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The PHQ-9 is the nine item depression scale of the Patient Health Questionnaire. The PHQ-9 isa powerful tool for assisting primary care clinicians in diagnosing depression as well as selectingand monitoring treatment. The primary care clinician and/or office staff should discuss with thepatient the reasons for completing the questionnaire and how to fill it out. After the patient hascompleted the PHQ-9 questionnaire, it is scored by the primary care clinician or office staff.

There are two components of the PHQ-9:• Assessing symptoms and functional impairment to make a tentative depression

diagnosis, and• Deriving a severity score to help select and monitor treatment

The PHQ-9 is based directly on the diagnostic criteria for major depressive disorder in theDiagnostic and Statistical Manual Fourth Edition (DSM-IV).

For easy of use, Pfizer and others have suggested using a simpler scoring proxy system toestimate diagnostic categories. The MacArthur Initiative on Depression and Primary Carerecommends using the initial two component scoring system. We also recommend regular use ofa chronicity question to aid consideration of mild chronic depression (dysthymic disorder).

On the following pages we provide the listed items to assist in learning about using the PHQ-9.For more extensive training and/or consultation please contact us.

Sample PHQ-9Guide for Making a Tentative DiagnosisGuide for Severity ScoringProvisional Diagnosis TableTreatment Response TableReproduction Quality Blank PHQ-(Download - English version)Reproduction Quality Blank PHQ-(Download - Spanish version)

ReferencesSpitzer R, Kroenke K, Williams J. Validation and utility of a self-report version of PRIME-MD:

the PHQ Primary Care Study. Journal of the American Medical Association 1999; 282: 1737-1744. Abstract

Kroenke K, Spitzer R L, Williams J B. The PHQ-9: validity of a brief depression severitymeasure. Journal of General Internal Medicine 2001; 16(9): 606-613 Abstract

Rost K, Smith J. Retooling multiple levels to improve primary care depression treatment.Journal of General Internal Medicine 16: 644-645, 2001 PubMed Citation

Kroenke K, Spitzer RL. The PHQ-9: A new depression and diagnostic severity measure.Psychiatric Annals 2002; 32: 509-521.

Williams JW, Noel PH, Cordes J A, Ramirez G,Pignone M. Is this patient clinicallydepressed? Journal of the American Medical Association 2002; 287: 1160-1170. Abstract

Lowe B, Unutzer J, Callahan CM, Perkins AJ, Kroenke K. Monitoring depression treatmentoutcomes with the patient health questionnaire-9. Medical Care, 2004. 42(12): 1194-201.Abstract

Pinto-Meza A, Serrano-Blanco A, Penarrubia MT, Blanco E, Haro JM. Assessing depressionin primary care with the PHQ-9: can it be carried out over the telephone? Journal of GeneralInternal Medicine, 2005. 20(8): 738-42. Abstract

The PHQ-9 is adapted from PRIMEMDTODAY, developed by Drs. Robert L. Spitzer, JanetB.W. Williams, Kurt Kroenke, and colleagues, with an educational grant from Pfizer Inc. Forresearch information, contact Dr Spitzer at rls8@columbia.edu. The names PRIME-MD®

and PRIMEMDTODAY™ are trademarks of Pfizer Inc.

PHQ9 Copyright © Pfizer Inc. All rights reserved. Reproduced with permission of Pfizer,Inc. PRIME-MD ® is a trademark of Pfizer Inc.

Patient Health Questionnaire (PHQ-9) < Previous | Next >

NAME:___________________________________________ DATE:______________________

Over the last 2 weeks, how often have you beenbothered by any of the following problems?(use “ ” to indicate your answer)

1. Little interest or pleasure in doing things 0 1 2 3

2. Feeling down, depressed, or hopeless 0 1 2 3

3. Trouble falling or staying asleep,or sleeping too much 0 1 2 3

4. Feeling tired or having little energy 0 1 2 3

5. Poor appetite or overeating 0 1 2 3

6.Feeling bad about yourself—or thatyou are a failure or have let yourselfor your family down

0 1 2 3

7. Trouble concentrating on things, such as reading thenewspaper or watching television 0 1 2 3

8.Moving or speaking so slowly that other people couldhave noticed. Or the opposite—being so fidgetyor restless that you have been moving around a lotmore than usual

0 1 2 3

9. Thoughts that you would be better off dead,or of hurting yourself in some way 0 1 2 3

add columns: + + (Healthcare professional: For interpretation of TOTAL, TOTAL:

please refer to accompanying scoring card).

