Lighting the Way: Implementation of a Depression Screening Protocol in a Rural Primary Care Clinic

BACKGROUND: Depression is a leading cause of disability and affects 5–10% of primary care patients, more than double the rate of the general population. Nearly 25% of Tennesseans report experiencing depression, yet only 5% of primary care patients are routinely screened.

LOCAL PROBLEM: A rural free clinic in Tennessee, serving low-income adults, with a mix of volunteer and paid staff, lacked a depression screening protocol. This project aimed to screen 30% of primary care English-speaking patients and offer interventions.

METHODS: The Evidence-Based Practice Improvement Model guided the project using Plan-Do-Study-Act (PDSA) cycles. A literature review identified the Patient Health Questionnaire 9 (PHQ-9) as the most suitable screening tool for the site. Impact was measured by PHQ-9 completion rates and the number of referrals of patients scoring ≥10 to a local behavioral health clinic (BHC) for treatment. Twelve PDSA cycles resulted in modifications to referral processes, staff workflow, and provider assessment and documentation.

INTERVENTIONS: The PHQ-9 was administered to adult English-speaking patients of the lead provider between triage and provider arrival. Patients scoring ≥10 were offered a mental health referral, treatment by the provider, or resource handouts.

RESULTS: From a baseline of zero, 141 (91.6%) eligible patients were screened. Of those, 63 (44.7%) scored ≥10. Thirty (49.1%) were offered mental health referrals; 21 (70%) of those were already in care. Ten (15.9%) were referred to the BHC, 53 (84.1%) received resource handouts, and 6 (9.5%) received treatment from the provider.

CONCLUSIONS: This project identified a high prevalence of depression symptoms and demonstrated that a screening and referral protocol improved symptom recognition and access to care. High patient trust and strong staff dedication contributed to its success. This initiative is a vital first step toward integrating mental health into a free primary care clinic and lays a foundation for ongoing collaborative care for patients with mental illness.