Comparison of two self-rating scales to detect depression: HADS and PHQ-9

Background

More than half of patients with depression go undetected. Self-rating scales can be useful in screening for depression, and measuring severity and treatment outcome.

Aim

This study compares the Hospital Anxiety and Depression Scale (HADS) and the Patient Health Questionnaire (PHQ-9) with regard to their psychometric properties, and investigates their agreement at different cut-off scores.

Method

Swedish primary care patients and psychiatric outpatients (n = 737) who reported symptoms of depression completed the self-rating scales. Data were collected from 2006 to 2007. Analyses with respect to internal consistency, factor analysis, and agreement (Cohen''s κ) at recommended cut-offs were performed.

Results

Both scales had high internal consistency (α = 0.9) and stable factor structures. Using severity cut-offs, the PHQ-9 (≥5) diagnosed about 30% more patients than the HADS depression subscale (HADS-D; ≥8). They recognised the same prevalence of mild and moderate depression, but differed in relation to severe depression. When comparing recommended screening cut-offs, HADS-D ≥11 (33.5% of participants) and PHQ-9 ≥10 (65.9%) agreement was low (κ = 0.35). Using the lower recommended cut-off in the HADS-D (≥8), agreement with PHQ-9 ≥10 was moderate (κ = 0.52). The highest agreement (κ = 0.56) was found comparing HADS-D ≥8 with PHQ-9 ≥12. This also equalised the prevalence of depression found by the scales.

Conclusion

The HADS and PHQ-9 are both quick and reliable. The HADS has the advantage of evaluating both depression and anxiety, and the PHQ-9 of being strictly based upon the Diagnostic and Statistical Manual of Mental Disorders. The agreement between the scales at the best suitable cut-off is moderate, although the identified prevalence was similar. This indicates that the scales do not fully identify the same cases. This difference needs to be further explored.     

Measuring depression severity in general practice: discriminatory performance of the PHQ-9, HADS-D, and BDI-II

Background

The UK Quality and Outcomes Framework (QOF) rewards practices for measuring symptom severity in patients with depression, but the endorsed scales have not been comprehensively validated for this purpose.

Aim

To assess the discriminatory performance of the QOF depression severity measures.

Design and setting

Psychometric assessment in nine Scottish general practices.

Method

Adult primary care patients diagnosed with depression were invited to participate. The HADS-D, PHQ-9, and BDI-II were assessed against the HRSD-17 interview. Discriminatory performance was determined relative to the HRSD-17 cut-offs for symptoms of at least moderate severity, as per criteria set by the American Psychiatric Association (APA) and NICE. Receiver operating characteristic curves were plotted and area under the curve (AUC), sensitivity, specificity, and likelihood ratios (LRs) calculated.

Results

A total of 267 were recruited per protocol, mean age = 49.8 years (standard deviation [SD] = 14.1), 70% female, mean HRSD-17=12.6 (SD = 7.62, range = 0–34). For APA criteria, AUCs were: HADS-D = 0.84; PHQ-9 = 0.90; and BDI-II = 0.86. Optimal sensitivity and specificity were reached where HADS-D ≥9 (74%, 76%); PHQ-9 ≥12 (77%, 79%), and BDI-II ≥23 (74%, 75%). For NICE criteria: HADS-D AUC = 0.89; PHQ-9 AUC = 0.93; and BDI-II AUC = 0.90. Optimal sensitivity and specificity were reached where HADS-D ≥10 (82%, 75%), PHQ-9 ≥15 (89%, 83%), and BDI-II ≥28 (83%, 80%). LRs did not provide evidence of sufficient accuracy for clinical use.

Conclusion

As selecting treatment according to depression severity is informed by an evidence base derived from trials using HRSD-17, and none of the measures tested aligned adequately with that tool, they are inappropriate for use.     

Diagnosing depression in primary care using self-completed instruments: UK validation of PHQ-9 and CORE-OM.

