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patient health questionnaire - 9 (phq-9) depression scale
Availability
Please visit this website for more information about the instrument: Patient Health Questionnaire - 9 Depression Scale
Classification
NeuroRehab Supplemental - Highly Recommended
Recommendation for use: Indicated for studies requiring a measure for mood/anxiety.
 
Supplemental - Highly Recommended: Headache, Spinal Cord Injury (SCI)* and SCI-Pediatric* (ages 12 and older), and Stroke
 
*Recommendations for use: Indicated for studies requiring a screening measure for depression.
 
Supplemental: Epilepsy, Parkinson's Disease (PD), Sport-Related Concussion (SRC) Subacute (after 72 hours to 3 months) and Persistent/Chronic (3 months and greater post-concussion), and Traumatic Brain Injury (TBI).
 
Exploratory: Unruptured Cerebral Aneurysms and Subarachnoid Hemorrhage (SAH)
Short Description of Instrument
The PHQ-9 is a screening tool that is specific to depression. This 9-item measure asks participants whether and how often they have been bothered by depression related symptoms over the last two weeks.
Comments/Special Instructions
Rationale: PHQ-9 is a valid screening measure for major depressive disorder in people with SCI assessed during their initial inpatient rehabilitation. At a slightly higher cutoff than usual (greater than or equal to 11), the PHQ-9 has a sensitivity of 100% and a specificity of 84% and met stringent criteria for an adequate diagnostic test (Youden criterion). The PHQ-9 has also been found to be sensitive to change in the context of a clinical trial of antidepressant treatment as the "gold standard" Hamilton Depression Rating Scale and some other measures.
 
Parkinson's Disease-Specific: Has a question on suicide. Preferrable to assess the general population because it is not as tedious as the Columbia-Suicide Severity Rating Scale (C-SSR). Better designed for a study featuring depression (the Geriatric Depression Scale - 15 (GDS-15) is better for a general assessment of depression). A good predictive tool to help clinicians make psychiatric diagnoses.  
Sport-Related Concussion-Specific: Well validated, widely used screening instrument for depression symptoms. Although not a diagnostic instrument, at higher cut-off levels there is a high correlation with diagnostic interviews.
 
NeuroRehab-Specific: The validity of the PHQ-9 as a screen for major depressive disorder has been established in multiple neurological samples including stroke, TBI and SCI.
 
Age Range: 13 years and older
Scoring and Psychometric Properties
Scoring: 9 items are scored on a scale of 0 to 3, resulting in a total score of 0 to 27 for depression severity:
 
0 = not at all
1 = several days
2 = more than half the days
3 = nearly every day
Total Scores: (Kroenke, et al., 2001)
 
0-4 indicates minimal depression (no treatment action required)
 
5-9 indicates mild depression (watch and repeat PHQ-9 at follow-up)
 
10-14 indicates moderate depression (treatment plan and counseling recommended and/or pharmacotherapy)
 
15-19 indicates moderately severe depression (active treatment with pharmacotherapy and/or psychotherapy)
 
20-27 indicates severe depression (Immediate initiation of pharmacotherapy and, if severe impairment or poor response to therapy, expedited referral to a mental health specialist for psychotherapy and/or collaborative management)
 
Psychometric Properties: The PHQ-9 is a valid screening measure for major depressive disorder in people with SCI assessed during their initial inpatient rehabilitation. At a slightly higher cutoff than usual (greater than or equal to 11), the PHQ-9 has a sensitivity of 100% and a specificity of 84% and met stringent criteria for an adequate diagnostic test (Youden criterion). The PHQ-9 has also been found to be sensitive to change in the context of a clinical trial of antidepressant treatment as the "gold standard" Hamilton Depression Rating Scale and some other measures.
 
Maximal discrimination between depressed and non-depressed PD patients was reached with a cut-off score of 9 in the PHQ-9 (sensitivity of 100% and specificity of 83.1%. The internal consistency of the scale was 0.83 and, when used as a diagnostic instrument, the PHQ-9 had a sensitivity of 52.6% and specificity of 95.4%.
Rationale/Justification
Administration: 1 to 3 minutes; paper and pencil.
 
SCI-specific notes: This instrument has excellent internal consistency, as it showed promise as a tool with which to identify probable Major Depressive Disorder in people with SCI (Bombardier et al., 2004).
 
A shortened version of the PHQ-9 with just questions 1, 2 and 6 may be used to increase efficiency and reduce gender effects of the 9 item questionnaire (Graves and Bombardier, 2008).
References
Key Reference:
Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001 Sep;16(9):606-13.
 
Additional References:
Fann JR, Bombardier CH, Dikmen S, Esselman P, Warms CA, Pelzer E, Rau H, Temkin N. Validity of the Patient Health Questionnaire-9 in assessing depression following traumatic brain injury. J Head Trauma Rehabil. 2005 Nov-Dec;20(6):501-11.
 
