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Integrating PHQ-9 and GAD-7 Screening to Improve Early Behavioral Health Intervention in Rural Primary Care
Dissertation   Open access

Integrating PHQ-9 and GAD-7 Screening to Improve Early Behavioral Health Intervention in Rural Primary Care

Brandi R Claypool-Vercande
University of Iowa
Doctor of Nursing Practice (DNP), University of Iowa
Spring 2026
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Abstract

Background: Depression and anxiety are highly prevalent mental health conditions, affecting nearly 20% of U.S. adults annually and contributing to significant morbidity and suicide risk, particularly among adolescents and young adults. The U.S. Preventive Services Task Force recommends routine screening for depression in adolescents and adults and for anxiety in children, adolescents, and adults when systems are in place to ensure appropriate follow-up. Despite these recommendations, behavioral health conditions remain underidentified in rural primary care due to inconsistent screening practices, limited access to services, and structural barriers. At the project site, screening primarily relied on annual PHQ-2 administration, with an average completion rate of 29.7%, minimal PHQ-9 follow-up, and no routine anxiety screening, highlighting a gap in comprehensive behavioral health identification. Purpose: This quality improvement project aimed to improve early identification and management of depression and anxiety among patients aged 13–44 years through implementation of universal PHQ-9 and GAD-7 screening and a structured Behavioral Health Intervention Tool. Methods: Guided by the Knowledge-to-Action framework and the Iowa Model for Evidence-Based Practice, universal screening was implemented at all eligible encounters over 12 weeks (July–September 2025). Screening completion, intervention documentation, and changes in symptom severity among patients with repeat screenings were analyzed using descriptive statistics. Historical organizational data (2022–2024), reflecting PHQ-2 use, were reviewed for contextual comparison. Findings: Of 284 eligible encounters, 226 included completed PHQ-9 and GAD-7 screenings (79.6%), exceeding the project benchmark of 50%. Historical PHQ-2 screening averaged 29.7% with limited follow-up and no routine anxiety screening. Intervention documentation averaged 97%, exceeding the 70% benchmark. Among patients with repeat screenings available for comparison (n = 16), 63% demonstrated improvement in both PHQ-9 and GAD-7 scores, with reductions of two to three and approximately two points, respectively. Discussion: Implementation of universal screening with a structured intervention approach improved screening completion and consistency of follow-up. Findings support the feasibility of integrating standardized behavioral health screening into rural primary care and reinforce the role of early identification in enabling timely, appropriate intervention.
 behavioral health screening PHQ-9 GAD-7 rural primary care quality improvement depression anxiety

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