See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/277665632

Test review: Patient Health Questionnaire–9 (PHQ-9)

Article in Rehabilitation Counseling Bulletin · July 2014

DOI: 10.1177/0034355213515305

CITATIONS READS

63 5,293

2 authors:

Amber Mcdermott Terry L. Blackwell

Montana State University Billings Montana State University Billings
3 PUBLICATIONS 65 CITATIONS 24 PUBLICATIONS 308 CITATIONS

SEE PROFILE SEE PROFILE

All content following this page was uploaded by Amber Mcdermott on 03 June 2015.

The user has requested enhancement of the downloaded file.

515305
research-article2013
RCBXXX10.1177/0034355213515305Rehabilitation Counseling BulletinBlackwell and McDermott

Review
Rehabilitation Counseling Bulletin

Test Review: Patient Health

2014, Vol. 57(4) 246­–248
© Hammill Institute on Disabilities 2014
Reprints and permissions:
Questionnaire–9 (PHQ-9) sagepub.com/journalsPermissions.nav
DOI: 10.1177/0034355213515305
rcb.sagepub.com

Spitzer, R. L., Williams, J. B. W., & Kroenke, K., & Colleagues (n.d.). Patient Health Questionnaire–9 (PHQ-9). Pfizer.
The PHQ-9 is available in public domain and freely downloadable from the PHQ website (www.phqscreeners.com). Permission is not
required to reproduce, translate, display or distribute the PHQ-9. PHQ-2 (ultra-brief) form is also available.

Purpose and Nature of Test been bothered by each of the PHQ-9 symptoms over the
“last two weeks.” The nine items, based on DSM criteria for
The Patient Health Questionnaire–9 (PHQ-9) was devel- diagnosis of depression, are used to generate scores of 0, 1,
oped as a self-administered, diagnostic screening instru- 2, or 3 to the response categories of “not at all,” “several
ment used by health care professionals for assessing and days,” “more than half the days,” and “nearly every day,”
monitoring depression severity. The PHQ-9 is one version (Pfizer, n.d., p.5). Question 9 screens for the risk of self-
of the Patient Health Questionnaire family of brief, diag- harm (see Table 1).
nostic measures for five common types of mental disorders: Scoring the PHQ-9 is a relatively straightforward pro-
depression, anxiety, somatoform, alcohol, and eating. cess. In scoring, the clinician reviews the responses and
The PHQ-9 is designed for use with adults in assessing applies a diagnostic algorithm provided at the bottom of the
and monitoring depression severity based on Diagnostic questionnaire. Following the diagnostic items of the PHQ-
and Statistical Manual of Mental Disorders (4th ed.; 9, respondents who have endorsed any problem areas on the
DSM-IV; American Psychiatric Association [APA], 1994) questionnaire are asked to check “how difficult have these
and International Classification of Diseases,10th Edition problems made it for you to do your work, take care of
(ICD-10) diagnostic criteria (Lowe, Unutzer, Callahan, things at home, or get along with other people?” (Spitzer
Perkins, & Kroenke, 2004). The questionnaire consists of et al., n.d.). Kroenke and Spitzer (2002) note that “This
nine items that focus on the diagnostic criteria of the single item is an excellent global rating of functional impair-
DSM-IV for major depressive disorder (MDD). These ment and has been shown to correlate strongly with a num-
nine items have remained unchanged in the DSM-5 ber of quality of life, functional status and health care usage
update, and therefore the PHQ-9 is still theoretically con- measures” (pp. 1-2).
sistent with the revised manual (APA, 2013). In the pro- Kroenke, Spitzer, Williams, and Lowe (2010) note that
cess of revision, the DSM-5 depressive disorders scores from the
workgroup considered including the PHQ-9 as a measure
of severity for the MDD diagnosis, but eventually went PHQ-9 can be used either as a diagnostic algorithm to make a
with a more generic cross-cutting symptom measure that probable diagnosis of MDD or as a continuous measure with
could be used with multiple disorders (First, 2011). The scores ranging from 0 to 27 and cut points of 5, 10, 15 and 20
PHQ-9 is available in numerous languages, although the representing mild, moderate, moderately severe and severe
publisher cautions that unlike the English version, “few levels of depressive symptoms. (p. 346)
of the translations have been psychometrically validated
against an independent structured psychiatric interview” The publisher adds a cut point of 10 or greater, which
(Pfizer, n.d., p. 7). should be viewed as a “yellow flag” suggesting the possibil-
ity of a condition of clinical significance with a cut point of
15 seen as a “red flag” identifying individuals who probably
Practical Applications need active treatment.
The PHQ-9 is designed as a quick, cost-effective measure The Instruction Manual provides a quick, easy-to-follow
of probable depression in adults. The questionnaire can discussion for coding and scoring the PHQ-9, along with
typically be completed by the client in less than 5 min and the other versions of the PHQ measures. The manual is
easily scored by the clinician. The PHQ-9 can also be accessible online and can be downloaded from the publish-
administered repeatedly, to reflect improvement or worsen- er’s website at www.phqscreeners.com. Questions not
ing of depression in response to treatment. The question- addressed in the manual can be posed through email at
naire asks clients to check off the number of days they have [email protected]. User qualifications for

