How do you administer the Patient Health Questionnaire (PHQ)-9?

How to Administer the PHQ-9 Depression Screening Tool

The PHQ-9 is administered by having patients self-report the frequency of nine depressive symptoms over the past two weeks, with each item scored 0-3 based on frequency, and a total score range of 0-27 that categorizes depression severity. 1

Step-by-Step Administration Process

Initial Screening with PHQ-2

1. Begin with the first two questions of the PHQ-9 (the PHQ-2):

   • "Over the last 2 weeks, how often have you been bothered by little interest or pleasure in doing things?" (anhedonia)
   • "Over the last 2 weeks, how often have you been bothered by feeling down, depressed, or hopeless?" (depressed mood) 2

2. Score each question on a scale of 0-3:

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

3. If the patient scores ≥2 on either question (or both), proceed to administer the full PHQ-9 2

Full PHQ-9 Administration

1. Have the patient complete the remaining seven questions of the PHQ-9, rating the frequency of each symptom over the past two weeks:

   • Trouble sleeping or sleeping too much
   • Feeling tired or having little energy
   • Poor appetite or overeating
   • Feeling bad about yourself or that you're a failure
   • Trouble concentrating
   • Moving or speaking slowly, or being fidgety/restless
   • Thoughts of being better off dead or hurting yourself 4

2. Use the same 0-3 scoring scale for each item:

   • 0 = Not at all
   • 1 = Several days
   • 2 = More than half the days
   • 3 = Nearly every day 4

3. Calculate the total score by summing all nine items (range: 0-27) 4

Interpreting PHQ-9 Scores

• 1-4: Minimal or no depression
• 5-9: Mild depression
• 10-14: Moderate depression
• 15-19: Moderately severe depression
• 20-27: Severe depression 1, 4

Clinical Decision-Making Based on Scores

• Score 1-7: No intervention required; patient likely has effective coping skills
• Score 8-14: Consider consultation with psychology/psychiatry; evaluate for subthreshold depressive symptoms
• Score 15-19: Refer to psychology/psychiatry for diagnosis and treatment
• Score 20-27: Urgent referral for psychiatric evaluation 1

Important Administration Considerations

1. Do not omit the self-harm question (item 9). Omitting this question artificially lowers the score and may miss critical safety concerns 1

2. Assess risk immediately if the patient endorses any frequency of self-harm thoughts. If at risk of harm to self or others, provide emergency evaluation by a licensed mental health professional 2

3. Consider relevant history and risk factors when interpreting scores:

   • Prior mood disorders
   • Comorbid anxiety or substance use
   • Chronic illnesses
   • Social factors (being single, unemployed, low financial resources) 1

4. Be aware that PHQ-9 accuracy decreases in patients with cognitive impairment 2

Follow-up and Monitoring

1. Schedule follow-up within 2 weeks to assess treatment response, side effects, and suicidal thoughts/behaviors 1

2. Continue regular monitoring on a monthly basis, using the PHQ-9 to objectively measure response 1, 5

3. Target a 50% reduction in PHQ-9 score or achievement of score <5 (remission) 1

4. Re-administer the PHQ-9 at key timepoints:

   • Initial diagnosis
   • Regular intervals during treatment
   • 3,6, and 12 months after treatment
   • At diagnosis of recurrence or progression
   • During times of personal transition 2, 1

Common Pitfalls to Avoid

• Underutilization: The PHQ-9 is often underused for monitoring patients being treated for depression 6

• Inconsistent follow-up: Regular monitoring improves outcomes in depression treatment 6

• Omitting the self-harm question: This weakens the validity of the score and may miss critical safety concerns 1

• Relying solely on clinical impression: The PHQ-9 provides objective measurement of symptom severity 7

• Focusing only on total score: Individual item responses, especially item 9 on self-harm, provide important clinical information 1