At Alameda Health System (AHS) our patients’ mental, emotional and physical health are equally important and integrated components of their total health and wellbeing5.  That’s why AHS is taking a proactive and patient-centered approach to screen and monitor patients for depression.  

“Depression is a common problem that has effective treatment options like medication and therapy which highlights the importance of evaluating and diagnosing patients as a critical first step,” said Karen Wise, PsyD, director of behavioral health. “Unfortunately, most people with depression do not receive the care they need, and minority racial and ethnic groups are even less likely to receive care than their white counterparts.” 

As a result, Wise and her colleagues formed a work group to develop a strategy for identifying patients with depression and improving their quality of care. The strategy focuses on three core elements: annual behavioral health screening in primary care, integrated behavioral health service and depression reassessment.  

Depression screening is fully implemented in primary care throughout AHS and all primary care patients 12 years and older are screened at least once annually. To date, approximately 75% of patients have been screened this year.   

The screening process is facilitated as a self-administered, diagnostic screening instrument, the PHQ-9 that was developed by team of physicians at Columbia University with a Pfizer grant.  It is the most widely implemented diagnostic tool used by health care professionals for monitoring depression severity in a primary care setting. The nine item questionnaire is currently available for AHS patients in English, Spanish, Chinese, Tigrinya and Arabic among other languages.  

Wise shared that primary care providers have several treatment options for a positive patient screen. They may prescribe medication, consult with a psychiatrist, initiate a warm hand off to the behavioral health staff in the clinic or order a referral to the AHS behavioral health program.  All positive screens are re-screened within four to eight months to see if the patient’s symptoms have improved and determine next steps.   

Some patients with mild to moderate symptoms are treated internally with short-term therapy while others are connected to programs in the community. Leveraging the power of community, AHS behavioral health connects patients with various community partners for mental health services, intervention and prevention programs including Cultura y Bienestar, Crisis Support Services of Alameda County and Open Source Wellness.  

Connecting with patients for follow-up depression reassessments can be challenging but AHS is taking a two-pronged approach that includes both in-reach and outreach efforts.  For example, patients who register at an AHS location are given the PHQ-9 to complete. The provider reviews the results and takes additional action as needed. In addition, community health workers call patients who are due to repeat the PHQ-9 and also link patients to local integrated behavioral health (IBH) teams and primary care services as needed. 

“Through the dedication of AHS providers, staff and community partners we continue to help patients manage depression in support of their overall health and well-being,” said Wise.  

During the holiday season many people can experience feelings of anxiety or depression and it is important to take care of yourself and connect with friends and family. If you or someone you know are experiencing signs of depression, contact your primary care provider or for a mental health emergency contact: 

  • Crisis Support Services of Alameda County 24 Hour Crisis Line: 1-800-309-2131 
  • National Suicide and Crisis Lifeline: 988 


Visit the National Institute of Mental Health (NIMH) for signs and symptoms of depression.