Reference · Screening measures

Screening Measures in Progress Notes: PHQ-9, GAD-7, EPDS, SCARED and RSES

A quick reference to six common measures (PHQ-9, PHQ-A, GAD-7, EPDS, SCARED and the Rosenberg Self-Esteem Scale): what each one covers, who it is for, how many items it has, its score range and published cut-offs, where it comes from, and how to record a score in a progress note. The questionnaire items are not reproduced here; use the official version of each measure.

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General documentation reference, not clinical advice. Use the current official version of each measure, follow its scoring instructions and your organization's risk protocol, and check terms of use. All examples are fictional.

Quick answer

PHQ-9: depression, adults, 9 items, 0 to 27. Cut points 5, 10, 15, 20. Item 9 asks about thoughts of death or self-harm.
PHQ-A: the adolescent version; the APA's adapted version is for ages 11 to 17, 9 items, 0 to 27, same cut points.
GAD-7: anxiety, adults, 7 items, 0 to 21. Cut points 5, 10, 15; further evaluation at 10 or more.
EPDS: depression in pregnancy and after birth, 10 items, 0 to 30. Common thresholds 10 or more and 13 or more. Always check item 10.
SCARED: anxiety in children and adolescents (child and parent versions), 41 items, 0 to 82. Total of 25 or more may indicate an anxiety disorder.
Rosenberg Self-Esteem Scale (RSES): global self-esteem, 10 items, 0 to 30 (or 10 to 40). No clinical cut-off.
In the note: measure, date, who completed it, total, band, critical items, change since last time, and what you did about it. A score supports clinical judgment; it is not a diagnosis.

The six measures at a glance

Screening and outcome measures: coverage, age, items and score range
Measure	What it covers	Who it is for	Items and time frame	Score range
PHQ-9	Depressive symptoms, based on the DSM criteria for major depression	Adults	9 scored items, last 2 weeks, plus one unscored question about daily functioning	0 to 27
PHQ-A	Depressive symptoms in adolescents	Ages 11 to 17 (APA adapted version)	9 items, past 7 days in the APA version	0 to 27
GAD-7	Generalized anxiety symptoms	Adults	7 items, last 2 weeks	0 to 21
EPDS	Depressive symptoms in pregnancy and after birth	Pregnant and postnatal women	10 items, past 7 days	0 to 30
SCARED	Anxiety symptoms, with five subscales	Children and adolescents; child and parent versions	41 items, each 0 to 2	0 to 82
RSES	Global self-esteem	Developed with adolescents; widely used with adults	10 items, four-point agree-to-disagree scale	0 to 30 (0 to 3 scoring) or 10 to 40 (1 to 4 scoring)

Score ranges and published cut-offs

Use the bands published for the measure. Cut-offs flag who needs further assessment; they do not set a diagnosis or a severity specifier on their own.

Published score bands
Measure	Bands and thresholds	Critical items
PHQ-9	0 to 4 minimal, 5 to 9 mild, 10 to 14 moderate, 15 to 19 moderately severe, 20 to 27 severe. A score of 10 or more is the threshold most often used for further assessment.	Item 9 (thoughts of death or self-harm): any score above 0 needs same-day risk assessment.
PHQ-A (APA adapted)	Same bands as the PHQ-9; the APA labels 0 to 4 as "none".	Item 9, as for the PHQ-9.
GAD-7	0 to 4 minimal, 5 to 9 mild, 10 to 14 moderate, 15 to 21 severe. Further evaluation recommended at 10 or more.	None designated.
EPDS	No official severity bands. Validation studies used thresholds of about 9 to 13; 10 or more (possible depression) and 13 or more (probable depression) are common. Use your service's threshold.	Item 10 (thoughts of self-harm): check it on every form, whatever the total.
SCARED	Total of 25 or more may indicate an anxiety disorder; above 30 is more specific. Subscale thresholds: panic or somatic 7, generalized anxiety 9, separation anxiety 5, social anxiety 8, school avoidance 3.	None designated.
RSES	Higher score means higher self-esteem. No clinical cut-off from the developer; compare with the client's own earlier scores or published norms for a similar group.	None.