He C, Levis B, Riehm KE, Saadat N, Levis AW, Azar M, Rice DB, Krishnan A, Wu Y, Sun Y, Imran M, Boruff J, Cuijpers P, Gilbody S, Ioannidis JPA, Kloda LA, McMillan D, Patten SB, Shrier I, Ziegelstein RC, Akena DH, Arroll B, Ayalon L, Baradaran HR, Baron M, Beraldi A, Bombardier CH, Butterworth P, Carter G, Chagas MHN, Chan JCN, Cholera R, Clover K, Conwell Y, de Man-van Ginkel JM, Fann JR, Fischer FH, Fung D, Gelaye B, Goodyear-Smith F, Greeno CG, Hall BJ, Harrison PA, H?rter M, Hegerl U, Hides L, Hobfoll SE, Hudson M, Hyphantis TN, Inagaki M, Ismail K, JettÉ N, Khamseh ME, Kiely KM, Kwan Y, Lamers F, Liu SI, Lotrakul M, Loureiro SR, LÖwe B, Marsh L, McGuire A, Mohd-Sidik S, Munhoz TN, Muramatsu K, Osório FL, Patel V, Pence BW, Persoons P, Picardi A, Reuter K, Rooney AG, da Silva Dos Santos IS, Shaaban J, Sidebottom A, Simning A, Stafford L, Sung S, Tan PLL, Turner A, van Weert HCPM, White J, Whooley MA, Winkley K, Yamada M, Thombs BD, Benedetti A. The Accuracy of the Patient Health Questionnaire-9 Algorithm for Screening to Detect Major Depression: An Individual Participant Data Meta-Analysis. Psychother Psychosom. 2020;89(1):25-37.
 
Levis B, Benedetti A, Riehm KE, Saadat N, Levis AW, Azar M, Rice DB, Chiovitti MJ, Sanchez TA, Cuijpers P, Gilbody S, Ioannidis JPA, Kloda LA, McMillan D, Patten SB, Shrier I, Steele RJ, Ziegelstein RC, Akena DH, Arroll B, Ayalon L, Baradaran HR, Baron M, Beraldi A, Bombardier CH, Butterworth P, Carter G, Chagas MH, Chan JCN, Cholera R, Chowdhary N, Clover K, Conwell Y, de Man-van Ginkel JM, Delgadillo J, Fann JR, Fischer FH, Fischler B, Fung D, Gelaye B, Goodyear-Smith F, Greeno CG, Hall BJ, Hambridge J, Harrison PA, Hegerl U, Hides L, Hobfoll SE, Hudson M, Hyphantis T, Inagaki M, Ismail K, JettÉ N, Khamseh ME, Kiely KM, Lamers F, Liu SI, Lotrakul M, Loureiro SR, LÖwe B, Marsh L, McGuire A, Mohd Sidik S, Munhoz TN, Muramatsu K, Osório FL, Patel V, Pence BW, Persoons P, Picardi A, Rooney AG, Santos IS, Shaaban J, Sidebottom A, Simning A, Stafford L, Sung S, Tan PLL, Turner A, van der Feltz-Cornelis CM, van Weert HC, VÖhringer PA, White J, Whooley MA, Winkley K, Yamada M, Zhang Y, Thombs BD. Probability of major depression diagnostic classification using semi-structured versus fully structured diagnostic interviews. Br J Psychiatry. 2018 Jun;212(6):377-385.
 
Levis B, Benedetti A, Ioannidis JPA, Sun Y, Negeri Z, He C, Wu Y, Krishnan A, Bhandari PM, Neupane D, Imran M, Rice DB, Riehm KE, Saadat N, Azar M, Boruff J, Cuijpers P, Gilbody S, Kloda LA, McMillan D, Patten SB, Shrier I, Ziegelstein RC, Alamri SH, Amtmann D, Ayalon L, Baradaran HR, Beraldi A, Bernstein CN, Bhana A, Bombardier CH, Carter G, Chagas MH, Chibanda D, Clover K, Conwell Y, Diez-Quevedo C, Fann JR, Fischer FH, Gholizadeh L, Gibson LJ, Green EP, Greeno CG, Hall BJ, Haroz EE, Ismail K, JettÉ N, Khamseh ME, Kwan Y, Lara MA, Liu SI, Loureiro SR, LÖwe B, Marrie RA, Marsh L, McGuire A, Muramatsu K, Navarrete L, Osório FL, Petersen I, Picardi A, Pugh SL, Quinn TJ, Rooney AG, Shinn EH, Sidebottom A, Spangenberg L, Tan PLL, Taylor-Rowan M, Turner A, van Weert HC, VÖhringer PA, Wagner LI, White J, Winkley K, Thombs BD. Patient Health Questionnaire-9 scores do not accurately estimate depression prevalence: individual participant data meta-analysis. J Clin Epidemiol. 2020 Jun;122:115-128.
 
