Cited by 1,279Anxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesMental Health Treatment and AccessTreatment of Major Depression

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Validation of PHQ-2 and PHQ-9 to Screen for Major Depression in the Primary Care Population

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Arroll, B., Goodyear-Smith, F., Crengle, S., Gunn, J., Kerse, N., Fishman, T., Falloon, K., Hatcher, S.·2010·The Annals of Family Medicine

DOI 10.1370/afm.1139PMC PMC2906530

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Abstract

PURPOSE: Although screening for unipolar depression is controversial, it is potentially an efficient way to find undetected cases and improve diagnostic acumen. Using a reference standard, we aimed to validate the 2- and 9-question Patient Health Questionnaires (PHQ-2 and PHQ-9) in primary care settings. The PHQ-2 comprises the first 2 questions of the PHQ-9. METHODS: Consecutive adult patients attending Auckland family practices completed the PHQ-9, after which they completed the Composite International Diagnostic Interview (CIDI) depression reference standard. Sensitivities and specificities for PHQ-2 and PHQ-9 were analyzed. RESULTS: There were 2,642 patients who completed both the PHQ-9 and the CIDI. Sensitivity and specificity of the PHQ-2 for diagnosing major depression were 86% and 78%, respectively, with a score of 2 or higher and 61% and 92% with a score 3 or higher; for the PHQ-9, they were 74% and 91%, respectively, with a score of 10 or higher. For the PHQ-2 a score of 2 or higher detected more cases of depression than a score of 3 or higher. For the PHQ-9 a score of 10 or higher detected more cases of major depression than the PHQ determination of major depression originally described by Spitzer et al in 1999. CONCLUSIONS: We report the largest validation study of the PHQ-2 and PHQ-9, compared with a reference standard interview, undertaken in an exclusively primary care population. The PHQ-2 score or 2 or higher had good sensitivity but poor specificity in detecting major depression. Using a PHQ-2 threshold score of 2 or higher rather than 3 or higher resulted in more depressed patients being correctly identified. A PHQ-9 score of 10 or higher appears to detect more depressed patients than the originally described PHQ-9 scoring for major depression.

