PHQ-9
Patient Health Questionnaire-9
Nine-item self-report screen and severity measure for depression, mapped 1:1 to DSM criteria.
The PHQ-9 is the nine-item depression module of the Patient Health Questionnaire developed by Kroenke, Spitzer and Williams (2001). It maps 1:1 onto the DSM criteria for major depressive disorder and is the most widely used depression screen in primary care and behavioral-health settings.
When to use the PHQ-9
Use the PHQ-9 at intake for any client presenting with low mood, fatigue, hopelessness, or loss of interest, and then every 2–4 weeks to track treatment response. It is the fastest validated way to establish depression severity and to see whether therapy is working.
What the PHQ-9 measures
Frequency over the past two weeks of each of the nine DSM-5 symptoms of major depressive disorder. Item 9 separately assesses passive suicidal ideation and self-harm thoughts. A tenth functional impact question is sometimes included.
Use the PHQ-9 when
- Intake screening for every new client, regardless of presenting concern
- A client reports low mood, anhedonia, sleep change, or fatigue
- Measurement-based care: tracking whether depression is improving across episodes of care
- Before and after a course of CBT, BA, or a medication change
- Documenting medical necessity and progress for insurance or supervision
Why use the PHQ-9 instead of another measure
The PHQ-9 maps one-to-one onto the DSM criteria for major depressive disorder, so the score doubles as a symptom checklist you can review item by item. It is nine items, public domain, and has the largest normative base of any depression measure — which makes cross-setting comparison and reimbursement documentation straightforward.
When not to use the PHQ-9
- You need to distinguish unipolar from bipolar depression — screen with the MDQ as well
- The client has a medical condition (thyroid, anemia, sleep apnea) that could account for somatic items — interpret cautiously
- You need a standalone suicide risk assessment — item 9 is a screen, not a risk formulation
- The client is under 11; use the PHQ-A or a child-specific measure
Scoring and bands
Cutoffs
A score of ≥10 has 88% sensitivity and 88% specificity for major depression in primary care samples. A 5-point change is generally considered clinically meaningful.
What PHQ-9 results mean — and what to do next
Minimal or no depressive symptoms.
Next stepNo depression-specific treatment indicated. Re-screen if the presentation changes.
Mild depression.
Next stepWatchful waiting, behavioral activation, sleep and exercise work; repeat in 2–4 weeks.
Moderate depression — the standard clinical threshold.
Next stepBegin an active, structured treatment (CBT, BA, IPT) and consider a medication consult.
Moderately severe depression.
Next stepStructured psychotherapy plus a psychiatric referral; increase session frequency and monitor safety.
Severe depression.
Next stepCombined psychotherapy and pharmacotherapy, formal safety planning, and consider a higher level of care.
How often to re-administer
Every session or every 2–4 weeks. A 5-point drop is clinically meaningful improvement; a 5-point rise warrants re-formulation.
What to pair it with
GAD-7 (anxiety frequently co-occurs), MDQ (rule out bipolarity before starting an antidepressant), and WHODAS 2.0 (functional impact).
How to talk about the score
Share the total and what the band means, then talk about which items drove the score. Always discuss item 9 directly — never skip it. Frame the measure as a tool you use with everyone, not a verdict on the person.
Limitations
- Self-report — vulnerable to under- or over-reporting
- Two-week window may miss episodic patterns
- Doesn't distinguish unipolar from bipolar depression
- Item 9 is a screen, not a risk assessment by itself
Best used for
- Routine intake screening
- Session-to-session tracking
- Treatment response monitoring
- Primary-care depression screening
The PHQ-9 items
Over the last two weeks, how often have you been bothered by the following problems?
- Little interest or pleasure in doing things
- Feeling down, depressed, or hopeless
- Trouble falling or staying asleep, or sleeping too much
- Feeling tired or having little energy
- Poor appetite or overeating
- Feeling bad about yourself — or that you are a failure or have let yourself or your family down
- Trouble concentrating on things, such as reading the newspaper or watching television
- Moving or speaking so slowly that other people could have noticed — or the opposite, being so fidgety or restless that you have been moving around a lot more than usual
- Thoughts that you would be better off dead or of hurting yourself in some way(Item 9 — suicidal ideation screen)
PHQ-9 scoring — total score and severity bands
Each item is scored 0–3. Total range is 0–27. Bands: 0–4 minimal or none, 5–9 mild, 10–14 moderate, 15–19 moderately severe, 20–27 severe. The standard clinical cutoff of ≥10 has 88% sensitivity and 88% specificity for major depressive disorder. A 5-point change is generally considered clinically meaningful.
What does a PHQ-9 score of 10, 15, or 20 mean?
10 = moderate depression and the standard threshold to consider active treatment. 15 = moderately severe — typically warrants a structured intervention (psychotherapy, pharmacotherapy, or both). 20 or higher = severe depression; safety assessment and active treatment are indicated. Always discuss item 9 (suicidal ideation) regardless of total score.
PHQ-9 item 9 and safety
Item 9 asks about thoughts of being better off dead or of self-harm. Any non-zero response should prompt a follow-up safety conversation — but item 9 is a screen, not a risk assessment. A client can score 0 on item 9 and still be at risk. Use a structured safety assessment (such as the C-SSRS) whenever clinical signals warrant it.
Free PHQ-9 PDF and printable versions
The PHQ-9 is in the public domain (free for clinical, educational, and research use, including translations). It was developed by Drs. Spitzer, Williams and Kroenke with an educational grant from Pfizer Inc. Send the PHQ-9 interactively from your TherapistAssist account to track total scores and item-level trend over time.
Frequently asked questions about the PHQ-9
What if a client scores 0 on item 9 but presents with risk?
Trust the clinical picture. The PHQ-9 is a screen, not a risk assessment. Conduct a full safety assessment any time clinical signals warrant it, regardless of the item-9 score.
How often should I re-administer?
Weekly to monthly is typical during active treatment. The measure is sensitive enough to detect change at that interval and brief enough to fit into a session.
Is the PHQ-9 valid for adolescents?
The PHQ-A is the adolescent-adapted version (ages 11–17) and is preferred for that age group. The standard PHQ-9 can be used 12+ in many settings.
Is the PHQ-9 free to use?
Yes. The PHQ-9 is in the public domain. No permission is required for clinical, educational, or research use.
How long does the PHQ-9 take?
Most clients complete the nine items in 2–3 minutes. Scoring takes well under a minute.
What is the PHQ-9 cutoff for depression?
A total score of ≥10 is the standard clinical cutoff and yields 88% sensitivity and 88% specificity for major depressive disorder.