Administering the Patient Health Questionnaires 2 and 9 (PHQ 2 and 9) in Integrated Care Settings

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July 2016                 


Administering the Patient Health Questionnaires 2 and 9 (PHQ 2 and 9) in Integrated Care Settings
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Administering the Patient Health Questionnaires 2 and 9 (PHQ 2 and 9) in Integrated Care Settings

Purpose of this document

This document has been developed to help clarify and address common questions on the use and administration of the Patient Health Questionnaires 2 and 9 (PHQ 2 and 9) as preventive depression screening tools in the integrated care setting.

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How are the PHQ 2 and 9 tools used?

The PHQ 2 is a tool used to screen for depression, while the PHQ 9 tool is used to screen or diagnose depression, measure the severity of symptoms, and measure a patient´s response to treatment. The PHQ 2 and 9 are validated tools, developed and owned by Pfizer, and are quick and easy to administer.1,2

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What is the difference between a PHQ 2 and 9?

The PHQ 2 is a preliminary screening tool administered prior to the PHQ 9. If a patient responds ‘not at all´ to both questions on the PHQ 2 (asking if the patient has experienced little interest or pleasure in doing things and/or has felt down, depressed, or hopeless in the previous 2 weeks), then no additional screening or intervention is required, unless otherwise clinically indicated. If a patient responds ‘yes´ to one or both questions on the PHQ 2, the PHQ 9 should be administered and scored to inform treatment planning. Guidance on how often the PHQ 2 and 9 should be administered is included in the sections" How often should the PHQ 2 depression screening tool be administered?" and "How often should the PHQ 9 tool be re–administered to assess changes in a patient´s status?"

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Who can use the PHQ 2 and 9?

The PHQ 2 and 9 are both publicly available, and no permission is required to use, reproduce, or distribute the tools. Additionally, the tools are free of cost to use and can be incorporated into electronic health records.

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Who can administer the PHQ 2 and 9 to patients?

The PHQ 2 and 9 are useful tools for integrated care settings, as they can be administered by a variety of different staff and can be used with different approaches. The PHQ 2 and 9 should be completed by the patient, usually in the waiting room, and then scored by a staff person. Often administrative staff or medical assistants score this form and subsequently enter the score into the electronic health record. In cases where patients have difficulty with reading or comprehension, a staff member can assist the patient in completing the tool. Assistance with completing the tools can be provided by any level of staff who has been trained in understanding the purpose and importance of the PHQ tools and in strategies for engagement and completion of the tools.

Each organization will need to identify the PHQ 9 score that necessitates intervention in their particular setting. This is generally a score of 10 or above and/or a positive answer on question 9 of the PHQ 9, which is a screening for suicidal symptoms.3,4 A workflow will need to be developed to identify appropriate staff responsibilities and procedures for responding to these scores. This workflow includes review by the team (primary care provider and behavioral health staff, if available). Ideally, this pathway is then embedded into the electronic health record as part of the standard care delivery process.

Patients receiving intervention should be provided with regular follow up and tracked for improvement in their PHQ 9 score. The administration of the PHQ for follow up can be done using phone calls and/or a smartphone application.5,6 Results from studies that have analyzed telephonic and electronic administration of the tool have demonstrated that these methods yield similar results to being administered in person.

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In which populations should the PHQ 2 and 9 tools be used?

The PHQ 2 and 9 are appropriate to be used with individuals 12 years of age and older. Alternative screening tools have been developed and validated for use among special populations including youth and older adults. These alternative tools can be accessed at:–library/phq–9–depression–scale.

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How often should the PHQ 2 depression screening tool be administered?

The U. S Preventive Services Task Force (USPSTF) recommends screening for depression in adolescents ages 12 – 18 and in adults, including pregnant and postpartum women. "Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow–up."7 The American Academy of Family Physician recommendations mirror those of the USPSTF.8 The American Academy of Pediatrics recommends depression screening for adolescents beginning at age 11.9 At this time, there is no definitive guidance on how frequently someone should be screened for depression. The USPSTF states: "The optimum interval for screening for depression is also unknown; more evidence for all populations is needed to identify ideal screening intervals. A pragmatic approach in the absence of data might include screening all adults who have not been screened previously and using clinical judgment in consideration of risk factors, comorbid conditions, and life events to determine if additional screening of high–risk patients is warranted."10 Certain populations with higher risks for depression, such as those with HIV infection, may be considered for regular screening. For example, the NY State AIDS Institute HIV guidelines recommend screening "for depression as part of the annual mental health assessment and whenever symptoms suggest its presence."11 There is growing consensus that screening using evidence–based tools like the PHQ 9 is a critical component of delivering integrated care. The choice of how often and when is a workflow consideration.

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What does the PHQ 9 score mean for treatment planning?

The following chart provides guidance on how to use the PHQ 9 score to inform treatment planning.

