The Therapists Are Struggling Too: Four Questions Reveal Anxiety and Depression in Clinical Psychologists

The people we trust to hold our darkest moments together are, in many cases, quietly struggling themselves. A new study published in Trends in Psychology has put a precise, statistical spotlight on the mental health of clinical psychologists in Mexico, and its findings carry an uncomfortable irony: the professionals who screen for anxiety and depression every day are not immune to the conditions they treat. Using one of the shortest screening tools in medicine, a research team led by L. J. Avalos-Salcedo and Pablo D. Valencia set out to answer two questions at once. Could the four-item Patient Health Questionnaire-4, known as the PHQ-4, reliably measure anxiety and depression in this specific professional group? And which characteristics of a psychologist’s life and work are actually linked to psychological distress?

The answer to the first question is a resounding yes, and the answer to the second is more surprising than anyone might have predicted. Among the 212 Mexican clinical psychologists surveyed, two factors stood out as significantly associated with lower levels of both anxiety and depression: being male, and having greater confidence in one’s own clinical skills. Just as striking were the factors that showed no significant relationship at all. Age, a personal history of psychotherapy, and whether the psychologist received clinical supervision all failed to predict symptom levels, challenging assumptions drawn from earlier studies across multiple countries.

The PHQ-4 itself is a marvel of compression. It consists of only four questions, two drawn from the PHQ-2 depression screener and two from the GAD-2 anxiety screener, each rated on a four-point scale of how often the respondent has experienced the symptom over the past two weeks. The depression items probe persistent low mood and loss of interest or pleasure, while the anxiety items ask about feeling nervous, anxious, or on edge, and about being unable to stop or control worrying. Because it takes less than a minute to complete, the instrument has become a workhorse of epidemiological research and primary care screening worldwide. Yet, until now, its psychometric performance specifically in clinical psychologists, a population under chronic emotional strain, had never been rigorously examined.

To test the instrument, the researchers turned to confirmatory factor analysis, a statistical technique that evaluates whether the pattern of responses matches a hypothesized underlying structure. Because the four items are rated on ordinal scales rather than continuous measurements, the team used the WLSMV estimator, which is specifically designed for categorical data. They then compared two competing models. The first treated all four items as measuring a single dimension of general psychological distress, an approach adopted by several previous studies in other populations. The second preserved the original design, separating anxiety items from depression items as two correlated but distinct factors.

The results were decisive. The unidimensional model failed badly, with a robust root-mean-square error of approximation of 0.49, far above the accepted threshold of 0.06, and a robust Tucker-Lewis index of just 0.45. The two-factor model, by contrast, fit the data almost perfectly: the comparative fit index and its robust version both reached 1.00, the robust RMSEA was 0.05, and the standardized root-mean-square residual was a mere 0.01. Every factor loading exceeded 0.80, indicating that each item strongly reflected its intended construct. Reliability, estimated with the categorical omega coefficient appropriate for ordinal items, came in at 0.78 for the anxiety subscale and 0.82 for the depression subscale, both comfortably within the range considered adequate for research and screening purposes.

One nuance deserves attention. The correlation between the latent anxiety and depression factors was high, at 0.73, confirming what clinicians have long observed: these two conditions travel together. This overlap explains why some research teams in other countries, including studies of healthcare workers in Taiwan and HIV care providers in China, have collapsed the PHQ-4 into a single distress score. The Mexican team argues, however, that maintaining the two-dimensional structure captures important nuances that a single score would erase, and their fit statistics give that argument considerable weight. The finding suggests that while anxiety and depression are deeply intertwined in this population, they remain distinguishable, and screening tools should treat them as such.

The second half of the study embedded the PHQ-4 within a full structural equation model, treating sex, age, psychotherapy history, clinical supervision, and confidence in clinical skills as potential predictors of the two latent symptom dimensions. This model also fit the data exceptionally well. Two paths emerged as statistically significant. Male psychologists reported lower levels of both anxiety and depression, a result consistent with broader epidemiological patterns in Mexico and beyond, where women consistently report more emotional distress. The authors caution that this gender gap must be interpreted carefully. More than 75 percent of Mexican clinical psychologists are women, and societal expectations may lead men to underreport emotional difficulties, while women in the profession may face compounded stressors from balancing professional and personal responsibilities.

The second significant predictor is arguably the study’s most actionable finding. Psychologists who expressed greater confidence in their own clinical skills reported significantly fewer symptoms of anxiety and depression. This echoes earlier research linking professional self-efficacy to mental health, including studies of psychology students in the United Arab Emirates and psychotherapists in Sweden, where low self-perceived competence predicted burnout. The mechanism is intuitive: a therapist who feels effective in daily work experiences a sense of mastery that buffers against the emotional toll of the job. Conversely, doubting one’s clinical abilities may amplify the rumination and worry that define anxiety, and the hopelessness that defines depression. Notably, receiving clinical supervision and having undergone personal psychotherapy, two interventions often assumed to protect therapists, showed no significant association with symptom levels in this sample, adding to a genuinely mixed international literature on these practices.

The implications reach well beyond Mexico. Clinical psychologists form the backbone of mental health care systems worldwide, and the COVID-19 pandemic exposed their vulnerability in stark terms. Studies cited in the paper found that 17 percent of Belgian psychologists experienced depression and 12 percent anxiety during the crisis, while 70 percent of Brazilian psychologists reported changes in their mental health. If confidence in clinical skills functions as a protective factor, then training programs, continuing education, and high-quality supervision designed to build genuine competence, rather than merely being offered supervision, could become explicit targets of mental health policy for the professionals themselves. The validated PHQ-4 offers an efficient way to monitor distress in this workforce, requiring almost no time burden while distinguishing anxiety from depression.

The authors are candid about the study’s limits. The sample was recruited through convenience sampling on social networks, was overwhelmingly female, and relied on self-selection, meaning psychologists experiencing distress may have been more motivated to respond. The cross-sectional design prevents any claim that confidence causes lower distress rather than the reverse. Still, the study marks a rare empirical examination of psychopathology measurement in clinical psychologists themselves, a population more often studied as assessors than as assessed. Future work, the team suggests, should test the PHQ-4 across cultures, explore bifactor models that separate general distress from specific symptoms, and follow professionals over time to untangle the direction of the relationship between self-efficacy and mental health. For now, the message is clear and quietly urgent: the healers need measuring too, and the four shortest questions in the field may be exactly the right ones to ask.

Subject of Research: Psychometric validation of the PHQ-4 anxiety and depression screening tool and associated risk and protective factors among clinical psychologists in Mexico

Article Title: Anxiety, Depression, and Associated Factors in Clinical Psychologists: Psychometric Evaluation of the PHQ-4

Article References: Avalos-Salcedo, L. J., González-Hernández, A. B., Blancas-Guillen, J., Ccoyllo-Gonzalez, L., Varela, S., & Valencia, P. D. (2025). Anxiety, Depression, and Associated Factors in Clinical Psychologists: Psychometric Evaluation of the PHQ-4. Trends in Psychology. https://doi.org/10.1007/s43076-025-00499-z

Image Credits: AI Generated

DOI: 10.1007/s43076-025-00499-z

Keywords: clinical psychologists, PHQ-4, anxiety, depression, psychometrics, confirmatory factor analysis, self-efficacy, mental health screening, Mexico, clinical supervision, psychological distress, structural equation modeling