Psychiatric Screening for Depression and Anxiety in Primary Care
This paper presents a psychiatric screening case study for a 56-year-old Caucasian female presenting in a primary care setting. Using the Beck Depression Inventory (BDI) and the Generalized Anxiety Disorder 7-item scale (GAD-7), the clinician assesses the patient's symptoms of depression and anxiety. The BDI yields a score of 22, indicating moderate depression, while the GAD-7 yields a score of 5, indicating mild anxiety. The paper discusses the psychometric rationale for selecting each tool, item-by-item scoring with clinical rationale, recommended laboratory tests to rule out organic causes, and a pharmacological treatment plan centered on Sertraline (Zoloft), a first-line SSRI, including dosing, titration, patient education, and expected outcomes.
- Introduction to Psychiatric Screening Tools: Rationale for selecting BDI and GAD-7 tools
- BDI Scoring and Clinical Rationale: Item-by-item BDI scores with patient context
- GAD-7 Scoring and Clinical Rationale: GAD-7 scores and anxiety severity interpretation
- Recommended Laboratory Tests: Labs to rule out organic causes of symptoms
- Diagnosis and Pharmacological Treatment: SSRI mechanism and Sertraline prescribing rationale
- Prescription and Patient Education: Dosing, titration, side effects, and expected outcomes
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What makes this paper effective
- The paper clearly justifies tool selection by citing psychometric properties — validity, reliability, sensitivity, and specificity — before presenting scores, grounding clinical decisions in evidence.
- The item-by-item scoring tables link each response to patient-specific context, demonstrating clinical reasoning rather than mechanical score reporting.
- The treatment section logically flows from diagnosis to mechanism of action to prescribing rationale, creating a coherent clinical narrative that connects pharmacology to patient presentation.
Key academic technique demonstrated
This paper demonstrates evidence-based clinical reasoning: the author does not merely report scores but explicitly connects screening results to differential diagnosis, laboratory workup, and medication selection. Citing comparative meta-analyses (Cipriani et al., 2018) to justify choosing Sertraline over alternatives is a strong example of using research to support a specific clinical decision rather than a general claim.
Structure breakdown
The paper moves through six logical stages: (1) epidemiological context and tool introduction, (2) BDI administration and scored table with rationale, (3) GAD-7 administration and scored table with rationale, (4) recommended laboratory investigations, (5) diagnosis and SSRI pharmacology, and (6) the formal prescription with patient education. This structure mirrors a real clinical documentation workflow, making it an effective model for psychiatric nursing or advanced practice papers.
Introduction to Psychiatric Screening Tools
Depression and anxiety are the most common psychiatric problems affecting patients in primary care. Data from the National Alliance on Mental Illness (NAMI) places the prevalence of depression among American adults at 7.8 percent (representing 19.4 million people), and that of anxiety disorders at 19.1 percent (representing 48 million people) (NAMI, 2021). This case study focuses on administering relevant screening tools to detect symptoms of depression and anxiety in a presenting client, a 56-year-old Caucasian female. The Beck Depression Inventory (BDI) was selected to screen for symptoms of depression, while the Generalized Anxiety Disorder 7-item scale (GAD-7) was selected to screen for anxiety symptoms.
The BDI is a 21-item questionnaire that assesses the intensity of symptoms associated with psychoanalytic aspects of depression, including social withdrawal, suicidal ideation, guilt, feelings of failure, and sadness (Park et al., 2020). It measures the severity and frequency of depression symptoms experienced in the past two weeks on a 4-point scale. It is one of the most widely studied measures for assessing depression, with well-established psychometric properties (Garcia-Batista et al., 2018). The 21 items are scored from 1 to 3, yielding a maximum score of 63 and a minimum score of zero. Scores between 1 and 10 indicate normal ups and downs; scores of 21 to 30 indicate moderate depression; 31 to 40 indicate severe depression; and scores over 40 indicate extreme depression. The BDI was selected not only for its high validity and reliability, but also because it can be used both as a screening tool and as a measure of the severity of depressive symptoms (Park et al., 2020). As such, the clinician does not need to administer a separate tool to measure the effect of prescribed medication on symptoms at the time of review. Furthermore, the BDI allows for self-rating, enabling the client to regularly monitor the progression of their symptoms.
BDI Scoring and Clinical Rationale
The following table presents the client's BDI item scores along with the clinical rationale for each scored response.
Sadness — Score: 2 ("I feel sad"): The client reports feeling sad mostly in the morning but snaps out of it as the day progresses.
Pessimism — Score: 0: Not present.
Sense of Failure — Score: 2 ("As I look back on my life, I see a lot of failures"): The client feels like a failure for losing her son's custody to her abusive husband and for not playing an active role in raising him.
