PHQ-9

Last updated
Patient Health Questionnaire 9 item
Synonyms PHQ-9; PHQ Quick Depression Assessment; Resident mood interview
LOINC 44249-1, 54635-8

The nine-item Patient Health Questionnaire (PHQ-9) is a depressive symptom scale and diagnostic tool introduced in 2001 to screen adult patients in primary care settings. The instrument assesses for the presence and severity of depressive symptoms and a possible depressive disorder. [1] [2] [3] The PHQ-9 is a component of the larger self-administered Patient Health Questionnaire (PHQ), but can be used as a stand-alone instrument. [4] The PHQ is part of Pfizer's larger suite of trademarked products, called the Primary Care Evaluation of Mental Disorders (PRIME-MD). [5] The PHQ-9 takes less than three minutes to complete. It is scored by simply adding up the individual items' scores. Each of the nine items reflects a DSM-5 symptom of depression. [6] Primary care providers can use the PHQ-9 to screen for possible depression in patients. [1]

Contents

History

The PHQ-9 is the nine-item depression scale found in the 59-item PHQ. The PHQ is a self-administered version of the PRIME-MD, a screening tool that assesses 12 mental and emotional health disorders. [7] It has modules on mood (PHQ-9), anxiety, alcohol, eating, and somatoform disorders. [8] Robert L. Spitzer, Janet B.W. Williams, and Kurt Kroenke developed the PHQ in the mid-1990s and the PHQ-9 in 1999 with a grant from Pfizer. [1] [2]

Survey items

A patient may take the PHQ-9 in written form or be presented the survey items in interview form. The PHQ-9 questions reflect the diagnostic criteria for major depressive disorder (MDD) found in the DSM-5. [6] The items ask about the patient's experience in the last two weeks. Questions are about the level of interest/pleasure in doing things (anhedonia), feeling down or depressed, sleep-related problems (sleeping too much/difficulty falling or staying asleep), low energy or fatigue, eating problems (poor appetite or eating too much), self-worth (feeling like a failure), ability to concentrate, psychomotor problems (speaking/moving slowly or fidgety/restless), and thoughts of suicide. Responses range from “0” (Not at all) to “3” (nearly every day). [3] A tenth question asks about the extent to which the previously mentioned symptoms make functioning in daily life difficult. The response to the tenth question is not factored into the final score; however, clinicians may use the response to help gauge the patient's level of impairment. [4] A massive study of almost 60,000 participants (involving 29 samples from seven countries and speaking five languages) that employed exploratory structural equation modeling bifactor analysis showed the PHQ-9 is essentially unidimensional; cognitive-affective and somatic specific factors were relatively weak. [9]

Interpretation of results

The total sum of the responses roughly indexes levels of depression. Scores range from 0 to 27. In general, a total of 10 or above is suggestive of the presence of depression. Listed below are PHQ-9 totals, the levels of depression that they relate to, and suggested treatment for each level of depression: [10]

PHQ-9 ScoreDepression severitySuggested Intervention
0-4None-minimalNone
5-9MildRepeat PHQ-9 at follow-up
10-14ModerateMake treatment plan, consider counseling, follow-up, and/or prescription drugs
15-19Moderately SeverePrescribe prescription drugs and counseling
20-27SeverePrescribe prescription drugs. If there are poor responses to treatment, immediately refer the patient to a mental health specialist for counseling.

A provisional diagnosis of MDD can be made by using the pattern of responses to PHQ-9 items. According to the DSM-5, MDD is likely if five or more of the nine criterion symptoms are present for “most of the day, nearly every day" over the past 2 weeks; however, one of the symptoms must be either depressed mood or anhedonia (questions 1 and 2 on the PHQ-9). Any degree of suicidal thoughts counts toward a provisional diagnosis. The symptoms must also cause significant distress and loss of function. The PHQ-9 is limited to making a provisional diagnosis. It cannot be used to make an actual diagnosis. Only a trained clinician can do that. For example, a trained clinician can determine if the symptoms can be better explained by substance use or another medical or psychiatric condition. Clinicians, however, may use the PHQ-9 to evaluate the efficacy of treatments for depression. A change of PHQ-9 score to less than 10 is considered a “partial response” to treatment and a change of PHQ-9 score to less than 5 is considered to be “remission.” [10]

