Abstract
Background: Persistent somatic symptoms are associated with psychological distress, impaired function, and medical help-seeking behavior. The Patient Health Questionnaire (PHQ)-15 is used as a screening instrument for somatization and as a monitoring instrument for somatic symptom severity. A bifactorial model has been described, with one general factor and four orthogonal specific symptom factors. The objective of the present study was to assess and to clarify the factor structure of the PHQ-15 within and between different countries in Western Europe and China.Method: Cross-sectional secondary data analysis performed in three patient data samples from two Western European countries (Germany N = 2,517, the Netherlands N = 456) and from China (N = 1,329). Confirmatory factor analyses (CFA), and structural equation modeling (SEM) analysis were performed.Results: The general factor is found in every sample. However, although the outcomes of the PHQ-15 estimate severity of somatic symptoms in different facets, these subscales may have different meanings in the European and Chinese setting. Replication of the factorial structure was possible in the German and Dutch datasets but not in the dataset from China. For the Chinese dataset, a bifactorial model with a different structure for the cardiopulmonary factor is suggested. The PHQ-15 could discern somatization from anxiety and depression within the three samples.Conclusion: The PHQ-15 is a valid questionnaire that can discern somatization from anxiety and depression within different cultures like Europe or China. It can be fitted to a bifactorial model for categorical data, however, the model can only be recommended for use of the general factor. Application of the orthogonal subscales in non-European samples is not corroborated by the results. The differences cannot be ascribed to differences in health care settings or by differences in concomitant depression or anxiety but instead, a cultural factor involving concepts of disease may play a role in this as they may play a role in the translation of the questionnaire. Further research is needed to explore this, and replication studies are needed regarding the factorial structure of the PHQ-15 in China.
Highlights
Persistent somatic symptoms are associated with psychological distress, impaired function, and medical help-seeking behavior
Germany and the Netherlands but the participants from China are significantly older, with a range of up to over 90 years, and have significantly more male participants. This may have to do with the fact that for both Germany and the Netherlands, but not in China, separate health services exist for patients older than 70 years
The findings of this study suggest that the different factorial structure of the Patient Health Questionnaire (PHQ)-15 in China is not to be explained by differences in concomitant depression or anxiety
Summary
Persistent somatic symptoms are associated with psychological distress, impaired function, and medical help-seeking behavior. Patients with multiple distressing somatic symptoms present themselves in a variety of health care settings, such as primary, secondary and tertiary patientcenters [3,4,5,6]. Poor self-rated health of patients was found to be associated with multiple somatic symptoms in Europe and in China [7,8,9,10]. The number of somatic symptoms correlates well with impaired function and medical help-seeking behavior even after controlling for mental disorders [5]. In Western countries, a high number of somatic symptoms is associated with higher psychological distress, more functional impairment, higher disability, more health care utilization and a reduced quality of life [13,14,15]. Given the large burden of somatic symptoms, especially unexplained symptoms that are currently not taken sufficiently seriously, the assessment of somatic symptoms and the analysis of the different facets of somatic symptoms is a useful and necessary part of every medical diagnostic process
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