Notes on each measure

PHQ-9 and PHQ-A

The PHQ-9 is the depression module of the Patient Health Questionnaire, developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues with an educational grant from Pfizer Inc. It was validated by Kroenke, Spitzer and Williams (2001). Its published terms of use say no permission is required to reproduce, translate, display or distribute it. Clients rate each of the nine symptoms by how often it occurred over the last two weeks.

The PHQ-A adapts the PHQ for adolescents (Johnson, Harris, Spitzer and Williams, 2002). The American Psychiatric Association publishes an adapted version as the Severity Measure for Depression, Child Age 11 to 17, which the young person completes before the visit; the APA states it may be reproduced without permission by clinicians for use with their patients.

GAD-7

The GAD-7 was developed by Spitzer, Kroenke, Williams and Löwe (2006) to screen for generalized anxiety disorder in primary care, and comes from the same PHQ family as the PHQ-9. Many practices give the PHQ-9 and GAD-7 together at intake and repeat them to track change.

EPDS

The Edinburgh Postnatal Depression Scale was published by Cox, Holden and Sagovsky (1987) in the British Journal of Psychiatry. It is used during pregnancy and after birth, and the person rates how they have felt over the past 7 days. Copyright is held by the Royal College of Psychiatrists; its statement allows individual clinicians to photocopy the scale for their own use, copied in full with the source acknowledged, and asks for written permission for other distribution or republication. Check the current terms before building it into a form.

SCARED

The Screen for Child Anxiety Related Disorders was developed by Boris Birmaher and colleagues at the University of Pittsburgh (scale construction published in 1997; the 41-item version was described in 1999). There is a child version and a parent version. The University of Pittsburgh form recommends that, for children aged 8 to 11, the clinician explains the questions or an adult sits with the child. The form states it is available at no cost from the University of Pittsburgh.

Rosenberg Self-Esteem Scale

Morris Rosenberg developed the scale for his 1965 book Society and the Adolescent Self-Image, first with high school students. The University of Maryland Department of Sociology publishes the scale and its scoring instructions. It measures global self-worth rather than symptoms, so it is better described in a note as an outcome or self-report measure than as a screen.

Critical items: PHQ-9 item 9 and EPDS item 10

Safety note

PHQ-9 item 9 (and the matching PHQ-A item) asks about thoughts of being better off dead or of self-harm. Any positive response needs a same-day suicide risk assessment by a qualified clinician, following your organization's protocol, even when the total score is low. EPDS item 10 asks about thoughts of self-harm and should be checked on every form in the same way.

The item is a prompt, not a risk assessment. Document the item response, the risk assessment you completed, your risk formulation and the actions taken (for example safety planning, means safety counselling, crisis resources including 988 in the US, and follow-up). See phrases for documenting suicidal ideation and the risk assessment glossary entry.

Screening is not diagnosis

A score shows that symptoms are reported and how severe they are; it does not establish a disorder. Diagnosis needs a clinical assessment against criteria.
Write what the measure shows: "PHQ-9 score of 16, in the moderately severe range", not "client has moderately severe major depressive disorder" unless your assessment supports the diagnosis.
Severity specifiers in a diagnosis (mild, moderate, severe) come from your clinical judgment of symptoms and impairment. A score can support that judgment but does not set it. See the depression ICD-10 codes and anxiety, PTSD and adjustment ICD-10 codes pages.
A low score does not rule out a problem the client describes in the interview. If the score and your observations disagree, say so in the note.

How to record a score in a progress note

Name the measure and version (for example PHQ-9, PHQ-A APA adapted version, SCARED parent version).
Date and who completed it: client self-report, parent report, or clinician-administered, and whether it was completed in session or before it.
Total score and band, using the measure's published bands. For the SCARED, add any subscale at or above its threshold.
Critical items: record the PHQ-9 item 9 or EPDS item 10 response, including a zero, and the risk assessment if it was positive.
Change over time: compare with the previous score and the date it was taken.
Interpretation: how the score fits what the client reported and what you observed.
Action: what you did with the result, such as a plan change, a referral, a rescreen date, or an update to the treatment plan goal.

