PHQ-4: anxiety and depression symptom screen

Overview

The PHQ-4 is a four-question adult symptom screen. It combines two questions from the GAD-7 with two from the PHQ-9 and produces a total from 0 to 12. Survey Doctor reports that total and a separate score for each pair of questions. The result describes recent anxiety and depression symptoms but does not diagnose a disorder.

What the PHQ-4 measures

All four questions refer to the previous two weeks. The two anxiety questions come first and the two depression questions follow, in the order of the published form. Each response is scored from 0 to 3.

The original PHQ-4 study by Kroenke and colleagues (2009) describes both a total distress score and separate two-question anxiety and depression scores. The anxiety pair is the GAD-2, and the depression pair is the PHQ-2. Survey Doctor shows the total and both pair scores.

Use the GAD-2 or PHQ-2 on its own when a workflow needs only one of those symptom areas. Use a fuller assessment when the response will guide clinical decisions.

How PHQ-4 scoring works

Survey Doctor adds the four response values for the total. The published total-score bands are:

The bands describe psychological distress. They do not establish which condition is present, whether symptoms have another cause, or what treatment is appropriate. Even a low total can miss an important concern when the relevant symptom is not among the four questions.

Survey Doctor also adds each pair of questions, giving an anxiety score and a depression score from 0 to 6. On either pair, 3 or more is the published screening cutoff. A score at or above the cutoff supports a closer look at that symptom area. It does not confirm a disorder, and a lower score does not rule one out.

What the result does not show

The PHQ-4 does not provide a complete depression or anxiety assessment. It does not ask about sleep, appetite, energy, concentration, panic, trauma, substance use, functioning, suicide, or self-harm.

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Safety needs separate questions. Assess urgent symptoms directly. Do not infer current safety from the PHQ-4 total.

The two pair scores show which symptom area reached the screening cutoff, but each rests on only two questions. When the distinction matters, follow with the GAD-7, PHQ-9, or a clinical interview chosen for the person's situation.

When the PHQ-4 is useful

The PHQ-4 can serve as a brief adult screen when a practice wants one opening measure for both symptom areas. It may also help a person summarize recent distress before a visit. Its value depends on having a clear process for reviewing the answers and deciding what assessment comes next.

The questionnaire should not be used as a stand-alone triage rule. A total in the highest band does not by itself define an emergency. A total in the lowest band does not prove that no care is needed.

Evidence from adult studies should not be assumed to apply unchanged to adolescents, a particular language, or a clinical population with different health conditions. Use a version and protocol supported for the intended group.

Repeating the PHQ-4

There is no universal repeat schedule. Choose timing according to the purpose of measurement, recent symptoms, risk, treatment context, and the setting's follow-up process. Keep the two-week recall period and administration method consistent when comparing totals.

A change in the total shows that the four responses changed. It does not prove why they changed. The two pair scores show which symptom area moved, but neither explains the cause.

For a plain-language walkthrough, read what your PHQ-4 score means.

Key limits

• The PHQ-4 cannot diagnose a disorder.
• Each pair score rests on two questions, so a score below 3 cannot rule out anxiety or depression.
• It does not measure functioning or current safety.
• Bands do not prescribe treatment or urgency.
• Follow-up depends on the answers, context, and intended population.