When are the Patient Health Questionnaire (PHQ)-9 and Generalized Anxiety Disorder (GAD)-7 assessments performed on an inpatient unit?

Timing of PHQ-9 and GAD-7 Administration on Inpatient Units

On inpatient units, the PHQ-9 and GAD-7 should be administered at admission, daily during the hospital stay, and at discharge, with additional screening triggered by clinical changes in disease status, treatment transitions, or patient distress. 1

Initial Screening Protocol

• Administer both PHQ-9 and GAD-7 at admission to establish baseline depression and anxiety symptom burden for all inpatients 1
• Screen using valid, reliable measures with established cutoffs (PHQ-9 cutoff ≥8 for depression; GAD-7 cutoff ≥8 for anxiety) 1, 2
• Use a phased approach: start with the 2-item PHQ-9 screening questions (anhedonia and depressed mood), and if patients score ≥2, complete the full 9-item questionnaire 1

Ongoing Inpatient Monitoring

• Rescreen daily for inpatients to monitor symptom trajectory and treatment response 1
• The daily screening approach is specifically endorsed for hospitalized patients to capture rapid clinical changes 1
• Document screening results automatically in the electronic medical record or via chart entry by clinical staff 1

Trigger-Based Screening

Beyond routine daily screening, administer PHQ-9 and GAD-7 when:

• Changes in disease status occur (diagnosis of recurrence, progression, or new complications) 1
• Treatment transitions happen (starting new treatments, transitioning to palliative care, approaching end-of-life care) 1
• Clinical deterioration is observed (increased pain, functional decline, new symptoms) 1
• Personal crises emerge (family crisis, significant life transitions, or periods of reappraisal) 1

Personnel and Administration Methods

• Nurses, medical assistants, and social workers most commonly administer these screens on inpatient units 1
• Administration can be via paper-and-pencil (52% of institutions), electronic tablet/computer (52%), or in-person interview (30%) 1
• Results trigger automatic triage at some institutions (33%) or manual review and referral by clinical staff (67%) 1

Critical Safety Considerations

• Immediately assess item 9 of the PHQ-9 (thoughts of self-harm) regardless of total score 1, 3, 4
• If any suicidal ideation is endorsed, immediate referral for emergency psychiatric evaluation is mandatory, with one-to-one observation and interventions to ensure a safe environment 1
• Do not omit item 9 from the PHQ-9, as this artificially lowers scores and weakens predictive validity, though some institutions choose to do so 1

Score Interpretation and Action Thresholds

For PHQ-9 scores:

• 1-7 (minimal/mild): No formal treatment needed; provide patient education, verify coping skills, and plan reassessment 4
• 8-14 (moderate): Seek consultation with psychology or psychiatry for diagnostic confirmation 1
• 15-27 (moderate-severe to severe): Immediate referral to psychology/psychiatry for diagnosis and treatment 1, 3

For GAD-7 scores:

• ≥8: Indicates clinically significant anxiety requiring further assessment 2
• ≥10: Higher specificity for generalized anxiety disorder, though lower sensitivity 2

Common Pitfalls to Avoid

• Do not fail to rescreen inpatients daily, as symptom burden can change rapidly during hospitalization 1
• Never skip assessment of suicidal ideation (PHQ-9 item 9), even when total scores are low, as patients can have low overall scores but still endorse self-harm thoughts 1, 4
• Avoid using only the total score without reviewing individual item endorsements, particularly the self-harm item 1
• Do not initiate treatment based solely on screening scores without comprehensive clinical assessment, as these are screening tools, not diagnostic instruments 5, 6

Practical Implementation Notes

• The PHQ-9 and GAD-7 show strong correlation (Spearman's rho = 0.74), with 78.4% of concurrent scores within 4 points of each other 7
• Both measures demonstrate excellent internal consistency and reliability in various populations 8, 5, 6
• Follow-up screening should continue at discharge and at subsequent outpatient visits (every 30-90 days or at clinical triggers) 1