The Manic and Depression Symptoms Paired Screening (PMQ-9 and PHQ-9) is a brief self-report assessment designed to support measurement-based care for adults with bipolar disorder. Details regarding the PHQ-9 are presented on its separate page.
This assessment combines the Patient Mania Questionnaire (PMQ-9), a 9-item measure of manic symptoms over the past week (Cerimele et al., 2022), with the Patient Health Questionnaire (PHQ-9), a widely used 9-item measure of depressive symptom severity (Kroenke et al., 2001). Together, the two measures enable concurrent monitoring of both manic and depressive symptoms, supporting ongoing clinical decision-making across primary care, mental health, and integrated care settings.
The Patient Mania Questionnaire-9 (PMQ-9) is a brief, 9-item self-report measure that assesses manic symptoms over the past week in adults with bipolar disorder. Items capture symptoms that may fall below the full criteria for a manic or hypomanic episode, with scores reflecting overall manic symptom severity (Cerimele et al., 2022). It is recommended for use in primary care and mental health care settings, as well as specialty mental health and integrated care, as a monitoring tool rather than a diagnostic instrument.
Developed within a measurement-based care (MBC) framework, the PMQ-9 supports the regular use of symptom tracking to monitor change and guide clinical decision-making. Changes in scores over time provide clinically relevant information about symptom course and response to treatment. Unlike some manic symptom measures developed primarily to detect acute mania or to distinguish diagnostic status, the PMQ-9 was designed for routine use in ongoing care. Furthermore, it was designed to intentionally align with the structure, response format, and scoring of the Patient Health Questionnaire-9 (PHQ-9), a widely used measure of depressive symptoms (additional information about the PHQ-9 is available).
The PMQ-9 assesses nine key domains of manic symptomatology commonly observed in bipolar disorder, informed by DSM-5 criteria (Cerimele et al., 2022):
By capturing these symptoms in a brief, standardised format, the PMQ-9 supports the detection of clinically meaningful changes in manic symptoms over time. It is important to note that because the PMQ-9 is intended for routine symptom monitoring rather than diagnosis, it does not attempt to assess every DSM manic symptom (e.g., grandiosity or elevated/expansive mood). Instead, consistent with MBC principles, it focuses on a subset of observable, behaviorally anchored manic symptoms that are well-suited to frequent self-report and to clinically actionable change over time.
The PMQ-9 was designed for paired use with the PHQ-9, allowing concurrent monitoring of manic and depressive symptoms using measures with parallel structure and scoring. This paired use of brief, parallel measures is consistent with recommended MBC practices, which emphasize the use of psychometrically strong tools in combination to support ongoing clinical monitoring and treatment decisions (Lewis et al., 2020). Clinical research and large-scale clinical studies further support the use of bipolar disorder symptom measures within an MBC approach to monitor treatment response and reduce treatment inertia (Cerimele et al., 2022).
Although bipolar disorder screening is common, measurement-based symptom monitoring remains underused despite its clinical importance (Cerimele et al., 2023). Regular monitoring of manic symptoms is particularly important in bipolar disorder, as manic symptoms in bipolar disorder are not confined to discrete episodes of mania or hypomania. Depressive and manic symptoms frequently co-occur (including during periods of bipolar depression), and manic symptoms that do not reach the severity of a full manic or hypomanic episode are common (Cerimele et al., 2022). Research has shown that people with bipolar disorder often experience ongoing depression or manic symptoms (e.g., changes in mood, energy, sleep, or thinking) even between full manic, hypomanic, or depressive episodes (Judd et al., 2002; Judd et al., 2003).
Research examining clinician and patient preferences indicates that the combination of the PMQ-9 and PHQ-9 is the most preferred approach for measurement-based care in bipolar disorder, reflecting its clinical relevance, ease of use, and interpretability (Cerimele et al., 2021; Cerimele & Fortney, 2023; Cerimele et al., 2024).
Within the NovoPsych platform, the PHQ-9 may be administered either independently or as part of a paired PMQ-9 and PHQ-9 assessment. The PMQ-9, however, is offered only as part of the paired approach, consistent with its intended use in MBC for bipolar disorder (Cerimele et al., 2021).