Downloaded from rcb.sagepub.com at MSU-Bozeman Library on June 3, 2015

Blackwell and McDermott 247

Table 1. Patient Health Questionnaire–9 (PHQ-9).

Over the last 2 weeks, how often have you been

bothered by any of the following problems? (use “✔” to Nearly
indicate your answer) Not at all Several days More than half the days every day
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 that you are a failure 0 1 2 3
or have let yourself or your family down
7. Trouble concentrating on things, such as reading the 0 1 2 3
newspaper or watching television
8. Moving or speaking so slowly that other people could 0 1 2 3
have noticed? Or the opposite—being so fidgety or
restless that you have been moving around a lot more
than usual
9. Thoughts that you would be better off dead or of 0 1 2 3
hurting yourself in some way
FOR OFFICE CODING 0 + ________
________ +
+ ________
=Total score:________
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home,
or get along with other people?
Not difficult Somewhat Very Extremely
at all difficult difficult difficult
   

Source. Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, and colleagues, with an educational grant from Pfizer Inc. No
permission required to reproduce, translate, display, or distribute. This form can be found on phqscreeners.com.

scoring and reporting the PHQ-9 should be by an “experi- PHQ-9 scores and other constructs related to depression,
enced clinician” and administered in the context of a clini- such as functional status, disability days, and symptom-
cal interview. related difficulty as measured by the Short-Form General
Health Survey (Stewart, Hays, & Ware, 1988). Findings
Technical Aspects from this validity study generalized from one large sample
(3,000) of primary care patients to a second large sample
The PHQ-9 was developed and empirically validated as a (3,000) of obstetrics-gynecology patients.
screening and diagnostic instrument to facilitate detection A summary score cut point of ≥ 10 was found to be opti-
of depression in primary care settings. Secondary analysis mal for maximizing sensitivity without loss of specificity.
of data from the original PHQ studies involving eight pri- Using this cut point, the PHQ-9 was found to have a sensi-
mary care (n = 3,000) and seven obstetrical clinics (n = tivity for major depression of 88% (screened positive for
3,000) established the reliability and validity of the PHQ-9.
probable major depression) and a specificity of 88% (12%
A description of the psychometric properties is found in the
will have a false positive finding).
article reference section of the manual.
The PHQ-9 has gained increasing use in both research
Reliability was assessed through internal consistency
and practice settings since it was developed (Pfizer, n.d.).
and test-retest. Internal reliability for the PHQ-9 is reported
as “excellent” with a Cronbach’s α of 0.89 and 0.86 in the The PHQ-9 has been studied in a wide range of adult popu-
primary care and obstetrical clinical studies, respectively. lations and medical conditions, including spinal cord injury,
Kroenke, Spitzer, and Williams (2001) also report test– stroke, cardiology, primary care, general medical outpa-
retest reliability to be excellent with a kappa of 0.84 over tient, oncology, and traumatic brain injury (Kroenke et al.,
the time span of 48 hr. 2010; Raad, 2013). In addition, the questionnaire has been
The PHQ-9 has evidence supporting its criterion, con- adopted “as a standard measure for depression screening”
struct, and external validity. Kroenke et al. (2001) found the (Kroenke et al., 2010, p. 349) across a variety of health care
test discriminates well between people with and without a systems, including the Department of Defense and the
MDD. The authors also found a strong relationship between Department of Veterans Affairs.

