NCLEX · General

A nurse is conducting a depression screen at a primary care visit. Which validated tool is the most widely used for depression screening?

Correct answer

Patient Health Questionnaire-9 (PHQ-9) — a 9-item self-report screening tool that aligns with DSM-5 diagnostic criteria; scores 0-27; widely used in primary care; validated in multiple populations

  1. A Hamilton Depression Rating Scale
  2. B Patient Health Questionnaire-9 (PHQ-9) — a 9-item self-report screening tool that aligns with DSM-5 diagnostic criteria; scores 0-27; widely used in primary care; validated in multiple populations
  3. C Beck Depression Inventory (BDI)
  4. D Columbia Suicide Severity Rating Scale (C-SSRS)

Why this is the answer

PHQ-9 (Patient Health Questionnaire-9): 9 questions about depressive symptoms over the past 2 weeks; each scored 0-3 (not at all to nearly every day); SCORES: 0-4 none/minimal; 5-9 mild; 10-14 moderate; 15-19 moderately severe; 20-27 severe; VALIDATED: Multiple clinical settings, populations, languages; recommended by USPSTF for routine screening in adults; SCREENING IS RECOMMENDED: USPSTF recommends depression screening for general adult population including pregnant and postpartum women; PHQ-2 (first 2 questions of PHQ-9) is used as ultra-brief screen — if positive, proceed to full PHQ-9; C-SSRS screens specifically for suicidal ideation, not depression broadly; Hamilton and BDI are clinician-administered or research-focused, less used in routine primary care.
Source: NCLEX-PN HP — Mental Health Promotion, PHQ-9

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