When the paired approach is used, it is recommended that the PHQ-9 be administered only within the paired assessment and not separately at the same time, as administering multiple PHQ-9s can create confusion in symptom tracking. Only PHQ-9 results collected within the paired PMQ-9 and PHQ-9 assessment will appear in the paired results view; PHQ-9 results collected separately using the standalone PHQ-9 measure will not be included in the paired results but can still be used to help inform clinical care.
The PMQ-9 assesses symptoms over the past week, whereas the standard PHQ-9 assesses bothersome symptoms over the past two weeks (Kroenke et al., 2001; Cerimele et al., 2022). In the PMQ-9 validation study, the PHQ-9 timeframe was modified to match the PMQ-9 (Cerimele et al., 2022). In NovoPsych, the standard PHQ-9 two-week timeframe as well as instructions are retained. Clinicians should consider these differences when interpreting paired results, as well as when comparing PHQ-9 scores directly against the validation study benchmarks.
Within the NovoPsych platform, the paired assessment is administered sequentially, with the PMQ-9 presented first (items 1–9) followed by the PHQ-9 (items 10–18). The PMQ-9 and PHQ-9 results are summed to yield a total score from 0 to 27 for each measure, with higher scores indicating greater symptom severity.
Both the PMQ-9 and PHQ-9 use a clinical cut-off score of 10 to classify symptom severity as either:
This shared classification framework allows for direct comparison between manic and depressive symptom burden, and underpins the four mood state classifications used in this report.
The PMQ-9 total score reflects the severity of manic symptoms experienced over the past week. Unlike the PHQ-9, the PMQ-9 does not have validated severity bands (e.g., mild, moderate, severe). Instead, available provisional evidence supports the use of a single cut-off of 10 or greater to distinguish subthreshold versus elevated manic symptom severity for monitoring purposes.
In addition to the raw score, percentile information is based on a longitudinal bipolar disorder clinical sample and provides descriptive context for interpreting an individual’s score relative to others in this clinical group. When tracking symptoms over time, a change of approximately 3 points on the PMQ-9 between sessions has been proposed as clinically meaningful.
The PHQ-9 total score reflects the severity of depressive symptoms over the past two weeks, with higher scores indicating more severe symptoms consistent with major depressive disorder. As with the PMQ-9, scores of 10 or more are classified as Elevated and scores below 10 as Subthreshold. Additionally, the PHQ-9 has well-established, validated severity descriptors which are shown in brackets alongside the Subthreshold/Elevated classification:
Percentile information based on community and clinical samples provides additional context for comparing an individual’s score with normative data. When monitoring change over time, a change of 5 or more points is typically considered reliable and clinically significant.
When administered together, the PMQ-9 and PHQ-9 support a paired interpretation framework that allows for monitoring manic and depressive symptoms concurrently in bipolar disorder. Each measure is scored and interpreted independently; however, interpreting the two scores together provides clinically useful information about relative symptom patterns over time, consistent with a measurement-based care approach (Cerimele et al., 2022).
Based on the proposed approach in the PMQ-9 literature, PMQ-9 and PHQ-9 total scores are each dichotomised using a cutoff score of 10, resulting in four possible paired symptom profiles (Cerimele et al., 2022). While these mood state classifications have not been formally validated for clinical decision-making, they provide a strong provisional descriptive framework for monitoring symptom patterns.
This paired approach allows clinicians to monitor changes in both symptom domains over time and identify shifts between mood states that may require treatment adjustments. Longitudinal tracking of these mood-state classifications provides clinically actionable information on symptom course and treatment response.
On first administration of the paired PMQ-9 and PHQ-9 assessment, three visualisations are presented to support clear interpretation of manic and depressive symptoms within a measurement-based care framework.
When multiple administrations are available, the initial score visualisations are replaced by a Multi-Administration Line Plot. These plots display PMQ-9 and PHQ-9 total scores across all administrations as line graphs plotted against time, with the cut score of 10 shown as a reference for each measure. This visualisation enables clinicians to monitor symptom trajectories over time, track treatment response, and identify patterns of improvement, deterioration, or shifts between manic, depressive, and mixed symptom presentations.