Levis B, Sun Y, He C, Wu Y, Krishnan A, Bhandari PM, Neupane D, Imran M, Brehaut E, Negeri Z, Fischer FH, Benedetti A, Thombs BD; Depression Screening Data (DEPRESSD) PHQ Collaboration, Che L, Levis A, Riehm K, Saadat N, Azar M, Rice D, Boruff J, Kloda L, Cuijpers P, Gilbody S, Ioannidis J, McMillan D, Patten S, Shrier I, Ziegelstein R, Moore A, Akena D, Amtmann D, Arroll B, Ayalon L, Baradaran H, Beraldi A, Bernstein C, Bhana A, Bombardier C, Buji RI, Butterworth P, Carter G, Chagas M, Chan J, Chan LF, Chibanda D, Cholera R, Clover K, Conway A, Conwell Y, Daray F, de Man-van Ginkel J, Delgadillo J, Diez-Quevedo C, Fann J, Field S, Fisher J, Fung D, Garman E, Gelaye B, Gholizadeh L, Gibson L, Goodyear-Smith F, Green E, Greeno C, Hall B, Hampel P, Hantsoo L, Haroz E, Harter M, Hegerl U, Hides L, Hobfoll S, Honikman S, Hudson M, Hyphantis T, Inagaki M, Ismail K, Jeon HJ, JettÉ N, Khamseh M, Kiely K, Kohler S, Kohrt B, Kwan Y, Lamers F, Asunción Lara M, Levin-Aspenson H, Lino V, Liu SI, Lotrakul M, Loureiro S, LÖwe B, Luitel N, Lund C, Marrie RA, Marsh L, Marx B, McGuire A, Mohd Sidik S, Munhoz T, Muramatsu K, Nakku J, Navarrete L, Osório F, Patel V, Pence B, Persoons P, Petersen I, Picardi A, Pugh S, Quinn T, Rancans E, Rathod S, Reuter K, Roch S, Rooney A, Rowe H, Santos I, Schram M, Shaaban J, Shinn E, Sidebottom A, Simning A, Spangenberg L, Stafford L, Sung S, Suzuki K, Swartz R, Tan PLL, Taylor-Rowan M, Tran T, Turner A, van der Feltz-Cornelis C, van Heyningen T, van Weert H, Wagner L, Li Wang J, White J, Winkley K, Wynter K, Yamada M, Zhi Zeng Q, Zhang Y. Accuracy of the PHQ-2 Alone and in Combination With the PHQ-9 for Screening to Detect Major Depression: Systematic Review and Meta-analysis. JAMA. 2020 Jun 9;323(22):2290-2300.
  
LÖwe B, Unützer J, Callahan CM, Perkins AJ, Kroenke K. Monitoring depression treatment outcomes with the patient health questionnaire-9. Med Care. 2004 Dec;42(12):1194-201.
 
Maizels M, Smitherman TA, Penzien DB. A review of screening tools for psychiatric comorbidity in headache patients. Headache. 2006 Oct;46 Suppl 3:S98-109.
 
Parkinson's Disease-Specific References:
Chagas MH, Tumas V, Rodrigues GR, Machado-de-Sousa JP, Filho AS, Hallak JE, Crippa JA. Validation and internal consistency of Patient Health Questionnaire-9 for major depression in Parkinson's disease. Age Ageing. 2013 Sep;42(5):645-9.
 
Williams JR, Hirsch ES, Anderson K, Bush AL, Goldstein SR, Grill S, Lehmann S, Little JT, Margolis RL, Palanci J, Pontone G, Weiss H, Rabins P, Marsh L. A comparison of nine scales to detect depression in Parkinson disease: which scale to use? Neurology. 2012 Mar 27;78(13):998-1006.
 
SCI-Specific References:
Bombardier CH, Kalpakjian CZ, Graves DE, Dyer JR, Tate DG, Fann JR. Validity of the Patient Health Questionnaire-9 in assessing major depressive disorder during inpatient spinal cord injury rehabilitation. Arch Phys Med Rehabil. 2012 Oct;93(10):1838-45.
 
Bombardier CH, Richards JS, Krause JS, Tulsky D, Tate DG. Symptoms of major depression in people with spinal cord injury: implications for screening. Arch Phys Med Rehabil. 2004 Nov;85(11):1749-56.
 
Graves DE, Bombardier CH. Improving the efficiency of screening for major depression in people with spinal cord injury. J Spinal Cord Med. 2008;31(2):177-84.
 
Stroke-Specific References:
de Man-van Ginkel JM, Gooskens F, Schepers VP, Schuurmans MJ, Lindeman E, Hafsteinsdóttir TB. Screening for poststroke depression using the patient health questionnaire. Nurs Res. 2012 Sep-Oct;61(5):333-41.
 
Turner A, Hambridge J, White J, Carter G, Clover K, Nelson L, Hackett M. Depression screening in stroke: a comparison of alternative measures with the structured diagnostic interview for the diagnostic and statistical manual of mental disorders, fourth edition (major depressive episode) as criterion standard. Stroke. 2012 Apr;43(4):1000-5.
 
Document last updated August 2022