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Best and promising practices: depression screening and management in primary care

Publication date: 09.07.2025

Routine Depression Screening in Primary Care Using PHQ-2 and PHQ-9

Target Group:

  • Adults visiting primary care facilities, including patients with somatic complaints
  • Internally displaced persons (IDPs) and other populations affected by war-related stress
  • Primary care physicians and nurses responsible for first-line screening

Target Aims:

  • To ensure early identification of depressive symptoms, including major depression, among the general and high-risk adult populations
  • To improve timely referral and treatment, including psychological support or pharmacotherapy, for individuals with depressive symptoms
  • To reduce the burden of undiagnosed depression, which has significantly increased during the ongoing war in Ukraine

Details of the Implementation:

    • Implementation Details:
      This practice is based on international evidence-based guidelines, particularly the U.S. Preventive Services Task Force (USPSTF) recommendations, which endorse depression screening for all adults, including pregnant and postpartum women, when appropriate systems for diagnosis and follow-up are in place. In Ukraine, this practice is adapted for wartime context through integration into routine primary care workflows and NGO-led psychosocial support programs.
    • Duration:
      Screening is ongoing and integrated into every clinical encounter with adults, particularly those with non-specific somatic symptoms or known psychosocial stressors.
    • How long has the practice been implemented?
      Depression screening tools (PHQ-2 and PHQ-9) have been used internationally for over 20 years. In Ukraine, their use has increased since 2014 and was significantly scaled up in 2022–2024 due to war-related needs.
    • How often is it carried out?
      Screening is continuous and routine, especially during first contact and periodic check-ups. Some practices repeat screening at intervals (e.g., every 3–6 months), especially for high-risk patients.
  • Main Activities:
      • Administering PHQ-2 as an initial screen
      • If PHQ-2 is positive (≥3), administering the full PHQ-9
      • Providing immediate psychological first aid or referrals based on severity
      • Documenting results and monitoring follow-up
  • What are the key steps of the practice?
      • Train healthcare providers in use and interpretation of PHQ-2/9
      • Integrate tools into standard patient intake forms or digital records
      • Screen adults during primary care visits
      • Offer brief intervention or referral based on score thresholds
      • Track patient outcomes
  • What methods are used?
      • Structured screening questionnaires
      • Brief motivational interviewing or problem-solving interventions
      • Referral pathways to psychologists or psychiatrists
      • Capacity building for providers (e.g., trainings, supervision)
  • What tools, materials, or resources are used during implementation?
    • PHQ-2 and PHQ-9 screening forms (paper or electronic)
    • WHO and USPSTF guidelines
    • National mental health protocols
    • Referral directories and digital case registries

Involved Stakeholders:

  • Organizations or Institutions Involved:
      • Ministry of Health of Ukraine
      • WHO Country Office in Ukraine
      • Ukrainian-Swiss Mental Health for Ukraine (MH4U) Project
      • NGOs providing mental health support (e.g., Médecins Sans Frontières, Red Cross, local NGOs)
  • Key Actors:
      • Family doctors and nurses
      • Mental health professionals
      • NGO case managers and outreach workers
      • Ministry of Health policy makers
      • Community leaders supporting trust-building
  • How do stakeholders collaborate?
    • National policy sets the screening standard
    • Healthcare providers conduct screening and provide initial support
    • NGOs assist with capacity building and referrals
    • Psychologists/psychiatrists provide follow-up care and supervision

Where was the good practice implemented?

  • Implemented in multiple regions of Ukraine, including conflict-affected areas and temporary accommodation centers for IDPs
  • Also used by mobile health units and in NGO-supported clinics

Can it be transferred or adapted to other locations?
Yes. PHQ-2 and PHQ-9 are open-access, validated instruments that can be adapted for other countries, crises, or vulnerable groups, provided that follow-up systems are in place.

What has been achieved through the practice?

  • Increased identification of depressive symptoms in primary care settings
  • Earlier access to care for vulnerable groups
  • Reduction of stigma around mental health through routine integration into somatic consultations

What types of feedback have been received?

  • Providers report that the tools are quick, easy to use, and clinically helpful
  • Patients feel heard and validated when mental health is addressed during routine care
  • NGOs note improved case detection and referral quality

Are there any measurable outcomes or observable changes?

  • PHQ-9 scores allow for measurable tracking of depressive symptom severity
  • Increased referrals to mental health services
  • Improved provider confidence and screening rates (based on internal audits)

To what extent is the practice sustainable in the long term?

