The Patient Health Questionnaire 9 (PHQ-9) is the depression scale from Patient Health Questionnaire (PHQ). It is used for assessing and monitoring depression severity.
The Patient Health Questionnaire (PHQ) is a diagnostic tool used by healthcare professionals to quickly and easily identify mental health disorders in patients. It was developed in the mid-1990s by Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, and colleagues at Columbia University in collaboration with researchers at the Regenstrief Institute at Indiana University, and with the support of Pfizer Inc. The PHQ is a self-administered version of the Primary Care Evaluation of Mental Disorders (PRIME-MD), and contains modules on various mental health disorders, including mood, anxiety, alcohol, eating, and somatoform disorders. The PHQ-9, a specific tool for identifying depression, scores DSM-IV criteria for the disorder based on the mood module from PRIME-MD.
The PHQ-9 has been validated for ages 13 years and above.
The PHQ-9 instructions include;
- Over the last 2 weeks, how often have you been bothered by any of the following problems?
The PHQ-9 consists of 9 questions that ask about the frequency of certain symptoms of depression over the past two weeks.
|1||Little interest or pleasure in doing things|
|2||Feeling down, depressed, or hopeless|
|3||Trouble falling or staying asleep, or sleeping too much|
|4||Feeling tired or having little energy|
|5||Poor appetite or overeating|
|6||Feeling bad about yourself — or that you are a failure or have let yourself or your family down|
|7||Trouble concentrating on things, such as reading the newspaper or watching television|
|8||Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual|
|9||Thoughts that you would be better off dead or of hurting yourself in some way|
Each question on the PHQ-9 has 4 answer options;
- Not at all
- Several days
- More than half the days
- Nearly every day
PHQ-9 Scoring and Interpretation
This is calculated by assigning scores of 0, 1, 2, and 3, to the response categories of ―not at all, ―several days, ―more than half the days, and ―nearly every day, respectively. PHQ-9 total score for the nine items ranges from 0 to 27. Scores of 5, 10, 15, and 20 represent cut-points for mild, moderate, moderately severe and severe depression, respectively. Sensitivity to change has also been confirmed.
|PHQ-9 Score||Depression Severity|
|0 – 4||None-Minimal|
|5 – 9||Mild|
|10 – 14||Moderate|
|15 – 19||Moderately Severe|
|20 – 27||Severe|
Here is a screenshot of response sheet/score sheet of PHQ-9 generated by PsyPack;
Major Depressive Disorder Diagnosis
The criteria for Major Depressive Syndrome are met since if item 1 or 2 and five or more of item 1-9 are at least ―More than half the days. Note that item 9, suicidal ideation, is counted whenever it is present.
Other Depressive Disorder Diagnosis
The criteria for Other Depressive Syndrome are met since if item 1 or 2 and two, three, or four of item 1-9 are at least ―More than half the days. Note that item 9, suicidal ideation, is counted whenever it is present.
Special attention must be paid to the responses to item 9 as indicator of possible risk of self-harm.
Here is a screenshot of results of PHQ-9 automatically produced by PsyPack;
Practitioner’s guide – Important considerations
Since the questionnaire relies on client self-report, all responses should be verified by the clinician, and a definitive diagnosis is made on clinical grounds taking into account how well the client understood the questionnaire, as well as other relevant information from the client.
Cutpoint of 10 or greater is considered a “yellow flag” (i.e., drawing attention to a possible clinically significant condition), while a cutpoint of 15 is a “red flag” (i.e., targeting individuals in whom active treatment is probably warranted).
Diagnosis of Major Depressive Disorder or Other Depressive Disorder also require impairment of social, occupational, or other important areas of functioning (Question #10) and ruling out normal bereavement, a history of a Manic Episode (Bipolar Disorder), a physical disorder and medication, or other drug as the biological cause of the depressive symptoms.
Endorsement of item 9 (Suicidal Thoughts) is an indicator of possible suicidal risk. A final decision about the actual risk of self-harm requires further assessment and clinical interview. Further assessment of suicide risk can be made by asking about the “4 P’s”: past suicide attempts, a plan, probability of completing suicide, and preventive factors. You can use the Columbia-Suicide Severity Rating Scale (C-SSRS), which is also available on PsyPack, to assess risk of self-harm.
The final question on the PHQ-9 asks the clients to report ―how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? This single client-rated difficulty item is not used in calculating the PHQ-9 score or diagnosis but rather represents the patient‘s global impression of symptom-related impairment. It may be useful in decisions regarding initiation of or adjustments to treatment since it is strongly associated with both psychiatric symptom severity as well as multiple measures of impairment and health-related quality of life.
Sensitivity to change for monitoring treatment outcomes: A particularly important use of a measure is its responsiveness to changes of condition severity over time. This is well- established for the PHQ-9 which is increasingly used as a measure to assess the level of depression severity (for initial treatment decisions) as well as an outcome tool (to determine treatment response). PsyPack can help you easily track treatment progress. Here is a screenshot of Track Progress graph;
After making a provisional diagnosis with the PHQ-9, there are additional clinical considerations that may affect decisions about management and treatment.
- Have current symptoms been triggered by psychosocial stressor(s)?
- What is the duration of the current disturbance and has the patient received any treatment for it?
- To what extent are the patient’s symptoms impairing his or her usual work and activities?
- Is there a history of similar episodes, and were they treated?
- Is there a family history of similar conditions?
You can easily conduct the PHQ-9 online with PsyPack assessments.
If you are a therapist, PsyPack can help you conduct psychological assessments via tele-health easily. PsyPack is an online software to help psychologists, therapists, social workers and counselors, administer psychological tests online to their clients, score tests automatically, and prepare detailed reports in a fraction of second. It helps you store your clinical records of your testing in a HIPAA compliant manner.
PsyPack comes pre-loaded with numerous standardised psychological tests. And, the PHQ-9 is available in the free forever Beginner Plan of PsyPack. Try PsyPack now;
- Official Website
- Spitzer RL, Kroenke K, Williams JBW, for the Patient Health Questionnaire Primary Care Study Group. Validation and utility of a self-report version of PRIME-MD: the PHQ Primary Care Study. JAMA 1999;282:1737-1744.
- Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: validity of a brief depression severity measure. Journal of general internal medicine, 16(9), 606–613.
- Richardson, L. P., McCauley, E., Grossman, D. C., McCarty, C. A., Richards, J., Russo, J. E., Rockhill, C., & Katon, W. (2010). Evaluation of the Patient Health Questionnaire-9 Item for detecting major depression among adolescents. Pediatrics, 126(6), 1117–1123.