This test is composed of 4 sentences, each one representing a symptom.
Ask the patient: how often has he/she been bothered by the following over the past 2 weeks?
1. Feeling down, depressed, or hopeless
2. Feeling nervous or anxious, or tense
3. Little interest or pleasure in doing things
4. Not being able to stop or control worrying
Each sentence has four possible answers
Not at all = 0
Several Days = 1
More than half the days = 2
Nearly every day = 3
0 - 2 = none
3 - 5 = mild
6 - 8 = moderate
9 - 12 = severe
Anxiety subscale = items 1 + 2 (score range: 0 to 6)
Depression subscale = items 3 + 4 (score range: 0 to 6)
On each subscale, a score of 3 or greater is considered positive for screening purposes.
See reference for more information.
Adapted from Tools and Resources. Center to Advance Palliative Care (CAPC). Anxiety and depression: PHQ-4 screening tool. Internet. Available at https://www.capc.org/documents/download/467/ Accessed on October 15, 2021.