The psychometric evaluation of the PMQ-9 was initially conducted using data from the Study to Promote Innovation in Rural Integrated Telepsychiatry (SPIRIT), a pragmatic randomized effectiveness trial across 12 U.S. Federally Qualified Health Center systems (Cerimele et al., 2022).
Two samples were examined:
Internal Consistency. In the longitudinal bipolar disorder sample, the PMQ-9 demonstrated high internal consistency (Cronbach’s α = .88), comparable to the PHQ-9 administered in the same cohort (Cerimele et al., 2022).
Test–retest reliability. Test–retest reliability assessed approximately 30 minutes apart in the mixed-diagnosis sample was excellent (r = .85), indicating strong short-term score stability (Cerimele et al., 2022).
Concurrent validity was evaluated through associations with established self-report measures of manic symptoms. PMQ-9 scores were strongly correlated with the Internal State Scale – Activation Subscale (ISS-AS; r = .70) and more modestly correlated with the Altman Mania Rating Scale (AMRS; r = .26). The lower correlation with the AMRS is consistent with differences in measure purpose, as the PMQ-9 was designed for longitudinal symptom monitoring in routine clinical care, whereas the AMRS is typically used to assess current manic symptom severity in inpatient settings (Cerimele et al., 2022).
Research has found that those classified as currently hypomanic or manic using ISS criteria had significantly higher PMQ-9 scores than those not meeting these criteria, supporting the measure’s ability to differentiate clinically relevant mood states (Cerimele et al., 2022). Overall, psychometric evaluation revealed that the PMQ-9 performed favorably relative to two well-established manic symptom measures, providing evidence for its clinical utility.
Confirmatory factor analysis of PMQ-9 and PHQ-9 items administered together supported a two-factor structure representing largely distinct manic and depressive symptom dimensions. PMQ-9 items loaded primarily on a manic symptom factor, while PHQ-9 items loaded primarily on a depressive symptom factor, with limited cross-loading. These findings support the interpretation of PMQ-9 and PHQ-9 scores as related but non-redundant indicators of bipolar symptom severity (Cerimele et al., 2022).
Sensitivity to Change & Minimally Important Difference (MID)
In the longitudinal bipolar disorder sample, PMQ-9 scores decreased substantially over the course of treatment, with a 27% reduction in mean score from first to last clinical encounter, indicating sensitivity to change (Cerimele et al., 2022). Distribution-based estimates using standard error of measurement and standard deviation benchmarks yielded a minimally important difference (MID; the smallest change in score considered clinically meaningful) of approximately 3 points, with a plausible range of 2–4 points (Cerimele et al., 2022).
The PMQ-9 was designed for paired administration with the PHQ-9 to support concurrent monitoring of manic and depressive symptoms in bipolar disorder (Cerimele et al., 2022). Longitudinal analyses demonstrated correlated changes in PMQ-9 and PHQ-9 scores over time, whereas factor-analytic results indicate that the two measures assess largely independent symptom domains (Cerimele et al., 2022).
Clinician survey data indicate that the PMQ-9 and PHQ-9 combination was rated as the most acceptable and clinically helpful symptom measure set among commonly used bipolar disorder instruments (Cerimele et al., 2021). Studies examining patient preferences similarly found that the PMQ-9 and PHQ-9 combination was the most preferred approach for ongoing symptom monitoring (Cerimele & Fortney, 2023; Cerimele et al., 2024).
Provisional score thresholds for the PMQ-9 were defined to support longitudinal symptom monitoring and mood state classification (Cerimele et al., 2022). Scores below 10 were used to indicate lower levels of manic symptom severity, and scores of 10 or higher to indicate elevated levels of manic symptoms. This clinical cutoff was selected based on clinical judgment and alignment with PHQ-9 conventions (rather than empirical optimization) and should be interpreted as provisional rather than diagnostically definitive (Cerimele et al., 2022). The determination of operating characteristics (i.e., sensitivity and specificity) has not yet been formally evaluated. The PMQ-9 clinical cutoff was combined with the psychometrically validated PHQ-9 clinical cutoff (also 10 or higher) to classify four mood states reflecting relative manic and depressive symptom severity.
