Many people seeking mental health care may encounter confusion when completing symptom questionnaires, according to a new study led by University of Arizona psychologist Zachary Cohen. These forms, such as the Patient Health Questionnaire (PHQ), have been widely used since the 1990s and are mandated by organizations like the National Institutes of Health.
The research, soon to be published in JAMA Psychiatry, indicates that misunderstanding these questionnaires could affect the accuracy of diagnoses and treatment plans. Cohen noted that during his clinical training, nearly every patient required clarification about how to answer certain questions. "Oh, just do your best," was often all clinicians could advise.
"This is the questionnaire that everyone fills out, and it's a such a common experience of being confused – it's potentially catastrophic," said Cohen. "Because everything we do in mental health research is dependent on, to a large extent, people's report of their mental health symptoms, so if you don't have good data on that, you're building a house of cards."
A key issue identified in the study is the phrasing within the PHQ instructions. Patients are asked how often they have been "bothered by" specific symptoms but may interpret this differently. For example, participants were given a scenario where they overslept nearly every day but were not bothered by it. When asked how they would respond on the questionnaire, only 38% chose what researchers considered the correct answer based strictly on whether they were bothered.
"If you're reading the instructions to the letter, you would actually expect a 'not at all' there," Cohen explained.
Furthermore, only 17% indicated they would use "bothered by" as their future basis for answering PHQ questions. This inconsistency could lead to unreliable data for providers and researchers.
"If you're using smartwatches to do passive sensing of sleep...your passive sensing will look like noise when it's not really," Cohen added.
Cohen also pointed out potential implications with trends such as GLP-1 weight loss drugs: "For someone who is on Ozempic, experiencing reduced appetite probably shouldn't be counted as an indicator of depression – that's the main reason they're taking the drug."
He emphasized that simply revising question wording could help clarify whether respondents should focus on symptom frequency or distress caused by those symptoms. "If I want to know how frequently people are oversleeping, then just change the wording of the instructions and make it very clear that I'm just asking about the frequency of oversleeping," Cohen said. He suggested further studies are needed but believes these changes could provide an effective solution.
"I struggle to imagine that it's a good thing to have some people answering one way, and some people answering the exact opposite way for the same experience," he said. "There's just no way that that can be a good thing – and in this paper, we show that it's happening and provide preliminary evidence of how that can be a problem."
The study highlights ongoing challenges in accurately assessing mental health through self-reported measures and suggests avenues for improving standard practices moving forward.
