Validity of the Brief Patient Health Questionnaire Mood Scale (PHQ-9) in the general population

OBJECTIVE: The aim of this study was to assess the validity of the Patient Health Questionnaire depression module (PHQ-9). It has been subject to studies in medical settings, but its validity as a screening for depression in the general population is unknown. METHOD: A representative population sample (2,066 subjects, 14-93 years) filled in the PHQ-9 for diagnosis [major depressive disorder, other depressive disorder, depression screen-positive (DS+) and depression screen-negative (DS-)] and other measures for distress (GHQ-12), depression (Brief-BDI) and subjective health perception (EuroQOL; SF-36). RESULTS: A prevalence rate of 9.2% of a current PHQ depressive disorder (major depression 3.8%, subthreshold other depressive disorder 5.4%) was identified. The two depression groups had higher Brief-BDI and GHQ-12 scores, and reported lower health status (EuroQOL) and health-related quality of life (SF-36) than did the DS- group (P's < .001). Strong associations between PHQ-9 depression severity and convergent variables were found (with BDI r = .73, with GHQ-12 r = .59). CONCLUSION: The results support the construct validity of the PHQ depression scale, which seems to be a useful tool to recognize not only major depression but also subthreshold depressive disorder in the general population.     

Validity of the mental health component scale of the 12-item Short-Form Health Survey (MCS-12) as measure of common mental disorders in the general population

This study assessed the screening utility of the 12-item Short-Form Health Survey's (SF-12) mental health component scale (MCS-12) for diagnosable depression and anxiety disorders in a general population sample, and thus, the validity of this scale as a measure of mental health in epidemiological research. Data were from the Australian National Survey of Mental Health and Wellbeing (N=10,504). Diagnoses were made using the Composite International Diagnostic Interview. The MCS-12 was compared to other brief scales: the RAND Mental Health Component scale (RAND MHC-12, an alternative scoring method for the MCS-12), the 12-item General Health Questionnaire (GHQ-12), the Kessler Psychological Distress Scale (K10 and K6), and an estimate of the Mental Health Inventory (MHI-5). The MCS-12 and RAND MHC-12 were equally able to discriminate respondents with the target diagnoses. The MCS-12 performed better than the GHQ-12, and equally to the K6 for diagnoses of depression, though not anxiety disorders, where the K6 showed greater utility. The K10 out-performed the MCS-12 for all diagnoses. Areas under receiver operating characteristics curves (AUC) indicated that the MCS-12 is valid measure of mental health in epidemiological research, and a useful screening tool for both depression (AUC=0.92) and anxiety disorders (AUC=0.83).     

Discriminant validity of the 12-item version of the general health questionnaire in a Swedish case-control study

Background: The 12-item version of the General Health Questionnaire (GHQ-12) is widely used as a proxy for Affective Disorders in public health surveys, although the cut-off points for distress vary considerably between studies. The agreement between the GHQ-12 score and having a clinical disorder in the study population is usually unknown.

Aims: This study aimed to assess the criterion validity and to determine the sensitivity and specificity of the GHQ-12 in the Swedish population.

Methods: This study used 556 patient cases surveyed in specialized psychiatric care outpatient age- and sex-matched with 556 controls from the Stockholm Health Survey. Criterion validity for two scoring methods of GHQ-12 was tested using Receiver Operating Characteristics (ROC) analyses with Area Under the Curve (AUC) as a measure of agreement. Reference standard was (1) specialized psychiatric care and (2) current depression, anxiety or adjustment disorder.

Results: Both the Likert and Standard GHQ-12 scoring method discriminated excellently between individuals using specialized psychiatric services and healthy controls (Likert index AUC?=?0.86, GHQ index AUC?=?0.83), and between individuals with current disorder from healthy controls (Likert index AUC?=?0.90, GHQ index AUC?=?0.88). The best cut-off point for the GHQ index was ≥4 (sensitivity?=?81.7 and specificity?=?85.4), and for the Likert index ≥14 (sensitivity?=?85.5 and specificity?=?83.2).

Conclusions: The GHQ-12 has excellent discriminant validity and is well suited as a non-specific measure of affective disorders in public mental health surveys.     

