Depression screening tools compared: PHQ-9, CESD-R, DASS-21, HAM-D, MADRS, and more

There are over a dozen validated depression screening tools in clinical use. Some take 30 seconds. Others require a trained clinician and 20 minutes. Some measure depression alone. Others fold it into broader emotional assessments. Choosing the right one depends on your setting, your patients, your clinical question, and your available time.

This guide compares the depression tools available on Survey Doctor: the PHQ-9, PHQ-2, CESD-R, DASS-21, HAM-D, and MADRS. We'll cover what each measures, how they score, their psychometric properties, and when each is the best choice.

The big comparison table

Self-report tools: What you can administer without a clinician

PHQ-9 (Patient Health Questionnaire-9)

The PHQ-9 is the most widely used depression screening tool in the world. If you work in primary care and you're reading this, there's a good chance your clinic already uses it.

What it measures: Nine items mapping directly to the nine DSM criteria for major depressive disorder -- anhedonia, depressed mood, sleep problems, fatigue, appetite changes, self-worth, concentration, psychomotor changes, and suicidal ideation.

Scoring: Sum of all items, range 0-27. Each item scored 0-3 based on frequency ("Not at all" to "Nearly every day").

Severity bands:

Psychometric properties: At a cutoff of 10, the PHQ-9 achieves 88% sensitivity and 88% specificity for major depression, validated against structured psychiatric interviews (Kroenke et al., 2001, Journal of General Internal Medicine). A 5-point change is clinically meaningful. A 50% reduction from baseline indicates treatment response.

Key strengths:
- Direct DSM alignment enables provisional diagnosis through a diagnostic algorithm
- Five severity levels give granular treatment guidance
- Item 9 provides built-in suicidal ideation screening
- Includes a functional impairment assessment question
- Validated in 12+ age group and across dozens of languages
- Free with no permission required
- Universally recognized -- the common language of depression screening

Key limitations:
- Does not differentiate depression from anxiety (symptoms overlap)
- Self-report may underestimate severity in patients who minimize symptoms
- Somatic symptoms (fatigue, sleep, appetite) can inflate scores in medically ill patients
- Does not assess atypical depression features well

Best for: Primary care screening, treatment monitoring, quality metrics, referral documentation, universal screening programs.

Reference: Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-613.

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PHQ-2 (Patient Health Questionnaire-2)

The PHQ-2 is the first two items of the PHQ-9, used as an ultra-brief screening gate.

What it measures: The two cardinal symptoms of major depression -- anhedonia ("Little interest or pleasure in doing things") and depressed mood ("Feeling down, depressed, or hopeless").

Scoring: Sum of two items, range 0-6. Same 0-3 response scale as the PHQ-9.

Interpretation:

Psychometric properties: At a cutoff of 3, the PHQ-2 achieves 83% sensitivity and 92% specificity (Kroenke et al., 2003, Medical Care). In older adults (65+), sensitivity approaches 100% with specificity of 77% (Li et al., 2007).

Key strengths:
- Extremely brief (30 seconds)
- High specificity (92%) means few false positives
- Works well as a first-step gatekeeper before the PHQ-9
- Can be administered verbally, on paper, or digitally
- Reduces screening burden by 60-70% when used in stepped approach

Key limitations:
- No severity grading (only positive/negative)
- Misses approximately 17% of depressed patients (those presenting with primarily somatic symptoms)
- No suicidal ideation item
- Cannot monitor treatment response meaningfully
- Not sufficient for clinical documentation of depression severity

Best for: Universal first-step screening in high-volume settings, quick clinical triage, population-level screening.

Reference: Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care. 2003;41(11):1284-92.

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CESD-R (Center for Epidemiologic Studies Depression Scale - Revised)

The CESD-R was originally developed for epidemiological research and is one of the most widely used depression measures in population-based studies.

What it measures: 20 items covering nine symptom groups aligned with DSM-IV depression criteria: sadness, loss of interest, appetite, sleep, thinking/concentration, guilt, fatigue, movement (psychomotor changes), and suicidal ideation.