Dissatisfaction — Score: 1 ("I do not enjoy things the way I used to"): She no longer enjoys yoga and meditation.
Guilt — Score: 2 ("I feel guilty most of the time"): The client reports feeling very guilty about divorcing and leaving her son in France.
Expectation of Punishment — Score: 0: Not present.
Self-Dislike — Score: 1 ("I am disappointed in myself"): The client is disappointed in herself for leaving her son in France.
Self-Accusations — Score: 1 ("I am critical of myself for my weaknesses").
Suicidal Ideas — Score: 0 ("I do not have thoughts of killing myself").
Crying — Score: 0: Not present.
Irritability — Score: 0: Not present.
Social Withdrawal — Score: 2 ("I have lost most of my interest in other people"): The client tries to engage in at least one social activity weekly, meaning she has not completely lost interest in others.
Indecisiveness — Score: Not assessed: No supporting information available.
Body Image Change — Score: Not assessed: No supporting information available.
Work Retardation — Score: 2 ("I have to push myself hard to do anything"): She has difficulty completing work projects and cannot stay focused.
Insomnia — Score: 3 ("I wake up several hours earlier and cannot go back to sleep"): The client must take medication in order to sleep.
Fatigue — Score: 2 ("I get tired from doing anything"): Activities that were previously enjoyable, such as attending social events, are now exhausting.
Anorexia — Score: 3 ("I have no appetite at all"): The client reports not feeling hungry.
Weight Loss — Score: 1 ("I have lost more than 5 pounds"): The client reports losing between 4 and 5 pounds.
Somatic Preoccupation — Score: Not assessed: No supporting information available.
Loss of Libido — Score: Not assessed: No supporting information available.
The BDI yields a total score of 22, signifying moderate depression (Park et al., 2020). The client was not scored on 8 items — including crying, irritability, indecisiveness, body image change, somatic preoccupation, and loss of libido — because no specific information was available to answer those questions. If the client were to provide additional information, one would expect the depression score to be even higher.
GAD-7 Scoring and Clinical Rationale
The GAD-7 scale is a self-administered questionnaire used to assess the presence and severity of anxiety symptoms over the past two weeks (Johnson et al., 2019). It is scored by assigning values of 0 to 3 to the response categories of "not at all," "several days," "more than half the days," and "nearly every day," and then summing the scores to obtain the total anxiety score (Johnson et al., 2019). Scores of 5, 10, and 15 serve as cut-off points for mild, moderate, and severe anxiety, respectively. The GAD-7 was selected for its proven psychometric properties, including a specificity of 82 percent and a sensitivity of 89 percent for generalized anxiety disorder (Johnson et al., 2019). Like the BDI, the GAD-7 can be used both as a screening tool and as a measure of symptom severity, providing an invaluable means for identifying anxiety and assessing the effectiveness of treatment plans (Johnson et al., 2019).
The client's GAD-7 item scores are as follows:
Feeling anxious, nervous, or on edge — Score: 3: The client is employed as a full-time consultant and reports that she can no longer stay focused or complete work projects. The inability to stay focused was interpreted as a sign of anxiety or nervousness; because she works full-time, this effect is felt nearly every day.
Not being able to control or stop worrying — Score: 2: The client does not always struggle to control worry — at least once a week she takes part in social events, though she finds these activities exhausting. She has no means to control worry on the remaining days, which represent more than half the days of the week.
Worrying too much about different things — Score: 0
Trouble relaxing — Score: 0
Being so restless that it is hard to sit still — Score: 0
Being easily irritable or annoyed — Score: 0
Feeling afraid as if something awful might happen — Score: 0
The client was not scored on the remaining five items because there is insufficient information to support such scoring. Her total GAD-7 score is therefore 5, signifying mild anxiety. It should be noted that the GAD-7 assesses symptoms over the past two weeks; the anxiety reported four months earlier — when the client felt nervous about leaving her son in France — cannot be subjected to assessment using this scoring tool.
References
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Cipriani, A., Furukawa, T., Salanti, G., Chaimani, A., Atkinson, L., & Ogawa, Y. (2018). Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: A systematic review and network meta-analysis. The Lancet, 391(10128), 1357–1366.
FDA. (2016). Zoloft: Highlights of prescribing information. Food and Drug Administration. Retrieved from https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/019839S74S86S87_20990S35S44S45lbl.pdf
Garcia-Batista, Z., Guerra-Pena, K., Cano-Vindel, A., Herrera-Martinez, S., & Medrano, L. (2018). Validity and reliability of the Beck Depression Inventory in general and hospital populations of the Dominican Republic. PLOS ONE. doi:10.1371/journal.pone.0199750
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NAMI. (2021). Mental health by the numbers. National Alliance on Mental Illness. Retrieved from https://www.nami.org/mhstats
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