Validity and reliability

Kroenke, Spitzer, and Williams [1] conducted validity and reliability research on the PHQ-9 in 2001. With regard to reliability, they found that Cronbach's alpha for the PHQ-9 was 0.89 in a sample comprising 3,000 primary care patients and 0.86 among 3,000 OB-GYN patients. However, some research suggests that the scale is not purely unidimensional, with the scale reflecting two latent factors, somatic and cognitive/affective factors. [11] By contrast, the results of the massive study by Bianchi et al. (2022) [9] indicate that the PHQ-9's total score is essentially unidimensional.

The test-retest reliability was found to be excellent. The correlation between PHQ-9 scores obtained from in-person and phone interviews with the same patients was 0.84. [1] The PHQ-9 showed acceptable psychometric properties in a rural Indian population. [11] In general, psychometric research supports the use of total scores, i.e., summing the item scores, in research and practice. [1] [11] [9]

In an assessment of construct validity, Kroenke et al. [1] found that the correlation between the PHQ-9 and the SF-20 mental health scale was 0.73. To assess criterion validity, a mental health professional validated depression diagnoses from PHQ-9 scores from 580 participants, resulting in 88% sensitivity and 88% specificity. [1]

Readability

Preliminary work using gold standard readability measures suggests that a significant minority of patients might find interpretation of the PHQ-9 difficult without support. [12]

Applications

The National Institute for Health and Clinical Excellence endorsed the PHQ-9 for measuring depression severity and responsiveness to treatment in adults in a primary care setting. [13] The Behavioral Risk Factor Surveillance Survey (BRFSS), the National Health and Nutrition Examination Survey, the Medical Expenditure Panel Survey, the National Epidemiologic Survey on Alcohol and Related Conditions, the Medicare Health Support program, and the Millennium Cohort Study use the full PHQ-9 or a shortened form of it. The Veterans Administration, Department of Defense, and Kaiser Permanente adopted the PHQ-9 as a standard measure for depression screening. The PHQ-9 is also the most commonly used depression measure in the United Kingdom's National Health Service, which requires providers to use a depression screening instrument when treating depression. [14]

Studies found the PHQ-9 is also useful for screening for depression in psychiatric clinics. [15] Researchers have used the PHQ-9 to study the mental health of patients with diabetes, [16] HIV-AIDS, [17] chronic pain, arthritis, fibromyalgia, epilepsy, and substance abuse. [13] It also is used in studies involving patients with physical disabilities as well as older adults, students, and adolescents. [13] The PHQ-9 has been extensively used in research investigating the relationship between burnout and depression. [18] [19] The instrument is available in over 30 languages [20] [5] and may be valid for use in different ethnic groups. [13] Pfizer owns the copyright of the PHQ-9 and allows it to be accessed for free. [5] [7]

The PHQ-2 is a shortened version of the PHQ-9. It contains the first 2 questions of the PHQ-9 and takes less than a minute to administer. A score of 3 or greater on the PHQ-2 will generally lead to the subsequent administration of the PHQ-9. The Veterans Administration uses this method to screen for depression in patients. [13]

The PHQ-8 consists of all of the PHQ-9 instruments except for the last question (suicidal thoughts). The 8-item version of the instrument is commonly used in research on general population samples, which mostly comprises individuals who are not depressed. [4] Researchers generally use the PHQ-8 because timing and resource restraints may leave researchers unable to intervene with study participants who indicate that they have experienced suicidal thoughts. The absence of the ninth question has little effect on scoring between the PHQ-8 and PHQ-9. A study found that scores between the two tests are highly correlated (r = 0.998). [14]

