PHQ-9 & GAD-7: Screening for Depression & Anxiety in Primary Care | RxMedCalc
How the PHQ-9 and GAD-7 work, what each score means, management by severity, antidepressants and therapy, the special case of PHQ-9 Item 9, and mental health resources in India.
🆘 If you or someone you know is in crisis
iCall (India): 9152987821 · Vandrevala Foundation: 1860-2662-345 · NIMHANS: 080-46110007 · iCall also offers online counselling at icallhelpline.org
Depression and anxiety are the two most common mental health conditions in the world — and also the two most under-diagnosed. The World Health Organization estimates that over 300 million people live with depression globally. In India, the National Mental Health Survey found that approximately 1 in 7 Indians suffers from a mental health condition, with depression and anxiety disorders leading the list. Yet fewer than 20% ever receive any form of treatment.
One of the most significant barriers to treatment is identification. A busy GP or physician sees dozens of patients daily. A patient with depression rarely walks in and says "I am depressed" — they come in with fatigue, headaches, sleep problems, or vague bodily complaints. Without a systematic screening tool, the diagnosis is missed.
The PHQ-9 and GAD-7 are the solution. They are brief, validated, free questionnaires that can be completed by the patient in under 3 minutes — and they transform subjective distress into an objective, actionable score.
What Is the PHQ-9?
The Patient Health Questionnaire-9 (PHQ-9) was developed by Dr Kurt Kroenke and Dr Robert Spitzer in 2001. Its nine questions correspond directly to the nine diagnostic criteria for Major Depressive Disorder (MDD) in the DSM-5. Each question asks how often the patient has been bothered by a symptom over the past two weeks, scored from 0 (not at all) to 3 (nearly every day), giving a maximum total of 27.
The PHQ-9 has a sensitivity of 88% and specificity of 88% for major depressive disorder at a cutoff of ≥10. It is recommended by NICE (CG90), the WHO mhGAP programme, and virtually all international primary care depression guidelines as the first-line screening and monitoring tool.
The 9 PHQ-9 Questions
Over the last 2 weeks, how often have you been bothered by the following?
| # | Symptom | DSM-5 Criterion |
|---|---|---|
| 1 | Little interest or pleasure in doing things | Anhedonia |
| 2 | Feeling down, depressed, or hopeless | Depressed mood |
| 3 | Trouble falling or staying asleep, or sleeping too much | Sleep disturbance |
| 4 | Feeling tired or having little energy | Fatigue |
| 5 | Poor appetite or overeating | Appetite change |
| 6 | Feeling bad about yourself — or that you are a failure | Worthlessness/guilt |
| 7 | Trouble concentrating on things | Poor concentration |
| 8 | Moving or speaking so slowly others could notice — or being fidgety | Psychomotor change |
| 9 | Thoughts that you would be better off dead, or of hurting yourself | Suicidality |
⚠️ PHQ-9 Item 9 — Suicidality requires immediate attention. Any score > 0 on item 9 mandates a structured suicide risk assessment regardless of the total score. Ask directly: Do they have a plan? Access to means? Intent? Protective factors? Never leave a patient who endorses item 9 without a safety plan or appropriate referral.
PHQ-9 Score Interpretation & Management
| Score | Severity | Management |
|---|---|---|
| 0–4 | Minimal depression | No treatment needed. Psychoeducation. Routine follow-up. |
| 5–9 | Mild depression | Watchful waiting. Psychoeducation. Lifestyle advice. Reassess in 4 weeks. |
| 10–14 | Moderate depression | Treatment plan. Antidepressant and/or structured psychotherapy (CBT). Follow up in 2–4 weeks. |
| 15–19 | Moderately severe | Active treatment with antidepressant. Psychotherapy referral. Weekly monitoring initially. |
| 20–27 | Severe depression | Immediate pharmacotherapy. Urgent psychiatric referral. Assess suicide risk at every contact. |
What Is the GAD-7?
The Generalised Anxiety Disorder-7 (GAD-7) was developed by the same team in 2006. Its seven questions screen for generalised anxiety disorder but also detect panic disorder, social anxiety disorder, and PTSD with reasonable accuracy. Each question is scored 0–3 over the past two weeks, giving a maximum total of 21.
The GAD-7 has a sensitivity of 89% and specificity of 82% for generalised anxiety disorder at a cutoff of ≥10. It is the most widely used anxiety screening tool in primary care globally.
The 7 GAD-7 Questions
Over the last 2 weeks, how often have you been bothered by the following?
| # | Symptom |
|---|---|
| 1 | Feeling nervous, anxious, or on edge |
| 2 | Not being able to stop or control worrying |
| 3 | Worrying too much about different things |
| 4 | Trouble relaxing |
| 5 | Being so restless it's hard to sit still |
| 6 | Becoming easily annoyed or irritable |
| 7 | Feeling afraid, as if something awful might happen |
GAD-7 Score Interpretation & Management
| Score | Severity | Management |
|---|---|---|
| 0–4 | Minimal anxiety | No treatment needed. Reassurance and routine care. |
| 5–9 | Mild anxiety | Psychoeducation. Stress management, relaxation techniques. Monitor. |
| 10–14 | Moderate anxiety | Consider referral for CBT or pharmacotherapy (SSRI). Active monitoring. |
| 15–21 | Severe anxiety | Active treatment required. SSRI or SNRI. CBT referral. Psychiatric review if not responding. |
🧠 Use the RxMedCalc PHQ-9 & GAD-7 Calculator — both tools in one place, with clinical interpretation and management guidance per NICE guidelines.
