What score on the Patient Health Questionnaire-9 (PHQ-9) indicates a positive depression screening?

PHQ-9 Positive Depression Screening Threshold

A PHQ-9 score of 8 or higher indicates a positive depression screening and warrants clinical intervention. 1, 2

Evidence-Based Cutoff Score

The American Society of Clinical Oncology guideline specifically recommends a cutoff score of 8 rather than the traditional cutoff of 10, based on diagnostic accuracy studies in cancer outpatients and supported by meta-analysis data. 1, 2 This lower threshold improves sensitivity for detecting clinically significant depression while maintaining acceptable specificity. 1

Phased Screening Approach

Initial Two-Item Screen:

• Begin with the first two PHQ-9 items assessing anhedonia ("Little interest or pleasure in doing things") and depressed mood ("Feeling down, depressed, or helpless"). 1, 2
• If either item scores 2 or higher (occurring "more than half the days" or "nearly every day"), complete the full 9-item PHQ-9. 1
• If both items score 0-1, no further screening is needed. 1, 2

This phased approach reduces burden, as only 25-30% of patients require completion of the full questionnaire. 1

Score Interpretation and Clinical Action

Score 1-7 (Minimal/Mild):

• No or minimal symptoms of depression 1, 2
• Effective coping skills and social support typically present 1, 2
• No formal treatment required, but provide patient education and schedule reassessment 2, 3

Score 8-14 (Moderate):

• Subthreshold depressive symptoms with mild to moderate functional impairment 1, 2
• Seek consultation with psychology or psychiatry for diagnostic confirmation 1
• Consider low-intensity interventions: guided self-help based on cognitive behavioral therapy, structured physical activity programs, or pharmacologic treatment 2, 4

Score 15-19 (Moderately Severe):

• Most depressive symptoms present with moderate to marked functional interference 1, 2
• Mandatory referral to psychology and/or psychiatry for diagnosis and treatment 1, 2

Score 20-27 (Severe):

• Severe symptomatology with significant functional impairment 1, 2
• Immediate referral to psychology and/or psychiatry required 1, 2

Critical Safety Assessment

Never omit Item 9 regarding self-harm thoughts ("Thoughts that you would be better off dead or hurting yourself in some way"). 1, 2

• If any self-harm ideation is endorsed at any frequency, immediate referral for emergency psychiatric evaluation is mandatory regardless of total PHQ-9 score. 1, 2, 3
• Facilitate a safe environment and one-to-one observation if self-harm risk is present. 1, 2
• Omitting this item artificially lowers scores and misses critical risk information, weakening the predictive validity of the assessment. 1, 2

Common Pitfalls to Avoid

• Do not use the traditional cutoff of 10—the evidence-based threshold of 8 detects more cases of clinically significant depression. 1, 2
• Do not fail to complete the full PHQ-9 if either of the first two items scores ≥2. 1, 2
• Do not underestimate scores in the 8-14 range—these represent clinically significant depression requiring active intervention, not just watchful waiting. 2, 4
• Do not omit the self-harm assessment even with low total scores, as patients can have minimal overall symptoms but still endorse suicidal ideation. 1, 2, 3

Special Considerations

• Use culturally sensitive assessments when possible and tailor evaluation for patients with learning disabilities or cognitive impairments. 1, 2
• The PHQ-9 loses accuracy in patients with significant cognitive impairment; consider alternative assessment methods in this population. 2
• Assess associated sociodemographic factors, psychiatric or health comorbidities, social impairments, and duration of depressive symptoms when interpreting scores. 1, 2

Screening Timing

Administer the PHQ-9 at:

• Initial diagnosis or start of treatment 1, 2
• Regular intervals during treatment 1, 2
• 3,6, and 12 months after treatment completion 1, 2
• Diagnosis of recurrence or progression 1
• Times of personal transition, family crisis, or changes in health status 1, 2
• When approaching end of life in palliative care settings 2