A new brief report published in JAMA Psychiatry finds that the instructions for the Patient Health Questionnaire (PHQ), a self-report assessment translated into more than 100 languages and widely used by general practitioners and OB-GYNs to screen for depression, is often misinterpreted by the people taking it. This means that rates of depression are likely overestimated using this assessment tool. The current work, led by Margarita Panayiotou from the University of Manchester, additionally finds that people labeled as having moderate to severe depression by the PHQ are much more likely to misinterpret the instructions. This misinterpretation continued even after participants had time to consider the intended meaning behind the instructions. The authors write:
“Our findings may raise certain concerns: participants tend to skip the instructions of self-report measures and in our case misinterpreted them even after they had explicitly considered them. Furthermore, most patients in the clinical sample misinterpreted the hypothetical scenario, more so than the general sample, possibly due to greater cognitive difficulties. This may not only make group-level findings uninterpretable but may also result in unreliable clinical cutoffs, and consequently flawed treatment decisions.”
This research shows one way that a widely used depression screening tool is likely overestimating depression. It also calls into question the research findings and treatment decisions based on this assessment tool. If the PHQ is not a reliable measure of depression, this would invalidate thousands of studies and mean that a huge number of people have been needlessly exposed to dangerous treatments for depression.
The goal of the current work was to explore interpretation issues with the PHQ. The authors used data collected from a general population sample in March 2022 and from a sample of people labeled as having moderate to severe depression by the PHQ between October 2022 and December 2023. In total, 503 people not labeled as having depression, and 349 labeled as having moderate to severe depression, participated in the current study.
Measures
The participants took the PHQ-8, a depression assessment tool that is similar to the more commonly used PHQ-9 with an item asking about suicide omitted. This assessment asks participants to indicate how often they were bothered by a specific issue in the past two weeks on a scale from 0 (not at all) to 3 (nearly everyday). The intended interpretation of these instructions hinges upon the term bothered by. If the participant is not bothered by the presented issue, the correct score is 0, even if the issue occurs frequently. Scores of 10 or higher are supposed to indicate moderate to severe depression.
After completing the PHQ-8, participants responded to 3 additional questions meant to access misinterpretation of the PHQ. The first question presented the following hypothetical scenario: you have overslept nearly everyday for the past two weeks, but you are not bothered by oversleeping. They then rated the oversleeping issue on the same scale as the other items in the PHQ-8. The correct response to this prompt, according to the intended interpretation of the PHQ instructions, would be “0,” because while the frequency of oversleeping is high the prompt specifically says that they were not bothered by oversleeping. The authors equated any answer other than “0” as a misinterpretation of the PHQ’s instructions.
The second question asked participants to indicate if they were answering the PHQ questions based on (1) the bothered by distinction, which is the intended interpretation of the instructions, (2) based solely on the frequency that the described scenario occurred, or (3) some combination of both interpretations. The authors equated any answer other than (1) as a misinterpretation of the PHQ. The third question asked participants how they would answer PHQ questions in the future after having been told the intended interpretation of the instructions.
Misinterpretation Rates
Overall, 38.5% of participants gave the correct response to the oversleeping hypothetical scenario. This means 61.5% of participants misinterpreted the instructions and likely gave at least some inaccurate answers on the PHQ-8. Participants that scored higher on the PHQ-8 (10 or above) were more likely to rate the hypothetical scenario incorrectly compared to participants that scored lower. 45.3% of those scoring below the clinical cutoff (9 or less), indicating no serious depression, rated the hypothetical scenario incorrectly. The vast majority (84.5%) of those scoring 10 or above on the PHQ-8, indicating moderate to severe depression, rated the hypothetical scenario incorrectly.
The authors note that this discrepancy may be explained by greater cognitive difficulty in the participants scoring 10 or higher on the PHQ-8. This discrepancy could also be explained by inflated scores in the high scoring group as a result of misinterpreting the instructions.
Overall, only 17.25% of participants indicated that they were answering questions on the PHQ-8 using the correct interpretation of the instructions. This means 82.75% of participants answered PHQ-8 questions based on an incorrect interpretation of the instructions. Misinterpretation was more common for participants that scored 10 or higher on the PHQ-8. 78.7% of those scoring below the clinical cutoff (9 or less) answered questions based on an inaccurate interpretation of instructions compared to 88.3% of those scoring 10 or higher.
After being told the intended interpretation of the PHQ instructions, just 17.14% of participants indicated that they would use the correct interpretation when answering PHQ questions in the future. Once again, participants scoring 10 or higher on the PHQ-8 were more likely to persist in their misinterpretation. 77.7% of those scoring 9 or less said they would persist in their misinterpretation when taking the PHQ in the future compared to 90.1% of those scoring 10 or higher.