The PHQ-15 is a 15-item scale derived from the larger PHQ. The PHQ-15 inquires in 15 symptoms relating to somatoform disorders. The questions on the PHQ-15 account for 90% of all symptoms that providers observe in primary care settings. [14] Patients must rate the extent to which symptoms bothered them over the last month. Responses range from "not at all" (a score of 0) to "bothered a lot" (a score of 2). Higher scores on the PHQ-15 are strongly associated with functional impairment, disability, and healthcare utilization. [14]

The GAD-7 is a seven-item anxiety screening instrument developed in 2006 with a similar format to that of the PHQ-9. [21] Total scores range from 0 to 21 with scores of 5, 10, and 15 indicating mild, moderate, and severe anxiety. Unlike the PHQ-9, clinicians use the GAD-7 to assess the severity of anxiety only. Unlike the PHQ-9, the GAD-7 does not generate provisional diagnoses. A clinical interview must be given to arrive at a clinical diagnosis. The GAD-2 is a 2-question shortened version of the GAD-7; it uses the first two items on the GAD-7. A total score that is greater than 3 indicates that a clinician should administer the full GAD-7 and conduct a clinical interview to assess the presence and type of anxiety disorder. [14]

See also

Related Research Articles

Psychological testing refers to the administration of psychological tests. Psychological tests are administered or scored by trained evaluators. A person's responses are evaluated according to carefully prescribed guidelines. Scores are thought to reflect individual or group differences in the construct the test purports to measure. The science behind psychological testing is psychometrics.

The Beck Depression Inventory, created by Aaron T. Beck, is a 21-question multiple-choice self-report inventory, one of the most widely used psychometric tests for measuring the severity of depression. Its development marked a shift among mental health professionals, who had until then, viewed depression from a psychodynamic perspective, instead of it being rooted in the patient's own thoughts.

The Hamilton Rating Scale for Depression (HRSD), also called the Hamilton Depression Rating Scale (HDRS), sometimes also abbreviated as HAM-D, is a multiple-item questionnaire used to provide an indication of depression, and as a guide to evaluate recovery. Max Hamilton originally published the scale in 1960 and revised it in 1966, 1967, 1969, and 1980. The questionnaire is designed for adults and is used to rate the severity of their depression by probing mood, feelings of guilt, suicide ideation, insomnia, agitation or retardation, anxiety, weight loss, and somatic symptoms.

A depression rating scale is a psychometric instrument (tool), usually a questionnaire whose wording has been validated with experimental evidence, having descriptive words and phrases that indicate the severity of depression for a time period. When used, an observer may make judgements and rate a person at a specified scale level with respect to identified characteristics. Rather than being used to diagnose depression, a depression rating scale may be used to assign a score to a person's behaviour where that score may be used to determine whether that person should be evaluated more thoroughly for a depressive disorder diagnosis. Several rating scales are used for this purpose.

Behavioral health outcome management (BHOM) involves the use of behavioral health outcome measurement data to help guide and inform the treatment of each individual patient. Like blood pressure, cholesterol and other routine lab work that helps to guide and inform general medical practice, the use of routine measurement in behavioral health is proving to be invaluable in assisting therapists to deliver better quality care.

The My Mood Monitor Screen is a quick, validated, self-rated, multi-dimensional mental health symptom checklist that screens for and monitors changes in potential mood and anxiety symptoms.

The Health Dynamics Inventory (HDI) is a 50 item self-report questionnaire developed to evaluate mental health functioning and change over time and treatment. The HDI was written to evaluate the three aspects of mental disorders as described in the Diagnostic and Statistical Manual of Mental Disorders (DSM): "clinically significant behavioral or psychological syndrome or pattern...associated with present distress...or disability". This also corresponds to the phase model described by Howard and colleagues Accordingly, the HDI assesses (1) the experience of emotional or behavioral symptoms that define mental illness, such as dysphoria, worry, angry outbursts, low self-esteem, or excessive drinking, (2) the level of emotional distress related to these symptoms, and (3) the impairment or problems fulfilling the major roles of one's life.

