Heart Education Awareness Resource and Training through eLearning (HEARTe)

Assessing Sheila

Sheila completes the PHQ9 Questionnaire.

PHQ-9 form Sheila's details

Depression Severity score:

  • 0-4 None
  • 5-9 Mild
  • 10-14 Moderate
  • 15-19 Moderately severe
  • 20-27 Severe

Based on her score, the GP diagnoses Sheila with moderately severe depression. This indicates the need for referral to specialised support services (Step 3 of the Stepped Care model referred to earlier in the module).

It is important to remember that, while screening tools can be useful in indicating the presence of depression, they are not a substitute for diagnosis.

Patient Health Questionnaire – 9 (PHQ-9)

Over the last 2 weeks, how often have you been bothered
by any of the following problems?
(Use “✔” to indicate your answer)		 Not at all Several days More than half the days Nearly every day
1. Little interest or pleasure in doing things 0 1 2 ✔ 3
2. Feeling down, depressed, or hopeless 0 1 2 ✔ 3
3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3 ✔
4. Feeling tired or having little energy 0 1 2 ✔ 3
5. Poor appetite or overeating 0 1 2 ✔ 3
6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down 0 1 2 ✔ 3
7. Trouble concentrating on things, such as reading the newspaper or watching television 0 1 ✔ 2 3
8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual 0 ✔ 1 2 3
9. Thoughts that you would be better off dead or of hurting yourself in some way 0 1 ✔ 2 3
For office coding 0 2 10 3
= Total Score: 15
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
Not difficult at all Somewhat difficult Very difficult ✔ Extremely difficult

Pulse point

The GP notes that Sheila has scored 1 on question 9. Any person with a positive depression screen should be assessed for suicidal thoughts. A positive score, the presence of suicidal thoughts and/or your clinical judgment can indicate that further assessment is warranted. Immediate referral is recommended for those with suicidal ideation and/or a severe score. The GP confirms with Sheila that, although she has had these thoughts in the past, she is not currently experiencing them.

The following are useful resources for healthcare practitioners dealing with potentially suicidal patients:

Page last reviewed: 25 Sep 2020