Screening for depression in primary care with Patient Health Questionnaire-9 (PHQ-9): A systematic review

J Affect Disord. 2021 Jan 15:279:473-483. doi: 10.1016/j.jad.2020.09.131. Epub 2020 Oct 6.


Background: Depression is a leading cause of disability. International guidelines recommend screening for depression and the Patient Health Questionnaire 9 (PHQ-9) has been identified as the most reliable screening tool. We reviewed the evidence for using it within the primary care setting.

Methods: We retrieved studies from MEDLINE, Embase, PsycINFO, CINAHL and the Cochrane Library that carried out primary care-based depression screening using PHQ-9 in populations older than 12, from 1995 to 2018.

Results: Forty-two studies were included in the systematic review. Most of the studies were cross-sectional (N=40, 95%), conducted in high-income countries (N=27, 71%) and recruited adult populations (N=38, 90%). The accuracy of the PHQ-9 was evaluated in 31 (74%) studies with a two-stage screening system, with structured interview most often carried out by primary care and mental health professionals. Most of the studies employed a cut-off score of 10 (N=24, 57%, total range 5 - 15). The overall sensitivity of PHQ-9 ranged from 0.37 to 0.98, specificity from 0.42 to 0.99, positive predictive value from 0.09 to 0.92, and negative predictive value from 0.8 to 1.

Limitations: Lack of longitudinal studies, small sample size, and the heterogeneity of primary-care settings limited the generalizability of our results.

Conclusions: PHQ-9 has been widely validated and is recommended in a two-stage screening process. Longitudinal studies are necessary to provide evidence of long-term screening effectiveness.

Keywords: PHQ-9; depression; primary care; screening.

Publication types

  • Review
  • Systematic Review

MeSH terms

  • Adult
  • Cross-Sectional Studies
  • Depression / diagnosis
  • Depressive Disorder, Major*
  • Humans
  • Mass Screening
  • Patient Health Questionnaire*
  • Primary Health Care
  • Reproducibility of Results
  • Sensitivity and Specificity
  • Surveys and Questionnaires