PHQ-9 and GAD-7: The Evidence Behind the Screening Tool

A 34-year-old schoolteacher from Udupi comes to the medicine outpatient clinic with headaches and poor sleep for two months. Her examination is normal. You ask her to fill in the PHQ-9 and the GAD-7 while you write. Her PHQ-9 total is 8 and her GAD-7 total is 12. On question 9 of the PHQ-9, about thoughts that she would be better off dead or of hurting herself, she has ticked “Several days”. This is an illustrative case, not a real patient.

By the end of this article you will know what each of those three answers means, which one you deal with first, and what the scores cannot tell you.

1. Question 9 Comes First

“Her total is only 8. That is mild, isn’t it?” The total is mild. Question 9 is not. A patient can score low overall and still endorse question 9, and the total is not a safety net for that one item. Any answer other than “Not at all” on question 9 warrants a direct, structured follow-up conversation about suicidal ideation and plan, in the same visit, whatever the rest of the questionnaire shows.

That conversation is not a calculator. Ask about current thoughts, intent, plan and access to means, and involve psychiatry the same day where risk seems current. The national Tele-MANAS service, 14416 or 1-800-891-4416, is available 24 hours, in multiple languages. The patient can call it directly, or be connected to it during the consultation.

“Will asking put the idea in her head?” It is a common fear, and the tool’s answer is to ask, directly, in the same visit. A patient who ticked the box has already told you she has the thought. The question gives her the chance to say how close it is.

2. What the PHQ-9 Bands Suggest

Once the safety question is settled, the total tells you about the burden of symptoms over the last two weeks:

The action column is the interpretation guide published alongside the instrument itself, not a finding independent of it. And the score does not establish a diagnosis. That needs the DSM-5 or ICD-11 criteria, applied in a clinical interview.

3. The GAD-7, and Why Both Are Run Together

The GAD-7 has three points worth remembering. A score of 5 to 9 identifies mild symptoms worth monitoring. A score of 10 or more is the threshold the original validation study reported as reasonably sensitive and specific for generalised anxiety disorder; it is the point at which further evaluation is generally warranted. And 15 or more suggests severe anxiety that usually needs active treatment.

Our patient’s 12 calls for further evaluation. Notice that she came with headaches, not with worry. Depression and anxiety are frequently comorbid, and a patient who screens positive on one is more likely to screen positive on the other. Running both at once catches the combination, rather than whichever condition happened to prompt the visit.

4. Do the Cut-Offs Hold in India?

A fair question, since both questionnaires were written and validated in the United States. The tool used to summarise the Indian work as its section 4:

4. What Indian Validation Has Found

• Rural Kerala cohort. A psychometric analysis found the factor structure of both instruments comparable to the Western validation samples, supporting their use in an Indian primary care population. It proposed no India-specific cut-off and cautioned against splitting either instrument into subscales.
• Hindi adaptation for palliative care patients. Acceptable internal consistency and a two-factor structure, again without establishing a different diagnostic threshold.

The original bands above are what these studies have used, not what they have replaced.

Factor structure means the way the questions cluster together. If Indian patients answered the questions in the same pattern as the original samples, the instrument is measuring the same thing here. Internal consistency means the questions agree with each other. Neither study found a reason for a different cut-off, so the tool uses the original bands.

The tool does not reproduce the Hindi and Kannada versions, though they exist under the same free-use terms as the English original. The item wording has not been independently sourced and checked. An invented or imprecisely remembered translation is worse than no translation.

5. The Common Mistake

The common mistake is to read the total and stop. It is easy to see why: the total is the number at the bottom of the form, and the bands are printed beside it. But the one item that can change what you do today is question 9, and it hides inside a reassuring total. The second mistake is the opposite one: to write “depression” in the notes because the score was high. A high score raises the probability of the disorder and prompts a clinical assessment. It does not establish the diagnosis, and a low score does not exclude one in a patient who otherwise looks unwell.

Back to Our Patient

You put the pen down and ask her about question 9. She has had the thought that she would be better off dead on a few nights, but no plan and no intent, and she has not harmed herself. You give her the Tele-MANAS number, 14416, and arrange to see her again soon. Her PHQ-9 of 8 is mild, and her GAD-7 of 12 warrants further evaluation for an anxiety disorder, in a clinical interview rather than from the score.

Try This

A 58-year-old man recovering from a stroke scores 17 on the PHQ-9 and 3 on the GAD-7. He answered “Not at all” to question 9. What do the scores suggest? Illustrative case.

Answer. A PHQ-9 of 17 falls in the moderately severe band, 15 to 19, for which the guide suggests active pharmacotherapy and/or psychotherapy. A GAD-7 of 3 is below the mild band. Question 9 needs no separate conversation today. The diagnosis still rests on a clinical interview against the DSM-5 or ICD-11 criteria.

Take-Home Points

• Any answer other than “Not at all” on question 9 needs a direct conversation in the same visit, whatever the total.
• Tele-MANAS, 14416 or 1-800-891-4416, is available 24 hours, in multiple languages.
• A PHQ-9 of 10 to 14 is moderate and calls for a treatment plan; a GAD-7 of 10 or more warrants further evaluation.
• Run both together: depression and anxiety are frequently comorbid.
• A score is a screen, not a diagnosis; the Indian studies kept the original bands.

Declaration: the author built and maintains the tool, which is still in administrator preview. It is free to use. The figures in this article are those the tool carried in its Evidence tab on 5 November 2026, each from the source the tool names. The illustrative cases follow the tool’s rules; check the tool’s result for a real patient.

References

1. Kroenke K, Spitzer RL, Williams JBW. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-613.
2. Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092-1097.
3. Kroenke K, Spitzer RL. The PHQ-9: a new depression diagnostic and severity measure. Psychiatr Ann. 2002;32(9):509-515.
4. Löwe B, Decker O, Müller S, et al. Validation and standardization of the Generalized Anxiety Disorder Screener (GAD-7) in the general population. Med Care. 2008;46(3):266-274.
5. Pfizer Inc. Instructions for Patient Health Questionnaire (PHQ) and GAD-7 Measures. Developed by Spitzer RL, Williams JBW, Kroenke K, and colleagues; no permission required to reproduce, translate, display or distribute.
6. De Man J, Absetz P, Sathish T, et al. Are the PHQ-9 and GAD-7 suitable for use in India? A psychometric analysis. Front Psychol. 2021;12:676398.
7. Bhardwaj T, Arora N, Rajvanshi A. Psychometric evaluation of Patient Health Questionnaire 9 Hindi for use with patients with cancer in community palliative care settings. Indian J Palliat Care. 2025;31(2):177-185.
8. Ministry of Health and Family Welfare, Government of India. Tele-MANAS: National Tele Mental Health Programme. NIMHANS, coordinating institute. telemanas.mohfw.gov.in.
9. Gautam S, Jain A, Gautam M, Vahia VN, Grover S. Clinical Practice Guidelines for the management of Depression. Indian J Psychiatry. 2017;59(Suppl 1):S34-S50.
10. United States Food and Drug Administration. Antidepressant use in children, adolescents, and adults: revisions to product labelling. 2007.