronic health record and reliance on data from a single hospital system are noted. ConclusionsFindings highlight misalignments in screening and risk status that are important to address to ensure more equitable screening implementation and health outcomes.

Integration of behavioral health services and adolescent depression screening in primary care.

Integration of behavioral health services and adolescent depression screening in primary care.

Diagnoses and Treatment After Depression Screening in Primary Care Among Youth

Depression screening is universally recommended for adolescents presenting in primary care settings in the U.S. However, little is known about how depression screening affects the likelihood of being diagnosed with a mental disorder or accessing mental health care over time. This longitudinal cohort study used insurance claims data from adolescents who attended a well-visit between 2014 and 2017. Propensity score matching was used to compare adolescents who were screened for depression with similar unscreened adolescents. Diagnoses and treatment uptake were examined over a 6-month follow-up and included depression diagnoses, mood-related diagnoses, antidepressant medications, any mental health medication, and psychotherapy. Heterogeneity of associations by sex was also examined. Analyses were conducted from December 2020 to June 2021. The sample included 57,732 adolescents (mean age, 14.26 years; 48.9% female). Compared with adolescents who were not screened for depression, adolescents screened for depression were 30% more likely to be diagnosed with depression (risk ratio=1.30, 95% CI=1.11, 1.52) and 17% more likely to receive a mood-related diagnosis (risk ratio=1.17, 95% CI=1.08, 1.27) but were not more likely to be treated with an antidepressant medication (risk ratio=1.11, 95% CI=0.82, 1.51), any mental health medication (risk ratio=1.15, 95% CI=0.87, 1.53), or psychotherapy (risk ratio=1.13, 95% CI=0.98, 1.31). Associations were generally stronger among female adolescents. Adolescents who were screened for depression during a well-visit were more likely to receive a diagnosis of depression or a mood-related disorder in the 6 months after screening. Future research should explore methods for increasing treatment uptake after screening.

A pilot study of participatory and rapid implementation approaches to increase depression screening in primary care

BackgroundMost individuals with depression go unidentified and untreated. In 2016 the US Preventive Services Task Force released guidelines recommending universal screening in primary care to identify patients with depression and to link them to treatment. Feasible, acceptable, and effective strategies to implement these guidelines are needed.MethodsThis three-phased study employed rapid participatory methods to design and test strategies to increase depression screening at Penn Medicine, a large health system with 90 primary care practices. First, researchers solicited ideas and barriers from stakeholders to increase screening using an innovation tournament—a crowdsourcing method that invites stakeholders to submit ideas to address a workplace challenge. Second, a panel of stakeholders and scientists deliberated over and ranked the tournament ideas. An instant runoff election was held to select the winning idea. Third, the research team piloted the winning idea in a primary care practice using rapid prototyping, an approach that quickly refines and iterates strategy designs.ResultsThe innovation tournament yielded 31 ideas and 32 barriers from diverse stakeholders (12 primary care physicians, 10 medical assistants, 4 nurse practitioners, 2 practice managers, and 4 patient support assistants). A panel of 6 stakeholders and scientists deliberated on the ideas and voted for patient self-report (i.e., through tablet computers, text message, or an online patient portal) as the winning idea. The research team rapid prototyped tablets in one primary care practice with one physician over 5 five-hour shifts to examine the feasibility, acceptability, and effectiveness of the strategy. Most patients, the physician, and medical assistants found the tablets acceptable and feasible. However, patient support assistants struggled to incorporate them in their workflow and expressed concerns about scaling up the process. Depression screening rates were higher using tablets compared to usual care; follow-up was comparable between tablets and usual care.ConclusionsRapid participatory methods engaged and amplified the voices of diverse stakeholders in primary care. These methods helped design an acceptable and feasible implementation strategy that showed promise for increasing depression screening in a primary care setting. The next step is to evaluate the strategy in a randomized controlled trial across primary care practices.

Primary care and mental health: Where do we go from here?

Primary care has been dubbed the “de facto” mental health system of the United States since the 1970s. Since then, various forms of mental health delivery models for primary care have proven effective in improving patient outcomes and satisfaction and reducing costs. Despite increases in collaborative care implementation and reimbursement, prevalence rates of major depression in the United States remain unchanged while anxiety and suicide rates continue to climb. Meanwhile, primary care task forces in countries like the United Kingdom and Canada are recommending against depression screening in primary care altogether, citing lack of trials demonstrating improved outcomes in screened vs unscreened patients when the same treatment is available, high false-positive results, and small treatment effects. In this perspective, a primary care physician and two psychiatrists address the question of why we are not making headway in treating common mental health conditions in primary care. In addition, we propose systemic changes to improve the dissemination of mental health treatment in primary care.

