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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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“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]
Experimental — accuracy not yet measuredThe cited source says what the claim attributes to it.
In the citing paper
“Scoring ≥10 suggests a likely depression diagnosis. 38”
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In the citing paper
“A meta-analysis concluded that it is a good screening tool for the detection of depression (Manea et al., 2012).”
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“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
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In the citing paper
“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]
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“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]
In the citing paper
“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]
In the citing paper
“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
In the citing paper
“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]
In the citing paper
“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]
In the citing paper
“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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Metadata
- 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
- Health Sciences › Medicine › Psychiatry and Mental health › Mental Health Treatment and Access
- Health Sciences › Medicine › Pharmacology (medical) › 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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