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Validation and Utility of a Self-report Version of PRIME-MD<SUBTITLE>The PHQ Primary Care Study</SUBTITLE>
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“Sensitivity and specificity for PHQ-2 are 86% and 78%, respectively [4]; GAD-2 has a sensitivity of 76% and specificity of 81% [75].”
BackgroundMethod
Psychosocial Support in Pulmonary Rehabilitation
Yohannes, A. M. (2024) · Respiratory Care · doi:10.4187/respcare.11850 · Cited by 12
Serum neurofilament light chain levels are associated with depression among US adults: a cross-sectional analysis among US adults, 2013–2014
Song, Y., Jiao, H., Weng, Q., Liu, H., & Li, Y. (2024) · BMC Psychiatry · doi:10.1186/s12888-024-05964-0 · Cited by 12
“In this study, participants were defined as having clinically significant depressive symptoms at a cutoff of ≥ 10, with a sensitivity and specificity of 74% and 91%, respectively [2, 25, 28].”
Background
An Interpretable Model With Probabilistic Integrated Scoring for Mental Health Treatment Prediction: Design Study
Kelly, A., Jensen, E. S., Grua, E. M., Mathiasen, K., & van de Ven, P. W. J. (2025) · JMIR Medical Informatics · doi:10.2196/64617 · Cited by 10
The Relationship of Undergraduate Major and Housing with Depression in Undergraduate Students
Ajinkya, S., Schaus, J. F., & Deichen, M. (2016) · Cureus · doi:10.7759/cureus.786 · Cited by 12
“This study seeks to answer this using the Patient Health Questionnaire 9 (PHQ-9) survey, a well-validated measure of depression [12-13] in a sample of students seeking care (for any reason) at the student health center of a large public university.”
Method
Psychometric properties and correlates of the PHQ-2 and PHQ-9 after traumatic brain injury
Donders, J., & Darland, K. (2017) · Brain Injury · doi:10.1080/02699052.2017.1334962 · Cited by 12
An evaluation of mHealth adoption and health self-management in emerging adulthood.
Drake, C., Cannady, M., Howley, K., Shea, C. M., & D, R. S. M. (2019) · PubMed Central · Cited by 12
Depression Following Operative Treatments for Achilles Ruptures and Ankle Fractures
Davison, R., Daniel, J.-P. A., Idarraga, A. J. P., Perticone, K., Lin, J. L., Holmes, G. B., Lee, S., Hamid, K. S., & Bohl, D. D. (2021) · Foot & Ankle International · doi:10.1177/10711007211020346 · Cited by 12
“9 For patients with acute ankle injuries undergoing surgery, orthopaedic surgeons might consider (1) screening postoperative patients with PHQ-9 assessments and referring those with elevated scores to mental health services, (2) providing information about mental health services to all patients, or (3) providing infor…”
Background
The Direct Clinic-Level Cost of the Implementation and Use of a Protocol to Assess and Address Social Needs in Diverse Community Health Center Primary Care Clinical Settings
Drake, C., Reiter, K. L., Weinberger, M., Eisenson, H., Edelman, D. E., Trogdon, J. G., & Shea, C. M. (2021) · Journal of Health Care for the Poor and Underserved · doi:10.1353/hpu.2021.0171 · Cited by 12
“27 Additional research is required to understand the potential for cost-effectively scaling PRAPARE and protocols like it by triaging patients and focusing resources on high-risk patients and families.”
Primary care-based mindfulness intervention for posttraumatic stress disorder and depression symptoms among Black adults: A pilot feasibility and acceptability randomized controlled trial.
Powers, A. D., Lathan, E. C., Dixon, H. D., Mekawi, Y., Hinrichs, R. C., Carter, S. E., Bradley, B., & Kaslow, N. J. (2022) · Psychological Trauma Theory Research Practice and Policy · doi:10.1037/tra0001390 · Cited by 15
Antidepressant Medication Use Among Patients with Depression: Comparison between Usual Care and Collaborative Care Using Care Managers
DeJesus, R. S., Angstman, K. B., Cha, S. S., & Williams, M. D. (2013) · Clinical Practice and Epidemiology in Mental Health · doi:10.2174/1745017901309010084 · Cited by 12
“The initiative chose to adopt the PHQ-9, a well-validated tool that can be used both to screen for depression and track treatment response in primary care practices [11, 12].”
Method
Feasibility of Screening for Preschool Behavioral and Emotional Problems in Primary Care Using the Early Childhood Screening Assessment
Fallucco, E. M., Blackmore, E. R., Bejarano, C. M., Wysocki, T., Kozikowski, C. B., & Gleason, M. M. (2016) · Clinical Pediatrics · doi:10.1177/0009922816638077 · Cited by 12
Psychometric evaluation of a screening question for persistent depressive disorder
Brinkmann, E., Glanert, S., Hüppe, M., Garay, A. S. M., Tschepe, S., Schweiger, U., & Klein, J. P. (2019) · BMC Psychiatry · doi:10.1186/s12888-019-2100-0 · Cited by 12
“Very short screening instruments have proven to adequately detect depression, like the Patient Health Questionnaire-2 (PHQ-2; [18, 19]) or the 5-Item World Health Organization Well-Being Index (WHO-5; [20]).”
MethodResult
The Impact of Preoperative Depression on Hospital Consumer Assessment of Healthcare Providers and Systems Survey Results in a Cervical Spine Surgery Setting
Levin, J. M., Rabah, N. M., Winkelman, R., Mroz, T. E., & Steinmetz, M. P. (2019) · Spine · doi:10.1097/brs.0000000000003222 · Cited by 12
Evaluating resilience as a predictor of outcomes in lung transplant candidates
Bui, Y., Hathcock, M. A., Benzo, R. P., Budev, M. M., Chandrashekaran, S., Erasmus, D. B., Lease, E. D., Levine, D. J., Thompson, K. L., Johnson, B. K., et al. (2020) · Clinical Transplantation · doi:10.1111/ctr.14056 · Cited by 12
