The PHQ-9 depression screening test is now baked into modern healthcare. It shows up in primary care, hospital admissions, and especially the Medicare annual wellness visit depression screening workflow. On paper, it sounds responsible: “screen early, catch depression, help people.” In real life, it often does something else. It turns normal human experiences into a diagnosis, converts nuance into a score, and nudges clinicians toward the fastest “solution” the system rewards: a prescription.
This episode was a reminder of a bigger theme A Return to Healing: when medicine becomes numbers-based, we start treating the number, not the person.
Listen to the Podcast Episode
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How We Went From “Pain Scores” to Depression Scores
If you practiced medicine during the opioid era, you remember the “pain scale,” pain rated 1 to 10, treated like a vital sign. It wasn’t just suggested; it was pushed into workflows and compliance metrics. The idea was simple: if pain is high, treat it. And the treatment pipeline was obvious.
The PHQ-2 and PHQ-9 depression screening tools follow the same pattern:
- turn a human experience into a number,
- set a cutoff,
- convert the score into a “quality measure,”
- and build an implied next step into the note: treat.
The problem isn’t that depression doesn’t exist. It does, and it can be devastating. The problem is that check-box screening tools can’t reliably separate true clinical depression from normal stress, aging, grief, isolation, poor sleep, job burnout, and the simple fact that modern life can be exhausting.
The PHQ-9 is a test designed for humans… which is the problem
One reason the PHQ-9 catches so many “positives” is that it asks about symptoms most humans experience at times:
- low energy
- poor sleep
- changes in appetite
- trouble concentrating
- feeling down
- feeling like you’re not doing enough
If you’re older, if you’re working too hard, if you’re caregiving, if you’re isolated, if you’re watching a steady stream of bad news, many of these answers drift toward “yes.” That doesn’t automatically mean you have an illness that should be treated with medication. It means you’re alive in 2026.
Here’s where relationship-based primary care matters. When you know a patient, really know them, you can often see depression without a tool. And you can also see when a “positive” score is just a snapshot of a rough season, not a diagnosis that should follow them for years.
“Ask the next question” is the part the workflow doesn’t reward
In an ideal world, a PHQ-9 prompt would trigger curiosity:
- What changed recently?
- Is this grief? loneliness? insomnia? pain? financial stress? caregiver burnout?
- Are you eating well? moving? getting sunlight? connected to a community?
- Do you feel safe at home?
- Are you using alcohol or cannabis to cope?
That is medicine.
But the system doesn’t pay for that conversation. It pays for speed, coding, and downstream interventions. And if you’re a clinician with 15 minutes and a packed schedule, the path of least resistance becomes: “Let’s start a medication.”
The downstream costs nobody counts
A positive depression screen doesn’t just create a chart diagnosis. It creates a cascade:
- follow-up appointments to “monitor meds”
- added testing when side effects show up
- new referrals
- more paperwork
- more disability claims and time away from work
- and, for some people, a new identity: “I’m depressed, so I can’t.”
This is not a moral critique of patients. It’s a systems critique: when you medicalize normal feelings, you create patients who believe they are broken. That belief can be sticky, and it can shrink lives.
The therapy access crisis makes the prescription path even more tempting
The tragedy is that many patients who actually need mental health support can’t get it, especially if they rely on insurance. Many therapists and psychologists don’t accept insurance anymore, and waitlists can be brutal.
So the system does what it always does when it can’t provide what people need: it substitutes what it can deliver quickly.
That means more meds.
And in the episode we make another point that almost never gets said out loud: replacing psychologists with prescription-first models doesn’t just change treatment, it changes outcomes.
SSRIs: not harmless, not universally helpful
Let’s talk plainly about SSRI risks.
These medications are often described to the public as gentle “chemical balance” tools. In real life, they can cause:
- sexual dysfunction
- weight gain
- sedation or agitation
- drug interactions
- increased falls (especially in older adults)
- GI bleeding risks in some contexts
They also carry a black box warning regarding increased risk of suicidal thinking and behavior in children, adolescents, and young adults. That warning exists for a reason.
To be clear: SSRIs can help some people. The issue is that our current screening-and-prescribe model pushes these drugs into situations where the underlying problem is loneliness, sleep deprivation, grief, social isolation, or a life that has become unlivable—not a serotonin deficiency.
COVID showed what real depression looks like... and why we don’t need a checkbox
When society locked down, isolated people, and fed them fear daily, it created a massive wave of suffering, especially in younger people. In the episode we talk about a painful idea: when you isolate and scare people, and then add medications that can worsen self-harm risk in susceptible populations, you can create a real mental health catastrophe.
A PHQ-9 didn’t reveal that. Life did.
And it should have forced a different lesson: mental health is deeply tied to community, meaning, sleep, movement, sunlight, and the ability to live like a human being, not just to prescriptions.
What actually helps: a more human model
If you’re a patient, or you’re a clinician who wants to practice real medicine, here’s a better approach than “score to prescription.”
1) Treat the person, not the score
If the PHQ-9 is positive, the next step should be a real conversation: context, timeline, stressors, sleep, isolation, and grief.
2) Don’t confuse sadness with depression
Sadness is normal. Grief is normal. Exhaustion is normal. The goal isn’t to medicate normal life.
3) Address the upstream drivers
For many people: sleep, movement, nutrition, sunlight, community, purpose, and reducing constant threat exposure (news/social feeds) move the needle more than a pill.
4) Use meds thoughtfully, when the situation truly fits
When depression is debilitating and persistent, medication can be part of a plan. But it shouldn’t be the default response to a checkbox.
How We Return to Healing
If you’ve ever taken a PHQ-9 depression screening and walked out with a diagnosis that didn’t feel like you, or a prescription that came faster than a conversation, this episode may feel familiar.
Watch the episode and share it with someone who’s been turned into a number.
Watch the episode on YouTube
Download the Full Transcript (PDF)
Download the full transcript of Episode 51 of the A Return to Healing Podcast.
Frequently Asked Questions (FAQ)
What is PHQ-9 depression screening?
PHQ-9 is a 9-question screening questionnaire used to assess depressive symptoms. In many settings it’s used as a required checkbox tool, including wellness visits, to standardize documentation and follow-up.
What is PHQ-2?
PHQ-2 is a shorter, 2-question screen that often serves as a quick first step before the full PHQ-9 is administered.
Does a positive PHQ-9 mean I definitely have depression?
Not necessarily. A positive score means symptoms were reported that correlate with depression, but context matters. Grief, poor sleep, chronic stress, pain, aging, and loneliness can all raise scores without indicating clinical depression.
Why is Medicare annual wellness visit depression screening required?
Many practices include it because it’s built into wellness-visit requirements and quality metrics. The concern is that required screening can become “numbers-based medicine” if it replaces relationship care and real conversation.
Are SSRIs safe?
SSRIs can be appropriate for some people, but they also have real risks and side effects, and they aren’t universally effective. They should be prescribed thoughtfully, with monitoring and a clear rationale.
What should I do if I’m struggling but don’t want medication?
Ask for a full conversation about what’s driving symptoms, and request non-medication supports: therapy (if accessible), sleep support, movement, community connection, stress reduction, and practical changes. If symptoms are severe or include self-harm thoughts, seek urgent help immediately.
Proofed by Dr. Andy Lazris
This post was reviewed for medical clarity and balance. The goal is to protect relationship-based care—and avoid turning normal human suffering into a score and a prescription.
