What a PHQ-9 of 4 can miss

Zenara Team December 23, 2025

When screening scores say ‘minimal symptoms’ but something’s clearly wrong. A case study in state-dependent functioning.

You’ve seen it. The PHQ-9 says 4—“minimal symptoms”—but your gut says something’s off. The story doesn’t line up with the number. Work is shaky. Evenings are collapsing. The patient says, “I’m fine,” and then tells you they sleep 3 hours, haven’t opened their mail in weeks, and cancel plans most nights. This is where tools end and care begins. The PHQ-9 is invaluable—and incomplete. It measures depressive symptoms over two weeks. It doesn’t fully capture how a person functions across states, contexts, and time.

A case in real life
A 39-year-old product manager—call her Maya—presented for a “med check.” PHQ-9: 4. No suicidality endorsed. In the room, she looked composed, even upbeat. If I’d stopped there, I would have missed everything that mattered. Two minutes later, a different picture emerged. She performed well under external structure (meetings, deadlines), but crashed at home. Evenings were marked by paralysis and self-criticism. Weekends swung between frantic catch-up and total withdrawal. She “forgot” to eat, mind-raced at night, and drank to sleep twice a week. Anxiety flares—especially around conflict—were near-panic. She’d been told “that’s just how high performers are.”

What the PHQ-9 missed (and why)

  • State-dependent functioning. People can perform in one state (structured, observed, time-pressured) and collapse in another (unstructured, relational, low-stimulus). A two-week average blurs peaks and troughs.
  • Comorbidity that drives impairment. Anxiety, trauma, ADHD, sleep disorders, pain, thyroid issues, and substance use can impair function with relatively low depressive symptom scores.
  • Mixed features. Irritability, decreased need for sleep, and agitation can coexist with low reported sadness and still devastate function. The PHQ-9 doesn’t screen for hypomania.
  • Masking and recall. Conscientious patients minimize symptoms. “I don’t want to seem dramatic.” Or they anchor on today’s “good day” and discount last weekend’s crash.
  • Function isn’t scored. The PHQ-9 includes a functional difficulty question many EHRs omit or clinicians don’t review. When it’s missing, you lose a critical signal.

How we made the truth visible
We slowed down and mapped experience by state, not just score.

  • A day-in-the-life map. Morning to night, weekday vs weekend. Where does energy drop? What triggers the spiral?
  • Function measures alongside symptoms. We added the Sheehan Disability Scale (SDS) or Work and Social Adjustment Scale (WSAS). Her PHQ-9 was 4; her WSAS was 24—moderate to severe functional impairment.
  • Paired screens. GAD-7 for anxiety (13), ASRS for ADHD (positive), sleep screen (STOP-Bang flagged risk), alcohol screen (AUDIT-C positive). PTSD symptoms emerged with relational triggers.
  • Safety, explicitly. PHQ-9 item 9 was 0, but we asked directly about impulsive moments, passive death wishes, and recent “I can’t do this” spirals. No intent or plan, but risk in specific states. We built a concrete safety plan anyway.
  • Medical checks. TSH and B12 were normal. Sleep study referral placed.

What changed in the plan

  • Targets included function, not just symptom score. We set “PHQ-9 < 5 and WSAS ≤ 10” as the goal, with a timeline.
  • Treat-to-target adjustments every 2–4 weeks. SSRI dose optimized; therapy cadence increased; CBT-I introduced; stimulant trial considered after sleep stabilized; alcohol boundary set.
  • Between-visit measurement. Short weekly check-ins via portal with PHQ-9, GAD-7, and a 60-second “function snapshot” (three domains, 0–8 scale).
  • State-aware strategies. Evening structure added (meals, wind-down, light exposure), micro-tasks for executive load, and a script for conflict activation.
  • Clear escalation rules. If weekly function scores rose ≥6 in any domain or item 9 > 0, same-week touch and reassessment.

Within eight weeks, the PHQ-9 hovered at 3—but the WSAS dropped from 24 to 10. Sleep reached 6.5 hours. Evenings became workable. Weekends were no longer collapses. That’s recovery you can feel.

Five questions when the PHQ-9 says 0–4 and your gut says “not right”
Ask these, verbatim if it helps:

  1. Walk me through your last bad evening, hour by hour. What actually happened?
  2. What gets unreliable when life gets shaky—work, home, people, money? What drops first?
  3. Do you ever feel wired-tired—exhausted but unable to stop? Any stretches of little sleep with lots of energy?
  4. When anxiety hits, where does it live—in the body, in thoughts, in actions? What’s the worst version?
  5. What’s your one nonnegotiable this week that would make next week meaningfully easier?

When to add or switch measures

  • Always pair PHQ-9 with GAD-7 if anxiety is in the story.
  • Add SDS/WSAS when function is unclear or the story and PHQ-9 conflict.
  • Screen targeted domains when flags appear:
    • Sleep: Insomnia Severity Index or STOP-Bang
    • ADHD: ASRS-5
    • Trauma: PC-PTSD-5 or PCL-5
    • Alcohol/substances: AUDIT-C, DAST-10
    • Bipolar spectrum: MDQ/CIDI screen if mixed features suspected
  • Use brief weekly pulses early in treatment or after a change; taper frequency as stability returns.

Safety note on item 9
Item 9 is a radar, not a verdict. A “0” doesn’t rule out risk, and a “1” demands context—not panic. If any risk signal appears, pause and assess intent, plan, means, past attempts, substance use, agitation, protective factors, and willingness to accept help. Update the safety plan. Set a follow-up window you’ll keep.Why this works (and what the evidence says)

  • Measurement-based care improves outcomes and speeds decisions when paired with timely adjustments.
  • PHQ-9 is valid and responsive—but it’s not a diagnostic interview and doesn’t replace clinical judgment.
  • Functional measures (SDS/WSAS) capture what patients live with day to day and don’t always move in lockstep with symptom scores.
  • Item 9 correlates with elevated risk in the following weeks; it should trigger assessment, not replace it.

A note from practice
I’ve run “mental vitals” in my San Francisco practice for a decade: PHQ-9 and GAD-7 at every relevant visit, weekly early pulses, functional scores where the story and numbers diverge. The lesson repeats: when the measure and your gut disagree, assume the measure is incomplete, not that the person is “fine.” Add context, add function, then adjust the plan.

If you want the exact state-dependent workflow—the prompts, the brief function tracker, and the safety script—we can share what’s working. Request a practice assessment or join the waitlist. We’ll fit it to your current stack.

References
Measurement-based care and PHQ-9

Functional impairment measures

Anxiety, sleep, and comorbidity screens

Item 9 and suicide risk

Quality and policy context

* Note: References illustrate the evidence behind symptom measurement, functional assessment, and suicide risk screening. Clinical decisions should integrate instruments with judgment and patient context.

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