Effectiveness of a multimedia outreach kit for families of wounded veterans
Walker, D. I., Cardin, J.-F., Chawla, N., Topp, D. B., Burton, E. T., & Wadsworth, S. M. (2013) · Disability and health journal · doi:10.1016/j.dhjo.2013.11.004 · Cited by 12
Detecting recurrent major depressive disorder within primary care rapidly and reliably using short questionnaire measures
Thapar, A. K., Hammerton, G., Collishaw, S., Potter, R., Rice, F. J., Harold, G. T., Craddock, N. J., Thapar, A., & Smıth, D. J. (2013) · British Journal of General Practice · doi:10.3399/bjgp14x676438 · Cited by 12
Evidence-Based Practice Guideline: Late-Life Depression Detection
Smith, M., Haedtke, C., & Shibley, D. (2015) · Journal of Gerontological Nursing · doi:10.3928/00989134-20150115-01 · Cited by 12
The Implications of Measuring Complexity
Green, L. A. (2010) · The Annals of Family Medicine · doi:10.1370/afm.1147 · Cited by 12
The PRESIDE (PhaRmacogEnomicS In DEpression) Trial: a double-blind randomised controlled trial of pharmacogenomic-informed prescribing of antidepressants on depression outcomes in patients with major depressive disorder in primary care
Saya, S., Chondros, P., Abela, A., Mihalopolous, C., Chatterton, M. L., Gunn, J. M., Chen, T. F., Polasek, T. M., Dettmann, E., Brooks, R., et al. (2023) · Trials · doi:10.1186/s13063-023-07361-6 · Cited by 11
“The PHQ-9 is a validated, self-reported diagnostic measure in primary care [34] with demonstrated efficacy and sensitivity as an outcome measure for treatment trials with a recommended Reliable Change Index [35].”
MethodSelf-citation
Psychometric network analysis of the Patient Health Questionnaire-4 (PHQ-4) in Paraguayan general population
Caycho‐Rodríguez, T., Travezaño-Cabrera, A., Torales, J. C., Barrios, I., Vilca, L. W., Samaniego-Pinho, A., Moreta‐Herrera, R., Reyes-Bossio, M. A., Barria‐Asenjo, N. A., Ayala-Colqui, J., et al. (2024) · Psicologia Reflexão e Crítica · doi:10.1186/s41155-024-00299-x · Cited by 12
“Brief tools can help improve clinical outcomes by reducing misdiagnosis rates in primary care (Arroll et al., 2010; Schumann et al., 2012).”
Background
A comparison of PHQ-9 and TBI-QOL depression measures among individuals with traumatic brain injury.
Cohen, M. L., Holdnack, J. A., Kisala, P. A., & Tulsky, D. S. (2018) · Rehabilitation Psychology · doi:10.1037/rep0000216 · Cited by 11
Association between patient-reported barriers and HIV clinic appointment attendance: A prospective cohort study
Judd, R. T., Friedman, E. E., Schmitt, J., & Ridgway, J. P. (2021) · AIDS Care · doi:10.1080/09540121.2021.1906401 · Cited by 11
Levels, Predictors, and Distribution of Interpersonal Solidarity during the COVID-19 Pandemic
Kaup, T., Schweda, A., Krakowczyk, J. B., Dinse, H., Skoda, E., Teufel, M., & Bäuerle, A. (2022) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph19042041 · Cited by 11
“Depression symptoms were measured via the Patient Health Questionnaire 2 (PHQ-2), using a 4-point Likert scale (from 0 = “never” to 3 = “nearly every day” [26,27]), with 2 items screening the frequency of depression symptoms over the previous 2 weeks, yielding an internal consistency of α = 0.”
Method
Resilience as a Factor Influencing Psychological Distress Experience in Patients with Neuro-Oncological Disease
Ilgen, J., Renovanz, M., Stengel, A., Zipfel, S., & Schäffeler, N. (2022) · Current Oncology · doi:10.3390/curroncol29120776 · Cited by 11
“Two items are used to inquire about patients’ loss of interest and joy, as well as dejection, which are regarded as leading symptoms of depression [28,29].”
Background
Healthcare utilization and costs of singaporean youth with symptoms of depression and anxiety: results from a 2022 web panel
Chodavadia, P. A., Teo, I., Poremski, D., Fung, D. S. S., & Finkelstein, E. A. (2023) · Child and Adolescent Psychiatry and Mental Health · doi:10.1186/s13034-023-00604-z · Cited by 13
Post-COVID Conditions and Burden of Disease
TABACOF, L. R., Nicolau, E., Rivera, A., & Putrino, D. F. (2023) · Physical Medicine and Rehabilitation Clinics of North America · doi:10.1016/j.pmr.2023.04.007 · Cited by 11
Factor structure of the patient health questionnaire-4 in adults with attention-deficit/hyperactivity disorder
Havnen, A., Lydersen, S., Mandahl, A., & Lara‐Cabrera, M. L. (2023) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2023.1176298 · Cited by 11
Challenges to Standardizing the Care for Adult Cancer Survivors: Highlighting ASCO's Fatigue and Anxiety and Depression Guidelines
Partridge, A. H., Jacobsen, P. B., & Andersen, B. L. (2015) · American Society of Clinical Oncology Educational Book · doi:10.14694/edbook_am.2015.35.188 · Cited by 11
Quantifying the importance of disease burden on perceived general health and depressive symptoms in patients within the Mayo Clinic Biobank
Ryu, E., Takahashi, P. Y., Olson, J. E., Hathcock, M. A., Novotny, P. J., Pathak, J., Bielinski, S. J., Cerhan, J. R., & Sloan, J. A. (2015) · Health and Quality of Life Outcomes · doi:10.1186/s12955-015-0285-6 · Cited by 11
“For depressive symptoms, a recent study reported that roughly 11 % of the subjects in the primary care population had PHQ-2 scores 3 or higher [31].”
Co-occurring depression and alcohol misuse is under-identified in general practice: A cross-sectional study