The effectiveness of very short scales for depression screening in elderly medical patients

OBJECTIVE: To compare very short scales for screening for depression with longer, widely used scales. METHODS: Eighty-seven patients over the age of 60 who were admitted to rehabilitation wards or were attending a day rehabilitation facility at a British teaching hospital were screened for depression using the 1-item mental health inventory, and the 4-item, 15-item and 30-item geriatric depression scales. The sensitivity, specificity, and areas under receiver operating characteristic curves were compared, with the diagnostic criteria for research of ICD-10 providing the criterion diagnosis of depressive episode. RESULTS: All the scales had comparable sensitivity (82.4-100%), specificity (60.0-71.4%), and positive predictive values (33.3-42.9%). Comparison of receiver operating characteristic curves for each scale showed no statistically significant difference between them (range 0.80-0.88). CONCLUSIONS: The very short scales performed just as well as the widely used longer screening scales in this population. They are worthy of further examination in elderly populations at risk of depression, and may be particularly suitable for older adults due to their brevity and ease of use.     

The factor structure of the General Health Questionnaire (GHQ): a scaled version for general practice in Spain.

BACKGROUND: The 28-item version of the General Health Questionnaire (GHQ-28) developed by Goldberg and Hillier in 1979 is constructed on the basis of a principal components analysis of the GHQ-60. When used on a Spanish population, a translation of the GHQ-28 developed for an English population may lead to worse predictive values. METHODS: We used our Spanish sample to replicate the entire process of construction of the GHQ-28 administered in a primary-care setting. RESULTS: Two shorter versions were proposed: one with six scales and 30 items, and the other with four scales and 28 items. CONCLUSIONS: The resulting GHQ-28 was a successful adaptation for use on the Spanish sample. When compared with the original version, only 21 items were the same. Moreover, contrary to the English version, which groups sleep problems and anxiety in the same scale, a scale with items related exclusively to 'Sleep disturbances' was found.     

Life satisfaction and depression in a 15-year follow-up of healthy adults

OBJECTIVE: The aim of this study was to investigate the cross-sectional and longitudinal relationship between life satisfaction and depressive symptoms in healthy adults. METHOD: This is a 15-year prospective cohort study with a nationwide sample of healthy Finnish adults (N = 9679), aged 18-45, who responded to postal questionnaires in 1975, 1981 and 1990 including a 4-item life satisfaction (LS) scale (range 4-20) and, in 1990, the 21-item Beck Depression Inventory (BDI). RESULTS: A strong linear association was found between concurrent LS and BDI scales (r = 0.6). With an LS cut-off point of 11/12, moderate/severe depression (BDI > or = 19) was detected with 87% sensitivity, 88 % specificity and a 94% area under the ROC curve. Longitudinally, a strongly increased risk of moderate/severe depression in 1990 was observed among the dissatisfied (LS 12-20) compared with the satisfied (LS 4-6) in 1975 (OR = 6.7; 95 %CI 4.2-10.9) and in 1981 (OR = 10.4; 6.1-17.6). CONCLUSION: The 4-item LS scale can identify a group of healthy people from the general population with a high risk of having or developing depressive symptoms. Since low life satisfaction also indicates an elevated risk of other adverse health outcomes, the assessment of subjective well-being should be encouraged both in surveys and in clinical practice.     

The Inventory of Depressive Symptomatology: German translation and psychometric validation

The Inventory of Depressive Symptomatology (IDS) is a rating scale for depression, widely used in international multicentre studies. There are two corresponding versions: a self-rated (IDS-SR) and a clinician-rated (IDS-C) scale. The aim of this study was to evaluate the reliability and validity of the German versions of the IDS-SR and IDS-C in comparison to the Hamilton Rating Scale for Depression (HRSD) and to the Beck Depression Inventory (BDI). The sample consisted of 59 inpatients and outpatients treated for unipolar or bipolar disorders. Internal consistency of the IDS-SR and IDS-C was found highly acceptable (alpha = 0.94 and alpha = 0.93). Item-total-correlations of the IDS-SR revealed that 68% of the items were strongly correlated with the sum score (> or =0.50). This was in the same range with the IDS-C (54%), the HRSD (53%) and the BDI (76%). Furthermore, there is a high concurrent validity (r > or = 0.88) of the IDS-SR with the IDS-C, the BDI and the HRSD. Substantial score-differences between inpatients and outpatients indicate a good discriminant validity. It is concluded that the German version of the IDS is a useful instrument for the assessment of depressive symptoms and that it has the same highly acceptable psychometric properties as the original English version.     

