Optimal cut-off score for diagnosing depression with the Patient Health Questionnaire (PHQ-9): a meta-analysis
Open accessAbstract
BACKGROUND: The brief Patient Health Questionnaire (PHQ-9) is commonly used to screen for depression with 10 often recommended as the cut-off score. We summarized the psychometric properties of the PHQ-9 across a range of studies and cut-off scores to select the optimal cut-off for detecting depression. METHODS: We searched Embase, MEDLINE and PsycINFO from 1999 to August 2010 for studies that reported the diagnostic accuracy of PHQ-9 to diagnose major depressive disorders. We calculated summary sensitivity, specificity, likelihood ratios and diagnostic odds ratios for detecting major depressive disorder at different cut-off scores and in different settings. We used random-effects bivariate meta-analysis at cutoff points between 7 and 15 to produce summary receiver operating characteristic curves. RESULTS: We identified 18 validation studies (n = 7180) conducted in various clinical settings. Eleven studies provided details about the diagnostic properties of the questionnaire at more than one cut-off score (including 10), four studies reported a cut-off score of 10, and three studies reported cut-off scores other than 10. The pooled specificity results ranged from 0.73 (95% confidence interval [CI] 0.63-0.82) for a cut-off score of 7 to 0.96 (95% CI 0.94-0.97) for a cut-off score of 15. There was major variability in sensitivity for cut-off scores between 7 and 15. There were no substantial differences in the pooled sensitivity and specificity for a range of cut-off scores (8-11). INTERPRETATION: The PHQ-9 was found to have acceptable diagnostic properties for detecting major depressive disorder for cut-off scores between 8 and 11. Authors of future validation studies should consistently report the outcomes for different cut-off scores.
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Patient Health Questionnaire-9 item total scores of 10 or above are used to indicate clinically significant depressive symptoms with 88% sensitivity and 88% specificity.
“total scores ≥ 10 are used to indicate clinically significant depressive symptoms [35] with 88% sensitivity and 88% specificity [28].”
From Internet videoconferencing delivered cognitive behavior therapy for generalized anxiety disorder: protocol for a randomized controlled trial (2022) · cites this paper as [35]
The Abstract reports 88% sensitivity and 88% specificity at a PHQ-9 cut-off of 10, but identifies these as results from the initial validation study for detecting major depressive disorder. This paper’s own pooled estimates are 85% sensitivity and 89% specificity (Meta-analysis), so the unqualified figures should not be presented as its meta-analytic results or as established for clinically significant depressive symptoms more broadly. (LLM, conf=0.86)
Experimental — accuracy not yet measuredScoring ≥10 on the PHQ-9 suggests a likely depression diagnosis.
“Scoring ≥10 suggests a likely depression diagnosis. 38”
A meta-analysis concluded that the PHQ-9 is a good screening tool for the detection of depression.
“A meta-analysis concluded that it is a good screening tool for the detection of depression (Manea et al., 2012).”
The PHQ-9 has demonstrated sound psychometric properties.
“This measure has demonstrated sound psychometric properties (Manea et al., 2012).”
From Health Anxiety and Mental Health Outcome During COVID-19 Lockdown in Italy: The Mediating and Moderating Roles of Psychological Flexibility (2020) · cites this paper as Manea et al., 2012
As individuals with subthreshold symptoms benefit from iCBT, diagnosis is not required for iCBT.
“As individuals with subthreshold symptoms benefit from iCBT, diagnosis is not required for iCBT. 38”
From Utilization, Patient Characteristics, and Longitudinal Improvements among Patients from a Provincially Funded Transdiagnostic Internet-delivered Cognitive Behavioural Therapy Program: Observational Study of Trends over 6 Years (2022) · cites this paper as [38]
The Meta-analysis section evaluates PHQ-9 cut-off scores for detecting major depressive disorder, and the Conclusions discuss its use as a screening tool. Searches for subthreshold symptoms and internet-based cognitive behavioural therapy found no passage addressing whether such patients benefit from iCBT or whether a diagnosis is required for it. Page numbers are unavailable in our copy. (LLM, conf=0.76)
Experimental — accuracy not yet measured
The GAD-7 performs nearly as well for panic disorder, social anxiety disorder, and posttraumatic stress disorder as it does for generalized anxiety disorder.