There is increased emphasis on routine assessment of depression in primary care. This report is the first UK validation of two self-completed measures: the Patient Health Questionnaire (PHQ-9) and the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM). Optimum cut-off points were established against a diagnostic gold standard in 93 patients. PHQ-9 sensitivity = 91.7% (95% confidence interval [CI] = 77.5 to 98.3%) and specificity 78.3% (95% CI = 65.8 to 87.9%). CORE-OM sensitivity = 91.7% (95% CI = 77.5 to 98.2%) and specificity = 76.7% (95% CI = 64.0 to 86.6%). Brief self-rated questionnaires are as good as clinician-administered instruments in detecting depression in UK primary care.     

Identifying depression among adolescents using three key questions: a validation study in primary care

Background

Depression in adolescents is a serious psychiatric illness. GPs play an important role in identifying adolescents with depression and those at risk of developing depression. Few validated tools are suitable for identifying adolescent depression in general practice.

Aim

To determine if three verbally asked key questions are valid for identifying depression in adolescents.

Design and setting

A cross-sectional, general practice multicentre, validation study was conducted in Oslo, Norway, and Aarhus, Denmark.

Method

A total of 294 adolescents answered three verbally asked key questions followed by a Composite International Diagnostic Interview (CIDI) for psychiatric diagnosis. Inclusion criteria were age (14–16 years) and fluency in the Norwegian or Danish language. The primary outcome was ROC curve statistics in terms of sensitivity and specificity, predictive values, and likelihood ratios of the three key questions. Secondary outcomes were Loevinger’s H, Cronbach’s α, and prevalence of depression.

Results

The three key questions met the criteria for construct and criterion validity for detecting depression among the adolescents. ROC curve statistics for the three key questions demonstrated an AUC of 0.79 for the answer ‘yes’ to either screening question and of 0.73 for the answer ‘yes’ to the help question. The positive predictive value was 31% and the negative predictive value was 97%.

Conclusion

The three key questions are useful for identifying depression in adolescents in primary health care.     

Graduate mental health worker case management of depression in UK primary care: a pilot study.

BACKGROUND: Based on data from large multicentre US trials, the National Institute for Health and Clinical Excellence (NICE) is advocating a stepped-care model for the management of depression, with 'case management' or 'collaborative care' for selected patients in primary care. AIM: To conduct a pilot study examining the use of graduate mental health workers case managing depressed primary care NHS patients. DESIGN OF STUDY: A randomised controlled trial comparing usual GP care with or without case management over 16 weeks of acute antidepressant drug treatment. SETTING: Three primary care practices in the North East of England. METHOD: Patients with depression, aged 18-65 years, who had failed to adequately respond to antidepressant treatment, were randomised to the two treatments. Assessments were made at baseline, 12, and 24 weeks using a combination of observer and self ratings. RESULTS: Randomisation of 62 patients required screening of 1073 potential patients. There was little difference in outcome between the two treatment arms but a gradual improvement in symptoms over time was seen. Client satisfaction was assessed as high across both treatments. CONCLUSION: While this pilot study confirmed the integrity of the study protocol and the suitability of the outcome measures and randomisation procedure, it raises questions regarding the practicality of recruitment and feasibility of the intervention. It would be crucial to address these issues prior to the implementation of a large multi-centre randomised controlled trial.     

Late-life depression in the primary care setting: Challenges,collaborative care,and prevention

Late-life depression is highly prevalent worldwide. In addition to being a debilitating illness, it is a risk factor for excess morbidity and mortality. Older adults with depression are at risk for dementia, coronary heart disease, stroke, cancer and suicide. Individuals with late-life depression often have significant medical comorbidity and, poor treatment adherence. Furthermore, psychosocial considerations such as gender, ethnicity, stigma and bereavement are necessary to understand the full context of late-life depression.     

Patient centredness and the outcome of primary care consultations with patients with depression in areas of high and low socioeconomic deprivation

Background

Most patients with depression are managed in general practice. In deprived areas, depression is more common and poorer outcomes have been reported.

Aim

To compare general practice consultations and early outcomes for patients with depression living in areas of high or low socioeconomic deprivation.

Design and setting

Secondary data analysis of a prospective observational study involving 25 GPs and 356 consultations in deprived areas, and 20 GPs and 303 consultations in more affluent areas, with follow-up at 1 month.

Method

Validated measures were used to (a) objectively assess the patient centredness of consultations, and (b) record patient perceptions of GP empathy.

