Measuring progress in therapy

How to tell real change from week-to-week wobble — for clients tracking their own scores and clinicians using measurement-based care.

Questionnaires like the PHQ-9 and GAD-7 turn "I think I'm a bit better" into numbers you can track. But every score has some noise in it. Knowing how big a change has to be before it's meaningful keeps everyone honest — about improvement and about when things aren't working.

Step-by-step

1. Take a baseline at the start of therapy.
2. Repeat every session or every two weeks, using the private check-ins or your clinic's system.
3. Compare against reliable change, not against zero — the reliable change calculator does the arithmetic.
4. Talk about it. A score is a prompt for a conversation, not a verdict.

The scores

• PHQ-9 (depression), 0–27: 0–4 minimal, 5–9 mild, 10–14 moderate, 15–19 moderately severe, 20–27 severe.
• GAD-7 (anxiety), 0–21: 0–4 minimal, 5–9 mild, 10–14 moderate, 15–21 severe.

Question 9 of the PHQ-9 asks about thoughts of being better off dead or of self-harm. Any answer above "Not at all" matters regardless of the total and should always be discussed.

Reliable change

A reliable change is one larger than a measure's normal measurement error. NHS Talking Therapies uses a change of 6 or more points on the PHQ-9 and 4 or more on the GAD-7. For other measures, the Jacobson & Truax reliable change index divides the change by the standard error of the difference, worked out from the measure's standard deviation and reliability; beyond ±1.96 is reliable at the 95% level.

Recovery and reliable recovery

NHS Talking Therapies treats 10 on the PHQ-9 and 8 on the GAD-7 as clinical thresholds. Recovery means moving from at or above the threshold to below it. Reliable recovery means recovery together with a reliable improvement — the strongest result. Moving just across the line by a point or two is recovery on paper but may be noise.

For clinicians: measurement-based care

Routinely collecting and reviewing outcome measures with clients helps spot early when therapy isn't working and adjust. Keep client scores in your own records system; the reliable change calculator takes only two numbers and stores nothing, so no protected health information is entered. The private practice planner covers caseload and income.

Frequently asked questions

What counts as a reliable change on the PHQ-9?

NHS Talking Therapies uses a change of 6 points or more. On the GAD-7 it uses 4 points or more.

What is the PHQ-9 cut-off?

10 is the most commonly used threshold for probable depression needing further assessment, and the start of the moderate range.

What is reliable recovery?

Moving from at or above the clinical threshold to below it, together with a reliable improvement in score.

Is a lower score always better?

On the PHQ-9 and GAD-7, yes. On some other measures a higher score is better, so check the direction before interpreting change.