This screening test comprises four sentences: each represents a symptom.
Ask the patient:
How often have you been bothered by any of the following problems over the last 2 weeks?
1. Feeling down, depressed, or hopeless
2. Feeling nervous, anxious, or tense
3. Have little interest or pleasure in doing things
4. Not being able to stop or control worrying
Each problem has four possible answers:
Not at all = 0
Several days = 1
More than half of 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 more 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.