Example sentences (fictional)

"PHQ-9 completed by client in session: total 12 (moderate range), down from 18 at intake four weeks ago. Item 9 scored 0."
"GAD-7 completed before session: total 9 (mild range), from 15 at intake. Client links the change to using the worry-time skill most days."
"EPDS completed at 6 weeks after birth: total 14, above the clinic threshold of 13. Item 10 scored 0. Discussed results with client; diagnostic assessment scheduled for next session."
"SCARED parent version: total 31; separation anxiety subscale 7 (threshold 5) and school avoidance 4 (threshold 3). Consistent with parent's report of morning refusal on school days."
"RSES: 14 of 30, from 9 of 30 at baseline; scored 0 to 3 per item. Client reports more confidence speaking up at work."

Fictional DAP note with a PHQ-9 and GAD-7

DAP note (fictional client)

Adult client · Individual session, 53 minutes · Week 8 of treatment · Fictional example written for this page; no real PHI

Data: Client completed the PHQ-9 and GAD-7 in the waiting room. PHQ-9 total 11 (moderate range), from 17 (moderately severe) at intake and 14 at week 4. Item 9 scored 0; client denies thoughts of death or self-harm when asked directly. GAD-7 total 8 (mild range), from 13 at intake. Client reports getting up at a regular time on 5 of 7 days and walking with a friend twice this week. Still describes low energy in the afternoons.

Assessment: Scores are consistent with the client's report and with session observations of brighter affect and more spontaneous speech. Symptoms remain in the moderate range on the PHQ-9; progress toward treatment plan goal 1 (reduce depressive symptoms) is partial. No current risk indicators.

Plan: Continue weekly CBT with behavioral activation; add one planned afternoon activity. Repeat PHQ-9 and GAD-7 at week 12. Client knows how to reach 988 and the clinic's after-hours line.

Fictional SOAP note with a positive EPDS item 10

SOAP note (fictional client)

Adult client, 7 weeks after birth · Individual session, 50 minutes · Fictional example written for this page; no real PHI

Subjective: Client reports feeling tearful most days, sleeping poorly even when the baby sleeps, and worrying she is not a good parent.

Objective: EPDS completed at the start of session: total 15, above the clinic threshold of 13. Item 10 scored 1. Affect tearful, speech normal in rate, oriented, engaged throughout.

Assessment: Positive item 10 followed up with a suicide risk assessment in session, per clinic protocol. Client describes brief passive thoughts that the family would manage without her, most recently three days ago; denies intent, plan or preparatory behavior and denies thoughts of harming the baby. Protective factors: partner at home, wants to get better for her child, engaged in treatment. Risk formulated as low acute risk, with elevated depressive symptoms needing further diagnostic assessment.

Plan: Written safety plan completed with client and shared with partner at client's request. Crisis resources reviewed, including 988. With client's written authorization, coordinate with her obstetric provider this week. Diagnostic assessment and rescreen next session in 7 days.

Common documentation mistakes

Recording a score without the measure name or version, so the number cannot be interpreted later.
Leaving out a zero on PHQ-9 item 9 or EPDS item 10. A documented zero shows the item was checked.
Treating a cut-off as a diagnosis, or copying the severity band into the diagnosis without your own assessment.
Mixing scoring conventions, for example reporting an RSES of 25 without saying whether it was scored 0 to 30 or 10 to 40.
Reproducing a copyrighted questionnaire in your forms without checking its terms of use.

How MentalNote fits

MentalNote drafts progress notes from a recorded session (with your client's consent) or, in the Word add-in, from a summary you type. It does not administer, score or assign screening measures. You give and score the measure, then state the score in the session or include it in your summary so it can appear in the draft. Check every number in the draft against the scored form, and review every draft before it goes in the record.

MentalNote is HIPAA-compliant, with a BAA included on every plan. The free plan includes 5 web-app scribe sessions a month with no credit card; Premium is $99/month or $990/year (pricing). See AI progress notes for therapists, the intake assessment template, and progress notes for depression.

Sources

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.
Johnson JG, Harris ES, Spitzer RL, Williams JBW. The Patient Health Questionnaire for Adolescents: validation of an instrument for the assessment of mental disorders among adolescent primary care patients. J Adolesc Health. 2002;30(3):196-204.
American Psychiatric Association. Severity Measure for Depression, Child Age 11 to 17 (adapted from the PHQ-9 modified for Adolescents). Online assessment measures for DSM-5-TR.
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.
Cox JL, Holden JM, Sagovsky R. Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1987;150:782-786.
Birmaher B, Khetarpal S, Brent D, et al. The Screen for Child Anxiety Related Emotional Disorders (SCARED): scale construction and psychometric characteristics. J Am Acad Child Adolesc Psychiatry. 1997;36(4):545-553.
Birmaher B, Brent DA, Chiappetta L, Bridge J, Monga S, Baugher M. Psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED): a replication study. J Am Acad Child Adolesc Psychiatry. 1999;38(10):1230-1236.
Rosenberg M. Society and the Adolescent Self-Image. Princeton, NJ: Princeton University Press; 1965.

