Your Patient Says They're Fine. Ask One of These Four Questions.

Your patient scores a 4 on the PHQ-9.

They tell you they're doing "okay." They're taking their medications, sleep is "okay," and they deny depression.

You could just finish the visit, renew the prescriptions, and move on.

But you care more than that.

Something doesn't quite fit. Their affect suggests there's more to the story. This is why you went to school. Not to be a mediocre PMHNP. You want to be great at this.

Maybe they're quieter than usual. Maybe they've stopped doing things they once enjoyed. Or maybe you've known this patient for months, and something about today's conversation feels different.

What do you ask next?

Not another version of "Are you depressed?"

Not another yes-or-no question or box to check.

And not another screening instrument.

Sometimes, the most revealing information comes from asking a better question, one the patient hasn't considered asking themselves.

In this article, we'll explore four questions borrowed from motivational interviewing (MI) and acceptance and commitment therapy (ACT) that can help uncover hidden distress, emotional avoidance, and the things patients struggle to put into words.

But first, there's an interesting reason to reconsider how much confidence we place in one of our most familiar screening tools.

The PHQ-9 Isn't Telling You Everything

A study published October 6, 2026, in Frontiers in Psychiatry examined how well the PHQ-9 identifies psychological distress beyond depression.

Researchers compared PHQ-9 scores with a broader mental health assessment capturing 47 symptoms across multiple psychiatric domains in 5,750 participants.

Here's what they found:

At the moderately severe cutoff, the PHQ-9 identified only 46% of people experiencing five or more severe mental health symptoms.

Lowering the cutoff to mild depression increased sensitivity to approximately 93%, but significantly reduced specificity.

In other words, the PHQ-9 wasn't particularly good at identifying broader psychological distress when used as a stand-alone mental health screening tool.

That's an important distinction. The PHQ-9 was designed to assess depressive symptoms, not every form of emotional suffering.

The study had limitations, including a self-selected online sample and the use of another self-report assessment rather than clinician-confirmed diagnoses as its comparison standard. It doesn't demonstrate that the PHQ-9 misses half of depression cases.

What if we're so focused on measuring symptoms that we're overlooking the person's experience?

Read the original research in Frontiers in Psychiatry

These aren't magic questions. You need to sense when to use each one, and with whom. They won't work with every patient, and they aren't substitutes for a comprehensive assessment.

But they will movet the conversation away from what the clinician is trying to measure and toward what the patient is actually experiencing.

Before we get to the questions, there's an important distinction worth understanding.

When Should You Lean Toward MI or ACT?

Both motivational interviewing and ACT can help patients explore difficult experiences, but they approach the conversation from different directions.

☕️ Motivational interviewing is useful when the patient isn't sure there's a problem or feels uneasy about making a change.

Perhaps they minimize their alcohol consumption, insist their stress is manageable, or acknowledge a vague concern but don't see a reason to act.

With MI, we're not trying to convince the patient that something is wrong. We're helping them explore their own concerns, discrepancies, and reasons for change.

☕️ ACT is particularly useful when the patient recognizes they're struggling but feels stuck.

They may understand that avoidance is limiting their life, yet continue waiting for anxiety, sadness, embarrassment, or uncertainty to disappear before living a rich and meaningful life..

ACT helps explore the relationship between uncomfortable internal experiences and the choices we make in response to them.

Here's a simple way to think about it:

Of course, people rarely fit neatly into one category. A patient may first need help recognizing their ambivalence and later need help moving toward something meaningful despite discomfort.

These approaches can complement each other.

The skill is recognizing what the patient needs from the conversation right now.

☕️☕️  "What's been harder lately than you let your friends or family, see?"

Motivational interviewing: Open-ended exploration

Some patients are remarkably good at looking okay.

They show up for work and school. They manage their responsibilities. They care for their families.

From the outside, everything appears reasonably stable.

But functioning alone doesn't always mean someone is doing well.

"I guess I'm exhausted from pretending everything is okay at work."

Or:

"Nobody knows that I come home and sit in my car for 15 minutes because I can't face another conversation."

Now you have information that may never have emerged from a PHQ-9 checklist.

Why this question works: It's an MI-consistent, open-ended invitation to explore the difference between outward functioning and internal experience. It communicates curiosity without imposing a diagnosis.

A great follow-up: "What does it take out of you to keep that up?"

The follow-up matters. It moves the conversation from describing the problem toward understanding its emotional and functional cost.

And notice what you haven't done.

You haven't told the patient what's wrong with them.

You've invited them to tell you.

 "What worries you most about the way things have been going?"

Motivational interviewing: Evoking concern and ambivalence

A direct question like "Do you think your drinking has become a problem?" may produce an immediate no.

But asking what worries them about their current situation can open a different door.

Consider a patient who uses alcohol nightly to unwind but denies significant depression or anxiety.

You ask:

"What worries you most about the way things have been going?"

