Validation of PHQ-2 and PHQ-9 to Screen for Major Depression in the Primary Care Population

PURPOSE Although screening for unipolar depression is controversial, it is potentially an efficient way to find undetected cases and improve diagnostic acumen. Using a reference standard, we aimed to validate the 2- and 9-question Patient Health Questionnaires (PHQ-2 and PHQ-9) in primary care settings. The PHQ-2 comprises the first 2 questions of the PHQ-9.METHODS Consecutive adult patients attending Auckland family practices completed the PHQ-9, after which they completed the Composite International Diagnostic Interview (CIDI) depression reference standard. Sensitivities and specificities for PHQ-2 and PHQ-9 were analyzed.RESULTS There were 2,642 patients who completed both the PHQ-9 and the CIDI. Sensitivity and specificity of the PHQ-2 for diagnosing major depression were 86% and 78%, respectively, with a score of 2 or higher and 61% and 92% with a score 3 or higher; for the PHQ-9, they were 74% and 91%, respectively, with a score of 10 or higher. For the PHQ-2 a score of 2 or higher detected more cases of depression than a score of 3 or higher. For the PHQ-9 a score of 10 or higher detected more cases of major depression than the PHQ determination of major depression originally described by Spitzer et al in 1999.CONCLUSIONS We report the largest validation study of the PHQ-2 and PHQ-9, compared with a reference standard interview, undertaken in an exclusively primary care population. The PHQ-2 score or 2 or higher had good sensitivity but poor specificity in detecting major depression. Using a PHQ-2 threshold score of 2 or higher rather than 3 or higher resulted in more depressed patients being correctly identified. A PHQ-9 score of 10 or higher appears to detect more depressed patients than the originally described PHQ-9 scoring for major depression.     

Routine PHQ-9 depression screening in home health care: depression, prevalence, clinical and treatment characteristics and screening implementation

This study aimed to examine: the prevalence and correlates of depression among adults age 65 and over on admission to diverse home health care programs; nurse compliance with routine screening using the PHQ-9; and concordance between the number of depressed individuals identified by the PHQ-9 and Medicare-mandated nursing assessment following targeted nurse training in identifying depression among the elderly using a standard diagnostic screen. Data are drawn from routine screening of 9,178 patients (a 77% screening compliance rate). Of all patients screened, 782 (8.5%) met criteria for probable major depression and 148 (1.6%) for mild depression. Concordance between nurse identified depression via PHQ-9 and OASIS depression assessment improved over that reported in previous studies. Findings suggest that the use of a routine screening tool for depression can be implemented with minimal in-house training and improves detection of depression among older adults with significant physical and functional impairment.     

中国四城市部分职业人群职业紧张及影响因素分析

目的 探讨应对方式在外来务工人员社会支持与负性情绪间的中介作用。 方法 于2018年7 — 9月,随机抽取广东省深圳市南山区1所企业,并对该企业中所有≥18岁的非深户务工人员777人,采用自制量表、社会支持量表（SRSS）等进行问卷调查。 结果 南山区外来务工人员可能有中度及以上抑郁人数43（5.5 %）;可能有中度及以上焦虑的人数21（2.7 %）ULS-6平均得分为（9.5 ± 3.6）分。结构方程模型结果显示,社会支持对负性情绪水平发挥直接影响（β = – 0.51,P < 0.001）,社会支持对消极应对方式发挥直接影响（β = – 0.11,P = 0.023）,消极应对方式对负性情绪水平发挥直接影响（β = 0.30,P < 0.001）。Bootstrap法验证了消极应对方式在外来务工人员社会支持与负性情绪间有中介效应。 结论 外来务工人员的社会支持水平通过应对方式影响负性情绪。     

Validation of geriatric depression scale in a general outpatient clinic

OBJECTIVE: The Geriatric Depression Scale for screening depressive symptoms in the elderly has not been assessed in elderly outpatients who seek primary health care in Brazil. The objective was to determine the validity of the Short Scale for Major Depressive Episode or Dysthymia (GDS-15) in elderly outpatients. METHODS: The scale was applied in 302 subjects with 65 years and older and then examined by an independent geriatrician, blinded to the results. Major depression and dysthymia were diagnosed using the Diagnostic and Statistical Manual of Mental Disorders-IV criteria. Sensitivity and specificity were calculated at several cutoff values and a Receiver Operating Characteristic curve was plotted. RESULTS: The best equilibrium was at the cutoff value of 5/6 showing 81% sensitivity and 71% specificity; the area under the Receiver Operating Characteristic curve was 0.85 (95% CI: 0.79-0.91). CONCLUSIONS: The GDS-15 can be used for screening depressive symptoms in Brazilian elderly outpatients. The previously suggested cutoff value of 5/6 is adequate.     

