How should patients with elevated Patient Health Questionnaire (PHQ) 9 and Generalized Anxiety Disorder (GAD) 7 scores be managed?

PHQ-9 and GAD-7 Score Interpretation and Management

Score Interpretation

PHQ-9 (Depression) Scoring

The PHQ-9 uses the following severity categories based on total scores ranging from 0-27: 1

• 0-4: Minimal anxiety (no intervention needed)
• 5-9: Mild depression (supportive care and monitoring)
• 10-14: Moderate depression (consider low-intensity interventions)
• 15-19: Moderately severe depression (requires mental health referral)
• 20-27: Severe depression (immediate mental health referral required)

GAD-7 (Anxiety) Scoring

The GAD-7 uses the following severity categories based on total scores ranging from 0-21: 1

• 0-4: Minimal anxiety (no intervention needed)
• 5-9: Mild anxiety (supportive care and monitoring)
• 10-14: Moderate anxiety (consider low-intensity interventions)
• 15-21: Severe anxiety (requires mental health referral)

Critical Safety Assessment - ALWAYS FIRST

Regardless of total score, immediately assess item 9 of the PHQ-9 regarding thoughts of self-harm or being better off dead. 2, 3

• If ANY frequency is endorsed on item 9: Immediate referral for emergency psychiatric evaluation by a licensed mental health professional is mandatory, even if the total PHQ-9 score is low 1, 2
• Additional red flags requiring immediate referral: Risk of harm to others, severe agitation, psychosis, or confusion/delirium 1
• Never omit item 9 assessment - patients can have low total scores but still endorse suicidal ideation 2, 3

Management Algorithm by Score Range

Minimal Symptoms (PHQ-9: 0-4, GAD-7: 0-4)

No formal intervention required. 1

• Provide patient education about normal stress responses and the spectrum of depressive/anxiety symptoms 2
• Verify adequate coping skills and social support systems 2
• Schedule reassessment at future visits rather than initiating treatment 2

Mild Symptoms (PHQ-9: 5-9, GAD-7: 5-9)

Supportive care with scheduled monitoring, not formal treatment. 1, 2

• Educate patient about depression/anxiety and normalize their experience while validating concerns 2
• Identify pertinent history or specific risk factors (family history, prior psychiatric disorders, substance use, chronic illness, recent stressors) 1
• Do NOT initiate antidepressant medication or formal psychotherapy - this represents overtreatment of mild symptoms that typically respond to supportive care 2
• Plan repeat screening at 3,6, and 12 months, or during times of personal transition, family crisis, or changes in health status 2, 3

Moderate Symptoms (PHQ-9: 10-14, GAD-7: 10-14)

Consider low-intensity interventions and consultation with mental health professionals for diagnostic confirmation. 1, 3

• Conduct further diagnostic assessment to identify the nature and extent of symptoms and presence/absence of a mood or anxiety disorder 1
• Rule out medical or substance-induced causes (e.g., interferon administration, thyroid disorders, medication side effects) 1
• Low-intensity intervention options: 3
  • Individually guided self-help based on cognitive behavioral therapy (CBT) with behavioral activation
  • Structured physical activity programs
  • Problem-solving therapy
  • Pharmacologic treatment as appropriate
• Assess functional impairment (work, home responsibilities, interpersonal relationships) 1
• Consider comorbid anxiety diagnoses such as panic disorder or social phobia 1

Moderate to Severe/Severe Symptoms (PHQ-9: 15-27, GAD-7: 15-21)

Immediate referral to psychology and/or psychiatry for formal diagnosis and high-intensity treatment is mandatory. 1, 4

• Symptoms at this level interfere moderately to markedly with functioning 1, 4
• High-intensity interventions delivered by licensed mental health professionals: 3, 4
  • Individual psychological therapy using treatment manuals incorporating cognitive change, behavioral activation, and biobehavioral strategies
  • Cognitive behavioral therapy (CBT)
  • Education and relaxation techniques
  • Behavioral couples' therapy if patient has a regular partner and relationship issues contribute to symptoms 4
• The clinical team must decide when referral to a psychiatrist, psychologist, or equivalently trained professional is necessary 1
• Regularly reassess PHQ-9/GAD-7 scores to track treatment response 4

Screening Implementation Strategy

Phased Screening Approach

Use a two-step screening process to maximize efficiency: 3

1. Initial screen: Administer only the first two items of PHQ-9 (anhedonia and depressed mood) 3
2. If either item scores ≥2: Complete the full 9-item PHQ-9 questionnaire 3
3. If both items score 0-1: Screen is negative, no further assessment needed 3

Timing of Screening

Administer PHQ-9 and GAD-7 at: 3

• Initial diagnosis or start of treatment
• Regular intervals during treatment
• 3,6, and 12 months after treatment completion
• Times of personal transition or family crisis
• When approaching end of life in palliative care settings

Common Pitfalls to Avoid

Critical errors that compromise patient safety and care quality:

• Failing to assess item 9 on self-harm - this artificially lowers scores and misses critical risk information 2, 3
• Initiating antidepressants or formal psychotherapy for scores <10 - represents overtreatment of mild symptoms 2
• Not completing the full PHQ-9 when initial screening items suggest depression 3
• Underestimating the severity of scores ≥15 - this represents significant clinical depression requiring professional intervention 4
• Using PHQ-9 in patients with cognitive impairment - the scale loses accuracy in this population; use alternative assessment methods like informant-based tools 3
• Failing to use culturally sensitive assessments when appropriate, or to tailor evaluation for patients with learning disabilities 3

Special Considerations

Correlation Between PHQ-9 and GAD-7

The two scales show substantial correlation (Spearman's rho = 0.74), with 78.4% of concurrent scores within 4 points of each other. 5

• Depression and anxiety commonly co-occur 5
• 56.4% of score pairs fall into the same severity class 5
• Both scales should still be administered as they provide complementary information about symptom burden 5

Diagnostic Accuracy

The PHQ-9 has strong diagnostic validity with 89.5% sensitivity and 77.5% specificity at a cut-off score of 11 for detecting major depressive disorder. 4

• A cut-off of ≥10 for PHQ-9 results in 71% sensitivity and 66% specificity for recognizing patients at increased risk 6
• A cut-off of ≥9 for GAD-7 results in 73% sensitivity and 70% specificity for recognizing patients at risk 6
• Due to low specificity and high false positive rates, both scales are recommended only as initial screening tools; positive cases should be assessed using more comprehensive instruments 6

Generalized Anxiety Disorder Presentation

Patients with GAD may not present with obvious anxiety symptoms. 1

• The pathognomonic GAD symptom (multiple excessive worries) may present as "concerns" or "fears" 1
• GAD worry or fear may be disproportionate to actual risk (e.g., excessive fear of recurrence, worry about multiple symptoms not associated with current condition) 1
• Consider possible comorbid anxiety diagnoses such as panic disorder, social phobia, or PTSD 1