Results

PHQ-9 scores >10 (suggestive of caseness for moderate to severe depression) were significantly more common in deprived than in affluent areas (30.1% versus 18.5%, P<0.001). Patients with depression in deprived areas had more multimorbidity (65.4% versus 48.2%, P<0.05). Perceived GP empathy and observer-rated patient-centred communication were significantly lower in consultations in deprived areas. Outcomes at 1 month were significantly worse (persistent caseness 71.4% deprived, 43.2% affluent, P = 0.01). After multilevel multiregression modelling, observer-rated patient centredness in the consultation was predictive of improvement in PHQ-9 score in both affluent and deprived areas.

Conclusion

In deprived areas, patients with depression are more common and early outcomes are poorer compared with affluent areas. Patient-centred consulting appears to improve early outcome but may be difficult to achieve in deprived areas because of the inverse care law and the burden of multimorbidity.     

Recorded quality of care for depression in general practice: an observational study

Background

Depression is a leading cause of disease and disability internationally, and is responsible for many primary care consultations. Little is known about the quality of primary care for depression in the UK.

Aim

To determine the prevalence of good-quality primary care for depression, and to analyse variations in quality by patient and practice characteristics.

Design of study

Retrospective observational study.

Setting

Eighteen general practices in England.

Method

Medical records were examined for 279 patients. The percentage of eligible participants diagnosed with depression who received the care specified by each of six quality indicators in 2002 and 2004 was assessed. Associations between quality achievement and age, sex, patient deprivation score, timepoint, and practice size were estimated using logistic regression.

Results

There was very wide variation in achievement of different indicators (range 1–97%). Achievement was higher for indicators referring to treatment and follow-up than for indicators referring to history taking. Achievement of quality indicators was low overall (37%). Quality did not vary significantly by patient or practice characteristics.

Conclusion

There is substantial scope for improvement in the quality of primary care for depression, if the highest achievement rates could be matched for all indicators. Given the lack of variation by practice characteristics, system-level and educational interventions may be the best ways to improve quality. The equitable distribution of quality by patient deprivation score is an important achievement that may be challenging to maintain as quality improves.     

Psychological distress in primary care patients with heart failure: a longitudinal study.

BACKGROUND: Psychological distress is a common phenomenon in patients with heart failure. Depressive symptoms are often under-diagnosed or inadequately treated in primary care. AIM: To analyse anxiety and/or depression in primary care patients with heart failure according to psychosocial factors, and to identify protective factors for the resolution of psychological distress. DESIGN OF STUDY: Longitudinal observation study. SETTING: Primary care practices in lower Saxony, Germany. METHOD: In 291 primary care patients with heart failure the following factors were measured using validated questionnaires at baseline and 9 months later: anxiety and depression (Hospital Anxiety and Depression Scale [HADS]), quality of life (Minnesota Living with Heart Failure Questionnaire), coping with illness (Freiburg questionnaire for coping with illness), and social support (social support questionnaire). Severity of heart failure (New York Heart Association [NYHA] classification and Goldman's Specific Activity Scale), and sociodemographic characteristics were documented using self-report instruments. RESULTS: Twenty-six (32.5%) of the 80 patients who were distressed at baseline had normal HADS scores 9 months later, while the remainder stayed distressed. In logistic regression, baseline distress (odds ratios [OR] 5.51; 95% confidence intervals [CI] = 2.56 to 11.62), emotional problems (OR = 1.08; 95% CI = 1.00 to 1.17), social support (OR = 0.54; 95% CI = 0.35 to 0.83), and NYHA classification (OR = 1.70; 95% CI = 1.05 to 2.77) independently predicted distress at follow up. High social support contributed to a resolution of anxiety or depression, while partnership and low levels of emotional problems protected patients who began the study in a good emotional state from psychological distress. CONCLUSION: In everyday practice it is important to consider that a high NYHA classification and emotional problems may contribute to anxiety or depression, while high social support and living in a relationship may positively influence the psychological health of patients with heart failure.     

Identification of depression in diabetes: the efficacy of PHQ-9 and HADS-D

Background

Clinical guidelines advise screening for depression in patients with diabetes. The Patient Health Questionnaire (PHQ-9) and the depression subscale of the Hospital Anxiety and Depression Scale (HADS-D) are commonly used in primary care.

