PHQ-9 Scoring and Interpretation: The Complete Clinical Guide
Nine items, 0-27, two minutes — the most widely used depression screening and severity measure in medicine.
What the PHQ-9 measures
The PHQ-9 asks how often, over the last two weeks, a person has been bothered by the nine DSM criteria for a major depressive episode: loss of interest, low mood, sleep problems, fatigue, appetite change, feelings of worthlessness or guilt, poor concentration, psychomotor change, and thoughts of being better off dead or of hurting oneself.
Each item scores 0 (not at all) to 3 (nearly every day), so the total runs from 0 to 27. Cut-points of 5, 10, 15 and 20 mark mild, moderate, moderately severe and severe depression, and a total of 10 or more is the standard threshold for probable major depression.
The PHQ-9 is a severity and monitoring measure as well as a screen. Because it maps directly onto the diagnostic criteria and is sensitive to change, repeat scores are the backbone of measurement-based care, HEDIS depression reporting and value-based contracts.
How to score the PHQ-9
Score range: 0-27 (nine items scored 0-3)
- 1Score each item 0 = not at all, 1 = several days, 2 = more than half the days, 3 = nearly every day.
- 2Add the nine items for a total from 0 to 27. There are no reverse-scored items, no weighting and no subscales.
- 3Apply the bands: 0-4 minimal, 5-9 mild, 10-14 moderate, 15-19 moderately severe, 20-27 severe.
- 4Read Item 9 on its own. Any response above 0 requires a same-visit suicide risk assessment regardless of the total.
- 5Optionally apply the diagnostic algorithm: 5 or more items at 2 or higher (Item 9 counts at 1 or higher), and one of those must be Item 1 or Item 2.
- 6Record the unscored functional-impairment question in the note alongside the total.
PHQ-9 score interpretation
| Score | Severity | What it means clinically |
|---|---|---|
| 0-4 | Minimal or none | No treatment indicated on this measure. This is the remission target when tracking treatment — a final score under 5 is how remission is defined. |
| 5-9 | Mild depression | Watchful waiting, psychoeducation, behavioural activation, sleep and substance review. Repeat in two to four weeks rather than starting medication on this score alone. |
| 10-14 | Moderate depression | Probable major depression. Confirm diagnostically and start active treatment — psychotherapy, an antidepressant, or both. This is the standard screening cut-off. |
| 15-19 | Moderately severe depression | Active treatment indicated, usually medication plus psychotherapy. Increase visit frequency and assess suicide risk, function and support at every contact. |
| 20-27 | Severe depression | Immediate active treatment, expedited psychiatric referral, and a formal safety assessment. Consider higher level of care, and review for psychosis, catatonia and bipolarity before starting an antidepressant alone. |
What specific PHQ-9 scores mean
What does a PHQ-9 score of 5 mean?
Five is the bottom of the mild band. It means some depressive symptoms are present but usually below the level at which medication is indicated. Give psychoeducation, address sleep, activity and alcohol, and repeat the measure in two to four weeks.
What does a PHQ-9 score of 10 mean?
Ten is the standard cut-off for probable major depression, with roughly 88% sensitivity and 88% specificity. It indicates moderate depression and calls for diagnostic confirmation and active treatment rather than watchful waiting.
What does a PHQ-9 score of 15 mean?
Fifteen begins the moderately severe band. Combined psychotherapy and medication is the usual recommendation, visits should be more frequent, and suicide risk should be assessed at each contact.
What does a PHQ-9 score of 20 mean?
Twenty or more is severe depression. Treat immediately, arrange expedited psychiatric involvement, complete a formal safety assessment, and consider whether a higher level of care is needed.
What is a normal PHQ-9 score?
A total of 0 to 4 is minimal and is treated as the normal range. It is also the remission target: a post-treatment score below 5 is the standard definition of remission.
How much PHQ-9 change is clinically meaningful?
A drop of 5 points or more, or a 50% reduction from baseline, is the usual definition of treatment response. Smaller movements sit inside measurement error and should not be read as improvement.
Can the PHQ-9 diagnose depression?
No. It is a screening and severity measure. A score of 10 or more indicates probable major depression and requires a clinical interview to confirm the diagnosis and rule out bipolar disorder, grief, thyroid disease, anaemia, substance effects and medication side effects.
What does PHQ-9 Item 9 mean?
Item 9 asks about thoughts of being better off dead or of hurting oneself. Any score above 0 requires a same-visit suicide risk assessment and a safety plan, even when the total falls in the minimal or mild band.
Item 9 overrides the total
The single most important rule in PHQ-9 interpretation is that Item 9 is read separately. A patient can total 6 — nominally mild — and still endorse thoughts of being better off dead several days a week. The band is not the clinical picture.
Any response above 0 on Item 9 should trigger a structured risk assessment in the same visit, a safety plan, means restriction counselling, and a documented follow-up interval. In TouchpointHQ this fires an alert to the clinician automatically rather than waiting for the chart to be reviewed.