After a pause, they respond:

"I don't like that I need a few drinks before I can relax. My father was the same way."

Now the conversation has changed.

The concern came from the patient, not the clinician.

Why this question works: MI emphasizes evoking the patient's own concerns and motivations rather than confronting them with our interpretation.

It also helps uncover ambivalence, that uncomfortable place where someone recognizes a problem but isn't certain they're ready to change.

Evoking continued: "And what do you think might happen if things continue this way?"

☕️☕️  "What have you been working really hard not to feel lately?"

ACT: Exploring experiential avoidance.

This is one of my favorites.

Some patients don't describe themselves as anxious or depressed because they've become very good at avoiding the situations and emotions that make them uncomfortable.

They stay busy.

They avoid difficult conversations.

They stop going places that challenge them or make them anxious.

They distract themselves whenever uncomfortable thoughts appear.

On the surface, they may even look productive and motivated.

But being busy isn't always the same as moving forward.

Sometimes productivity becomes another way to avoid sitting with something uncomfortable.

Over time, their lives may become organized around avoiding distress rather than pursuing what matters.

Consider someone who denies anxiety but hasn't traveled, attended a social gathering, or tried anything unfamiliar in several years.

Their symptoms may seem manageable.

But their world has become remarkably small.

Ask:

"What have you been working really hard not to feel lately?"

They might respond:

"I don't want to feel embarrassed."

Or:

"I can't stand the possibility of disappointing my parents."

Now you've uncovered something worth exploring.

Why this question works: ACT focuses partly on experiential avoidance, the tendency to escape or control unwanted internal experiences, particularly when doing so interferes with meaningful living.

Avoidance isn't always unhealthy. It becomes clinically interesting when avoiding discomfort consistently takes precedence over living.

A useful follow-up: "What has avoiding that feeling cost you?"

That question can be powerful.

A patient who initially reports minimal symptoms may suddenly recognize how much of their life has been shaped by trying not to experience something uncomfortable.

☕️☕️ "If you didn't have to feel better first, what would you want to be doing differently with your life?"

ACT: Values clarification and committed action.

We spend a great deal of time asking patients what they want to stop feeling.

Less anxiety.

Less sadness.

Less worry.

Fewer intrusive thoughts.

But what if the more interesting question isn't what they want to eliminate?

What if it's what they want to move toward?

Imagine a patient who has spent years waiting to feel less anxious before reconnecting with friends.

Or someone who wants to return to school but believes they must first eliminate every possibility of failure.

Ask:

"If you didn't have to feel better first, what would you want to be doing differently with your life?"

You might hear:

"I'd take my grandchildren somewhere."

"I'd finally apply for that better position."

"I'd stop making excuses and call my brother."

Now, It’s about identifying a life the patient wants to participate in.

Why this question works: ACT emphasizes psychological flexibility: the ability to make choices guided by personal values even when difficult thoughts and emotions are present.

The goal isn't to convince someone that their suffering doesn't matter.

It's to explore whether waiting for discomfort to disappear has become another barrier to meaningful action.

AI therapy bots can already generate remarkably sophisticated therapeutic responses.

They can ask open-ended questions, reflect emotions, and guide users through structured exercises drawn from established psychotherapy models.

Some may ask questions very similar to the four we've just explored.

But there's an important difference between generating a good question and recognizing when that question needs to be asked.

Think about the patient who says they're fine but looks different from their last visit.

Their usual humor is missing. Their affect has changed. They hesitate when describing something that previously brought them joy.

☕️ A chatbot may know thousands of therapeutic questions. An experienced clinician may recognize the moment when one particular question matters right now.

The PHQ-9 remains a useful instrument for depression screening and symptom monitoring.

And these four questions aren't validated screening tools. They don't establish a diagnosis, replace risk assessment, or rule out conditions such as bipolar disorder, trauma-related disorders, substance use disorders, or medical causes of psychiatric symptoms.

If a patient's presentation raises concerns, additional assessment is necessary. Clinical intuition should prompt investigation, not serve as evidence by itself.

Sometimes it appears as avoidance.

Sometimes it looks like a person who has slowly stopped participating in their own life.

And sometimes it looks like a patient who insists everything is “fine”.

During your next patient encounter, when the symptom scores look reassuring but something about the conversation doesn't quite fit, try one of these four questions.

If the patient seems uncertain or ambivalent about a problem, consider an MI question.

If they recognize they're struggling but seem trapped by avoidance or the need to feel better before acting, consider an ACT question.

Then resist the urge to immediately speak.

Give the patient time to think.

Newson JJ, Parameshwaran D, Schweitzer J, Thiagarajan TC. Limitations of PHQ-9 as a first line mental health screener in primary care. Frontiers in Psychiatry. 2026;17:1823578. Published October 6, 2026. https://doi.org/10.3389/fpsyt.2026.1823578