Aim

To compare the efficacy of HADS-D and PHQ-9 in identifying moderate to severe depression among primary care patients with type 2 diabetes.

Design of study

Self-report postal survey, clinical records assessed by GPs.

Setting

Seven metropolitan and rural general practices in Victoria, Australia.

Method

Postal questionnaires were sent to all patients with diabetes on the registers of seven practices in Victoria. A total of 561 completed postal questionnaires were returned, giving a response rate 47%. Surveys included demographic information, and history of diabetes and depression. Participants completed both the PHQ-9 and HADS-D. Clinical data from patient records included glycosylated hemoglobin (HbA1c) levels and medications.

Results

The proportion of the total sample completing HADS-D was 96.8% compared with 82.4% for PHQ-9. Level of education was unrelated to responses on the HADS-D but was related to completion of the PHQ-9. Using complete data (n = 456) from both measures, 40 responders showed HADS-D scores in the moderate to severe range, compared with 103 cases identified by PHQ-9. Only 35 cases were classified in the moderate to severe category by both the PHQ-9 and HADS-D. Items with the highest proportions of positive responses on the PHQ-9 were related to tiredness and sleeping problems and, on the HADS-D, feeling slowed down.

Conclusion

It may be that the items contributing to the higher prevalence of moderate to severe depression using the PHQ-9 are due to diabetes-related symptoms or sleep disorders.     

Assessing depression severity using the UK Quality and Outcomes Framework depression indicators: a systematic review

BackgroundDepression is a major cause of chronic ill-health and is managed in primary care. Indicators on depression severity assessment were introduced into the UK Quality and Outcomes Framework (QOF) in 2006 and 2009. QOF is a pay-for-performance scheme and indicators should have evidence to support their use; potential unintended consequences should also have been considered.AimTo review the effectiveness of routine assessment of depression severity using structured tools in primary care, and to determine the views of GPs and patients regarding their use.DesignSystematic review.MethodStudies were identified by searching electronic databases; study selection, data abstraction, and quality assessment were carried out by one reviewer, with checks from other authors and GRADE (grading of recommendations, assessment, development and evaluation) tables completed for included effectiveness studies.ResultsEight studies met the eligibility criteria. There was very low-quality evidence that assessing severity in a structured way at diagnosis using a validated tool led to interventions that were appropriate to the severity of depression. Patients and GPs had different perceptions of the assessment of depression at diagnosis, with patients being more positive. GPs highlighted unintended consequences. There was low-quality evidence that structured assessment at follow-up led to increased rates of remission and response, but changes to management were not seen. Patients used this assessment to measure their own response to treatment.ConclusionAny estimate of the effect of structured assessment of depression severity in UK general practice is uncertain. GPs consider routine use of questionnaires as incentivised by the QOF has unintended consequences, which could adversely affect patient care.     

Comorbidity of generalized social anxiety disorder and depression in a pediatric primary care sample

Background: Comorbidity between adult social anxiety disorder and major depression is extensive. Considerably less information about this relationship is available among youth. Methods: A randomly selected (from enrollees in a pediatric primary care clinic) sample of 190 families with children between the ages of 8 and 17 responded by mail to questionnaires assessing social anxiety, depression, and social functioning. Parents also completed a semi-structured telephone diagnostic interview about their child. Results: The generalized type of social anxiety disorder was highly comorbid with major depression, generalized anxiety disorder, specific phobias, and ADHD, while little comorbidity was present for the nongeneralized subtype of social anxiety disorder. Logistic regression analyses indicated that generalized social anxiety disorder was the only anxiety disorder associated with an increased likelihood of major depression (OR=5.1). In all cases, social anxiety disorder had a significantly earlier age of onset than major depression. Limitations: This study relies on cross-sectional data and diagnoses are based on parent reporting of child behavior. Conclusions: Generalized social anxiety disorder is strongly associated with depressive illness in youth. Screening and treatment approaches that consider both social anxiety and depressive symptoms are necessary. Early intervention to treat social anxiety disorder may prevent later depressive disorders.     

Advance care planning for cancer patients in primary care: a feasibility study

Background

Advance care planning is being promoted as a central component of end-of-life policies in many developed countries, but there is concern that professionals find its implementation challenging.