  • Adoptability: Yes, it is low-cost, scalable, and endorsed by WHO and USPSTF
  • Conditions for successful replication:
    • Training of primary care staff
    • Clear referral mechanisms
    • Availability of follow-up care
    • Leadership support for integration into routine care
    • Digital or paper-based documentation systems

Link or Source:

How it could support the pilot implementation in your country:

This good practice enables non-specialist providers to detect depression early, especially under conditions of high stress and displacement. During war or displacement, psychological distress is common, and many patients present with somatic symptoms masking mental illness. Systematic use of PHQ-2/9 in Ukraine has shown that brief tools can uncover hidden distress, guide interventions, and improve care without burdening clinicians. For pilot sites, this approach offers evidence-based, scalable mental health support with measurable outcomes and high provider acceptability.

II Name of the Good Practice:
Need in  Assessment Questionnaire for Healthcare Professionals to Support the Implementation of Depression Screening

Target Group:
Primary care physicians (family doctors) and other healthcare professionals involved in mental health service delivery at the primary care level.

Target Aims:
To identify and evaluate the specific needs of healthcare professionals for effectively implementing depression screening using PHQ-2 and PHQ-9, as recommended by the USPSTF.
Rather than measuring behavioral determinants per se, the goal is to assess the importance of needs and gather insights on how to support implementation efforts.

Details of the Implementation

    • Implementation Status:
      Currently in the final development phase; implementation is planned for June 2025.
    • Duration:
      The questionnaire is administered before each new implementation of evidence-based mental health interventions, particularly depression screening.
    • Frequency:
      Periodic, depending on the implementation cycle; typically used before new projects or process changes in primary care practices.
  • Main Activities:
      • Literature analysis of relevant implementation frameworks (DIBQ, PMA).
      • Selection and adaptation of relevant items to design the new questionnaire focused on needs.
      • Iterative formulation of items tailored to the Ukrainian healthcare context.
      • Expert consultations to refine and validate questionnaire content.
      • Content validity assessment (using CVI and CVR) by 12 Ukrainian academic experts.
      • Face/external validity testing among 25 practicing family physicians (IIS score).
      • Final piloting with clinicians for additional improvements and insights on importance and satisfaction of identified needs.
  • Key Steps of the Practice:
      • Needs item extraction from validated implementation questionnaires.
      • Reformulation to align with needs-based evaluation.
      • Two-step validation (content + external).
      • Final piloting and revisions based on user feedback.
      • Implementation through clinical leadership in selected facilities.
  • Methods Used:
      • Literature analysis and synthesis.
      • Expert consultation and validation (quantitative and qualitative).
      • Online surveys and structured feedback collection.
      • Statistical analysis (CVI, CVR, IIS).
  • Tools, Materials, or Resources Used:
    • Adapted items from DIBQ and PMA.
    • Google Forms for data collection.
    • Google Sheets and Excel for statistical validation analysis.
    • Final version of the Needs Assessment Questionnaire.

Involved Stakeholders:

  • Organizations/Institutions Involved:
      • Research team from the pilot group.
      • Ukrainian academic family medicine institutions.
      • Primary healthcare facilities in Uzhhorod and Zakarpattia region.
  • Key Actors:
      • International expert (Michael Harris).
      • Ukrainian clinical educators and practicing family doctors (as expert validators).
      • Clinical leadership teams (as users of data for implementation planning).
      • Practicing physicians participating in the pilot.
  • Collaboration:
    • Researchers lead the design and analysis.
    • International and local experts review and refine content.
    • Practitioners validate relevance and clarity.
    • Clinic managers use findings to support tailored implementation of screening protocols.

Implementation Site:
Initial implementation in Uzhhorod, Ukraine. Further rollout is planned in the Zakarpattia region and potentially across other regions of Ukraine.

Transferability and Adaptability:
Yes, the practice is highly transferable. The questionnaire structure and methodology can be adapted for other healthcare settings, countries, or thematic areas (e.g., anxiety, trauma, chronic disease management). It can also be applied before other mental health innovations.

Achievements:

  • High perceived relevance and usefulness by clinical and academic experts.
  • Final validated version reflects actual needs and challenges identified by frontline practitioners.
  • Enables management teams to make informed decisions about support mechanisms (training, time, materials, supervision).