The Geriatric Depression Scale and the Cornell Scale for Depression in Dementia. A validity study

The study is a validation study of two psychogeriatric depression rating scales, The Geriatric Depression Scale (GDS) and the Cornell Scale for Depression in Dementia (CSDD). The sensitivity and specificity, and the convergent and criterion validity of the two scales as well as the inter-rater reliability of the CSDD are reported. Two independent clinicians using the ICD-10 for depression and dementia, the Clinical Global Impression (CGI), the Hamilton Depression rating scale 17-items and the Mini-Mental-State Examination (MMSE), interviewed each patient or control subject. One hundred forty-five persons of 65 years or more of age were included, 73 were depressed only, 36 depressed and demented; 36 persons were control subjects, 11 of these were demented. The inter-rater reliabilities were high or very high equalling perfect correlation. There was very high convergent validity between the screening tools and the severity scales; the shorter versions of the GDS (15-, 10- or four-item version) had lower though still almost perfect correlations. The criterion validity in the total population showed the CSDD as the better scale with sensitivity and specificity of 93% and 97% with a cut-off value of > or =6. The GDS versions had sensitivities and specificities ranging from 82% to 90% and 75% to 94% respectively with cut-off values > or =9, 4, 3 and 1. The CSDD retained its validity and specificity as a screening tool for depression in a population of demented, while the GDS versions all diminished in validity. The GDS and the CSDD are both valid screening tools for depression in the elderly; however, the CSDD alone seems to be equally valid in populations of demented and non-demented.     

The Inventory for Depressive Symptomatology (IDS): preliminary findings

The Inventory for Depressive Symptomatology (IDS) is a new measure of depressive signs and symptoms. Both self-report and clinician-rated versions are under development. The IDS-SR (self-report) was completed by 289 patients, 285 of whom were outpatients. Unipolar major depression (n = 174), bipolar disorder (n = 44), euthymic (S/P unipolar or bipolar) depression (n = 33), and other psychiatric disorders (n = 38) were included. The IDS-SR had good internal reliability (coefficient alpha = 0.85), and significantly correlated with both the Hamilton Rating Scale for Depression (HRSD) (r = 0.67) and the Beck Depression Inventory (BDI) (r = 0.78). The clinician-rated IDS (IDS-C) was administered to 82 outpatients (75 with unipolar or bipolar disorder, 5 with other psychiatric disorders, and 2 euthymic (S/P unipolar) depressions). Coefficient alpha (0.88) suggested strong internal consistency. The IDS-C correlated highly with both the HRSD (r = 0.92) and the BDI (r = 0.61). Discriminant and factor analyses provided evidence for construct validity for both the IDS-C and IDS-SR. Both scales significantly differentiated endogenous from nonendogenous depression defined by Research Diagnostic Criteria (RDC). Factor structures for the IDS-SR revealed four factors: mood/cognition, anxiety, selected endogenous symptoms, and hyperphagia-hypersomnia. The IDS appears applicable to both inpatients and outpatients with endogenous, atypical, and nonendogenous major depression, and may have utility with dysthymics.     

The Beck Depression Inventory in clinical practice]

The German version of the Beck Depression Inventory (BDI) was administered to 477 depressed in- and out-patients, 180 patients with chronic pain and 86 matched healthy control subjects. Earlier studies have applied the German BDI successfully, but only on students and other non-clinical samples. The clinical use of the BDI was found to have good internal consistency and validity. Cronbach's alpha reached 0.88, the average item-total correlation was 0.47. With one exception (weight loss), all items showed significant item-total correlation with the overall severity of depression. Correlations with other self-rating scales were 0.72 and 0.74 and with the Hamilton rating scale 0.34 and 0.37. A factor analysis showed a general factor as the most appropriate solution. Age, sex, and diagnostic subgroups (e.g. endogenous depression) had no significant influence on these results. A score of 18 and higher indicates depressive symptoms severe enough to require further clinical consideration. The BDI is also sensitive to changes in symptomatology over one week or one month, and can be used for pre-post comparisons in psychological and/or pharmacological interventions. Altogether, the German BDI proved to be a useful psychometric instrument for measuring the intensity of depressive symptoms in clinical samples.     