Validity of the Patient Health Questionnaire-9 (PHQ-9) for depression screening in adult primary care users in Bucaramanga, Colombia

The patient health questionnaire-9 (PHQ-9) is one of the most widely used self-report instruments in primary care. There is no criterion validity of the PHQ-9 in Colombia. The objective was to validate the PHQ-9 as a screening tool in primary care. A cross-sectional, scale criterion validity study was performed using as reference criterion the mini neuropsychiatric interview (MINI) in male and female adult users of primary care centres. We calculated the internal consistency and convergent and criterion validity of the PHQ-9 by analysing the receiver operating characteristics (ROC) and the area under the curve (AUC). We analysed 243 participants; 184 (75.7%) were female. The average age was 34.05 (median of 31 and SD=12.47). Cronbach's α was 0.80 and McDonald's ω was 0.81. Spearman's Rho was 0.64 for HADS-D (P<0.010) and 0.70 for PHQ-2 (P<0.010). The AUC was 0.92 (95% CI 0.880–0.963). The optimal cut-off point of PHQ-9 was ≥7: sensitivity of 90.38 (95% CI: 81.41–99.36); specificity of 81.68 (95% CI: 75.93–87.42); PPV 57.32 (95% CI: 46.00–68.63); NPV 96.89 (95% CI: 93.90–99.88); Youden index 0.72 (95% CI: 0.62–0.82); LR+ 4.93 (95% CI: 3.61–6.74); LR− 0.12 (95% CI: 0.005–0.270). In sum, the Colombian version of PHQ-9 is a valid and reliable instrument for depression screening in primary care in Bucaramanga, with a cut-off point ≥7.

A breakthrough in research on depression screening: from validation to efficacy studies.

In the last two decades the awareness of depression as a public health issue has increased and the literature has flourished towards its primary and secondary prevention. Whereas timely targeting of depression risk factors is a frontier towards reducing the incidence of the disorder, nowadays the early diagnosis is of primary importance. Screening depressive disorders is paramount, since there are several types of depression. Besides, early diagnosis would improve the outcome of treatment, reduce the frequency of relapses and generally lead to higher levels of quality of life. We highlight the feasibility of depression screening in primary care and the need of a comprehensive public health approach. (www.actabiomedica.it)

Barriers and enablers to screening and diagnosing depression and diabetes distress in people with type 2 diabetes mellitus; protocol of a qualitative evidence synthesis.

Background: Depression and diabetes distress are common in people with type 2 diabetes (T2DM). These conditions are independently associated with poorer T2DM outcomes and increased healthcare utilisation and costs. Questions remain regarding the most appropriate ways of initially detecting depression and diabetes distress in this group. Diabetes guidelines recommend depression screening in primary care for people with T2DM but their implementation in practice is suboptimal. As health care professionals influence detection practices, their perceptions and experiences of these guidelines can improve understanding of aspects of the guidelines that work, and those which are more difficult to implement in practice. This study describes the protocol for a qualitative evidence synthesis of primary care health professionals' perceived barriers and enablers to screen for and diagnose depression and diabetes distress in people with T2DM. Methods and analysis: Primary qualitative studies will be identified using a systematic search of electronic databases and supplementary searching. We selected 'best-fit framework synthesis' as the approach to synthesise primary data using the RETREAT (Review question-Epistemology-Time/Timescale-Resources-Expertise-Audience and purpose-Type of Data) framework. Quality appraisal of primary studies and confidence in the overall review findings will be determined using the CASP (Critical Appraisal Skills Programme) and the GRADE-CERQual (Grading of Recommendations Assessment, Development, and Evaluation Confidence in the Evidence from Reviews of Qualitative research), respectively. Discussion: The planned review will provide the first, single point of reference of the available synthesised qualitative evidence on this topic. It will apply recommended approaches to ensure rigor and robustness of study and contribute meaningfully to understanding of how depression and diabetes distress can be initially detected in people with T2DM. This protocol is registered with the International Prospective Register of Systematic Reviews (PROSPERO) [registration number: CRD42019145483].

Barriers and enablers to screening and diagnosing depression and diabetes distress in people with type 2 diabetes mellitus; protocol of a qualitative evidence synthesis

Background: Depression and diabetes distress are common in people with type 2 diabetes (T2DM). These conditions are independently associated with poorer T2DM outcomes and increased healthcare utilisation and costs. Questions remain regarding the most appropriate ways of initially detecting depression and diabetes distress in this group. Diabetes guidelines recommend depression screening in primary care for people with T2DM but their implementation in practice is suboptimal. As health care professionals influence detection practices, their perceptions and experiences of these guidelines can improve understanding of aspects of the guidelines that work, and those which are more difficult to implement in practice. This study describes the protocol for a qualitative evidence synthesis of primary care health professionals’ perceived barriers and enablers to screen for and diagnose depression and diabetes distress in people with T2DM. Methods and analysis: Primary qualitative studies will be identified using a systematic search of electronic databases and supplementary searching. We selected ‘best-fit framework synthesis’ as the approach to synthesise primary data using the RETREAT (Review question-Epistemology-Time/Timescale-Resources-Expertise-Audience and purpose-Type of Data) framework. Quality appraisal of primary studies and confidence in the overall review findings will be determined using the CASP (Critical Appraisal Skills Programme) and the GRADE-CERQual (Grading of Recommendations Assessment, Development, and Evaluation Confidence in the Evidence from Reviews of Qualitative research), respectively. Discussion: The planned review will provide the first, single point of reference of the available synthesised qualitative evidence on this topic. It will apply recommended approaches to ensure rigor and robustness of study and contribute meaningfully to understanding of how depression and diabetes distress can be initially detected in people with T2DM. This protocol is registered with the International Prospective Register of Systematic Reviews (PROSPERO) [registration number: CRD42019145483].