The Generalized Anxiety Disorder 7 (GAD-7) is a self-reported questionnaire for screening and severity measuring of generalized anxiety disorder (GAD). The GAD-7 is normally used in outpatient and primary care settings for referral to a psychiatrist pending outcome.

The Patient Health Questionnaire (PHQ) is a multiple-choice self-report inventory that is used as a screening and diagnostic tool for mental health disorders of depression, anxiety, alcohol, eating, and somatoform disorders. It is the self-report version of the Primary Care Evaluation of Mental Disorders (PRIME-MD), a diagnostic tool developed in the mid-1990s by Pfizer Inc. The length of the original assessment limited its feasibility; consequently, a shorter version, consisting of 11 multi-part questions - the Patient Health Questionnaire was developed and validated.

The Hamilton Anxiety Rating Scale (HAM-A) is a psychological questionnaire used by clinicians to rate the severity of a patient's anxiety. Anxiety can refer to things such as "a mental state...a drive...a response to a particular situation…a personality trait...and a psychiatric disorder." Though it was one of the first anxiety rating scales to be published, the HAM-A remains widely used by clinicians. It was originally published by Max Hamilton in 1959. For clinical purposes, and the purpose of this scale, only severe or improper anxiety is attended to. This scale is considered a "clinical rating" of the extensiveness of anxiety, and is intended for individuals that are "already diagnosed with anxiety neurosis."

The Somatic Symptom Scale - 8 (SSS-8) is a brief self-report questionnaire used to assess somatic symptom burden. It measures the perceived burden of common somatic symptoms. These symptoms were originally chosen to reflect common symptoms in primary care but they are relevant for a large number of diseases and mental disorders. The SSS-8 is a brief version of the popular Patient Health Questionnaire - 15 (PHQ-15).

The Weinberg Screen Affective Scale (WSAS) is a free scale designed to screen for symptoms of depression in children and young adults ages 5–21. It can be used as an initial treatment scale and can be used to follow up on treatment efficacy. There are 56 self-report questions that screen for symptoms in 10 major categories of depression: dysphoric mood, low self-esteem, agitation, sleep disturbance, change in school performance, diminished socialization, change in attitude towards school, somatic complaints, loss of usual energy, and unusual change in weight and/or appetite. The scale is based on previously proposed criteria for depression in children. A study looking at the agreement between scales for depression diagnosis found 79.4% agreement between the DSM-III and the WSAS in a sample of 107 children.

The Child Mania Rating Scales (CMRS) is a 21-item diagnostic screening measure designed to identify symptoms of mania in children and adolescents aged 9–17 using diagnostic criteria from the DSM-IV, developed by Pavuluri and colleagues. There is also a 10-item short form. The measure assesses the child's mood and behavior symptoms, asking parents or teachers to rate how often the symptoms have caused a problem for the youth in the past month. Clinical studies have found the CMRS to be reliable and valid when completed by parents in the assessment of children's bipolar symptoms. The CMRS also can differentiate cases of pediatric bipolar disorder from those with ADHD or no disorder, as well as delineating bipolar subtypes. A meta-analysis comparing the different rating scales available found that the CMRS was one of the best performing scales in terms of telling cases with bipolar disorder apart from other clinical diagnoses. The CMRS has also been found to provide a reliable and valid assessment of symptoms longitudinally over the course of treatment. The combination of showing good reliability and validity across multiple samples and clinical settings, along with being free and brief to score, make the CMRS a promising tool, especially since most other checklists available for youths do not assess manic symptoms.

The Clinically Administered PTSD Scale (CAPS) is an in-person clinical assessment for measuring posttraumatic stress disorder (PTSD). The CAPS includes 30 items administered by a trained clinician to assess PTSD symptoms, including their frequency and severity. The CAPS distinguishes itself from other PTSD assessments in that it can also assess for current or past diagnoses of PTSD.

The Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) is a semi-structured interview aimed at early diagnosis of affective disorders such as depression, bipolar disorder, and anxiety disorder. There are different versions of the test that have use different versions of diagnostic criteria, cover somewhat different diagnoses and use different rating scales for the items. All versions are structured to include interviews with both the child and the parents or guardians, and all use a combination of screening questions and more comprehensive modules to balance interview length and thoroughness.

Goldberg test may refer to any of various psychiatric tests used to assess mental health in general or as screening tools for specific mental disorders e.g. depression or bipolar disorder. Goldberg, after whom some psychiatric tests are named, might be one of two psychiatrists who share the same last name: Ivan Goldberg, an American psychiatrist, and Sir David Goldberg, a British psychiatrist. Psychiatric screening tests generally don't substitute getting help from professionals.

The Somatic Symptom Disorder - B Criteria Scale (SSD-12) is a brief self-report questionnaire used to assess the B criteria of DSM-5 somatic symptom disorder, i.e. the patients’ perceptions of their symptom-related thoughts, feelings, and behaviors.

<span class="mw-page-title-main">Janet B. W. Williams</span> American social worker (born 1947)

Janet B. W. Williams is an American social worker who focuses on the diagnosis and assessment of mental disorders. She is Professor Emerita of Clinical Psychiatric Social Work at Columbia University. She was a major force in writing the PHQ-9, a 9-question instrument given to patients in a primary care setting to screen for the presence and severity of depression.

The Occupational Depression Inventory (ODI) is a psychometric instrument, the purpose of which is to assess the severity of work-related depressive symptoms and arrive at a provisional diagnosis of depressive disorder. The ODI can be used by occupational health specialists and epidemiologists.