Proposed Treatment Actions by PHQ 9 Score12

PHQ–9 Score Depression Severity Proposed Treatment Actions
0–4 None – Minimal None
5–9 Mild Watchful waiting; repeat PHQ 9 at follow–up
10–14 Moderate Treatment plan, consider counseling, follow up and/or pharmacotherapy
15–19 Moderately Severe Active treatment with pharmacotherapy and/or psychotherapy
20–27 Severe 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
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How often should the PHQ 9 tool be re–administered to assess changes in a patient´s status?

The University of Washington´s Advancing Integrated Mental Health Solutions (AIMS) Center develops and tests evidence–based collaborative care resources and tools. The AIMS Center provides the following guidance on how often the PHQ 9 should be administered13:

"Once a patient has been identified as having a behavioral health condition and has started treatment for that condition, it is very important to re–measure the symptoms at each contact so that the treating provider has specific information about whether or not symptoms are improving and which symptoms are, or are not, improving. Some people are concerned that the concept of measuring mental health with a validated rating instrument invalidates the patient´s feelings or experience or disregards the complexity of the patient´s story. These measures are an important piece of information about the patient but are not meant to represent the entire clinical picture of the patient, nor are they meant to replace the clinical judgment of the provider. They are an important tool to assist the clinician and the patient with identification of the specific symptoms causing difficulty for the patient and how well those symptoms respond to treatment over time. Frequent measurement of symptoms allows the treating providers and the patient to know whether the patient is having a full response, partial response or no response to treatment. These measures also provide clues about which symptoms are improving and which are not if there is a partial response to treatment. This information is critically important in making decisions about how to adjust treatment."

The PHQ 9 is a useful tool because, as noted above, it can be re–administered as needed. There are no strict guidelines on how often to re–administer the tool; however, a common recommendation for monitoring and adjusting treatment at 4–6 weeks includes14:

Treatment Response and Plan by Change in PHQ–9 Score

PHQ–9 Score at 4–6 weeks Treatment Response Treatment Plan
Drop of 5 points from baseline Adequate No treatment change needed Follow–up in 4 weeks
Drop of 2–4 points from baseline Possibly inadequate May warrant an increase in antidepressant dose or increase therapy intensity. Follow up in 2–4 weeks.
Drop of 1 point from baseline Inadequate Increase dose; Augmentation; Informal or formal psychiatric consultation; Add psychotherapy if not done Follow up in 1–2 weeks
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Are the PHQ 2 and 9 tools available in other languages?

The PHQ 2 and 9 and other versions of the PHQ are translated into other languages. Translated versions of the instrument can be found at

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Where can I find additional information?

Additional information on administering the PHQ–2 and PHQ–9 can be found at the following website:

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Document developed in collaboration with The National Council for Behavioral Health.
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1. Kroenke K, Spitzer R, Williams W. The PHQ–9: Validity of a brief depression severity measure. JGIM, 2001, 16:606–616.1
2. Pfizer to Offer Free Public Access to Mental Health Assessment Tools to Improve Diagnosis and Patient Care.;–releases/pfizer–to–offer–free–public–access–to–mental–health–assessment–tools–to–improve–diagnosis–and–patient–care–99025129.html. Published July 22, 2010. Accessed June 6, 2016.2
3. Instruction Manual: Instructions for Patient Health Questionnaire (PHQ) and GAD 7 Measures website. Published December 2014. Accessed June 6, 2016.3
4. Does Response on the PHQ–9 Depression Questionnaire Predict Subsequent Suicide Attempt or Suicide Death? Published December 2013. Accessed June 13, 2016.4
5. Pinto–Meza A, Serrano–Blanco A, Penarrubia M, et al. Assessing Depression in Primary Care with the PHQ–9: Can it be Carried Out over the Telephone? JGIM, 2005, 20:738–742.5
6. Torous J, Staples P, Shanahan M, et al. Utilizing a Personal Smartphone Custom App to Assess the Patient Health Questionnaire – 9 (PHQ–9) Depressive Symptoms in Patients with Major Depressive Disorder. JMIR Mental Health, 2015, 2:1–11. 6
7. US Preventive Services Task Force, Screening for Depression in Adults.–in–adults–screening1?ds=1&s=depression. Published January 2016. Accessed May 2016.7
8. Summary of Recommendations for Clinical Preventive Services. Available at:–recommendations.pdf. Published June 2016. Accessed June 2016.8
9. Recommendations for Preventive Pediatric Health Care. Available at:–us/Documents/periodicity_schedule.pdf. Published January 2016. Accessed June 2016. 9
10. US Preventive Services Task Force, Screening for Depression in Adults.–in–adults–screening1?ds=1&s=depression. Published January 2016. Accessed May 2016.10
11. Depression and Mania in Patients with HIV/AIDS. Available at:–guidelines/hiv–and–mental–health/depression–and–mania–in–patients–with–hivaids/. Published October 2010. Access June 2016.11
12. Instruction Manual: Instructions for Patient Health Questionnaire (PHQ) and GAD–7 Measures. Available at: Published December 2014. Accessed June 6, 2016.12
13. The University of Washington´s AIMS Center. Copyright© 2016 University of Washington.
14. Chung H, Pietruszewski P. Clinical Staff Webinar, National Council Depression Care Collaborative. 2015.14