What is the interpretation and recommended treatment for a patient with a Patient Health Questionnaire-9 (PHQ-9) score of 11, indicating moderate to severe depression?

PHQ-9 Score of 11: Moderate Depression Requiring Active Intervention

A PHQ-9 score of 11 falls within the moderate depression range (8-14) and requires active treatment with either low-intensity psychological interventions or pharmacologic therapy, combined with referral to psychology or psychiatry for diagnostic confirmation. 1, 2

Immediate Safety Assessment

Before proceeding with treatment planning, you must assess item 9 of the PHQ-9 regarding self-harm thoughts:

• If any self-harm ideation is endorsed, immediately refer for emergency psychiatric evaluation regardless of the total score of 11 2, 3
• Facilitate a safe environment with one-to-one observation if self-harm risk is present 1
• The frequency and specificity of self-harm thoughts are most critical for risk assessment 2

Clinical Significance of Score 11

This score indicates:

• The patient has most depressive symptoms with functional impairment ranging from mild to moderate 1, 2
• Symptoms interfere with work, relationships, and daily activities but may not meet full DSM-IV criteria for major depressive disorder 3
• This represents clinically significant depression requiring active treatment, not watchful waiting 3

Diagnostic Assessment Steps

Before initiating treatment, complete the following evaluation:

• Identify pertinent history including prior mood disorders, comorbid anxiety disorders, substance use, and chronic medical illnesses 1
• Rule out medical and substance-induced causes: check thyroid function, complete metabolic panel, complete blood count, vitamin B12/folate levels, and review medications for mood-altering side effects (interferon, corticosteroids, beta-blockers) 4
• Assess duration of symptoms, sociodemographic risk factors (unemployment, low financial resources, living alone, lower education), and degree of functional impairment 1, 3

Treatment Recommendations for Score 8-14

Initiate low-intensity interventions 1, 2:

• Individually guided self-help based on cognitive behavioral therapy (CBT) with behavioral activation and problem-solving 2, 3
• Structured physical activity programs 2, 3
• Psychosocial group interventions led by licensed mental health professionals covering stress reduction, positive coping strategies, enhancing social support, and health behavior change 1

Make referral to psychology or psychiatry for determination of formal diagnosis 1, 2

Consider pharmacologic treatment as appropriate based on clinical judgment and patient preference 4

Monitoring and Follow-Up

• Reassess with PHQ-9 at regular intervals during treatment 2
• A decrease of 5 points or more on the PHQ-9 represents a clinically meaningful improvement 5
• Treatment goal should be achieving a PHQ-9 score below 10 (response) and ideally below 5 (remission) 6, 7

Critical Pitfalls to Avoid

• Do not underestimate the severity—a score of 11 requires active treatment, not observation alone 3
• Never omit item 9 regarding self-harm, as this artificially lowers scores and misses critical safety information 2, 3
• Do not fail to complete the full 9-item PHQ-9 if you only administered the initial 2-item screen 2, 3
• Do not overlook medical causes of depression before diagnosing a primary mood disorder 4

Special Populations

• Use culturally sensitive assessments when possible 2, 3
• For patients with cognitive impairment, the PHQ-9 loses accuracy and alternative assessment methods should be used 2
• For elderly patients, consider using the Geriatric Depression Scale (GDS) instead 4