A single emphasized word changed PHQ-9 and GAD-7 scores

Clinical takeaway: Standardize administration of PHQ-9 and GAD-7 assessments whenever possible. Small differences in how instructions are emphasized may affect reported symptom severity and potentially influence clinical decision-making.

PHQ-9 and GAD-7 scores are widely used to guide diagnosis, treatment decisions, referrals, and research outcomes. This study suggests that even minor variations in how instructions are delivered may influence scores enough to shift patients across commonly used severity thresholds.

In a randomized trial of 200 US adults with clinician-diagnosed or treated depression or anxiety, investigators found that emphasizing the word “bothered” in the standard instructions of the PHQ-9 and GAD-7 led to substantially lower reported symptom scores compared with standard administration alone.

Participants completed both questionnaires twice during the same telephone session. In the intervention group, interviewers emphasized the word “bothered” before the second administration and clarified that responses should reflect symptoms that were bothersome rather than merely present. Control participants received standard instructions both times.

Depression scores fell by an average of 2.6 points and anxiety scores by 3.2 points in the intervention group, while scores changed little in controls. Overall, the intervention produced approximately 2.6-point greater reductions on both scales than standard administration.

Half of intervention participants achieved more than a 20% reduction in PHQ-9 scores versus 9% of controls, while 65% versus 16% achieved similar reductions on the GAD-7. More than half of intervention participants also shifted into a lower symptom-severity category, compared with only about 12% to 15% of controls.

As the authors noted, “the observed changes reflect differences in symptom reporting rather than true clinical improvement,” since no treatment occurred between assessments.

In an accompanying commentary, Kurt Kroenke, MD, emphasized that PHQ-9 and GAD-7 scores should be interpreted alongside functional impairment, treatment preferences, and clinical judgment, rather than serving as stand-alone determinants of care. He also noted that the findings warrant further study in self-administered written and digital formats, where these tools are increasingly used.

Source: Young SD, et al. (2026 July 20) JAMA Netw Open. Instructional Emphasis and PHQ-9 and GAD-7 Scores Among Participants With Anxiety or Depression: A Randomized Clinical Trial