Hobden, B., Bryant, J., Sanson‐Fisher, R., Oldmeadow, C. J., & Carey, M. L. (2016) · Journal of Health Psychology · doi:10.1177/1359105316643855 · Cited by 11
“Depression was assessed using the Patient Health Questionnaire (PHQ-9), a commonly used screening tool for depression in general practice (Arroll et al., 2010; Gilbody et al., 2007) with sound psychometric properties (Kroenke et al., 2001).”
Method
Psychosocial outcomes in active treatment through survivorship
Reed, S. C., Bell, J. F., Whitney, R. L., Lash, R. S., Kim, K. K., Bold, R. J., & Joseph, J. G. (2017) · Psycho-Oncology · doi:10.1002/pon.4444 · Cited by 10
“Because of previously reported concerns about the specificity of thePHQ‐2, a score of 2 or higher was used as the cut‐point for a positive screening.(22)”
Method
Post-deployment Mental Health Screening: A Systematic Review of Current Evidence and Future Directions
Panaite, V., Brown, R. M., Henry, M., Garcia, A., Powell‐Cope, G. M., Vanderploeg, R. D., & Belanger, H. G. (2018) · Administration and Policy in Mental Health and Mental Health Services Research · doi:10.1007/s10488-018-0869-7 · Cited by 11
“For example, while the PHQ-2 has been validated as a screener for depression (Arroll et al. 2010; Kroenke et al. 2003), to date, it has not been compared to clinical interviews in Veterans.”
Methods and logistics of an oral health cohort of university students from Pelotas, a Brazilian Southern city
Chisini, L. A., Cademartori, M. G., Collares, K., Tarquínio, S. B. C., Goettems, M. L., Demarco, F. F., Corrêa, M. B., & Azevedo, M. S. (2019) · Brazilian journal of oral sciences/Brazilian Journal of Oral Sciences · doi:10.20396/bjos.v18i0.8655316 · Cited by 11
Postpartum Depression Screening and Referrals in Special Supplemental Nutrition Program for Women, Infants, and Children Clinics
Coffman, M. J., Scott, V. C., Schuch, C., Mele, C., Mayfield, C. A., Balasubramanian, V., Stevens, A., & Dulin, M. (2019) · Journal of Obstetric, Gynecologic & Neonatal Nursing · doi:10.1016/j.jogn.2019.10.007 · Cited by 12
The Lebanese Heart Failure Snapshot: A National Presentation of Acute Heart Failure Admissions
Deek, H., Newton, P. J., Kabbani, S., Hassouna, B., Macdonald, P. S., & Davidson, P. M. (2020) · Journal of Nursing Scholarship · doi:10.1111/jnu.12583 · Cited by 10
High-School Football and Midlife Brain Health Problems
Iverson, G. L., Merz, Z. C., & Terry, D. P. (2021) · Clinical Journal of Sport Medicine · doi:10.1097/jsm.0000000000000898 · Cited by 12
Depression Is Transiently Increased in Patients Undergoing Two-Stage Revision Arthroplasty
Furdock, R. J., Jilakara, B., Moon, T. J., Bute, N., Rhea, L., McDonald, D. J., & Cipriano, C. A. (2022) · Arthroplasty Today · doi:10.1016/j.artd.2021.10.014 · Cited by 13
“The Patient Health Questionnaire-9 (PHQ-9) is a well-validated tool that is widely used in a variety of medical settings to screen, diagnose, and monitor treatment of major depressive disorder (MDD) [12-14].”
Trauma and orthopaedic team members’ mental health during the COVID-19 pandemic
Thakrar, A., Raheem, A., Chui, K., Karam, E., Wickramarachchi, L., & Chin, K. F. (2020) · Bone & Joint Open · doi:10.1302/2046-3758.16.bjo-2020-0053.r1 · Cited by 11
Depression in primary care
Alson, A. R., Robinson, D. M., Ivanova, D., Azer, J., Moreno, M., Turk, M. L., Nitturkar, A., & Blackman, K. (2016) · The International Journal of Psychiatry in Medicine · doi:10.1177/0091217416636580 · Cited by 12
“The first two questions of the PHQ-9 comprise the PHQ-2, which is independently validated as a screening tool to detect risk for depression using a cut-off score of 3.(20,21) The PHQ-9 is free and available on the internet in 78 international dialects.”
Method
Pulmonary rehabilitation in resource poor settings.
Gothi, D., & Joshi, J. (2011) · PubMed · Cited by 11
Targeting excessive worry with internet-based extinction therapy: a randomised controlled trial with mediation analysis and economical evaluation
Andersson, E., Ljótsson, B., Hedman-Lagerlöf, M., Nygren, L., Persson, M., Rosengren, K., Gezelius, A., Andersson, L., Sundquist, T., Ivanov, V. Z., et al. (2021) · Psychological Medicine · doi:10.1017/s0033291720000781 · Cited by 10
Depressive symptoms, lifestyle behaviors, and risk of cardiovascular disease and mortality in individuals of different socioeconomic status: A prospective cohort study
Lu, Q., Wang, Y., Geng, T., Zhang, Y., Tu, Z., Pan, A., & Liu, G. (2023) · Journal of Affective Disorders · doi:10.1016/j.jad.2023.11.046 · Cited by 10
Depressive and Anxious Symptoms in Spanish Adolescents: Normative Data for the PHQ-9 and GAD-7
García, M. D. L. A. C., Díez-Gómez, A., Pérez‐Albéniz, A., Lucas‐Molina, B., & Fonseca‐Pedrero, E. (2024) · Clínica y Salud · doi:10.5093/clysa2024a13 · Cited by 11
“…Questionnaire-9 (PHQ-9) and the Generalized Anxiety Disorder Assessment-7 (GAD-7) are two widely employed measurement instruments that have shown adequate psychometric properties across samples (Arroll et al., 2010; Kroenke, 2021; Löwe et al., 2008; Mossman et al., 2017; Spitzer et al., 2006).”
Effectiveness of a Mobile App (Meds@HOME) to Improve Medication Safety for Children With Medical Complexity: Protocol for a Randomized Controlled Trial
Werner, N. E., Morgen, M., Kooiman, S., Jolliff, A. F., Warner, G., Feinstein, J. A., Chui, M. A., Katz, B., Storhoff, B., Sodergren, K., et al. (2024) · JMIR Research Protocols · doi:10.2196/60621 · Cited by 10