Screening for adolescent depression: comparison of the Kutcher Adolescent Depression Scale with the Beck depression inventory

Self-report instruments commonly used to assess depression in adolescents have limited or unknown reliability and validity in this age group. We describe a new self-report scale, the Kutcher Adolescent Depression Scale (KADS), designed specifically to diagnose and assess the severity of adolescent depression. This report compares the diagnostic validity of the full 16-item instrument, brief versions of it, and the Beck Depression Inventory (BDI) against the criteria for major depressive episode (MDE) from the Mini International Neuropsychiatric Interview (MINI). Some 309 of 1,712 grade 7 to grade 12 students who completed the BDI had scores that exceeded 15. All were invited for further assessment, of whom 161 agreed to assessment by the KADS, the BDI again, and a MINI diagnostic interview for MDE. Receiver operating characteristic (ROC) curve analysis was used to determine which KADS items best identified subjects experiencing an MDE. Further ROC curve analyses established that the overall diagnostic ability of a six-item subscale of the KADS was at least as good as that of the BDI and was better than that of the full-length KADS. Used with a cutoff score of 6, the six-item KADS achieved sensitivity and specificity rates of 92% and 71%, respectively-a combination not achieved by other self-report instruments. The six-item KADS may prove to be an efficient and effective means of ruling out MDE in adolescents.     

Usefulness of Beck Depression Inventory (BDI) in the Korean elderly population

OBJECTIVES: This study aimed to evaluate the diagnostic validity of the Beck Depression Inventory (BDI) in the elderly and to suggest an optimal cut-off score in order to screen major depressive disorder. METHODS: The BDI and an elderly health questionnaire were administered to 2729 subjects over the age of 60 chosen by stratified random sampling in a Ansan City, South Korea. The BDI and geriatric depression scale (GDS) were examined at about a two-year interval. A reliability and validity test, a factor analysis and an ROC curve analysis were performed. RESULTS: Eighty-four subject had depression and 2645 subjects were rated as normal. The BDI showed significant positive internal consistency (r = 0.88) and test-retest reliability (r = 0.60). Convergent validity with GDS was significantly positive (r = 0.59), and an exploratory factor analysis revealed four factors. We suggest a score of 16 as the optimal cut-off point for the BDI when screening for major depression. CONCLUSION: The results of this study showed that the Korean version of the BDI is appropriate for screening for depression and 16 is the optimal cut-off score for the Korean elderly. Screening of elderly depression with BDI in the community would be valuable when comparing with younger adults and with their former BDI data which were taken when they were young.     

Depressive, anxiety, and somatoform disorders in primary care: prevalence and recognition

Recent studies emphasize the negative impact of comorbidity on the course of depression. If undiagnosed, depression and comorbidity contribute to high medical utilization. We aimed to assess (1) prevalences of depression alone and with comorbidity (anxiety/somatoform disorders) in primary care, (2) coexistence of anxiety/somatoform disorders in depressive patients, and (3) diagnostic validity of two screeners regarding depression with versus without comorbidity. We examined 394 primary care outpatients using the Composite International Diagnostic Interview (CIDI), the General Health Questionnaire (GHQ-12), and the Well-Being Index (WHO-5). We conducted configurational frequency analyses to identify nonrandom configurations of the disorders and receiver operating characteristic (ROC)-analyses to assess diagnostic validity of the screeners. Point prevalence of any depressive disorder was 22.8%; with at least one comorbid disorder, 15%; and with two comorbid conditions, 6.1%, which significantly exceeded expected percentage (0.9%, P< or =.0001). Depression without comorbidity occurred significantly less often than expected by chance (P< or =.0007). Comorbidity of depressive and anxiety or somatoform disorders was associated with a high odds ratio (6.25). The screeners were comparable regarding their diagnostic validity for depression with [GHQ-12: area under the curve (AUC)=0.86; WHO-5: AUC=0.88] and without comorbidity (GHQ-12: AUC=0.84; WHO-5: AUC=0.86). It can be concluded that comorbidity between depression and anxiety/somatoform disorders in primary care may occur much more frequently than expected. These results confirm assumptions that the current division between depression and anxiety might be debatable. Validity of screeners tested in our study was not affected by comorbid conditions (e.g., anxiety or somatoform disorders).     