Development of a brief diabetes distress screening instrument

PURPOSE Previous research has documented that diabetes distress, defined as patient concerns about disease management, support, emotional burden, and access to care, is an important condition distinct from depression. We wanted to develop a brief diabetes distress screen instrument for use in clinical settings.METHODS We assessed 496 community-based patients with type 2 diabetes on the previously validated, 17-item Diabetes Distress Scale (DDS17) and 6 biobehavioral measures: glycated hemoglobin (HbA_1c); non–high-density-lipoprotein (non-HDL) cholesterol; kilocalories, percentage of calories from fat, and number of fruit and vegetable servings consumed per day; and physical activity as measured by the International Physical Activity Questionnaire.RESULTS An average item score of ≥3 (moderate distress) discriminated high- from low-distressed subgroups. The 4 DDS17 items with the highest correlations with the DDS17 total (r = .56–.61) were selected. Composites, comprised of 2, 3, and 4 of these items (DDS2, DDS3, DDS4), yielded higher correlations (r=.69–.71). The sensitivity and specificity of the composites were .95 and .85, .93 and .87, and .97 and .86, respectively. The DDS3 had a lower sensitivity and higher percentages of false-negative and false-positive results. All 3 composites significantly discriminated subgroups on HbA_1c, non-HDL cholesterol, and kilocalories consumed per day; none discriminated subgroups on fruit and vegetable servings consumed per day; and only the DDS3 yielded significant results on the International Physical Activity Questionnaire. Because of its psychometric properties and brevity, the DDS2 was selected as a screening instrument.CONCLUSIONS The DDS2 is a 2-item diabetes distress screening instrument asking respondents to rate on a 6-point scale the degree to which the following items caused distress: (1) feeling overwhelmed by the demands of living with diabetes, and (2) feeling that I am often failing with my diabetes regimen. The DDS17 can be administered to those who have positive findings on the DDS2 to define the content of distress and to direct intervention.     

The potential of telehealth for 'business as usual' in outpatient clinics

A six-month pilot study was conducted to ascertain the value of using high-definition videoconferencing equipment in an outpatients' setting. The videoconferencing equipment, which included digital biometric equipment, was installed in the outpatient clinics of a remote health service in New Zealand. Use of the equipment was evaluated using action research techniques. Clinicians were interviewed about their assessment of the equipment's usefulness. Patients and their carers completed questionnaires about their clinic experience. During the pilot trial, 109 patients were seen in 25 clinics of six different specialities. Questionnaire results showed that patients and their companions had a good user experience, similar to a face-to-face appointment. Clinicians found that the large screen, sense of proximity, video clarity and definition, and lack of sound/picture lag worked well for certain types of outpatients' clinics, e.g. methadone maintenance clinics. The need for process changes made it difficult to turn telehealth into business as usual in an environment built for face-to-face appointments. We conclude that videoconference equipment has potential to become integral to outpatients' clinics.     

Assessing validity of a depression screening instrument in the absence of a gold standard

PurposeWe evaluated the extent to which use of a hypothesized imperfect gold standard, the Composite International Diagnostic Interview (CIDI), biases the estimates of diagnostic accuracy of the Patient Health Questionnaire-9 (PHQ-9). We also evaluate how statistical correction can be used to address this bias.MethodsThe study was conducted among 926 adults where structured interviews were conducted to collect information about participants' current major depressive disorder using PHQ-9 and CIDI instruments. First, we evaluated the relative psychometric properties of PHQ-9 using CIDI as a gold standard. Next, we used a Bayesian latent class model to correct for the bias.ResultsIn comparison with CIDI, the relative sensitivity and specificity of the PHQ-9 for detecting major depressive disorder at a cut point of 10 or more were 53.1% (95% confidence interval: 45.4%–60.8%) and 77.5% (95% confidence interval, 74.5%–80.5%), respectively. Using a Bayesian latent class model to correct for the bias arising from the use of an imperfect gold standard increased the sensitivity and specificity of PHQ-9 to 79.8% (95% Bayesian credible interval, 64.9%–90.8%) and 79.1% (95% Bayesian credible interval, 74.7%–83.7%), respectively.ConclusionsOur results provided evidence that assessing diagnostic validity of mental health screening instrument, where application of a gold standard might not be available, can be accomplished by using appropriate statistical methods.     

