The PHQ-9: A Depression Assessment Tool

December 2, 2020

Major depressive disorder is one of the most prevalent mental health conditions in the United States, affecting approximately 7% of American adults each year. Symptoms of depression can include feelings of intense or persistent sadness, loss of interest or pleasure in daily activities, fatigue, feelings of guilt or worthlessness, thoughts of death, difficulty concentrating, and more. 

If you think you might be suffering from major depressive disorder, also known as major depression, your healthcare provider may recommend that you take the PHQ-9 in order to evaluate the severity of your condition. With this information, your provider will be better equipped to recommend major depressive disorder treatments such as cognitive-behavioral therapy and antidepressants. Here’s what you need to know.

What is the PHQ-9?

If you’ve never heard of a PHQ (Patient Health Questionnaire), you’re not alone. The PHQ-9 is a 9 question assessment and diagnostic tool used by mental health professionals to assess the severity of depression in patients. 

Although there are a variety of different ways to diagnose depression, the PHQ-9 has many advantages, including:

  • Being shorter than other depression rating scales
  • The ability to be administered either in person by a clinician, over the telephone or virtually by a clinician, or self-administered by the patient
  • Facilitating the diagnosis and severity of major depressive disorder (MDD)
  • The ability to be used in children and adolescents as young as 12 years old
  • Being shown to be effective in a variety of populations

The higher a patient’s score on the PHQ-9 is, the more likely they are suffering from major depressive disorder. The PHQ-9 involves asking the patient nine different questions regarding the frequency of their experiences relating to a depressed mood over the last two weeks, and is based on criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM V). Possible responses to the questions include the following:

  • Not at all (0 points)
  • Several days (1 point)
  • More than half the days (2 points)
  • Nearly every day (3 points)

The questions included as part of the depression PHQ-9 are as follows:

  1. Over the past two weeks, how often have you been bothered by having little interest or pleasure in doing things?
  2. Over the past two weeks, how often have you been bothered by feeling down, depressed, or hopeless?
  3. Over the past two weeks, how often have you been bothered by trouble falling or staying asleep, or sleeping too much?
  4. Over the past two weeks, how often have you been bothered by feeling tired or having little energy?
  5. Over the past two weeks, how often have you been bothered by having a poor appetite or overeating?
  6. Over the past two weeks, how often have you been bothered by feeling bad about yourself – or that you are a failure or have let yourself or your family down?
  7. Over the past two weeks, how often have you been bothered by trouble concentrating on things, such as reading the newspaper or watching television?
  8. Over the past two weeks, how often have you been bothered by moving or speaking so slowly that other people could have noticed, or by being so fidgety or restless that you have been moving a lot more than usual?
  9. Over the past two weeks, how often have you been bothered by thoughts that you would be better off dead, or thoughts of hurting yourself in some way?

The scores are then ranked on a scale in order to help the mental health professional recommend the best course of treatment.​​​ The management summary is as follows:

  • Score of 0 – 4: Minimal or zero depression. The patient should be monitored but may not require treatment.
  • Score of 5 – 9: Mild depression. The mental health professional should use clinical judgement based on the symptom duration and functional impairment of the patient in order to determine the necessity of treatment.
  • Score of 10 – 14: Moderate depression. The mental health professional should use clinical judgement based on the symptom duration and functional impairment of the patient in order to determine the necessity of treatment.
  • Score of 15 – 19: Moderately severe depression. This condition warrants active treatment with psychotherapy, medications, or a combination of both.
  • Score of 20 – 27: Severe depression. This condition warrants active treatment with psychotherapy, medications, or a combination of both.

It should be noted that patients who indicate that they have experienced suicidal thoughts or ideation based on their response to question number nine should have a suicide risk assessment performed. Based on the patient’s score on the PHQ-9, the mental health professional may then make treatment recommendations ranging from therapy to psychiatry. 

What treatments are available for major depressive disorder?

Patients who are found to be suffering from major depressive disorder have several options. Your mental health professional will help you select the options that are right for you. Available treatments for major depressive disorder include antidepressant medications, psychotherapy, and lifestyle changes. 

Antidepressant Medications

Major depressive disorder is believed to be caused at least in part by imbalances in brain chemistry that can affect the amount of certain neurotransmitters, including serotonin and norepinephrine, in the brain. 

Selective serotonin reuptake inhibitors (SSRIs) are one of the most popular classes of antidepressant medications. These prescription drugs work by inhibiting the breakdown of serotonin in the brain, which increases the level of the neurotransmitter. Because serotonin is believed to play an important role in mood and sleeping patterns, increasing the amount of the chemical can result in improved mood and better sleep. Some of the most well known SSRIs are drugs like Prozac (fluoxetine) and Lexapro (escitalopram).

Serotonin-norepinephrine reuptake inhibitors (SNRIs) inhibit the breakdown of both serotonin and norepinephrine by the brain. SNRIs are a newer class of drugs than SSRIs and are increasing in popularity. Some of the most common SNRIs include Cymbalta (duloxetine) and Effexor (venlafaxine). 

Common side effects of antidepressants include weight gain, nausea, and drowsiness, but most patients do not experience side effects in a way that impacts their day to day. 

Other types of antidepressants include tricyclic antidepressants and atypical antidepressants. These medications are less commonly used and are usually recommended when treatment with SSRIs or SNRIs hasn’t helped. They can also be used for treatment-resistant depression. Wellbutrin is a well known atypical antidepressant.

Psychotherapy

Psychotherapy, also known as talk therapy, is another effective outpatient treatment option for major depressive disorder. Patients meet with a therapist on a regular basis to discuss their symptoms and related issues. Psychotherapy can be very helpful for people with major depressive disorder because it can help patients develop healthy coping mechanisms, increase their self-esteem, help replace negative thoughts and feelings with more positive ones, help patients adjust to stressful situations in their lives, and improve communication skills. 

Interpersonal therapy is a common therapy used to help with depression and major depressive episodes that focuses on the patient’s relationships with friends and loved ones, though it’s important to note that depression is not always caused by a traumatic or toxic relationships. 

Lifestyle Changes

In addition to antidepressant medications and psychotherapy, lifestyle changes are an important component of major depressive disorder treatment. Eating a healthy, well-balanced diet, avoiding alcohol and certain processed foods, getting plenty of exercise, and getting enough sleep can all help improve your energy level and minimize feelings of fatigue. 

In fact, implementing positive lifestyle changes is recommended by the American Psychiatric Association to help with many mood disorders and medical conditions alike — whole body and mind wellness can do a lot for improving depressive symptoms and reducing risk factors for comorbidities. 

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If you’re ready to take the first step toward getting help with your depression, consider getting started with YANA. YANA is an online mental health clinic that can match you to a qualified mental health provider to evaluate your symptoms and develop a personalized treatment plan that’s right for you. YANA makes mental healthcare easily accessible and affordable while keeping things discreet.

If you’re not quite ready just yet, head over to YANA’s blog for additional resources and information that can help educate and guide you in the right direction in the meantime. 

Sources:

https://www.psychiatry.org/patients-families/depression/what-is-depression

https://www.mdcalc.com/phq-9-patient-health-questionnaire-9

https://www.healthline.com/health/clinical-depression

https://www.nimh.nih.gov/health/statistics/major-depression.shtml

https://www.mayoclinic.org/diseases-conditions/depression/symptoms-causes/syc-20356007

https://www.webmd.com/depression/guide/major-depression#1

https://aims.uw.edu/resource-library/phq-9-depression-scale