10.If you checked off any problems, how Not difficult at all _________

difficult have these problems made it foryou to do your work, take care of things athome, or get along with other people?

Somewhat difficult _________ Very difficult _________ Extremely difficult _________

Patient Health Questionnaire (PHQ-9) < Previous | Next >

Using PHQ-9 Diagnosis and Score for Initial Treatment Selection

A depression diagnosis that warrants treatment or treatment change, needs at least one ofthe first two questions endorsed as positive (little pleasure, feeling depressed) indicating thesymptom has been present more than half the time in the past two weeks.

In addition, the tenth question about difficulty at work or home or getting along with others shouldbe answered at least “somewhat difficult.”

When a depression diagnosis has been made, patient preferences should be considered,especially when choosing between treatment recommendations of antidepressant treatment andpsychotherapy.

PHQ-9Score Provisional Diagnosis Treatment Recommendation

5-9 Minimal Symptoms* Support, educate to call if worse;return in 1 month

10-14

Minor depression++

Dysthymia*

Major depression, mild

Support, watchful waiting

Antidepressant or psychotherapy

Antidepressant or psychotherapy

15-19 Major depression,moderately severe Antidepressant or psychotherapy

≥ 20 Major depression, severeAntidepressant and psychotherapy

(especially if not improved on monotherapy)

*If symptoms present ≥ two years, then probable chronic depression whichwarrants antidepressants or psychotherapy (ask, "In the past 2 years haveyou felt depressed or sad most days, even if you felt okay sometimes?").

++If symptoms present ≥ one month or severe functional impairment, consideractive treatment.

Using the PHQ-9 to Assess Patient Response to Treatment

The goal of acute phase treatment is remission of symptoms as indicated by a PHQ-9Score of < 5 points.Patients who achieve this goal enter into the continuation phase of treatment.Patients who do not achieve this goal remain in the acute phase of treatment and requiresome alteration in treatment (dose increase, augmentation, combination treatment).Patients who do not achieve remission after two adequate trials of antidepressants and/orpsychological counseling or by 20 to 30 weeks would benefit from a formal or informalpsychiatric consultation for diagnostic and management suggestions.

Initial Response after Four - Six weeks of an Adequate Dose of anAntidepressant

PHQ-9 Score TreatmentResponse Treatment Plan

Drop of ≥ 5 points frombaseline Adequate No treatment change needed

Follow-up in four weeks.Drop of 2-4 points frombaseline

ProbablyInadequate

Often warrants an increase inantidepressant dose.

Drop of 1 point or nochange or increase Inadequate

Increase dose: Augmentation;Switch; Informal or formalpsychiatric consultation; Addpsychological counseling.

Initial Response to Psychological Counseling After Three Sessionsover Four - Six Weeks

PHQ-9 Score TreatmentResponse Treatment Plan

Drop of ≥ 5 points frombaseline Adequate No treatment change needed

Follow-up in four weeks.

Drop of 2-4 points frombaseline

ProbablyInadequate

Possibly no treatment changeneeded.Share PHQ-9 withpsychological counselor.

Drop of 1 point or nochange or increase Inadequate

If depression-specificpsychological counseling(CBT, PST, IPT*) discuss withtherapist, consider addingantidepressant.

For patients satisfied in othertype of psycholgical

change or increase counseling, consider startingantidepressant.

For patients dissatisfied inother psychologicalcounseling, review treatmentoptions and preferences.

* CBT - Cognitive-Behavioral Therapy; PST - Problem Solving Treatment; IPT- InterpersonalTherapy