Feedback from Participants and Stakeholders:

  • Experts and clinicians described the tool as timely and highly practical.
  • Considered helpful for diagnosing implementation gaps before rolling out new processes.

Measurable Outcomes:

  • High CVI and CVR scores demonstrate strong content validity.
  • IIS results from practicing doctors confirm strong face validity
  • Final version includes only items deemed relevant, clear, and aligned with intended purpose.

Sustainability:

    • Long-Term Use:
      Yes, the tool is sustainable and scalable. It can be integrated into quality improvement cycles.
    • Adoption by Others:
      Yes, with minimal contextual adaptation, it can be used by other healthcare institutions or in other countries.
  • Required Conditions/Resources:
    • Research/expert team to conduct contextual adaptation and validation.
    • Buy-in from clinical management to use findings for decision-making.
    • Simple digital tools (Google Forms, Sheets) for data collection and analysis.

Link or Source:
https://pubmed.ncbi.nlm.nih.gov/28407994/

https://pmc.ncbi.nlm.nih.gov/articles/PMC4000005/

https://docs.google.com/forms/d/1GNZEgr0V8vXZM6w0wgOdCPXB_3fd01CGzACojGOo2Ec/edit

(Currently in internal project documentation). 

How It Supports the Pilot Implementation in Ukraine:
This good practice is critical for ensuring contextually grounded, needs-responsive implementation of depression screening at the primary care level. It helps identify barriers and support needs ahead of rollout, increasing the likelihood of sustainable integration of PHQ-2 and PHQ-9 into clinical routines.

Depression management and promotion good practices

III Name of the good practice:
Implementation of WHO mhGAP Intervention Guide (mhGAP-IG) with the Planned Innovation of Post-Training Peer Case Discussion Clubs

Target Group:

  • Family doctors and other primary healthcare professionals working with internally displaced persons (IDPs)
  • Young professionals and medical interns involved in psychosocial support

Target Aims:

  • To enhance the capacity of non-specialist health workers in recognizing, managing, and treating priority mental health conditions using evidence-based psychosocial support strategies and promoting help-seeking in the field of mental health.
  • To ensure early identification of anxiety, depression, and stress-related disorders, especially among vulnerable populations such as IDPs
  • To foster practical skills and peer support through innovative case discussion clubs after formal training

Details of the Implementation:

    • Implementation Details:
      The core of the practice is based on WHO’s mhGAP-IG, implemented through in-person or blended training programs. As an innovative addition, we plan to launch Peer Case Discussion Clubs for those who have completed the training, enabling practical case-based learning and peer reflection in a safe, structured environment.
    • Duration:
      Core mhGAP training lasts 3–4 days; follow-up peer discussion sessions are planned monthly for at least 6 months after training.
    • How long has the practice been implemented?
      mhGAP-IG has been implemented globally since 2010 and in Ukraine since 2014 in various regions.
      The planned innovation (Discussion Clubs) is scheduled for pilot testing starting in 2025.
    • How often is it carried out?
      The mhGAP training is typically project-based. The Peer Case Discussion Clubs will be held monthly to ensure continuous development and retention of practical skills.
  • Main Activities:
      • Training healthcare workers using the mhGAP-IG modules
      • Practical exercises with clinical scenarios
      • Post-training peer case discussion clubs (planned innovation)
      • Mentorship and optional supervision support
  • Key Steps of the Practice:
      • Identification of target participants
      • Delivery of mhGAP-based training
      • Distribution of practical tools and job aids
      • Formation of small discussion groups
      • Facilitation of monthly peer case discussions with expert support
      • Evaluation of knowledge, confidence, and skill application
  • Methods Used:
      • Group work and simulation
      • Facilitated training sessions
      • Peer mentoring and supervision
      • Case-based learning and reflection sessions
  • Tools, Materials, or Resources Used:
    • WHO mhGAP-IG (paper and digital versions)
    • Clinical case scenarios and job aids
    • PHQ-9 and other validated screening tools
    • Facilitation guides for discussion clubs

Involved Stakeholders:

  • Organizations Involved:
      • World Health Organization (WHO)
      • Ministry of Health of Ukraine
      • Primary Health Care Centers
      • NGOs supporting IDPs and mental health response
  • Key Actors:
      • Primary care physicians
      • Medical managers and mentors
      • NGO coordinators and trainers
      • Psychiatrists and psychologists providing expert support
  • Stakeholder Collaboration:
    • National health authorities validate content and provide endorsement
    • NGOs facilitate the training and peer sessions
    • Mentors and peers co-lead the case discussions
    • Community feedback informs ongoing improvements

Where was the good practice implemented?