Authors: Arroll, B., Goodyear-Smith, F., Crengle, S., Gunn, J., Kerse, N., Fishman, T., Falloon, K., & Hatcher, S.
Affiliations: University of Auckland (NZ)
ORCID: Arroll, B.
Crengle, S.
Gunn, J.
Kerse, N.
Falloon, K.
Hatcher, S.
Venue: The Annals of Family Medicine
Publisher: Annals of Family Medicine
Published: 2010-07-01
Volume: 8
Issue: 4
Pages: 348-353
ISSN: 1544-1709 (ISSN-L)
1544-1717
DOI: 10.1370/afm.1139
PMC: PMC2906530
OpenAlex: W2122884679
Cited by: 1,279
References: 18
Citations by year: 2026: 60 · 2025: 89 · 2024: 115 · 2023: 115 · 2022: 137 · 2021: 182 · 2020: 116 · 2019: 92 · 2018: 71 · 2017: 63 · 2016: 60 · 2015: 55 · 2014: 39 · 2013: 42 · 2012: 23
FWCI: 34.75
Type: journal article
Language: en
Open access: diamond
doi.org
Locations: The Annals of Family Medicine (publishedVersion)
Europe PMC (PubMed Central) (publishedVersion)
PubMed Central (publishedVersion)
PubMed (publishedVersion)
ResearchSpace (University of Auckland) (submittedVersion, cc-by)
Funders: Health Research Council of New Zealand
Topics: Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
Health Sciences › Medicine › Psychiatry and Mental health › Mental Health Treatment and Access
Health Sciences › Medicine › Pharmacology (medical) › Treatment of Major Depression
Keywords: PHQ-2, PHQ-9, Patient Health Questionnaire, major depressive disorder, depression screening, primary care, screening sensitivity and specificity, Composite International Diagnostic Interview, threshold scores, general practice
MeSH terms: Adolescent, Adult, Aged, Aged, 80 and over, Major Depressive Disorder, Depressive Disorder, Major, Diagnosis, Computer-Assisted, Female, Humans, Male, Mass Screening, Middle Aged, New Zealand, Physicians, Family, Predictive Value of Tests, Primary Health Care, Psychometrics, Surveys and Questionnaires, Sensitivity and Specificity, Software, Time Factors, Prevalence, Young Adult

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Validation of PHQ-2 and PHQ-9 to Screen for Major Depression in the Primary Care Population

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