Validation of the Patient Health Questionnaire-9 Korean version in the elderly population: the Ansan Geriatric study

OBJECTIVE: We evaluated the diagnostic validity of the 9-item depression module of the Patient Health Questionnaire-9 (PHQ-9) in elderly Korean patients and suggest an optimal cutoff score to screen for major depressive disorders. METHOD: The PHQ-9 and an elderly health questionnaire were administered to 1060 subjects older than 60 years, chosen using a stratified random sample of the community. The PHQ-9 was measured and compared with the Geriatric Depression Scale, Center for Epidemiological Studies Depression Scale, and Beck Depression Inventory scores. Reliability and validity tests, factor analysis, and receiver operating characteristic curve analysis were performed. RESULTS: The PHQ-9 indicated that 175 subjects had depressive disorders, and 885 subjects were rated as healthy. The PHQ-9 showed significant positive internal consistency (r = 0.88) and test-retest reliability (r = 0.60). The convergent validity with Geriatric Depression Scale and Center for Epidemiological Studies Depression Scale was significantly positive (r = 0.74 and 0.66, respectively). We suggest a score of 5 as the optimal cutoff point when screening for depressive disorders using the PHQ-9. CONCLUSIONS: The Korean version of the PHQ-9 is an appropriate diagnostic tool for depression, and a score of 5 is the optimal cutoff for Korean elderly subjects. Screening for depression in the elderly population using the PHQ-9 would be valuable when medically ill patients show depressive symptoms in a primary health care setting.     

The Geriatric Depression Scale and the Cornell Scale for Depression in Dementia. A validity study

The study is a validation study of two psychogeriatric depression rating scales, The Geriatric Depression Scale (GDS) and the Cornell Scale for Depression in Dementia (CSDD). The sensitivity and specificity, and the convergent and criterion validity of the two scales as well as the inter-rater reliability of the CSDD are reported. Two independent clinicians using the ICD-10 for depression and dementia, the Clinical Global Impression (CGI), the Hamilton Depression rating scale 17-items and the Mini-Mental-State Examination (MMSE), interviewed each patient or control subject. One hundred forty-five persons of 65 years or more of age were included, 73 were depressed only, 36 depressed and demented; 36 persons were control subjects, 11 of these were demented. The inter-rater reliabilities were high or very high equalling perfect correlation. There was very high convergent validity between the screening tools and the severity scales; the shorter versions of the GDS (15-, 10- or four-item version) had lower though still almost perfect correlations. The criterion validity in the total population showed the CSDD as the better scale with sensitivity and specificity of 93% and 97% with a cut-off value of ≥6. The GDS versions had sensitivities and specificities ranging from 82% to 90% and 75% to 94% respectively with cut-off values ≥9, 4, 3 and 1. The CSDD retained its validity and specificity as a screening tool for depression in a population of demented, while the GDS versions all diminished in validity. The GDS and the CSDD are both valid screening tools for depression in the elderly; however, the CSDD alone seems to be equally valid in populations of demented and non-demented.     

Detection of the anxio-depressive disorders in liaison psychiatry. Contribution of the General Health Questionnaire

Among self-report inventories of psychopathology for adults, the General Health Questionnaire (GHQ) is one of the prominent instruments developed for the screening of minor psychiatric morbidity. Four versions of the GHQ were provided from the original 60 items (GHQ-30, 28, 20, 12) and three different scorings have been suggested. A large number of validity studies, mostly favourable, have been performed and are reviewed in this paper. Recent work has suggested that the sensitivity of the GHQ to clinical change was fair, compared to the Present State Examination. The most recent version, the GHQ-28, was built from factor analyses of the 60-item version and covered four dimensions, with seven items each: anxiety and insomnia, severe depression, social impairment, somatic complaints, but their subscores were not independent. Several international extensive studies have confirmed that the GHQ was an interesting tool in Community as well as in General Practice. But, as it falls short from detecting all the chronic cases, research aimed at improving its quality in this direction is still in progress. The use of the French version of the GHQ-28 is expected to be encouraged.     