Scoring: Sum of all items, range 0-60. Each item scored 0-3 based on frequency over the past week ("Not at all or less than 1 day" to "Nearly every day for 2 weeks").

Interpretation: A commonly used cutoff score is 16 for depression screening, though optimal cutoffs vary by population. Items 14-15 assess suicidality and require immediate clinical attention if endorsed.

Psychometric properties: The original CES-D (Radloff, 1977) is one of the most extensively validated depression measures in existence, with thousands of published studies. The revised version (CESD-R, Eaton et al., 2004) updated the item structure to better align with DSM-IV criteria. Sensitivity and specificity vary by population and cutoff but are generally in the 80-90% range at the standard cutoff of 16.

Key strengths:
- Extensive research base spanning nearly five decades
- Covers DSM symptom categories thoroughly (9 groups across 20 items)
- Includes two suicidal ideation items (items 14-15)
- Free to use (public domain)
- Excellent for epidemiological and research applications
- Validated across many populations, ages, and cultures
- Longer format allows more nuanced symptom assessment

Key limitations:
- 20 items is substantially longer than the PHQ-9 (9 items)
- Originally designed for research, not clinical screening
- Less widely used in clinical practice than the PHQ-9
- Score interpretation is less standardized than the PHQ-9's five-level system
- Does not include a functional impairment question
- DSM-IV alignment (not updated for DSM-5)

Best for: Research studies, epidemiological surveys, academic settings, situations where a more detailed self-report is desired.

Reference: Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Applied Psychological Measurement. 1977;1:385-401. Eaton WW et al. Center for Epidemiologic Studies Depression Scale: Review and revision (CESD and CESD-R). 2004.

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DASS-21 Depression Subscale (Depression Anxiety Stress Scales - 21)

The DASS-21 is a 21-item instrument with three 7-item subscales: depression, anxiety, and stress. Only the depression subscale is relevant here, but its context within the broader instrument affects how it should be interpreted.

What the depression subscale measures: Seven items focused on anhedonia and low positive affect: inability to experience positive feelings, difficulty initiating activities, nothing to look forward to, feeling down-hearted, inability to feel enthusiastic, low self-worth, and life feeling meaningless.

Scoring: Sum of 7 depression items, multiplied by 2 (to match DASS-42 norms). Final range: 0-42.

Depression subscale severity (after doubling):

Key strengths:
- Gets depression, anxiety, and stress scores from one administration
- Distinguishes between depression, anxiety, and stress as separate constructs
- Well-validated three-factor structure
- Useful for understanding the emotional picture when the presentation is mixed
- Five severity levels per subscale
- Free with attribution

Key limitations:
- Depression subscale is narrower than the PHQ-9 (focuses on anhedonia, omits somatic symptoms)
- No suicidal ideation item
- Dimensional measure, not diagnostic (doesn't map to DSM criteria)
- Scores must be doubled -- a common source of error
- Less widely used in primary care settings
- Severity labels describe population distribution, not clinical thresholds

Best for: Psychology/counseling settings, research, when you want depression/anxiety/stress differentiation from a single tool.

Reference: Lovibond SH, Lovibond PF. Manual for the Depression Anxiety Stress Scales. 2nd ed. Sydney: Psychology Foundation; 1995.

Clinician-administered tools: When expert rating adds value

HAM-D (Hamilton Depression Rating Scale)

The HAM-D is the oldest and most widely used clinician-rated depression scale. It remains the standard outcome measure in antidepressant clinical trials.

What it measures: 17 items rated by a trained clinician after a structured or semi-structured interview. Covers depressed mood, guilt, suicidal ideation, insomnia (early, middle, late), work and activities, psychomotor retardation, agitation, anxiety (psychological and somatic), somatic symptoms (gastrointestinal and general), genital symptoms, hypochondriasis, insight, and weight loss.

Scoring: Clinician rates each item on a 0-2 or 0-4 scale based on interview observations and patient report. Total score range: 0-52.

