How to Use the PHQ-9

For providers feeling stuck when treating clients with depression symptoms, there are tools that can help. The PHQ-9 or Patient Health Questionnaire-9 is a short depression screener that people can answer on their own. 

Coupled with its ease of use and scoring, the PHQ-9 is the gold standard in depression screening tools. Studies have shown that the PHQ-9 is widely recognized to have good reliability and validity.

Background information

The PHQ-9 pulls questions from the first assessment tool used by primary care providers, the Primary Care Evaluation of Mental Disorders or PRIME-MD. Primary care providers use the 26 questions from the PRIME-MD to assess mental health disorders.  

The Patient Health Questionnaire derives from the PRIME-MD and was created as a version that people could self-administer, without a clinician guiding them. Like the PRIME-MD, it covers several mental health symptoms someone might experience. The “9” in the this particular assessment’s title refers to the number of questions about depression in the PHQ. These questions are designed to address symptoms of depression noted in the Diagnostic and Statistical Manual V.

Developed in 1999 by Drs. R.L. Spitzer, J.B.W. Williams, and K. Kroenke, it was copyrighted in the same year by Pfizer. However, the PHQ-9 can be printed, distributed, and used without copyright infringement, allowing it to widely help providers and their clients.  

More recently, another question was added to the end of the questionnaire. The last question measures how difficult people’s daily lives are with these symptoms. 

Scoring

The PHQ-9 asks people to think how they’ve been feeling the past 2 weeks. They then rate how frequently they’ve been bothered by these problems on a scale from 0 to 3: 

• 0 — Not at all
• 1 — Several days
• 2 — More than half the days
• 3 — Nearly every day

The questions are:

Over the last 2 weeks, how often have you been bothered by any of the following problems? 

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 

Once the assessment is completed, answer scores are added together. The following scale is used to determine the severity of depression symptoms:

• 0 to 4 — No depression indicated
• 5 to 9 — Mild depression
• 10 to 14 — Moderate depression
• 15 to 19 — Moderately severe depression
• 20 to 27 — Severe depression

Treatment and next steps

The assessment scores inform treatment planning and interventions in several different ways. Here’s some general guidelines based on each score. 

Score of 0 to 4 — No depression indicated

No interventions required.

Score of 5 to 9 — Mild depression

Treatment should include education about symptoms and ongoing monitoring.

Score of 10 to 14 — Moderate depression

Treatment should include education about symptoms. Therapy services are suggested and medication could also be suggested.

Score of 15 to 19 — Moderately severe depression

Therapy services are highly encouraged. Medication is also highly encouraged. Treatment should also incorporate monitoring the client for worsening symptoms. 

Score of 20 to 27 — Severe depression

Therapy and medication are highly encouraged. Treatment should also incorporate  monitoring the client for worsening symptoms and safety planning for possible suicidal ideation. (Our clinical team has standards and guides for all providers to do safety planning.)

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Monitoring client progress

When clients first join UpLift, they receive the PHQ-9. As they continue therapy, they continue receiving the assessment to help their providers track the efficacy of the treatment. 

Ideally, their scores reduce by 5 points with consistent, engaged treatment at the time of the follow-up assessment. If PHQ-9 scores don’t drop by 5 points or more, then the provider should talk to the client about altering the treatment plan. That may include taking a different theoretical approach to treatment, increasing session frequency, doing additional homework between sessions as well as a medication consult. 

Talking with the client about their PHQ-9 scores should be a routine part of treatment. This includes providers encouraging clients to complete the PHQ-9 when they receive it. It’s quick to do and is one of the best indicators of treatment efficacy for depression symptoms. 

A popular and effective treatment approach for working with clients struggling with depression is Cognitive Behavioral Therapy or CBT. It can bring clients relief by helping them understand the links between thoughts and feelings, and can be effective in relatively few sessions.  

For clients with depression, it’s important to consider combining therapy with medication. As stated above, providers treating clients whose scores showed moderately severe to severe depression should speak to their clients about getting a psychiatric consultation.