PHQ assessments

The PHQ, or Patient Health Questionnaire, refers to a series of relatively quick, easy-to-administer, and psychometrically sound assessment tools.

PHQ assessments can easily be integrated into a wide array of mental health settings, including private practice, university counseling centers, community mental health, integrated behavioral health, and many more.

These measures have been studied numerous times in the psychological literature, allowing mental health therapists and clinicians to feel confident in their ability to measure various aspects of psychological distress with psychometrically validated sensitivity, specificity, and reliability.

In this article, we’ll cover what you need to know about the common PHQ assessments and how to utilize them in your clinical work effectively.

Types of PHQ assessments 

While each of the PHQ tests is unique, there are similarities among all of them:

• The number at the end of the PHQ represents how many items the assessment entails (e.g., PHQ-9 means there are nine items).
• The higher the Patient Health Questionnaire score, the greater the severity of the measured symptoms.
• None of the assessment tools are intended to be diagnostic on their own. Instead, they are used as screeners, assessment devices, and outcome-monitoring tools.

Patient Health Questionnaire-2

The PHQ-2 is a highly abbreviated measure aimed at capturing a client’s general level of depression symptoms with two simple questions.

This measure is best used as a quick and dirty screener and often takes clients less than a minute to complete.

Clients who score at or above a “3” (out of a total of “6” points) should be referred for a more in-depth depression assessment.

Patient Health Questionnaire-4

The PHQ-4 is another abbreviated measure.

However, unlike the PHQ-2, it is designed to give clinicians a quick glance at symptoms of both anxious distress and depression.

Clients can receive a total score out of “10.” A score of “3” or more on the anxiety items (the first two questions) or a score of “3” or more on the depression items (the last two questions) suggests the need for further assessment.

Notably, a total score can also be calculated by combining the scores of the four questions together.

This can give clinicians a straightforward measure of a client’s “general distress.”

Patient Health Questionnaire-9

Out of all of the Patient Health Questionnaire measures, the PHQ-9 is the most popular.

In fact, the PHQ-9 is one of the most commonly used evidence-based measures of depression, frequently used in both mental health settings and physical medicine.

Many primary care physicians now include the PHQ-9 as part of the paperwork for a person’s annual check-up.

The PHQ-9 includes nine questions about various depression symptoms one has experienced over the past two weeks.

Each item is scored on a 0-3 scale (e.g., 0 = Not at all; 1 = Several days; 2 = More than half the days; 3 = Nearly every day) for a total score of 27.

For every “5” points scored, individuals fall into increasingly severe categories of depression.

Scoring is as follows:

5-9 = Mild depression

10-14 = Moderate depression

15-20 = Moderately severe depression

21-27 = Severe depression

If you choose to utilize the PHQ-9, the last item (item 9) must always be looked at individually.

Item 9 asks about suicidality, and if a client endorses a 1 or higher, this would need to trigger a further suicide risk assessment.

Patient Health Questionnaire-15

Finally, the PHQ-15 is aimed at measuring somatic symptoms.

The PHQ-15 is intended to give a doctor or therapist an idea of how psychological distress interacts with physical pain, disability, or functional impairment. It can be an invaluable tool for clinicians working in chronic pain management settings or medical-oriented practices.

A PHQ-15 score of 10 or above typically indicates clinically relevant symptoms.

How to use PHQ assessments

Using the PHQ as a screener

One important use of Patient Health Questionnaire assessment tools is for the purpose of brief screening.

PHQ tools are easy to incorporate in one’s intake paperwork to provide an easy look at the client’s overall level of depression, anxiety, or somatic concerns.

Starting with the PHQ-2 or PHQ-4 is highly efficient, and you can send more in-depth assessments (e.g., PHQ-9) later if needed.

Using PHQ for diagnostics

The PHQ assessments are also great additions  to your toolbox of psychological assessments.

In any mental health diagnostic class, therapists learn that we can never rely on one specific tool to diagnose a client.

Proper diagnosis always entails the use of multiple tools and methods.

The Patient Health Questionnaire  assessments offer quick, objective, and psychometrically sound data that you can easily integrate into your intake assessment.

Furthermore, you can use the specific items on the PHQ assessments to follow up with clients during the intake interview to get more detailed information.

For example, if a client endorses a high score for item 1 (“Have you experienced little interest or pleasure in doing things over the past 2 weeks?”), it would be helpful to ask more about this in order to get a better sense of the client’s experience and functional impact of their symptoms.

Using PHQ for measurement-based care

Measurement-based care (MBC) is the practice of routinely administering psychological assessment tools and integrating the data from these tools into treatment.

Measurements may be sent out before and after treatment (e.g., pre- and post-measures) to get a sense of change over time.

However, they may also be administered more regularly (e.g., weekly, bimonthly, or monthly).

A sizable evidence base shows that regular client assessments can enhance treatment outcomes and reduce dropout rates significantly.

It’s essential to be strategic about which assessment measures a clinician uses for MBC, although the PHQ tests are typically great options due to their brevity and research base.

An important aspect of MBC is sharing scores with clients during sessions, thereby incorporating this assessment as an intervention.

This can help clients feel empowered as active collaborators in their treatment, increase their awareness of triggers, and help to direct the course of therapy.

For example, if a client’s PHQ-9 score is rising over time, it would be helpful to have a conversation with the client about what’s working and what needs to be changed.

PHQ and SimplePractice

SimplePractice offers an incredible range of assessment tools clinicians can send to their clients via the client portal.

The PHQ-9 and GAD-7 (a tool measuring generalized anxiety symptoms) are currently set up to be scored automatically and inputted on a graph.

This makes it easier for you and your clients to track progress over time and catch any potential deteriorations.

Sources

• Boswell, J. F., Hepner, K. A., Lysell, K., Rothrock, N. E., Bott, N., Childs, A. W., … & Bobbitt, B. L. (2023). The need for a measurement-based care professional practice guideline. Psychotherapy, 60(1), 1.
• Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ‐9: validity of a brief depression severity measure. Journal of general internal medicine, 16(9), 606-613.
• Kroenke, K., Spitzer, R. L., & Williams, J. B. (2002). The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosomatic medicine, 64(2), 258-266.
• Kroenke, K., Spitzer, R. L., & Williams, J. B. (2003). The Patient Health Questionnaire-2: validity of a two-item depression screener. Medical care, 41(11), 1284-1292.
• Kroenke, K., Spitzer, R. L., Williams, J. B., & Löwe, B. (2009). An ultra-brief screening scale for anxiety and depression: the PHQ–4. Psychosomatics, 50(6), 613-621.

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