Aim

To assess the feasibility of implementing advance care planning in UK primary care.

Design of study

Mixed methods evaluation of a pilot educational intervention.

Setting

Four general practices in south-east Scotland.

Method

Interviews with 20 GPs and eight community nurses before and after a practice-based workshop; this was followed by telephone interviews with nine other GPs with a special interest in palliative care from across the UK.

Results

End-of-life care planning for patients typically starts as an urgent response to clear evidence of a short prognosis, and aims to achieve a ‘good death’. Findings suggest that there were multiple barriers to earlier planning: prognostic uncertainty; limited collaboration with secondary care; a desire to maintain hope; and resistance to any kind of ‘tick-box’ approach. Following the workshop, participants'' knowledge and skills were enhanced but there was little evidence of more proactive planning. GPs from other parts of the UK described confusion over terminology and were concerned about the difficulties of implementing inflexible, policy-driven care.

Conclusion

A clear divide was found between UK policy directives and delivery of end-of-life care in the community that educational interventions targeting primary care professionals are unlikely to address. Advance care planning has the potential to promote autonomy and shared decision making about end-of-life care, but this will require a significant shift in attitudes.     

A randomised controlled trial to test the feasibility of a collaborative care model for the management of depression in older people

BACKGROUND: Depression is the most common mental health disorder in people aged over 65 years. Late-life depression is associated with chronic illness and disability. AIM: To investigate the feasibility of a collaborative care model for depression in older people in a primary care setting. DESIGN OF STUDY: Randomised controlled trial with 16-weeks follow up. SETTING: A primary care trust in Manchester. METHOD: Participants were 105 people aged 60 years or older who scored 5 or more on the Geriatric Depression Scale; 53 were randomly allocated to an intervention group and 52 to a usual care group. The intervention group received care managed by a community psychiatric nurse who delivered an intervention comprising a facilitated self-help programme with close liaison with primary care professionals and old-age psychiatry according to a defined protocol. The usual care group received usual GP care. A nested qualitative study explored the views of the health professionals and patients regarding the acceptability and effectiveness of the intervention. RESULTS: The main outcome measure was recovery from depression. Patients in the intervention group were less likely to suffer from major depressive disorder at follow up compared with usual care (0.32, 95% confidence = interval = 0.11 to 0.93, P = 0.036). The qualitative component of the study demonstrated the acceptability of the intervention to patients. CONCLUSION: A model of collaborative care for older people with depression, used in a primary care setting with a facilitated self-help intervention is more effective than usual GP care. This study demonstrates that the implementation of a collaborative care model is feasible in UK primary care and that the intervention is effective and acceptable to patients.     

Concordance between the PHQ-9 and the HSCL-20 in depressed primary care patients

BACKGROUND: Two instruments commonly used in primary care research to measure depressive severity are the Patient Health Questionnaire-9 (PHQ-9) and the Hopkins Symptom Checklist-20 (HSCL-20). However, there is little information regarding the relationship between clinical information derived from these scales. The present study investigates the psychometric properties of the PHQ-9 and HSCL-20, determines the degree of instrument concordance, and describes the factor structure of the HSCL-20. METHODS: A secondary data analysis from a randomized controlled trial was performed. A total of 405 primary care patients with major depressive disorder and/or dysthymia were administered the PHQ-9 and the HSCL-20 when recruited for the study. RESULTS: Good internal consistency reliability estimates were obtained for both scales (PHQ-9 alpha=0.803; HSCL-20 alpha=0.837). All PHQ-9 inter-item and corrected item-total correlations showed that no item detracted from overall scale functioning. HSCL-20 items assessing overeating, poor appetite, and sexual interest were poorly correlated with other items and with the total scale score. A positive, moderate strength relationship was found between the instruments (r=0.54, p<0.0001). Exploratory factor analysis of the HSCL-20 yielded a six-factor structure, which accounted for almost 63% of the variance in total score. The largest contribution to common variance in the scale was provided by an "anxiety and self-reproach" factor. CONCLUSIONS: PHQ-9 and HSCL-20 total scores were moderately correlated. Although the HSCL-20 is utilized as a measure of depression severity, it may lack sufficient specificity to be an accurate reflection of depression status per se.