Severity bands:

Key strengths:
- The most established clinician-rated measure, with over 60 years of use
- Required in most antidepressant clinical trials (FDA standard)
- Clinician observation captures symptoms patients may underreport
- Detailed assessment of insomnia (three separate items for early, middle, and late insomnia)
- Strong emphasis on somatic and neurovegetative symptoms
- Well-established norms across clinical populations
- Public domain

Key limitations:
- Requires trained clinician for administration (15-20 minutes)
- Not practical for routine primary care screening
- Inter-rater reliability varies (depends on clinician training)
- Heavily weighted toward somatic and insomnia symptoms, which can bias scores in medically ill or elderly patients
- Under-represents cognitive and emotional symptoms of depression
- Does not capture atypical features well (hypersomnia, increased appetite)
- Older item structure does not fully align with modern DSM-5 criteria

Best for: Clinical trials, psychiatric inpatient assessment, detailed severity evaluation by specialists, research requiring clinician-rated outcomes.

Reference: Hamilton M. A rating scale for depression. Journal of Neurology, Neurosurgery, and Psychiatry. 1960;23:56-62.

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MADRS (Montgomery-Asberg Depression Rating Scale)

The MADRS was designed specifically to be sensitive to treatment change -- to detect improvement during antidepressant therapy with more precision than the HAM-D.

What it measures: 10 items rated by a trained clinician: apparent sadness, reported sadness, inner tension, reduced sleep, reduced appetite, concentration difficulties, lassitude, inability to feel, pessimistic thoughts, and suicidal thoughts.

Scoring: Clinician rates each item on a 0-6 scale. Total score range: 0-60.

Severity bands:

Key strengths:
- Designed for treatment sensitivity -- detects change better than the HAM-D
- Focuses on core psychological symptoms of depression
- Less contaminated by anxiety and somatic symptoms than the HAM-D
- Increasingly used in modern clinical trials (especially for newer antidepressants)
- Ten items is shorter than the HAM-D's 17
- Item 10 (suicidal thoughts) provides structured suicide risk assessment
- Each item has detailed anchor descriptions for consistent rating

Key limitations:
- Requires trained clinician (10-15 minutes)
- Not practical for primary care screening
- Requires permission for commercial use
- Less emphasis on somatic/neurovegetative symptoms, which may underestimate depression in patients with prominent physical complaints
- Fewer items means less coverage than the HAM-D
- Less extensive research base than the HAM-D (though still substantial)

Best for: Clinical trials (especially for treatment sensitivity), specialist assessment, situations where distinguishing depression from anxiety is important, modern research protocols.

Reference: Montgomery SA, Asberg M. A new depression scale designed to be sensitive to change. British Journal of Psychiatry. 1979;134:382-389.

Choosing by clinical setting

Different settings call for different tools. Here's a decision framework:

Primary care

First choice: PHQ-9

The PHQ-9 is the standard for primary care depression screening. It's recommended by the USPSTF, APA, and most national guidelines. It's brief (2-3 minutes), free, self-administered, and provides both screening and severity assessment. Its DSM alignment supports clinical decision-making, and item 9 provides suicidal ideation screening.

Alternative stepped approach: PHQ-2 as gate, then PHQ-9 for positive screens. This reduces screening burden by 60-70% while maintaining strong accuracy.

When to consider the CESD-R or DASS-21: If your clinic already uses these tools, or if research protocols require them, they're reasonable alternatives. But for new implementations, the PHQ-9 has the broadest evidence base and clinical acceptance.

Specialty mental health (psychiatry, psychology)

For assessment: PHQ-9 as baseline self-report, supplemented by clinician-rated tools as needed.

For treatment monitoring in clinical trials: HAM-D or MADRS. The HAM-D is the traditional standard; the MADRS offers better treatment sensitivity. Many modern trials use both.

For dimensional assessment: DASS-21 when you want to separate depression, anxiety, and stress. This is particularly useful for CBT-focused practices.

Research

Epidemiological/survey research: CESD-R. Its extensive research base, thorough coverage, and free public domain status make it the standard for population-based depression research.

Clinical trials: HAM-D and/or MADRS as primary outcome, with PHQ-9 as self-report secondary outcome. This combination gives you both clinician-rated and patient-rated perspectives.