Depression screening using patient-targeted feedback in general practices: study protocol of the German multicentre GET.FEEDBACK.GP randomised controlled trial

IntroductionApproximately one out of six patients in primary care suffers from depression, which often remains undetected. Evidence regarding the efficacy of depression screening in primary care, however, is inconsistent. A...

Supplemental Material for Integration of Behavioral Health Services and Adolescent Depression Screening in Primary Care

Supplemental Material for Integration of Behavioral Health Services and Adolescent Depression Screening in Primary Care

Capsule Commentary on Pfoh et al.,the Impact of Systematic Depression Screening in Primary Care on Depression Identification and Treatment in a Large Health Care System: a Cohort Study.

Capsule Commentary on Pfoh et al.,the Impact of Systematic Depression Screening in Primary Care on Depression Identification and Treatment in a Large Health Care System: a Cohort Study.

Validity and item response theory properties of the Patient Health Questionnaire-9 for primary care depression screening in Mozambique (PHQ-9-MZ)

BackgroundDepression is one of the leading causes of disability in Mozambique; however, few patients with depression are identified in primary care. To our knowledge, there are no validated tools for depression screening in Mozambique. The aim of this study was to validate the Patient Health Questionnaire-9 (PHQ-9) for use in primary care settings in Mozambique.MethodsThe PHQ-9 was adapted using a structured multi-phase process led by a team of bilingual experts followed by a review by lay individuals and pilot-testing including cognitive interviews. The final Mozambican PHQ-9 (PHQ-9-MZ) was applied among 502 individuals randomly selected from antenatal, postpartum, and general outpatient consultations in three Ministry of Health primary healthcare clinics in Sofala Province, Mozambique. The PHQ-9-MZ was evaluated against the MINI 5.0-MZ as a gold standard diagnostic tool.ResultsThe majority of participants were female (74%), with a mean age of 28. Using the MINI 5.0-MZ, 43 (9%) of the sample tested positive for major depressive disorder. Items of the PHQ-9-MZ showed good discrimination and factor loadings. One latent factor of depression explained 54% of the variance in scores. Questions 3 (sleep) and 5 (appetite) had the lowest item discrimination and factor loadings. The PHQ-9-MZ showed good internal consistency, with a Cronbach’s alpha of 0.84, and an area under the receiver operating characteristic curve (AUROC) of 0.81 (95% CI: 0.73, 0.89). The PHQ-2-MZ had an AUROC of 0.78 (95% CI: 0.70, 0.85). Using a cut-point of ≥9, the PHQ-9-MZ had a sensitivity of 46.5% and a specificity of 93.5%. Using a cut-point of ≥2, the PHQ-2-MZ had a sensitivity of 74.4% and a specificity of 71.7%. Increasing the cut-point to ≥3, the PHQ-2-MZ has a sensitivity of 32.6% and a specificity of 94.6%.ConclusionsThe PHQ-9-MZ and PHQ-2-MZ emerge as two valid alternatives for screening for depression in primary health care settings in Mozambique. Depending on program needs and weighing the value of minimizing false positives and false negatives, the PHQ-9-MZ can be employed with cut-points ranging from ≥8 to ≥11, and the PHQ-2-MZ with cut-points ranging from ≥2 to ≥3.

The validity and reliability of the Patient Health Questionnaire-9 for screening depression in primary health care patients in Botswana

BackgroundThe lack of locally validated screening instruments contributes to poor detection of depression in primary care. The Patient Health Questionnaire-9 (PHQ-9) is a brief and freely available screening tool which was developed for primary care settings; however, its accuracy may be affected by the population in which it is administered. This study aimed to determine the validity and reliability of PHQ-9 for screening depression in a primary care population in Botswana.MethodsData was collected from a conveniently selected sample of 257 adult primary care attendants. The Mini International Neuropsychiatric Interview (MINI) depression module was used as a gold standard to assess criterion validity.ResultsSensitivity and specificity of the PHQ-9 for screening for major depression were 72.4 and 76.3 respectively at a cut off score of nine or more. The area under the ROC curve was 0.808. The PHQ-9 demonstrated good internal consistency with a Cronbach alpha of 0.799. Criterion validity was demonstrated by significant correlation (r = 0.528, p < 0.001) between PHQ-9 and the MINI. Significant negative correlation between PHQ-9 scores and all four domains of the WHO quality of life questionnaire- brief version scores demonstrated good convergent validity.ConclusionsThe PHQ-9 is a reliable and valid instrument to screen for depression in primary care facilities in Botswana. Primary care clinicians in Botswana may use the PHQ-9 to screen for depression with a cut –off score of nine. Further studies should focus on integrating routine depression screening in primary care.