Assessment of depression prevalence in primary care settings in Jhapa, Nepal, reveals significant insights into mental health challenges faced in low- and middle-income countries. A total of 1,897 adult patients aged 18–91 participated in the study, with 14.5% meeting the threshold for depression based on the Patient Health Questionnaire (PHQ-9) score. The most frequently reported symptoms included loss of energy and sleep difficulties, with only a small percentage of individuals meeting the DSM-5 criteria for depression when evaluated against hallmark symptoms. The findings indicate that reliance on total scores from screening tools like the PHQ-9 could overestimate prevalence rates and lead to false positives. Emphasizing the identification of hallmark symptoms may improve the accuracy of diagnosis and better allocate treatment resources in primary care settings.