Depression and Anxiety in India — The Burden
India faces a profound mental health crisis that is frequently underdiscussed. The National Mental Health Survey 2016 found:
- Approximately 1 in 7 Indians (150 million people) suffers from a mental health condition requiring treatment
- Depressive disorders are the leading cause of mental health-related disability
- Anxiety disorders affect approximately 3.5% of the population — and are dramatically underdiagnosed in primary care
- The treatment gap — the proportion of people with mental illness who receive no treatment — is over 80%
- India has fewer than 0.3 psychiatrists per 100,000 people — one of the lowest ratios in the world
This makes primary care screening with the PHQ-9 and GAD-7 particularly critical in India. The GP, MBBS physician, or family doctor is often the only mental health contact a patient will ever have. Systematic screening identifies patients who would otherwise leave the clinic with a prescription for antacids instead of an antidepressant.
Pharmacotherapy — Antidepressants in Primary Care
For moderate to severe depression (PHQ-9 ≥ 10) and moderate to severe anxiety (GAD-7 ≥ 10), pharmacotherapy is indicated. SSRIs (Selective Serotonin Reuptake Inhibitors) are first-line for both conditions.
| Drug | Class | Starting Dose | Usual Dose | Key Notes |
|---|---|---|---|---|
| Escitalopram | SSRI | 5–10 mg OD | 10–20 mg OD | Best-tolerated SSRI. First-line in India. Effective for both depression and anxiety. |
| Sertraline | SSRI | 25–50 mg OD | 50–200 mg OD | Excellent evidence base. Safe in pregnancy. First-line. |
| Fluoxetine | SSRI | 10–20 mg OD | 20–60 mg OD | Long half-life — easier to stop. More activating, can worsen anxiety initially. |
| Duloxetine | SNRI | 30 mg OD | 60–120 mg OD | Effective for both depression and anxiety. Also helpful for painful somatic symptoms. |
| Mirtazapine | NaSSA | 15 mg nocte | 15–45 mg nocte | Sedating — useful for insomnia. Less sexual side effects. Weight gain common. |
Key Prescribing Principles
- Start low, go slow: Begin at half the usual dose for 1–2 weeks to minimise initial side effects (particularly nausea and anxiety activation with SSRIs)
- Allow 4–6 weeks for a therapeutic effect — patients often abandon treatment because they expect immediate improvement. Set expectations clearly.
- Continue for at least 6 months after remission to prevent relapse — stopping early is the most common cause of recurrence
- Never stop abruptly — taper gradually (over 4–8 weeks) to avoid discontinuation syndrome (dizziness, electric shock sensations, flu-like symptoms)
- Reassess the PHQ-9 and GAD-7 at every follow-up visit to monitor treatment response objectively
Psychotherapy — The Non-Drug Pillar of Treatment
Cognitive Behavioural Therapy (CBT) has the strongest evidence base for both depression and anxiety — comparable to antidepressants for mild-to-moderate severity, and superior in preventing relapse when combined with medication. CBT is structured (typically 8–20 sessions), present-focused, and teaches patients to identify and change unhelpful thought patterns.
In India, access to trained CBT therapists has historically been a barrier. This is rapidly changing with the growth of digital mental health platforms (iCall, YourDOST, InnerHour, Wysa) that offer evidence-based psychological interventions remotely — making CBT accessible across urban and rural India.
Other evidence-based psychotherapies include: IPT (Interpersonal Therapy) for depression related to grief or relationship difficulties; mindfulness-based CBT (MBCT) for recurrent depression; and exposure therapy for anxiety disorders.
Limitations of the PHQ-9 and GAD-7
- They are screening tools, not diagnostic instruments. A PHQ-9 ≥ 10 does not diagnose major depression — it identifies patients warranting a full clinical assessment
- Scores can be elevated by physical illness (fatigue and sleep problems from anaemia, hypothyroidism, or chronic pain can inflate PHQ-9 scores without true depression)
- Not validated for bipolar disorder screening — always ask about manic episodes before starting antidepressants; SSRIs can trigger mania in undiagnosed bipolar patients
- Cultural adaptation: some PHQ-9 items may be interpreted differently across cultures — the tool performs well in India but clinician interpretation remains essential
- They do not assess psychosis, substance misuse, or personality disorders, which require additional screening
Key Takeaways
- PHQ-9 (9 questions, max 27) screens for depression; GAD-7 (7 questions, max 21) screens for anxiety
- PHQ-9 ≥ 10 = moderate depression → active treatment warranted. GAD-7 ≥ 10 = moderate anxiety → treatment recommended
- PHQ-9 Item 9 > 0 mandates immediate suicide risk assessment regardless of total score
- India's mental health treatment gap exceeds 80% — systematic primary care screening is essential
- SSRIs are first-line — escitalopram and sertraline are preferred. Start low, allow 4–6 weeks for effect
- Continue antidepressants for at least 6 months after remission — never stop abruptly
- CBT is as effective as medication for mild-to-moderate depression and anxiety, and superior for relapse prevention
- Rescreen with PHQ-9 / GAD-7 at every follow-up visit to objectively track treatment response
References
- Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-613.
- Spitzer RL et al. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092-1097.
- NICE. Depression in adults: recognition and management. Clinical Guideline CG90, updated 2022.
- WHO. mhGAP Intervention Guide — Mental Health Gap Action Programme. WHO, 2016.
- National Mental Health Survey of India, 2015–16. Prevalence, patterns and outcomes. NIMHANS, Bengaluru.
This article is for educational purposes based on NICE and WHO guidelines. Depression and anxiety require assessment and management by a qualified clinician. If you or someone you know is experiencing mental health difficulties, please seek professional help.
Built by an MBBS, AFIH Certified Physician in Punjab, India | RxMedCalc.com