FAQ

Screening measures: common questions

How is the PHQ-9 scored?

The PHQ-9 has nine items, each rated 0 to 3 for how often the symptom occurred over the last two weeks, so the total runs from 0 to 27. Scores of 5, 10, 15 and 20 mark the start of mild, moderate, moderately severe and severe depressive symptoms (0 to 4 is minimal). A score of 10 or more is the threshold most often used to prompt further assessment. A tenth question about how much the problems affect daily life is not added to the total.

What is the PHQ-A age range?

The PHQ-A is the adolescent version of the PHQ (Johnson, Harris, Spitzer and Williams, 2002). The American Psychiatric Association's adapted version, the Severity Measure for Depression for children age 11 to 17, is for ages 11 to 17. It has nine items rated 0 to 3 over the past 7 days, a total of 0 to 27, and uses the same 5, 10, 15 and 20 cut points as the PHQ-9.

What do GAD-7 scores mean?

The GAD-7 has seven items rated 0 to 3 over the last two weeks, for a total of 0 to 21. Scores of 5, 10 and 15 are the cut points for mild, moderate and severe anxiety symptoms. The developers recommend further evaluation at 10 or more. It was developed to screen for generalized anxiety disorder and is also used as a severity measure for anxiety symptoms more broadly.

What EPDS score is positive?

The Edinburgh Postnatal Depression Scale has ten items scored 0 to 3 for the past 7 days, a total of 0 to 30. There is no single universal cut-off: validation studies have used thresholds from about 9 to 13, and 10 or more (possible depression) and 13 or more (probable depression) are common. Follow the threshold your service uses, and always check item 10, which asks about thoughts of self-harm, whatever the total.

What does the SCARED measure, and who is it for?

The Screen for Child Anxiety Related Disorders (SCARED) screens for anxiety in children and adolescents, with a child version and a parent version. It has 41 items scored 0 to 2, so the total is 0 to 82. A total of 25 or more may indicate an anxiety disorder, and scores above 30 are more specific. It also gives five subscale scores: panic or somatic symptoms, generalized anxiety, separation anxiety, social anxiety and school avoidance.

How is the Rosenberg Self-Esteem Scale scored?

The Rosenberg Self-Esteem Scale has ten items answered on a four-point agree-to-disagree scale, with five items reverse-scored. Scored 0 to 3 per item, the total runs from 0 to 30; scored 1 to 4, it runs from 10 to 40. Higher scores mean higher self-esteem. It is a self-esteem measure, not a screen for a disorder, and the developer did not publish a clinical cut-off.

What should I do if a client endorses PHQ-9 item 9?

Item 9 asks about thoughts of being better off dead or of self-harm. Any response above 0 needs a same-day suicide risk assessment by a qualified clinician, following your organization's protocol, whatever the total score. The item alone does not measure risk. Document the item score, the risk assessment, your risk formulation and the actions taken, such as safety planning and crisis resources.

How do I record a screening score in a progress note?

Name the measure and version, the date, who completed it (client or parent), the total score and its published severity band, any critical item such as PHQ-9 item 9 or EPDS item 10, the change from the last score, and what you did with the result. Interpret the score alongside the clinical interview instead of letting it stand alone.

Is a positive screen a diagnosis?

No. A screening score shows that symptoms may be present and how severe they are reported to be. A diagnosis needs a clinical assessment against diagnostic criteria. Write "PHQ-9 score of 16, in the moderately severe range" rather than "client has moderately severe depression" unless your assessment supports that diagnosis.

Can MentalNote score the PHQ-9 or GAD-7?

No. MentalNote does not administer, score or assign screening measures. You give and score the measure, then state the score in the session or include it in the summary you type in the Word add-in, so it can appear in the draft. Check every number in the draft against the scored form before you sign.

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