Depression tends to dominate clinical attention in bipolar disorder because it is often what brings people into treatment and accounts for a large proportion of time spent unwell. However, manic and hypomanic symptoms are frequently present at subthreshold levels, including during depressive episodes, and can shift rapidly. Research has shown that people with bipolar disorder often experience ongoing changes in mood, energy, sleep, and thinking even between full episodes (Judd et al., 2002; Judd et al., 2003). Without routine monitoring of manic symptoms alongside depression, clinicians risk missing early signs of mood elevation, mixed presentations, or treatment-related shifts such as antidepressant-induced hypomania. The PMQ-9 and PHQ-9 Paired Screening addresses this gap by tracking both symptom domains concurrently, supporting earlier detection and more responsive clinical decision-making.
Manic and depressive symptoms in bipolar disorder do not always occur in isolation. They frequently co-occur, fluctuate independently, and can shift from one pole to another over the course of treatment. Monitoring only one symptom domain at a time creates blind spots. For example, a reduction in depressive symptoms might be accompanied by a rise in manic symptoms that goes undetected. By pairing the PMQ-9 and PHQ-9 in a single administration, clinicians can track the relative balance of both symptom types at each session, identify mixed presentations, and detect transitions between mood states. This paired approach is consistent with measurement-based care principles, which emphasise the use of brief, psychometrically strong tools in combination to support ongoing clinical monitoring (Lewis et al., 2020; Cerimele et al., 2022).
The PMQ-9 and PHQ-9 Paired Screening classifies respondents into one of four mood states based on whether each score falls above or below the clinical cut-off of 10:
These classifications provide a descriptive framework for understanding the respondent’s current symptom profile at a glance. Clinically, they help identify patterns such as mixed presentations (where both symptom domains are elevated) or predominantly depressive or manic profiles. When tracked longitudinally, shifts between mood state classifications can signal emerging episodes, treatment response, or the need for medication adjustment, giving clinicians actionable information that goes beyond simply tracking individual scores.
Yes. The paired screening was specifically designed for feasibility across a range of clinical settings, including primary care, mental health, and integrated care. Both the PMQ-9 and PHQ-9 are brief self-report measures with parallel structure and scoring, making them straightforward to administer and interpret without specialist training. The PMQ-9 was developed and validated within the SPIRIT trial, a large pragmatic effectiveness study conducted across 12 U.S. Federally Qualified Health Center systems — settings that closely resemble real-world primary care (Cerimele et al., 2022). Clinician and patient survey data have consistently rated the PMQ-9 and PHQ-9 combination as the most acceptable and clinically helpful symptom measure set among commonly used bipolar disorder instruments (Cerimele et al., 2021; Cerimele & Fortney, 2023; Cerimele et al., 2024).
Most existing manic symptom measures (e.g., GBI, MDQ) were developed for specific clinical purposes that differ from routine outpatient monitoring. The PMQ-9 was developed specifically for longitudinal symptom monitoring in outpatient care, consistent with a measurement-based care framework. It focuses on a subset of observable, behaviourally anchored manic symptoms (such as reduced need for sleep, impulsivity, racing thoughts, and pressured speech) that are well-suited to frequent self-report and to detecting clinically meaningful change over time. Importantly, it was intentionally designed to mirror the structure, response format, and scoring of the PHQ-9, enabling direct comparison between manic and depressive symptom severity within the same administration.
Cerimele, J. M., Russo, J., Bauer, A. M., Hawrilenko, M., Pyne, J. M., Dalack, G. W., Kroenke, K., Unützer, J., & Fortney, J. C. (2022). The patient mania questionnaire (PMQ-9): A brief scale for assessing and monitoring manic symptoms. Journal of General Internal Medicine, 37(7), 1680–1687. https://doi.org/10.1007/s11606-021-06947-7
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Cerimele, J. M., Blanchard, B. E., Bechtel, J. M., & Fortney, J. C. (2021). Clinician preferences for using bipolar disorder symptom severity and quality of life scales for measurement-based care. General Hospital Psychiatry, 73, 123–125. https://doi.org/10.1016/j.genhosppsych.2021.08.003
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