The factor structure of the General Health Questionnaire in a Japanese high school and university student sample

Factor structures of the 60- and 30-item versions of the General Health Questionnaire (GHQ) were explored, using data collected from 236 Japanese high-school and university students. The 60-item version produced factors interpretable as social functioning, anxiety, somatic symptoms, and severe depression; the 30-item version produced general dysphoria, social functioning, depressive thoughts, difficulty in concentration and insomnia. Although the two versions of the GHQ produced the same number of factors, their structures differed in content. Thus it may be necessary to examine the factor structures of the GHQ when using it in a study of a population containing subjects with different cultural backgrounds.     

Mental health and well-being in a 6-year follow-up of patients with depression

BACKGROUND: Psychiatric patients have the right to strive for well-being and not only be confined to symptom reduction. Studies are needed to assess global well-being during recovery from depression by comparing the assessments of patients and clinicians. METHOD: A 6-year natural follow-up of 185 depressive out-patients was carried out with health questionnaires at baseline, 0.5, 1, 2 and 6 years, including scales on depression (BDI, HDRS), general psychopathology (SCL), functional capacity (GAF, SOFAS) and life satisfaction (LS). A structured diagnostic interview was carried out at baseline, 2 and 6 years. Complete follow-up data were obtained from 121 patients. RESULTS: In general, depressive patients mainly attained a normal mood, adequate functional capacity and life satisfaction. Those with a slow recovery improved with successive treatment contacts, eventually reaching levels of mental health not significantly different from the others. Throughout the follow-up, recovery was similarly shown with the self-reported BDI-21, SCL-90 and LS-4, while intercorrelations between clinician ratings were low at baseline. CONCLUSIONS: Adequate mental health and global well-being can be reached among depressive patients, but it may take time in treatment. Subjective assessments are reliable. The 4-item life satisfaction scale is a global well-being indicator and a valid treatment outcome measure.     

Validity of the 12-item General Health Questionnaire (GHQ-12) in detecting depressive and anxiety disorders among high school students

Despite the common use of the 12-item General Health Questionnaire (GHQ-12) with adolescents, there is limited data supporting its validity with this population. The aims of the study were to investigate the psychometric properties of the GHQ-12 among high school students, to validate the GHQ-12 against the gold standard of a diagnostic interview, and to suggest a threshold score for detecting depressive and anxiety disorders. Six hundred and fifty-four high school students from years 10 to 12 (ages 15-18) completed the GHQ-12 (Likert scored) and the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders-IV-Test Revision (DSM-IV-TR). Receiver operating characteristic (ROC) curves were plotted. The mean GHQ-12 score for the total sample was 9.9 (S.D.=5.4). Results from the ROC curve indicated that the GHQ-12 performed better than chance at identifying depressive and anxiety disorders (area under the curve (AUC)=0.781). A GHQ-12 threshold score of 9/10 for males and 10/11 for females was found to be optimal. Given the significant proportion of mental illness among high school students, there may be a need to introduce screening for mental illnesses as part of the school curriculum. This can assist with the early identification and enable low stigma preventive intervention within the school environment.     

Screening instruments for depression and anxiety following stroke: experience in the Perth community stroke study

Evaluation of the relative efficacy of three screening instruments for depression and anxiety in a group of stroke patients was undertaken as part of the Perth community stroke study. Data are presented on the sensitivity and specificity of the Hospital Anxiety and Depression Scale (HAPS), the Geriatric Depression Scale and the General Health Questionnaire (GHQ) (28-item version) in screening patients 4 months after stroke for depressive and anxiety disorders diagnosed according to DSM-III criteria. The GHQ-28 and GDS but not the HADS depression, were shown to be satisfactory screening instruments for depression, with the GHQ-28 having an overall superiority. The performance of all 3 scales for screening post-stroke anxiety disorders was less satisfactory. The HADS anxiety had the best level of sensitivity, but the specificity and positive predictive values were low and the misclassification rate high.