The authors contend that the reason so many participants have issues interpreting the instructions for the PHQ-8 is because those instructions are ambiguous. Although the PHQ-8 claims to be a measure of depression severity, the way the items are rated seems to speak more to frequency. The authors conclude:
“Future work must consider clearer alternatives. Omitting “bothered by” from the instructions may improve consistency but would turn the PHQ into a measure of symptom frequency rather than severity. Researchers and clinicians must therefore be mindful of their assessment aims. If the goal is to capture severity, a different measure or a modified response scale (as was done in other PHQ-related measures) may be more appropriate.”
Limitations
The authors acknowledge several limitations to the current work. These findings need to be validated externally. More studies with other populations, different settings, and in other languages would be necessary to establish generalizability of the findings. The authors did not measure or consider possible confounding factors such as cognitive functioning in the current work.
A Flawed Assessment
The idea for the PHQ was initially pitched by Howard Kroplick, a marketer paid by the pharmaceutical company Pfizer to increase sales of the antidepressant Zoloft. The development of the PHQ was funded by Pfizer. Past research has found that the PHQ doubles rates of depression compared to clinical interviews. Experts have warned that doctors are too reliant on this industry produced depression screener and that widespread screening will inevitably lead to overdiagnosis.
While it may be a coincidence that a depression screener pitched by a marketer tasked with selling more antidepressants and funded by an industry notorious for corruption finds double the rate of depression compared to more reliable methods, a likelier explanation is that the PHQ is essentially a marketing tool designed to sell more drugs by labeling healthy people as “depressed.”
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Panayiotou, M., Razum, J., Eisele, G., Wang, S. B., Fried, E. I., & Cohen, Z. D. (2025). Interpretation issues with the Patient Health Questionnaire instructions. JAMA Psychiatry. (Link)
“PHQ is actually… a marketing tool designed to sell more drugs by labeling healthy people as depressed.”
Yes, that’s right… one of the biggest tactics of mainstream psychiatry… is to label healthy people – including those with depression – with “imaginary mental illnesses” and sell them more psychiatric drugs.
Because mainstream psychiatry… uses a ‘verification (confirmation)’ tactic within the psychiatric industry to transform healthy people into “real mentally ill” individuals. This confirmation tactic… is the confirmation of a “fictitious (imaginary) mental illness” diagnosis… with psychiatric drugs. (Mainstream psychiatrists know this and have been using this tactic for decades. This “verification (confirmation)” tactic… has been used for decades to transform healthy individuals into “real mentally ill” individuals.)
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So, how does this work?
Imagine an individual with a healthy brain experiencing a minor emotional distress (a natural psychological problem) that could later resolve spontaneously and/or with non-drug treatments and humane behavioral therapies. This individual seeks mainstream psychiatry to resolve their problem.
Mainstream psychiatry… (in order to transform healthy people into “real mentally ill” people)… is delighted when a “new customer (client)” falls into the trap. 🙂
In mainstream psychiatry… the tactic of transforming imaginary mental illness into reality (real mental illness) works as follows.
1) Mainstream psychiatry… labels an individual with one of thousands of “imaginary mental illnesses” — that is, it diagnoses them.
NOTE: It is a known fact that all “mental illness labels” found in so-called books like the DSM and ICD are “fictitious and imaginary (fabricated).” Mainstream psychiatrists know this.
2) Mainstream psychiatry… prescribes psychiatric drugs containing toxic chemicals that transform “imaginary mental illnesses” into reality (real mental illnesses) for the individual.
NOTE: It is a known fact that psychiatric drugs… relapse, create new, and/or worsen existing symptoms of mental illness. Mainstream psychiatrists know this.
3) Mainstream psychiatry… after prescribing psychiatric drugs to an individual… waits for that individual to experience “symptoms of mental illness” — that is, it begins to wait.
NOTE: Mainstream psychiatrists, knowing that psychiatric drugs… trigger, create, and worsen existing symptoms of mental illness, wait for individuals to become “real (truly) mentally ill.” Mainstream psychiatrists have used this tactic for decades because they know this.
4) Individuals… begin to experience a number (range) of strange, bizarre behaviors (symptoms of mental illness) after using the psychiatric drugs prescribed to them.
NOTE: Psychiatric drugs… first numb the healthy brains of individuals. This brain numbness… causes calmness in some individuals. (suppression of mental illness symptoms.) In some individuals, the opposite effect occurs. It leads to a relapse of symptoms and/or the development of new symptoms and/or a worsening of all symptoms. Individuals who become calmer… will likely begin to suffer from the same problems again after a while, once the effects of the psychiatric drugs – which numb healthy brains – wear off. Mainstream psychiatrists… know this, which is why they have been using this tactic for decades.