References

  1. 1 2 3 4 5 6 7 8 Kroenke K, Spitzer RL, Williams JB (September 2001). "The PHQ-9: validity of a brief depression severity measure". Journal of General Internal Medicine. 16 (9): 606–613. doi:10.1046/j.1525-1497.2001.016009606.x. PMC   1495268 . PMID   11556941.
  2. 1 2 Spitzer RL (1994-12-14). "Utility of a New Procedure for Diagnosing Mental Disorders in Primary Care: The PRIME-MD 1000 Study". JAMA. 272 (22): 1749–1756. doi:10.1001/jama.1994.03520220043029. ISSN   0098-7484. PMID   7966923. S2CID   13836141.
  3. 1 2 "PDF of the Patient Health Questionnaire-9" (PDF). Pfizer's PHQ Screeners. Archived (PDF) from the original on 10 January 2022. Retrieved 10 January 2022.
  4. 1 2 3 "Instruction Manual for Patient Health Questionnaire (PHQ) and GAD-7 Measures" (PDF). Pfizer's PHQ Screeners. Archived (PDF) from the original on 10 January 2022. Retrieved 10 January 2022.
  5. 1 2 3 "Patient Health Questionnaire Screeners". Pfizer's PHQ Screeners. Archived from the original on 10 January 2022. Retrieved 10 January 2022.
  6. 1 2 American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders: DSM-5-TR (5th ed.). Washington, DC: Author.
  7. 1 2 "PCOA PHQ Screener". Pfizer's Patient-Centered Outcomes Assessment. Retrieved 2022-01-10.
  8. ↑ "PHQ Screener Overview" (PDF). Patient Health Questionnaire (PHQ). Archived (PDF) from the original on 10 January 2022. Retrieved 10 January 2022.
  9. 1 2 3 Bianchi, R., Verkuilen, J., Toker, S., Schonfeld, I. S., Gerber, M., Brähler, E., & Kroenke, K. (2022). Is the PHQ-9 a unidimensional measure of depression? A 58,272-participant study. ‘’Psychological Assessment, 34’’(6), 595–603. https://doi.org/10.1037/pas0001124
  10. 1 2 Kroenke, Kurt; Spitzer, Robert L.; Williams, Janet B. W. (2001). "The PHQ-9: Validity of a brief depression severity measure". Journal of General Internal Medicine. 16 (9): 606–613. doi:10.1046/j.1525-1497.2001.016009606.x. ISSN   0884-8734. PMC   1495268 . PMID   11556941.
  11. 1 2 3 De Man J, Absetz P, Sathish T, Desloge A, Haregu T, Oldenburg B, et al. (2021-05-13). "Are the PHQ-9 and GAD-7 Suitable for Use in India? A Psychometric Analysis". Frontiers in Psychology. 12: 676398. doi: 10.3389/fpsyg.2021.676398 . PMC   8155718 . PMID   34054677.
  12. ↑ Cuffe, Ray (2021). "A readability analysis of the PHQ-9: How much of the general public may struggle to understand it?". Clinical Psychology Forum. 1 (347): 18–22. doi:10.53841/bpscpf.2021.1.347.18. S2CID   255873027.
  13. 1 2 3 4 5 Smarr KL, Keefer AL (November 2011). "Measures of depression and depressive symptoms: Beck Depression Inventory-II (BDI-II), Center for Epidemiologic Studies Depression Scale (CES-D), Geriatric Depression Scale (GDS), Hospital Anxiety and Depression Scale (HADS), and Patient Health Questionnaire-9 (PHQ-9)". Arthritis Care & Research. 63 (Suppl 11): S454–S466. doi:10.1002/acr.20556. PMID   22588766. S2CID   9086062.
  14. 1 2 3 4 5 Kroenke K, Spitzer RL, Williams JB, Löwe B (2010). "The Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales: a systematic review". General Hospital Psychiatry. 32 (4): 345–359. doi:10.1016/j.genhosppsych.2010.03.006. PMID   20633738. S2CID   34713999.
  15. ↑ Inoue T, Tanaka T, Nakagawa S, Nakato Y, Kameyama R, Boku S, et al. (July 2012). "Utility and limitations of PHQ-9 in a clinic specializing in psychiatric care". BMC Psychiatry. 12: 73. doi: 10.1186/1471-244X-12-73 . PMC   3416649 . PMID   22759625.
  16. ↑ van Steenbergen-Weijenburg KM, de Vroege L, Ploeger RR, Brals JW, Vloedbeld MG, Veneman TF, et al. (August 2010). "Validation of the PHQ-9 as a screening instrument for depression in diabetes patients in specialized outpatient clinics". BMC Health Services Research. 10: 235. doi: 10.1186/1472-6963-10-235 . PMC   2927590 . PMID   20704720.
  17. ↑ Monahan PO, Shacham E, Reece M, Kroenke K, Ong'or WO, Omollo O, et al. (February 2009). "Validity/reliability of PHQ-9 and PHQ-2 depression scales among adults living with HIV/AIDS in western Kenya". Journal of General Internal Medicine. 24 (2): 189–197. doi:10.1007/s11606-008-0846-z. PMC   2629000 . PMID   19031037.
  18. ↑ Bianchi, R., Verkuilen, J., Schonfeld, I. S., Hakanen, J. J., Jansson-Fröjmark, M., Manzano-García, G., Laurent, E., & Meier, L. L. (2021). Is burnout a depressive condition? A 14-sample meta-analytic and bifactor analytic study. Clinical Psychological Science, 9(4), 579-597. https://doi.org/10.1177/2167702620979597
  19. ↑ Meier, S. T., & Kim, S. (2022). Meta-regression analyses of relationships between burnout and depression with sampling and measurement methodological moderators. Journal of Occupational Health Psychology, 27(2), 195–206. https://doi.org/10.1037/ocp0000273
  20. ↑ "Patient Health Questionnaire (PHQ-9 & PHQ-2)". American Psychological Association.
  21. ↑ Spitzer, R. L., Kroenke, K., Williams, J. B., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder: The GAD-7. Archives of Internal Medicine, 166, 1092–1097. http://dx.doi.org/10.1001/archinte.166.10.1092
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