  • Locally in several Ukrainian regions (e.g., Kyiv, Lviv), as well as through national online formats during wartime.
  • Globally used in over 100 countries.

Can it be transferred or adapted to other locations?
Yes. The mhGAP framework is designed for global adaptation.
Our planned innovation — the Peer Case Discussion Clubs — can be tailored and replicated in other settings as a sustainable support mechanism for trained professionals.

What has been achieved through the practice?

  • Increased detection and treatment of mental health conditions at primary care level
  • Reduction of stigma among healthcare workers
  • Stronger peer support networks among trained professionals

What types of feedback have been received?

  • Participants praise the mhGAP guide for its practical relevance
  • Health centers report greater confidence in managing mental health cases
  • Anticipated feedback for the discussion clubs includes improved peer learning and reduced professional isolation

Are there any measurable outcomes or observable changes?

  • Improved knowledge and confidence (based on pre/post evaluations)
  • Increased identification and referral rates
  • Better adherence to evidence-based care protocols

To what extent is the practice sustainable in the long term?

  • Adoptability: Yes. It can be scaled to other clinics.
  • Conditions for successful replication include:
    • Trained facilitators and mentors
    • Institutional support for monthly meetings
    • Structured materials and ongoing monitoring

Link or Source:

How it could support the pilot implementation in your country:
The mhGAP-IG framework provides a globally validated training foundation for non-specialist mental health service delivery.
Our planned innovation—Peer Case Discussion Clubs—adds a unique, low-cost, high-impact layer of support, allowing trained professionals to apply their skills, consult peers on complex cases, and build confidence through experiential learning. This model strengthens long-term implementation by building sustainable communities of practice.

IV Name of the Good Practice:
Open-label Placebo (OLP) as a Potential First-Line Intervention for Mild to Moderate Depression in Primary Care. Research Projects.

Target Group:

  • Patients with mild to moderate depression seeking care at primary health care facilities
  • Family doctors trained under the WHO mhGAP program

Target Aims:

  • To examine the effectiveness of open-label placebo (OLP) in combination with psychosocial interventions in primary care settings
  • To enhance the accessibility and safety of depression treatment while minimizing the use of pharmacotherapy associated with potential adverse effects

Details of the Implementation:

Implementation Details:
This practice has been investigated by the Depression Clinic at Massachusetts General Hospital and Shalvata Mental Health Center, P.O.B 94, Hod-Hasharon, Israel.
It has not yet been conducted in Ukraine, and is currently under consideration for a pilot study.

A randomized controlled trial (RCT) design is used, where participants are allocated to:

  • Group A: open-label placebo (OLP) capsules + psychosocial support
  • Group B: psychosocial support only

Duration:

  • 28-day core intervention period, followed by a 14-day follow-up

How long has the practice been implemented?

  • Still at the experimental pilot stage

How often is it carried out?

  • Currently designed as a one-time intervention pilot, with the potential for routine integration based on outcomes

Main Activities and Key Steps Across All Countries (USA, Israel, Ukraine – planned):

    1. Provision of a rationale for open-label placebo (OLP):
      In all studies, participants were provided with a standardized rationale explaining why OLP might be effective. The rationale included:

      • Placebos in RCTs are often about 80% as effective as antidepressants
      • Classical conditioning can support automatic self-healing
      • Higher adherence to placebo intake is associated with better outcomes
      • Positive expectations may help, though skepticism is acceptable
        In the planned Ukrainian study, the rationale will be delivered in a non-suggestive, autonomy-supportive tone, with sensitivity to war-related trauma and mistrust, particularly among internally displaced persons (IDPs).
  • Assessment of depressive symptoms:
      • In the USA, assessments included the clinician-rated HAM-D-17 and self-report tools (QIDS, SDQ)
      • In Israel, self-report QIDS-SR-16 was used
      • In the planned Ukrainian study, clinicians will use the Montgomery–Åsberg Depression Rating Scale (MADRS), with validated Ukrainian-language instruments. This approach addresses the limitations of self-report tools and enhances clinical precision.
  • Randomization and group conditions:
    • In the USA and Israel, participants were randomized to receive either OLP or waitlist/TAU (treatment as usual)
    • In the planned Ukrainian study, both randomized groups will receive active psychosocial interventions; there will be no passive waitlist group. This decision was made to ensure ethical support and to reflect the realities of delivering care in a humanitarian context.
  2. OLP treatment duration and follow-up schedule:
    OLP treatment was given for 2–4 weeks in both the USA and Israel, with follow-ups at 2- or 4-week intervals.
    In the planned Ukrainian protocol, a longer observation period is included to assess the sustainability of OLP effects in real-world primary care and displacement-affected settings.
  3. Informed consent and participant engagement:
    All completed studies ensured informed consent. In the USA, participants received financial compensation and post-trial psychiatric care.
    In the planned Ukrainian study, participants will be invited to post-intervention debriefing sessions to reduce stigma, foster trust, and encourage further engagement with mental health services, especially within primary care.
  4. Feasibility and recruitment focus:
    The USA study (Massachusetts General Hospital) demonstrated fast recruitment and high retention (75%).
    In the planned Ukrainian study, a larger sample is anticipated, and structured feedback will be collected from both patients and providers to assess feasibility, acceptability, and contextual adaptation for conflict-affected populations

Methods Used:

  • Family doctor consultations
  • Psychoeducation on the mind-body connection and placebo mechanisms
  • Use of standardized clinical assessment tools (MADRS or HAM-D)
  • Use of IBM SPSS for statistical analysis
  • One-on-one interactions; group therapy is not used in this intervention
  • Supervision and mentorship of clinicians during the study phase

Tools, Materials, or Resources Used:

  • Open-label placebo capsules
  • PHQ-9 and MADRS or HAM-D depression scales
  • WHO mhGAP intervention guide
  • Randomization tables
  • G*Power 3.1 software for sample size calculation
  • IBM SPSS for data analysis

Involved Stakeholders:

Organizations or Institutions Involved:

  • Depression Clinic at Massachusetts General Hospital
  • Shalvata Mental Health Center, Hod-Hasharon, Israel
  • Uzhhorod National University, Ukraine
  • Primary health care centers
  • WHO (in relation to mhGAP materials)

Key Actors:

  • Patients
  • Family physicians
  • Academic researchers
  • Implementation coordinators

Collaboration Between Stakeholders:

  • Joint planning and training of health professionals
  • Physicians implement the intervention under supervision from the research team
  • Use of international protocols and evidence to structure the intervention

Where Was the Good Practice Implemented?

  • The original studies were conducted in the USA and Israel.
  • It has not yet been implemented in Ukraine, but is proposed for local pilot testing in several primary care facilities.

Can It Be Transferred or Adapted to Other Locations?
Yes. The practice is low-cost, ethically acceptable, and adaptable for primary care systems in other countries with established PHC networks.

Achievements:

  • Increased awareness of ethical placebo use among clinicians
  • Enhanced doctor-patient transparency and trust
  • Potential reduction in unnecessary pharmacological prescriptions
  • Promotion of patient participation in treatment decisions

Feedback Received:

  • Patients reported appreciation for the honesty and openness of the approach
  • Physicians expressed interest in safe alternatives to antidepressants
  • Some clinicians noted the need for additional guidance in explaining the rationale to patients

Measurable Outcomes or Observable Changes:

  • Reduction in scores after intervention
  • Comparison of outcomes between the OLP and control group
  • Patient adherence and follow-up completion rates

Sustainability in the Long Term:

  • High potential for scale-up with minimal cost
  • Requires institutional endorsement and integration into clinical guidelines
  • Training of family physicians is feasible through existing mhGAP infrastructure

Link or Source:

  • Kirsch I. (2019). Placebo Effect in the Treatment of Depression and Anxiety. Frontiers in Psychiatry, 10, 407
  • Charlesworth JE et al. (2017). Effects of placebos without deception compared with no treatment: a systematic review and meta-analysis. Journal of Evidence-Based Medicine, 10(2)
  • Nitzan U. (2020). Open-label placebo for major depressive disorder: A pilot study. PubMed
  • Kelley JM et al. (2012). PMC article on OLP and depression

Explanation of How It Could Support the Pilot Implementation in Your Country:
Open-label placebo (OLP) provides an ethically sound, safe, and potentially effective treatment option for mild depression—particularly relevant in Ukraine, where access to psychiatric services is limited, stigma around psychotropic medication is high, and PHC providers are overburdened.
Results from a local pilot could inform national guidelines and support the scale-up of this approach across the country.