5) Individuals who experience strange, bizarre behaviors (symptoms of mental illness) after using psychiatric drugs often return to mainstream psychiatry.
NOTE : This is because mainstream psychiatrists know very well that psychiatric drugs are ineffective, that they make things worse, and that patients will inevitably come back to them for these and similar reasons.
Mainstream psychiatry… rejoices (happy) when it sees a returning client. 🙂 Because… it sees that the client’s existing psychological problem hasn’t improved, has relapsed, and/or new symptoms have emerged, and/or has worsened. Mainstream psychiatrists… know all this.
This means that the “imaginary mental illness” label that mainstream psychiatry has placed on individuals has been CONFIRMED. Thus, mainstream psychiatry… CONFIRMS the “imaginary mental illness” label (diagnosis) it has placed on the individual. It achieves this through psychiatric drugs. In other words, it does so by transforming the “imaginary mental illness” label (diagnosis) into a “real mental illness.”
NOTE 2 : Mainstream psychiatry… has been employing this tactic of transforming “imaginary mental illnesses into real mental illnesses” — for decades—using psychiatric drugs.
– First, it paste (stick) labels individuals with “imaginary mental illness.”
– Then it prescribes psychiatric drugs that transform this imaginary mental illness into reality.
– Then it waits for individuals to use these psychiatric drugs.
– Individuals, after using psychiatric drugs, begin to experience a number of strange, bizarre behaviors (psychological problems/symptoms of mental illness) caused by the psychiatric drugs.
– When individuals begin to experience “symptoms of mental illness” caused by psychiatric drugs, mainstream psychiatry thus CONFIRMS the mental illness diagnosis they have labeled individuals with.
Mainstream psychiatry knows all of this. Mainstream psychiatry has known—for decades—that psychiatric drugs cause mental illness. Therefore, they knowingly and deliberately damage the healthy brains of healthy individuals (chemical brain damage), turning them into truly mentally ill people.
NOTE 3: This is actually… so terrifying… that there are probably very few people in the world who know about this “deadly tactic.”
People who don’t have enough information about how mainstream psychiatry works and how psychiatric drugs affect things, etc., might think that the person who wrote the above is “very fanciful, conspiratorial, etc.” after reading this.
But almost all of the information I mentioned above, which is probably considered a conspiracy theory, has evidence to back it. What is considered a conspiracy theory… might be this so-called “confirmation tactic” of mainstream psychiatry. However, none of the other information that is the subject of conspiracy theories is actually a conspiracy… they are all pieces of information backed by evidence.
So… with thousands of verifiable pieces of evidence available… can we ignore the mainstream psychiatry’s tactic of turning “healthy individuals into real (genuinely) mentally ill” people?
In my opinion… mainstream psychiatry has been using this “tactic of confirms (validating) the mental illness label” for decades to turn (transform) healthy individuals into “real (genuinely) mentally ill.
And we’ve seen it do this for decades – with evidence. And that’s not even counting the millions/billions of people maimed (injured, disapled, crippled) and killed by psychiatric drugs…. How horrible, isn’t it? – If these aren’t real… are we just “imagining” things? :(( Best regards.
With my sincerest wishes. 🙂 Y.E. Researcher blog writer (Blogger)
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As someone who doesn’t like psychiatric treatment, I think your framing of the issue *is* actually slightly conspiranoid and overblown. While there are malicious people in the field, I strongly doubt that most psychiatrists know what they are prescribing and the harms. They just repeat the textbook knowledge like parrots and are misled into thinking they are healing people by messing with brain chemistry when in reality they are just putting bandaids at best. I bet my ass they get a lot of training in “diagnosing” depression but no training in diagnosing drug-induced symptoms, which is why they usually just keep trying to put more bandaids when things go wrong or they believe (because I think most of them genuinely believe) stupid shit like “Your antidepressant revealed you are bipolar.” Also, the effects of psychiatric drugs on specific people aren’t so easy to predict as you make it seem.
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I had already read some of this article and was handed these questionnaire forms again at the outpatient clinic waiting room– I guess everyone gets these to fill out for every single visit. I too was confused by the wording “bothered”. I did not complete, as I do not wish to spend the time before my appointments feeling okay, but having to put my mind onto contemplating depression and anxiety symptoms while waiting for a visit. I wondered about confirmation bias and how many people felt worse after filling out these questionnaires.
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