PHQ-9 Score Interpretation & Management
| Score | Severity | Proposed Management |
|---|---|---|
| 0–4 | Minimal | No treatment needed. Routine review. |
| 5–9 | Mild | Watchful waiting. Psychoeducation. Reassess in 4 weeks. |
| 10–14 | Moderate | Treatment plan. Antidepressant and/or psychotherapy. Follow up. |
| 15–19 | Mod-Severe | Active treatment with antidepressant. Psychotherapy referral. |
| 20–27 | Severe | Immediate initiation of pharmacotherapy. Urgent psychiatric referral. |
About the PHQ-9
The Patient Health Questionnaire-9 (PHQ-9) was developed by Kroenke and Spitzer in 2001. It is derived from the primary care evaluation of mental disorders (PRIME-MD) diagnostic instrument. The nine questions correspond directly to the nine DSM diagnostic criteria for major depressive disorder. It has been validated in over 8,000 patients across primary care, obstetrics, internal medicine, and mental health settings.
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, and most international depression guidelines as the first-line screening and monitoring tool in primary care. It is free to use in clinical practice.
PHQ-9 Item 9 — Suicidality
Question 9 ("Thoughts that you would be better off dead, or thoughts of hurting yourself") requires specific attention regardless of total score. Any score >0 on item 9 mandates further suicide risk assessment — this should include a structured assessment of suicidal ideation, plan, intent, means, and protective factors. Never use the total PHQ-9 score to dismiss individual item 9 endorsement.
GAD-7 Score Interpretation
| Score | Severity | Proposed Management |
|---|---|---|
| 0–4 | Minimal | No treatment needed. |
| 5–9 | Mild | Psychoeducation, lifestyle advice, self-help resources. |
| 10–14 | Moderate | CBT referral. Consider SSRI. Safety net and follow-up. |
| 15–21 | Severe | SSRI + CBT. Consider psychiatric referral. Active monitoring. |
First-Line Treatments for Depression and Anxiety
Antidepressants (SSRI first-line): Escitalopram 10 mg OD (most tolerable, least drug interactions), Sertraline 50 mg OD (safest in cardiac disease, pregnancy), Fluoxetine 20 mg OD (longest half-life — useful if adherence concern). Allow 4–6 weeks for full effect. Continue for minimum 6–9 months after remission to prevent relapse.
Psychotherapy: Cognitive Behavioural Therapy (CBT) is first-line for both depression and GAD — 8–16 sessions. Equally effective to antidepressants for mild-moderate depression; superior for prevention of relapse. Mindfulness-Based Cognitive Therapy (MBCT) recommended for recurrent depression (≥3 episodes).
Combined treatment: For moderate-severe depression, combined pharmacotherapy + psychotherapy is superior to either alone. Start antidepressant immediately; refer for therapy concurrently.
Frequently Asked Questions
Related Calculators
About PHQ-9 and GAD-7
Depression and anxiety are the most prevalent mental health disorders worldwide and carry significant morbidity, mortality (through suicide and cardiovascular disease), and socioeconomic burden. In India, the National Mental Health Survey 2016 estimated that 1 in 7 Indians suffered from a mental disorder, with depression and anxiety accounting for the majority. Despite this burden, treatment gap remains enormous — estimated at 70-92% for mental disorders in India.
The PHQ-9 and GAD-7 were developed by Spitzer, Kroenke, and colleagues and directly operationalise DSM diagnostic criteria for major depression and generalised anxiety disorder respectively. They are freely available, require no training beyond basic clinical skills, and have been validated in multiple Indian languages. Both tools serve dual purposes: screening (identifying cases in the population) and severity monitoring (tracking treatment response over time).
An important clinical caveat: PHQ-9 and GAD-7 are screening tools — not diagnostic instruments. A high score prompts further clinical assessment; it does not automatically confirm diagnosis. Comorbid medical conditions (hypothyroidism, anaemia, chronic pain, sleep disorders) can elevate PHQ-9 scores independently of true depression. PHQ-9 item 9 (passive suicidal ideation) requires careful direct clinical assessment — any score above 0 on this item warrants a structured suicide risk assessment and documentation.