Prevalence of appropriate colorectal cancer screening and preferences for receiving screening advice among people attending outpatient clinics

Objective: To examine among people attending outpatient clinics aged 50–74 at average risk of colorectal cancer (CRC): 1) The proportion who report: a) faecal occult blood test (FOBT) within the past two years; and b) colonoscopy within the past five years, including the reasons for undergoing colonoscopy; 2) characteristics associated with under‐screening; 3) For those who are under‐screened, the proportion who are: a) willing to receive help and the acceptability of different methods of receiving help, and; b) unwilling to receive help and reasons for this. Methods: Cross‐sectional survey of 197 participants attending a major regional hospital in New South Wales, Australia. Multivariable logistic regression was used to determine correlates of under‐screening. Results: A total of 59% reported either FOBT in the past two years or colonoscopy in the past five years. Of those reporting colonoscopy in the past five years, 21% were potentially over‐screened. Males were more likely than females to be under‐screened. Of those under‐screened (41%), fewer than half were willing to receive screening advice. Conclusions and implications for public health: A significant proportion of people attending outpatient clinics are under‐screened for CRC, with some people also over‐screened. There is a need to explore strategies to overcome both under‐ and over‐screening.     

Self-report as a selection instrument in screening for cardiovascular disease risk

INTRODUCTION: Cardiovascular disease (CVD) risk screening may rely partly on self-report information. The accuracy of self-reporting in relation to the actual risk factor status is insufficiently known. DESIGN: Self-report (yes, no, don't know) of presence of hypertension, hyperlipidemia, and overweight was compared to the corresponding risk factor data obtained by physical examination and blood analysis. The examinations carried out in a primary health care setting in Sweden were on a randomized population of 122 men and 127 women aged 20 to 60 years. RESULTS: Unawareness of hyperlipidemia was 71% in women and 56% in men, as compared to 29% or lower for the other risk factors. The sensitivity of self-report was 69% or higher for the other risk factors, with the exception of hypertension in women, where it was 29%. Specificity was generally high, except for hyperlipidemia. CONCLUSION: On a population level, self-reports of hypertension, hyperlipidemia, and overweight provide a feasible selection instrument by which a subpopulation with high risk factor frequency can be identified. However, the rate of misclassification is considerable. For hyperlipidemia, the benefit of self-reporting is presently limited, due to the high unawareness of this risk factor. Individual awareness and accurate knowledge about the presence or absence of risk factors needs to improve before self-reporting can be used as a reliable instrument in risk factor screening.     

Use of outpatient clinics as a health indicator for communities around a coal-fired power plant.

The permit to operate the first coal fired power plant in Israel was issued with the condition that a comprehensive network to monitor its effects on the environment, health, and agriculture must be installed and operated around the plant. The health monitoring system consists of four studies, which started 1 year prior to the operation of the plant and were carried out for 10 years. In the framework of the health monitoring system, a study of requests for health services was carried out. In this survey, 8 clinics of the Sick Fund, served by 16 physicians, were followed up. The clinics were located as near as possible to air pollution monitoring stations and represent expected different levels of pollution. A health recorder summarized each day's visits to each physician and tabulated the total visits for each day and the visits due to respiratory tract complaints. Multivariate stepwise regressions on total as well as on respiratory complaints were carried out. The independent variables in the regressions were sulfur dioxide, meteorological parameters (such as temperature and humidity), and flu epidemics. Temperature was almost always significantly correlated with respiratory complaints, but less correlated with total visits among, adults and children. Sulfur dioxide, most meterological parameters and flu epidemics were not meaningful explanatory factor in the regressions. Ambient air pollution levels did not exceed the Israeli air quality or the more stringent local air quality standards, the monthly and annual average sulfur dioxide and nitrogen oxides values were very low.     

Migrating from a legacy fixed-format measure to CAT administration: calibrating the PHQ-9 to the PROMIS depression measures

Purpose

We provide detailed instructions for analyzing patient-reported outcome (PRO) data collected with an existing (legacy) instrument so that scores can be calibrated to the PRO Measurement Information System (PROMIS) metric. This calibration facilitates migration to computerized adaptive test (CAT) PROMIS data collection, while facilitating research using historical legacy data alongside new PROMIS data.

Methods

A cross-sectional convenience sample (n = 2,178) from the Universities of Washington and Alabama at Birmingham HIV clinics completed the PROMIS short form and Patient Health Questionnaire (PHQ-9) depression symptom measures between August 2008 and December 2009. We calibrated the tests using item response theory. We compared measurement precision of the PHQ-9, the PROMIS short form, and simulated PROMIS CAT.