“Although originally developed as a measure to detect generalized anxiety disorder32, the operating characteristics of the GAD-7 are nearly as good for the other common anxiety disorders in clinical practice – panic disorder, social anxiety disorder, and posttraumatic stress disorder.23”
From Patient Health Questionnaire Anxiety and Depression Scale: Initial Validation in Three Clinical Trials (2016) · cites this paper as [23]
The PHQ-9 and GAD-7 are among the best validated and most commonly used measures of depression and anxiety, respectively.
“The Patient Health Questionnaire 9-item depression scale (PHQ-9) and 7-item Generalized Anxiety Disorder scale (GAD-7) are among the best validated and most commonly used depression and anxiety measures, respectively.20-25”
From Patient Health Questionnaire Anxiety and Depression Scale: Initial Validation in Three Clinical Trials (2016) · cites this paper as [23]
According to recent meta-analyses, a PHQ-9 score of 10 has 85% sensitivity and 89% specificity for diagnosing major depressive disorder, and a GAD-7 score of 8 has 83% sensitivity and 84% specificity for diagnosing generalized anxiety disorder.
“According to recent meta-analyses, a PHQ-9 score of 10 has 85% sensitivity and 89% specificity for diagnosing major depressive disorder (Manea, Gilbody, & McMillan, 2012) and a GAD-7 score of 8 has 83% sensitivity and 84% specificity for diagnosing generalized anxiety disorder (Plummer, Manea, Trepel, & McMillan, 2016).”
From Bringing light into darkness: A multiple baseline mixed methods case series evaluation of Augmented Depression Therapy (ADepT) (2019) · cites this paper as Manea, Gilbody, & McMillan, 2012
A meta-analysis by Manea et al showed that a PHQ-9 cutoff score of ≥8 has acceptable screening properties.
“First, a meta-analysis by Manea et al [59] showed that a PHQ-9 cutoff score of ≥8 also has acceptable screening properties; in our sample, there were 22 (8.2%) participants who had scores of ≥8 at both assessments.”
From Digital Biomarkers for Depression Screening With Wearable Devices: Cross-sectional Study With Machine Learning Modeling (2021) · cites this paper as [59]
A PHQ-9 cut off value of 11 separates people with (≥11) from people without (≤10) a clinically relevant depression level.
“we chose a PHQ-9 cut off value of 11, in line with the PHQ-9 [22] to separate people with (≥11) from people without (≤10) a clinically relevant depression level.”
From Mobile Sensing and Support for People With Depression: A Pilot Trial in the Wild (2016) · cites this paper as [22]
A PHQ-9 score greater than 9 is typically used to identify a likely diagnosis of major depressive disorder.
“A score greater than 9 is typically used to identify a likely diagnosis of major depressive disorder [34].”
From Initial Outcomes of Transdiagnostic Internet-Delivered Cognitive Behavioral Therapy Tailored to Public Safety Personnel: Longitudinal Observational Study (2021) · cites this paper as [34]
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- Authors
- Manea, L., Gilbody, S., & McMillan, D.
- Affiliations
- University of York (GB)
- Venue
- Canadian Medical Association Journal
- Publisher
- CMA Impact Inc.
- Published
- 2011-12-19
- Volume
- 184
- Issue
- 3
- Pages
- E191-E196
- ISSN
- 0820-3946 (ISSN-L)
- 1488-2329
- PMC
- PMC3281183
- OpenAlex
- W2099274262
- Cited by
- 1,966
- References
- 38
- Citations by year
- 2026: 157 · 2025: 204 · 2024: 211 · 2023: 222 · 2022: 232 · 2021: 235 · 2020: 194 · 2019: 121 · 2018: 105 · 2017: 82 · 2016: 59 · 2015: 53 · 2014: 49 · 2013: 27 · 2012: 14
- FWCI
- 3.78
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Locations
- Canadian Medical Association Journal (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Institute for Health and Care Research (ACF-2009-03-004)
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Social Psychology › Mental Health Treatment and Access
- Health Sciences › Medicine › Pharmacology › Treatment of Major Depression
- Keywords
- PHQ-9, depression screening, major depressive disorder, cut-off values, diagnostic accuracy, sensitivity and specificity, likelihood ratios, diagnostic odds ratio, summary receiver operating characteristic, questionnaire validation
- MeSH terms
- Depressive Disorder, Major, Major Depressive Disorder, Humans, Psychiatric Status Rating Scales, Psychometrics, Surveys and Questionnaires, ROC Curve, Sensitivity and Specificity, Odds Ratio
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