Psychology research: DASS-21 for transdiagnostic research, or PHQ-9 for depression-specific studies.

Emergency departments and urgent care

First choice: PHQ-2 for rapid triage, followed by PHQ-9 if positive. Time is the critical constraint, and the stepped approach is optimized for high-volume settings.

Telehealth

First choice: PHQ-9. Self-report tools work naturally in telehealth -- patients can complete them before the session via digital forms. Clinician-administered tools (HAM-D, MADRS) can be conducted via video but require the clinician's time.

Head-to-head: Self-report accuracy comparison

How do the self-report tools compare specifically for detecting major depression?

The PHQ-9 has the most consistent and extensively validated screening accuracy data. The PHQ-2's slightly lower sensitivity (83% vs 88%) is the trade-off for its extreme brevity. The CESD-R performs comparably but has more variable results across populations. The DASS-21 was not designed as a diagnostic screener, so direct sensitivity/specificity comparisons for detecting DSM-defined depression are less straightforward.

Head-to-head: Clinician-rated tool comparison

The HAM-D vs MADRS debate in clinical research is longstanding. The HAM-D's dominance in FDA trials has made it the historical standard, but the MADRS's superior treatment sensitivity has led many modern trials to adopt it as the primary outcome measure -- or to use both.

Symptom coverage comparison

Different tools emphasize different aspects of depression. Here's what each covers:

This table reveals important differences:

- The PHQ-9 has the broadest single-instrument coverage for a self-report tool, touching all nine DSM criteria
- The HAM-D covers the widest range overall, including somatic and anxiety symptoms that other tools omit, but this breadth can reduce specificity for depression itself
- The MADRS and DASS-21 are better at capturing the psychological core of depression (hopelessness, inability to feel, loss of meaning)
- The PHQ-2 sacrifices coverage for brevity, capturing only the two cardinal symptoms
- The CESD-R matches the PHQ-9 in coverage and exceeds it in item count, providing more granularity

Special considerations for specific populations

Medically ill patients

Somatic symptoms (fatigue, sleep disruption, appetite changes) are common in many medical conditions. Tools heavily weighted toward somatic items may inflate depression scores in these patients.

- Best choice: MADRS (emphasizes psychological symptoms) or PHQ-9 with clinical judgment about somatic item interpretation
- Avoid over-relying on: HAM-D (somatic emphasis may inflate scores)

Older adults

Depression in older adults often presents differently -- more somatic complaints, less endorsed depressed mood, more cognitive symptoms.

- Best choice: PHQ-9 (validated for ages 12+, widely used in geriatric settings) or PHQ-2 for screening (validated in 65+)
- Consider: HAM-D, which captures somatic presentations well

Adolescents

- Best choice: PHQ-9 / PHQ-A (validated for ages 12-17)
- Also validated: CESD-R (validated for adolescents)
- Not appropriate: HAM-D and MADRS (designed for adult clinical populations)

Pregnant and postpartum patients

While dedicated tools exist (Edinburgh Postnatal Depression Scale), general depression tools are also used in perinatal settings.

- Commonly used: PHQ-9 (widely implemented in obstetric settings)
- Note: Somatic items on the PHQ-9 (fatigue, appetite, sleep) may reflect normal pregnancy/postpartum changes rather than depression

Cross-cultural settings

- Best validated cross-culturally: PHQ-9 and CESD-R (both translated and validated in dozens of languages)
- Consider: Some cultures emphasize somatic over psychological symptoms. Tools with strong somatic coverage (HAM-D) may perform differently than those focused on mood and cognition (MADRS)

A decision tree for choosing your tool

Question 1: Is this for screening or detailed assessment?

- Screening --> Go to Question 2
- Detailed assessment --> Go to Question 4

Question 2: How much time do you have per patient?

- 30 seconds --> PHQ-2 (follow positive screens with PHQ-9)
- 2-3 minutes --> PHQ-9
- 5-10 minutes --> PHQ-9 + GAD-7, or DASS-21

Question 3: What's your primary clinical question?