Results

Dimensionality analyses confirmed the PHQ-9 could be calibrated to the PROMIS metric. We provide code used to score the PHQ-9 on the PROMIS metric. The mean standard errors of measurement were 0.49 for the PHQ-9, 0.35 for the PROMIS short form, and 0.37, 0.28, and 0.27 for 3-, 8-, and 9-item-simulated CATs.

Conclusions

The strategy described here facilitated migration from a fixed-format legacy scale to PROMIS CAT administration and may be useful in other settings.

     

Validation of the PHQ-15 for Somatoform Disorder in the Occupational Health Care Setting

Introduction Within the occupational health setting, somatoform disorders are a frequent cause of sick leave. Few validated screening questionnaires for these disorders are available. The aim of this study is to validate the PHQ-15 in this setting. Methods In a cross-sectional study of 236 sicklisted employees, we studied the performance of the PHQ-15 in comparison with the Mini International Neuropsychiatric Interview (MINI) as golden reference standard. We approached employees who were sick listed for a period longer than 6 weeks and shorter than 2 years for participation. This study was conducted on one location of a large occupation health service in the Netherlands, serving companies with more than 500 employees. All employees who returned the PHQ-15 were invited for the MINI interview. Specificity and sensitivity were calculated for optimal cut point and a receiver operating characteristic (ROC) was constructed. Results A total of 107 participants consented to participate in the MINI interview. A non-response analysis showed no significant differences between groups. According to the MINI, the prevalence of somatoform disorders was 21.5%, and the most frequent found disorder was a pain disorder. The PHQ-15 had an optimal cut point of 9 (patients scoring 9 or higher (≥9) were most likely to suffer from a somatoform disorder), with specificity and sensitivity equal to 61.9 and 56.5%, respectively. ROCs showed an area under the curve (AUC) of 0.63. Conclusion The PHQ-15 shows moderate sensitivity but limited efficiency with a cut point of 9 and can be a useful questionnaire in the occupational health setting.     

Perceptions of influenza and influenza vaccination in patients attending hospital outpatient clinics

Influenza remains a major cause of morbidity and disruption to health services during winter. Annual vaccination of risk groups is the mainstay of influenza management policy. Despite much national publicity, vaccine uptake remains below desired levels. We investigated the perceptions of influenzal illness and opinions on vaccination in hospital outpatients attending clinics associated with risk and non-risk (i.e. control) morbidities. There were 270 recruited patients in risk groups: 90 each from diabetic, respiratory and cardiac clinics and equal numbers in three age groups (40-49, 50-59, 60-69 years). Equal numbers of controls were recruited from colorectal, fracture and dermatology clinics. The perceptions of influenza and knowledge of the preventive value of vaccination were fairly accurate in both groups. Fewer people in both groups had been vaccinated than had been specifically advised to be vaccinated. Advice for vaccination had been received by fewer people attending the cardiac clinic than the other two risk associated clinics. More use could be made of the health education opportunity afforded by attendance at hospital outpatient clinics.     

Summed score of the Patient Health Questionnaire-9 was a reliable and valid method for depression screening in chronically ill elderly patients

OBJECTIVE: To assess the psychometric properties of the Patient Health Questionnaire-9 (PHQ-9) as a screening instrument for depression in elderly patients with diabetes mellitus (DM) and chronic obstructive pulmonary disease (COPD) without known depression. STUDY DESIGN AND SETTING: DM and COPD patients aged >59 years were selected from general practices. A test-retest was conducted in 105 patients. Criterion validity, using the Mini International Neuropsychiatric Interview psychiatric interview to diagnose major depressive disorder (MDD) and any depressive disorder (ADD) as diagnostic standard, was evaluated for both summed and algorithm-based PHQ-9 score in 713 patients. Correlations with quality of life and severity of illness were calculated to assess construct validity. RESULTS: Cohen's kappa for the algorithm-based score was 0.71 for MDD and 0.69 for ADD. Correlation for test-retest assessment of the summed score was 0.91. The algorithm-based score had low sensitivity and high specificity, but both sensitivity and specificity were high for the optimal cut-off point of 6 on the summed score for ADD (Se 95.6%, Sp 81.0%). Correlations between summed score and quality of life and severity of illness were acceptable. CONCLUSION: The summed PHQ-9 score seems a valid and reliable screening instrument for depression in elderly primary care patients with DM and COPD.