How do I administer the Patient Health Questionnaire‑9 (PHQ‑9)?

How to Administer the PHQ-9

The PHQ-9 is a 9-item self-report questionnaire that patients complete themselves, assessing depressive symptoms over the past 2 weeks, with each item scored from 0 ("not at all") to 3 ("nearly every day"), yielding a total score of 0-27. 1

Administration Method

Step 1: Use a Phased Screening Approach

• Begin with the PHQ-2 (the first two items only) as an initial screen for all patients 1:

  • Item 1: "Little interest or pleasure in doing things" (anhedonia)
  • Item 2: "Feeling down, depressed or helpless" (depressed mood)

• If the patient scores 0 or 1 on the PHQ-2, no further screening is needed 1

• If the patient scores 2 or 3 on the PHQ-2 (endorsing either symptom as occurring "more than half the days" or "nearly every day"), proceed to administer the full PHQ-9 1

• This phased approach means only 25-30% of patients will need to complete all 9 items 1

Step 2: Complete the Full PHQ-9

The remaining 7 items assess 1:

• Sleep problems
• Low energy
• Appetite changes
• Low self-view
• Concentration difficulties
• Motor retardation or agitation
• Thoughts of self-harm

Administration Formats

The PHQ-9 can be administered in multiple ways 2, 3:

• Self-administered paper form - most common method 1
• Clinician-administered interview - takes 3-15 minutes, useful for low-literacy populations 2
• Touch screen computer/electronic format - feasible with 97% completion rates and approximately 2-minute completion time 3
• Embedded in electronic health records (EHR) - allows automatic scoring and clinical alerts 4

Scoring and Interpretation

Score Ranges

Use a cutoff score of 8 (not the traditional 10) for cancer patients and similar populations 1:

• Score 1-7: None/mild symptomatology - no or minimal symptoms of depression 1
• Score 8-14: Moderate symptomatology - subthreshold depressive symptoms with mild to moderate functional impairment 1
• Score 15-19: Moderate to severe symptomatology - most depressive symptoms present with moderate functional interference 1
• Score 20-27: Severe symptomatology - symptoms interfere markedly with functioning 1

The lower cutoff of 8 is supported by validation studies in cancer outpatients and meta-analyses 1

Critical Safety Considerations

Suicidality Assessment

Item 9 specifically assesses thoughts of self-harm: "Thoughts that you would be better off dead or hurting yourself in some way" 1

• Any endorsement of suicidality requires immediate evaluation of frequency and specificity of thoughts 1
• If patient is at risk of harm to self or others: immediate referral for emergency evaluation by a licensed mental health professional, facilitate safe environment, one-to-one observation, and initiate harm-reduction interventions 1

Do not omit item 9 - while some clinicians choose to administer only 8 items, this artificially lowers the score, risks missing patients with more severe symptoms, and weakens predictive validity 1

When to Screen

Screen at multiple time points 1:

• Initial diagnosis/start of treatment
• Regular intervals during treatment
• 3,6, and 12 months after treatment
• At diagnosis of recurrence or progression
• When approaching death
• During times of personal transition or family crisis

Important Implementation Considerations

Training Requirements

• Rater training requires approximately 30 minutes of instruction for physicians and medical students 2
• Quality monitoring is essential - in routine care settings, clinician-administered PHQ-9 may have high specificity (90-99%) but low sensitivity (23-68%) compared to carefully supervised administration 5
• Ongoing training, support, supervision, and monitoring are necessary to ensure quality administration 5

Cultural and Linguistic Adaptations

• No major modifications are typically needed for cultural differences in Spanish-speaking populations 2
• Be aware of potential item functioning differences across languages and cultures, particularly for items assessing appetite, sleep, and psychomotor changes 6
• Use culturally sensitive assessments when possible 1

Special Populations

• Tailor assessment for those with learning disabilities or cognitive impairments 1
• Be aware of difficulty detecting depression in older adults 1
• The PHQ-9 has been validated in low-literacy populations when administered by interview 2

Follow-Up Actions Based on Scores

For scores 8-14 (moderate): Seek consultation with psychology or psychiatry for determination of diagnosis 1

For scores 15-27 (moderate to severe/severe): Referral to psychology and/or psychiatry for diagnosis and treatment 1

Before treating depression symptoms: First address medical causes such as unrelieved pain, fatigue, or delirium from infection or electrolyte imbalance 1