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    Attention COACH STUDY participants:

    The principal investigators of the study request that you use the official version of the modified score here.

    PHQ-9 (Patient Health Questionnaire-9)

    Objectifies degree of depression severity.
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    When to Use
    Pearls/Pitfalls
    Why Use

    Use as a screening tool:

    • To assist the clinician in making the diagnosis of depression.
    • To quantify depression symptoms and monitor severity.
    • The Patient Health Questionnaire (PHQ)-9 is the major depressive disorder (MDD) module of the full PHQ.
    • Used to provisionally diagnose depression and grade severity of symptoms in general medical and mental health settings.
    • Scores each of the 9 DSM criteria of MDD as “0” (not at all) to “3” (nearly every day), providing a 0-27 severity score.
    • The last item (“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?”) is not included in score, but is a good indicator of the patient’s global impairment and can be used to track treatment response.
    • Higher PHQ-9 scores are associated with decreased functional status and increased symptom-related difficulties, sick days, and healthcare utilization.
    • May have high false-positive rates in primary care settings specifically (one meta-analysis found that only 50% of patients screening positive actually had major depression) (Levis 2019).

    Objectively determines severity of initial symptoms, and also monitors symptom changes and treatment effects over time.

    Ask the patient: how often have they been bothered by the following over the past 2 weeks?
    Not at all
    0
    Several days
    +1
    More than half the days
    +2
    Nearly every day
    +3
    Not at all
    0
    Several days
    +1
    More than half the days
    +2
    Nearly every day
    +3
    Not at all
    0
    Several days
    +1
    More than half the days
    +2
    Nearly every day
    +3
    Not at all
    0
    Several days
    +1
    More than half the days
    +2
    Nearly every day
    +3
    Not at all
    0
    Several days
    +1
    More than half the days
    +2
    Nearly every day
    +3
    Not at all
    0
    Several days
    +1
    More than half the days
    +2
    Nearly every day
    +3
    Not at all
    0
    Several days
    +1
    More than half the days
    +2
    Nearly every day
    +3
    Not at all
    0
    Several days
    +1
    More than half the days
    +2
    Nearly every day
    +3
    Not at all
    0
    Several days
    +1
    More than half the days
    +2
    Nearly every day
    +3

    Result:

    Please fill out required fields.

    Next Steps
    Evidence
    Creator Insights

    Advice

    Final diagnosis should be made with clinical interview and mental status examination including assessment of patient’s level of distress and functional impairment.

    Management

    PHQ-9 Management Summary

    Score Depression severity Comments
    0-4 Minimal or none Monitor; may not require treatment
    5-9 Mild Use clinical judgment (symptom duration, functional impairment) to determine necessity of treatment
    10-14 Moderate
    15-19 Moderately severe Warrants active treatment with psychotherapy, medications, or combination
    20-27 Severe

    Critical Actions

    • Perform suicide risk assessment in patients who respond positively to item 9 “Thoughts that you would be better off dead or of hurting yourself in some way.”
    • Rule out bipolar disorder, normal bereavement, and medical disorders causing depression.

    Formula

    Addition of the selected points.

    Facts & Figures

    The PHQ-9 is a validated, 9-question tool to assess for the degree of depression present in an individual; the last question is not scored, but is useful functionally to help the clinician assess the impact of the patient's symptoms on his or her life.

    Evidence Appraisal

    The PHQ-9 was initially developed by Kroenke et al (2001), as a subset of 9 questions from the full PHQ, which had previously been derived and studied in a cohort of 6,000 patients in 8 primary care clinics and 7 obstetrics-gynecology clinics (Spitzer 1999). PHQ-9 scores ≥10 were found to be 88% sensitive and also 88% specific for detecting MDD. Criterion validity was also assessed in a sample of 580 patients.

    Arroll et al (2010) validated the PHQ-9 as a screener for MDD in a cohort of 2,642 primary care patients and found slightly higher specificity (91%) and lower sensitivity (74%) at the same cutoff of 10 points.

    The PHQ-9 has also been validated in several additional subpopulations, including in psychiatric patients (Beard 2016), patients with medical comorbidities such as multiple sclerosis (Ferrando 2007) and Parkinson’s disease (Chagas 2013), pregnant patients (Sidebottom 2012), and in an occupational health setting (Volker 2016).

    A meta-analysis of 29 studies including 6,725 patients found similar sensitivity (88%, 95% CI 83-92%) and specificity (85%, 95% CI 82-88%) for a cutoff of ≥10 as did the previous studies, both overall and for subgroups. Notably, they found that when used in the primary care setting, only approximately 50% of patients screening positive on the PHQ-9 in fact had major depression (Levis 2019).

    Literature

    Validation

    Research PaperArroll B, Goodyear-Smith F, Crengle S, Gunn J, Kerse N, Fishman T, Falloon K, Hatcher S. Validation of PHQ-2 and PHQ-9 to screen for major depression in the primary care population. Ann Fam Med. 2010 Jul-Aug;8(4):348-53. doi: 10.1370/afm.1139. PubMed PMID: 20644190; PubMed Central PMCID: PMC2906530.Research PaperChagas MH, Tumas V, Rodrigues GR, et al. Validation and internal consistency of Patient Health Questionnaire-9 for major depression in Parkinson's disease. Age Ageing. 2013;42(5):645-9.Research PaperVolker D, Zijlstra-Vlasveld MC, Brouwers EP, et al. Validation of the Patient Health Questionnaire-9 for Major Depressive Disorder in the Occupational Health Setting. J Occup Rehabil. 2016;26(2):237-44.Research PaperFerrando SJ, Samton J, Mor N, et al. Patient Health Questionnaire-9 to Screen for Depression in Outpatients With Multiple Sclerosis. International Journal of MS Care: 2007;9(3):99-103.Research PaperBeard C, Hsu KJ, Rifkin LS, et al. Validation of the PHQ-9 in a psychiatric sample. J Affect Disord. 2016;193:267-73.Research PaperSidebottom AC, Harrison PA, Godecker A, Kim H. Validation of the Patient Health Questionnaire (PHQ)-9 for prenatal depression screening. Arch Womens Ment Health. 2012;15(5):367-74.Research PaperLevis B, Benedetti A, Thombs BD. Accuracy of Patient Health Questionnaire-9 (PHQ-9) for screening to detect major depression: individual participant data meta-analysis. BMJ. 2019;365:l1476.
    Dr. Kurt Kroenke

    About the Creator

    Kurt Kroenke, MD, is a professor of medicine at the Indiana University School of Medicine and Director of the Career Development, Education and Research Training (CERT) program for the Indiana Clinical and Translational Sciences Institute (CTSI). He has won numerous grants for his research in pain, depression, and anxiety. He has over 300 peer-reviewed research publications.

    To view Dr. Kurt Kroenke's publications, visit PubMed

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    About the Creator
    Dr. Kurt Kroenke
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