Using the PHQ-9 to track treatment, not just to screen
Screening once produces a number. Repeating the PHQ-9 produces a trajectory, which is what actually changes decisions: response is a 50% reduction or a drop of at least 5 points; remission is a total below 5; non-response by week six to eight is the signal to change dose, switch, or augment rather than to wait.
Practices report outcomes as the proportion of patients reaching response or remission within a defined window — 3, 6 or 12 months. That figure, not the average score, is what payers and quality programmes ask for.
Common misinterpretations
- Treating 10 as a diagnosis. It flags probability and triggers assessment; the interview makes the diagnosis.
- Pro-rating a total when items are missing, which shifts the score into the wrong band.
- Ignoring Item 9 because the total is low.
- Missing bipolar depression. The PHQ-9 does not ask about mania — screen with the MDQ before starting an antidepressant.
- Missing medical contributors: hypothyroidism, anaemia, vitamin B12 deficiency, obstructive sleep apnoea, chronic pain, and alcohol or sedative use.
- Reading a 2 or 3 point change as improvement when it is inside measurement noise.
PHQ-2, PHQ-9 and PHQ-15
The PHQ-2 is the first two PHQ-9 items scored 0-6, used as an ultra-brief screen; a score of 3 or more should be followed immediately by the full PHQ-9. The PHQ-15 is a separate somatic symptom measure, not a depression scale.
In high-volume settings the efficient sequence is PHQ-2 for everyone, PHQ-9 when the PHQ-2 is positive, and GAD-7 alongside the PHQ-9 because anxiety and depression co-occur in roughly 60% of cases.
Who the PHQ-9 is for
- Universal depression screening in primary care, integrated care and behavioural health intake
- Session-by-session or two-weekly severity monitoring during therapy, medication or TMS treatment
- Paired with the GAD-7 for a five-minute mood and anxiety screen
- HEDIS Depression Screening, Utilization and Remission measures and other quality reporting
Administration and re-testing
- Self-report covering the last two weeks. Reading the items aloud gives equivalent results when literacy or vision is a barrier.
- Score all nine items. If one is missing, ask for it rather than pro-rating; a missing Item 9 in particular must always be followed up.
- Administer at intake, then every session or every two weeks in active treatment, and at least every four to six weeks in maintenance.
- The tenth question about difficulty at work, home and relationships is not part of the total. Record it separately — it frequently changes the level of care decision.
Reliability and validity
- Internal consistency is excellent, with Cronbach's alpha typically reported between 0.86 and 0.89.
- At a cut-off of 10 the PHQ-9 has approximately 88% sensitivity and 88% specificity for major depression.
- Test-retest reliability is high, and the measure is responsive to treatment change, which is what makes it suitable for repeat administration.
- It has been validated in more than 30 languages and across primary care, obstetric, oncology, cardiology and behavioural health populations.
- Item 9 endorsement is associated with elevated suicide attempt risk over the following year, independently of the total score.
Licensing and use
The PHQ-9 is in the public domain. It can be copied, translated and used in clinical care, research and commercial software without permission or fee.
Frequently asked questions
How do you score the PHQ-9?
Score each of the nine items from 0 (not at all) to 3 (nearly every day) and add them for a total from 0 to 27. Bands are 0-4 minimal, 5-9 mild, 10-14 moderate, 15-19 moderately severe and 20-27 severe.
What is the PHQ-9 cut-off score?
Ten or higher is the standard cut-off for probable major depression and the point at which diagnostic assessment and active treatment are indicated.
Is the PHQ-9 free to use?
Yes. The PHQ-9 is in the public domain and can be reproduced, translated and built into software without permission or fee.
How is the tenth PHQ-9 question scored?
It is not scored. The functional-impairment question is recorded separately and used to inform level of care.
How often should the PHQ-9 be repeated?
At intake, then every session or every two weeks during active treatment, and every four to six weeks in maintenance. Repeat measurement is what allows response and remission to be documented.
What is the difference between the PHQ-9 and the PHQ-2?
The PHQ-2 is the first two PHQ-9 items scored 0-6 as an ultra-brief screen. A PHQ-2 of 3 or more should be followed by the full PHQ-9.
Is there a PHQ-9 for teenagers?
Yes. The PHQ-A adapts the wording and adds items for adolescents, and the PHQ-9 itself is validated from age 12.
What should happen if a patient endorses Item 9?
Any response above 0 requires a suicide risk assessment in the same visit, a safety plan, means restriction counselling and a documented follow-up interval, regardless of the total score.
References
- Kroenke K, Spitzer RL, Williams JBW. The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine. 2001;16(9):606-613.
- Manea L, Gilbody S, McMillan D. Optimal cut-off score for diagnosing depression with the PHQ-9: a meta-analysis. CMAJ. 2012;184(3):E191-196.
- Simon GE, Rutter CM, Peterson D, et al. Does response on the PHQ-9 Depression Questionnaire predict subsequent suicide attempt or suicide death? Psychiatric Services. 2013;64(12):1195-1202.
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This page is clinical reference information for professionals and the public. It is not medical advice, and no assessment score is a diagnosis. Discuss any result with a licensed clinician. Read our medical disclaimer.