Downloaded from rcb.sagepub.com at MSU-Bozeman Library on June 3, 2015

248 Rehabilitation Counseling Bulletin 57(4)

Conclusion American Psychiatric Association. (2013). Diagnostic and statis-

tical manual of mental disorders (5th ed.). Washington, DC:
The PHQ-9 is a brief, easily administered and scored screen- Author.
ing questionnaire that can be used to improve the recogni- Corson, K., Gerrity, M. S., & Dobscha, S. K. (2004). Screening
tion rate of major depression and facilitate treatment. As a for depression and suicidality in a VA primary care setting:
screener for depression, the questionnaire has been found to 2 items are better than 1 item. The American Journal of
have good diagnostic validity with comparable sensitivity Managed Care, 10, 839–845.
and specificity for major depression in adult populations First, M. B. (2011). DSM-V proposals for mood disorders: A cost-
(Kroenke et al., 2010). An advantage of the questionnaire is benefit analysis. Current Opinion in Psychiatry, 24, 1–9.
its exclusive focus on the nine diagnostic criteria for the Kroenke, K., & Spitzer, R. L. (2002). The PHQ-9: A new depres-
newly revised DSM-5 depressive disorders (APA, 2013). sion diagnostic and severity measure. Psychiatric Annals, 39,
The questionnaire provides the clinician with a quick, stand- 1–7.
alone, no cost screener for depression that can be easily inte- Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The
grated into counseling practice. Furthermore, the severity PHQ-9: Validity of a brief depression measure. Journal of
scores can be used to monitor treatment over time. General Internal Medicine, 16, 606–613.
Since its development, the PHQ-9 has established itself Kroenke, K., Spitzer, R. L., Williams, J. B. W., & Lowe, B. (2010).
as a practical tool for use in assisting with “depression diag- The patient health questionnaire somatic, anxiety, and depres-
noses, depression severity, and depression outcome” (Lowe sive symptom scales: A systematic review. General Hospital
Psychiatry, 32, 345–359.
et al., 2004, p. 1199). However, the clinician must be mind-
Lowe, B., Unutzer, J., Callahan, C., Perkins, A. J., & Kroenke, K.
ful, that as a screening questionnaire, the PHQ-9 is not suf-
(2004). Monitoring depression treatment outcomes with the
ficient by itself to confirm a depression diagnosis. As
Patient Health Questionnaire–9. Medical Care, 42, 1194–
Corson, Gerrity, and Dobscha (2004) assert, “Clinician
1201.
assessment must follow. In making a diagnosis, the clini- Pfizer. (n.d.). Instruction manual: Instructions for Patient Health
cian should take into account the patient’s history, comor- Questionnaire (PHQ) and GAD-7 measures. Retrieved from
bidities, functional status, and safety-considerations http://www.phqscreeners.com/instructions/instructions.pdf
precluded in any brief screening instrument” (p. 845). Raad, J. (2013). Rehab measures: Patient Health Questionnaire
(PHQ-9). Retrieved from http://www.rehabmeasures.org/
Terry L. Blackwell and Amber N. McDermott Spitzer, R. L., Williams, J. B. W., & Kroenke, K., & Colleagues
Montana State University–Billings, USA (n.d.). Patient Health Questionnaire–9 (PHQ-9). Retrieved from
http://www.phqscreeners.com/pdfs/02_PHQ-9/English.pdf
References Stewart, A. L., Hays, R. D., & Ware, J. E. (1988). The MOS short-
American Psychiatric Association. (1994). Diagnostic and statistical form General Health Survey: Reliability and validity in a
manual of mental disorders (4th ed.). Washington, DC: Author. patient population. Medical Care, 26, 724–732.

Downloaded from rcb.sagepub.com at MSU-Bozeman Library on June 3, 2015

View publication stats