The PHQ-9 (Patient Health Questionnaire-9) is a free, public-domain, 9-item self-report questionnaire that measures the severity of depressive symptoms over the previous two weeks. Each item maps to one of the nine DSM criteria for major depressive disorder. Totals run from 0 to 27 and are used to screen for depression, grade severity, and track response to treatment over time.
How is the PHQ-9 scored?
Each of the nine items is rated 0 (not at all), 1 (several days), 2 (more than half the days), or 3 (nearly every day), always for the past two weeks. The nine ratings are summed for a total of 0 to 27. A tenth question asks how difficult the symptoms have made daily functioning; it is recorded but not added to the score — a detail frequently missed when practices rebuild the form themselves.
| Total score | Severity | Typical clinical response |
|---|---|---|
| 1-4 | Minimal | Monitor; treatment not usually indicated |
| 5-9 | Mild | Watchful waiting; repeat at follow-up |
| 10-14 | Moderate | Treatment plan considered |
| 15-19 | Moderately severe | Active treatment |
| 20-27 | Severe | Prompt treatment and further evaluation |
The official scoring card begins the minimal band at 1 rather than 0. Most secondary sources round this to 0-4; the clinical interpretation is the same.
The PHQ-9 diagnostic algorithm most practices never implement
The severity total is only one of two ways the PHQ-9 is read. The instrument also carries a criteria-based algorithm drawn from DSM. The official instruction manual describes a major depressive syndrome as suggested when five or more items are scored 2 or higher (*more than half the days*), at least one of which is item 1 (little interest or pleasure) or item 2 (feeling down, depressed, or hopeless). Two to four such items, again including item 1 or item 2, suggest other depressive syndrome. Item 9 counts toward the algorithm whenever it is endorsed at all. The manual is explicit that a syndrome is not a diagnosis: bereavement, a history of mania, and physical or medication causes have to be ruled out clinically before major depressive disorder is established.
Paper forms almost never surface this, because it requires reading the pattern of item responses rather than the sum. A digital form can evaluate both at once and present the clinician with a severity band and an algorithm result side by side.
What quality programs expect after a positive PHQ-9
These are reporting requirements, not clinical mandates — but they shape what a practice has to capture and when.
- A documented follow-up plan. MIPS quality measure #134 requires screening with an age-appropriate standardized tool on the date of the encounter or up to 14 days prior, and a follow-up plan documented on the date of the encounter or up to two days after it. A score with no documented plan does not count toward the measure.
- A 30-day window. The HEDIS DSF-E measure (Depression Screening and Follow-Up for Adolescents and Adults) expects follow-up within 30 days of a positive screen for members aged 12 and older.
- A re-measurement. HEDIS DRR-E measures remission or response using a follow-up PHQ-9 taken 120 to 240 days after the elevated index score.
Item 9 and suicide risk
Item 9 asks about thoughts of being better off dead or of hurting oneself. It is a screening prompt, not a risk assessment. Research indicates that a positive item 9 identifies a group at measurably elevated risk of later self-harm, while most people who endorse it will not go on to attempt. In practice it is commonly used as a trigger for a structured risk assessment such as the C-SSRS, rather than being read as either a negligible finding or a crisis in itself. How a given practice responds is a clinical protocol decision.
The operational failure mode is queueing. A positive item 9 sitting unread in a form inbox overnight is precisely the risk that digital intake exists to remove: a digital form can notify a named clinician at the moment of submission, before the appointment, rather than at check-in.
Is the PHQ-9 free to use?
Yes. Pfizer released the PHQ family and the GAD-7 into the public domain on July 21, 2010, with no copyright restriction and at no charge. The official PDFs state plainly that no permission is required to reproduce, translate, display, or distribute the instrument, and translations in nearly 80 languages are freely available.
The confusion comes from the forms themselves. Many circulating copies still carry a Copyright © Pfizer Inc. line and a PRIME-MD trademark notice predating the 2010 release. That notice does not restrict clinical or commercial use. Practices can legally build the PHQ-9 into a digital intake stack without a license — unlike the BDI-II, which remains copyrighted and licensed by its publisher.