- "Is depression present, and how severe?" --> PHQ-9
- "Is it depression, anxiety, stress, or all three?" --> DASS-21
- "Do we need to screen as many people as possible?" --> PHQ-2, then PHQ-9

Question 4: Do you have a trained clinician available for administration?

- Yes --> Go to Question 5
- No --> PHQ-9 or CESD-R

Question 5: Is this for treatment monitoring or baseline assessment?

- Treatment monitoring (maximizing change detection) --> MADRS
- Clinical trial with FDA requirements --> HAM-D (often with MADRS as co-primary)
- Baseline assessment --> HAM-D

Question 6: Is this for research?

- Epidemiological study --> CESD-R
- Clinical trial --> HAM-D or MADRS + PHQ-9
- Psychology/transdiagnostic research --> DASS-21

For individuals: Which should you take?

If you're reading this as someone trying to understand your own mental health, the choice is simpler:

Start with the PHQ-9. It's the most widely used, well-validated, and clinically actionable self-report depression tool available. It gives you a clear severity score, checks for suicidal ideation, and produces a number your doctor will immediately understand.

Add the DASS-21 if you're not sure whether you're dealing with depression, anxiety, stress, or a combination. The three subscales help untangle the pattern.

Take the PHQ-2 if you want a very quick check. Two questions, 30 seconds. If both answers are "Not at all," you can feel reasonably reassured. If your score is 3 or higher, take the full PHQ-9.

You don't need to worry about the HAM-D or MADRS unless you're working with a clinician who administers them. These are clinician-rated tools that require trained administration.

Regardless of which tool you use, bring your results to a healthcare provider. Screening tools give you information. Providers give you context, diagnosis, and treatment options.

Common questions

Which single tool is best for depression screening?

The PHQ-9 has the strongest evidence base, broadest clinical acceptance, and most practical combination of brevity, accuracy, and utility. If you can only implement one tool, it's the PHQ-9.

Should I use self-report or clinician-rated tools?

In most settings, self-report is sufficient and practical. Clinician-rated tools add value in specialty settings, clinical trials, and complex cases where patient self-report may be unreliable (severe depression with poor insight, cognitive impairment, or significant secondary gain).

How often should depression screening happen?

The USPSTF recommends screening all adults for depression. Frequency depends on the setting: annually at wellness visits, at initial presentation in mental health settings, and every 2-4 weeks during active treatment.

Can I compare scores across different tools?

Not directly. A PHQ-9 score of 15 and a HAM-D score of 15 represent different levels of severity because the scales have different ranges, items, and scoring. Each tool's severity cutoffs are specific to that instrument.

Do I need to screen for both depression and anxiety?

Given the high comorbidity rate (50-60%), screening for both is clinically responsible. The PHQ-9 + GAD-7 combination takes about 5 minutes and covers both conditions. The DASS-21 offers an alternative that includes stress as a third dimension.

What about the BDI-II (Beck Depression Inventory)?

The BDI-II is a well-validated 21-item depression measure widely used in clinical psychology. However, it requires a commercial license, which limits its accessibility. The PHQ-9 provides comparable screening accuracy at no cost with fewer items. For clinical settings without licensing constraints, the BDI-II remains a solid choice, but for most purposes the freely available tools covered here are equivalent or superior.

The bottom line

Depression screening doesn't have a one-size-fits-all answer, but it does have clear best-fit recommendations:

- For most clinical screening: The PHQ-9 is the standard. Brief, free, DSM-aligned, with established treatment thresholds and built-in suicidal ideation screening.
- For ultra-brief gating: The PHQ-2 screens efficiently, with the PHQ-9 reserved for positive screens.
- For research and epidemiology: The CESD-R has the deepest evidence base for population-level research.
- For multi-dimensional assessment: The DASS-21 separates depression, anxiety, and stress in a single instrument.
- For clinician-rated severity: The HAM-D is the historical standard; the MADRS is increasingly preferred for its treatment sensitivity.

The best tool is the one that fits your setting, answers your clinical question, and gets used consistently. A PHQ-9 administered to every patient is more useful than a HAM-D administered to none.