PHQ-9 vs PHQ-2 vs PHQ-8
| Instrument | Items | Range | Positive at | Typical use |
|---|---|---|---|---|
| PHQ-2 | 2 | 0-6 | 3 or higher | First-pass screen at check-in |
| PHQ-8 | 8 | 0-24 | 10 or higher | Population research; omits item 9 |
| PHQ-9 | 9 | 0-27 | 10 or higher | Screening, severity grading, monitoring |
The PHQ-8 is the PHQ-9 with item 9 removed. It exists for large-scale survey and epidemiological work, where researchers cannot act on a self-harm response, and it is rarely the right choice in a clinical setting.
The standard clinical workflow is stepped: send the PHQ-2 to everyone and branch to the full PHQ-9 only when the short screen is positive. This is where conditional logic earns its keep — patients who screen negative answer two questions instead of nine, and the practice still captures a documented, dated screening result for every visit.
How accurate is the PHQ-9?
In the original validation across 15 primary care and obstetrics-gynecology clinics, a cutoff of 10 or higher produced a sensitivity of 88% and a specificity of 88% for major depression. A later individual-participant-data meta-analysis pooling 100 studies and 44,503 participants (Negeri et al., BMJ 2021) found sensitivity of 0.85 and specificity of 0.85 at the same cutoff — a slightly more conservative estimate drawn from a much broader evidence base.
The USPSTF gives depression screening in adults, including during pregnancy and postpartum, a Grade B recommendation. Grade B places it within Affordable Care Act preventive coverage requirements, so most commercial plans cover it without cost sharing.
How often should the PHQ-9 be repeated?
Because the recall window is two weeks, the PHQ-9 can meaningfully be repeated every two weeks during active treatment, and less often once symptoms are stable. HEDIS remission and response reporting anchors to a follow-up score between 120 and 240 days after an elevated result, so a practice reporting that measure needs at least one repeat administration inside that window. That is a scheduling problem more than a clinical one, and it is the kind of thing an automated re-send handles without anyone remembering.
Why quality programs name the PHQ-9 specifically
Two HEDIS measures — DRR-E and DMS-E — name the PHQ-9 by name, and both are reported through electronic clinical data. The numerator requires a discrete, dated PHQ-9 score in a structured field. A scanned PDF, an attached image, or a score typed into a free-text note does not satisfy it.
That is the practical argument for capturing the PHQ-9 digitally rather than on paper: not that it saves a few minutes at check-in, but that a hand-tallied score living inside a scanned document is invisible to the measure it was collected for.
How Zentake handles the PHQ-9
- Auto-scoring on submit. Totals and severity bands are calculated the moment the patient submits — no hand-tallying, no transcription step.
- Item 9 escalation. Any non-zero response can trigger a conditional alert to a named on-call clinician before the appointment rather than after it.
- Stepped PHQ-2 to PHQ-9 logic. Conditional branching expands to the full instrument only when the two-item screen is positive.
- Longitudinal tracking. Re-send on a schedule and read the score trend across visits instead of flipping through charts.
- Discrete write-back. The total, severity band, and item-level responses land in the chart as structured values, not a PDF attachment.
- HIPAA-ready. Encrypted in transit and at rest with a signed BAA on every plan. See how it fits mental health intake and primary care intake.
References
Kroenke K, Spitzer RL, Williams JBW. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-613.
Negeri ZF, Levis B, Sun Y, et al. Accuracy of the Patient Health Questionnaire-9 for screening to detect major depression: updated systematic review and individual participant data meta-analysis. BMJ. 2021;375:n2183.
US Preventive Services Task Force. Depression and Suicide Risk in Adults: Screening. June 20, 2023.
NCQA. HEDIS depression measures specified for electronic clinical data.
Official instrument, scoring card, and translations: phqscreeners.com.
Last updated: August 2026. This page describes how the PHQ-9 is used clinically and is not medical advice. If you are struggling with thoughts of self-harm, contact a clinician or, in the US, call or text 988.