The Patient Health Questionnaire-4 (PHQ-4) as a Brief Screening Tool for Anxiety and Depression: A Study of Iranian Samples

The diagnosis of depression or anxiety is often difficult to establish in patients with Chronic Obstructive Pulmonary Disease (COPD) as many physical symptoms are shared. There is no consensus on a screening tool for depression and anxiety in patients with COPD. The aim of this systematic review is to review screening tools for depression and anxiety suitable for application among patients with COPD in the clinical setting. A systematic review was made using predefined search terms and eligibility criteria. Of 274 initially screened articles, seven studies were found eligible. Three depression screening tools (BASDEC, BDI-II and HADS-D) had a sensitivity of 100% and a specificity >85%. The best performing anxiety screening tool (GAI) had a sensitivity of 86% and a specificity of 78%. Three screening tools had acceptable psychometric properties according to sensitivity and specificity to detect depression among patients with COPD, but the screening tools for anxiety were of less quality. Further research in and validation of the screening tools is needed to recommend one specific tool.

To evaluate the level of burnout among international limb reconstruction surgeons. Burnout describes chronic workplace stress that has not been successfully managed. Limb reconstruction surgeons may be particularly at risk for burnout. The development of necessary skills and expertise has a steep learning curve and the patients are among the most complex in orthopaedics, with multiple failed surgeries and high complication rates. An internet-based REDCap survey consisted of demographic questions, four open-ended questions, and two valid, reliable measures: (1) Patient Health Questionnaire 4 (PHQ-4)-a screening tool for anxiety and depression, and (2) The Maslach Burnout Inventory-Human Services Survey for Medical Personnel (MBI-HSS-MP) which measures levels of depersonalization, emotional exhaustion, and low personal achievement. The surveys were distributed to international limb reconstruction surgeons. Statistical analysis consisted of descriptive and non-parametric analysis: Chi-square and Kruskal-Wallis tests. There were 103 surgeon responses from at least one country of each of the six populated continents. Eighty-three percent of the respondents were male. The career level distribution was early (1-10 years' experience) = 51%, mid (11-20 years' experience) = 30%, and late (>20 years' experience) = 20%. Twenty-four percent stated they were currently being treated or had been treated in the past for mood or anxiety or both with medication or counselling. Based on the MBI-HSS-MP scores, 38% of limb reconstruction surgeons displayed burnout symptoms, and 16% exhibited severe burnout. The mid-career had the highest levels of overall burnout; there was no statistical significance between the groups. The PHQ-4 scores were within normal limits. In this study sample, 38% displayed burnout symptoms and 16% exhibited severe burnout. The mid-career group had the highest level of burnout. Unmanaged burnout can lead to major depression or suicidal ideation, or both. Support systems for limb reconstruction surgeons need to be developed and maintained. Iobst C, Tulchin-Francis K, Richard HM. The Prevalence of Burnout in Limb Lengthening and Reconstruction Surgeons. Strategies Trauma Limb Reconstr 2024;19(2):67-72.

Individuals with congenital heart disease (CHD) face daily life limitations, increasing the risk of anxiety and depression. Diagnosing these disorders in adults with CHD (ACHD) remains challenging in the clinical routine, because physical symptoms can be misattributed to a patient's physical condition. Several screening instruments are available, and studies revealed that they can be used to diagnose varying numbers of people with clinically relevant symptoms. Therefore, we compared frequently used screening tools for depression and anxiety in ACHD in Germany. Participants were recruited from the German National Register for Congenital Heart Defects. A total of 1486 patients aged 18 to 85 (Mage = 36.84; 60.8% female) were classified as simple, moderate or complex CHD. Self-reported measures of depression [Hospital Anxiety and Depression Scale (HADS-D); Patient Health Questionnaire-9 (PHQ-9)], anxiety [Hospital Anxiety and Depression Scale (HADS-A); Generalized Anxiety Disorder-7 (GAD-7)], psychotherapy utilization, secondary illnesses and sociodemographic characteristics, were recorded. The PHQ-9 recorded about 39% more patients with depressive symptoms compared to the HADS-D. The GAD-7 detected approximately 15% more patients with anxiety symptoms in comparison to the HADS-A. PHQ-9 and GAD-7 demonstrated higher sensitivity (89.6%/86.8%) but lower specificity (48.1%/53.5%) compared to the HADS-D/HADS-A (sensitivity: 56.3%/78.0%; specificity: 87.8%/67.2%). No significant differences were found between the CHD severity levels. The screening tools we compared were used to diagnose a significantly different number of patients with depression or anxiety in ACHD. Because even mild symptoms have a significant impact on quality of life, using PHQ-9 and GAD-7 in clinical practice is recommended to minimize false negatives and ensure mental health in ACHD.

Sexuality and gender invariance of the PHQ-9 and GAD-7: Implications for 16 identity groups

Background: Psychological factors, such as depression and anxiety are among the risk factors in coronary heart disease (CHD). Therefore, we need the necessary interventions in this field to quickly diagnose these disorders. Objectives: The aim of this study was to determine the psychometric properties of Patient Health questionnaires-4 (PHQ-4) as a screening tool for depression and anxiety in CHD patients in Iran. Methods: In this study, 279 CHD patients completed PHQ-4, Patient Health questionnaires-9 (PHQ-9), generalized anxiety disorder-7 (GAD-7) scale, and Beck depression inventory version-II (BDI-II). Semi-structured clinical interviews (SCID) based on DSM-5 were also used to diagnose depression and anxiety. Results: Cronbach’s alpha for PHQ-2, GAD-2, and PHQ-4 were reported to be 0.79, 0.75, and 0.78 respectively. The correlations of the PHQ-4 questionnaire with the BDI-II, GAD-7, GAD-2, PHQ-9, and PHQ-2 were found to be 0.72, 0.63, 0.85, 0.79, and 0.88 respectively. The results of fitting one-factor and two-factor models showed that the two-factor model has a more suitable fit. The optimal cut-off point of PHQ-4 ≥ 7 to measure depression and anxiety concurrently (sensitivity = 0.86, specificity = 0.90, and the area under the curve was 0.93 (CI = 0.90 - 0.96). Conclusions: The PHQ-4 questionnaire is an appropriate tool for diagnosis of and screening for depression and anxiety in the population of CHD patients.

Back to table of contents Previous article Next article Clinical & ResearchFull AccessPHQ-9 Overestimates Depression PrevalenceTerri D'ArrigoTerri D'ArrigoSearch for more papers by this authorPublished Online:4 Jun 2020https://doi.org/10.1176/appi.pn.2020.5b6AbstractFor accurate estimates, use data amassed through diagnostic methods rather than through the Patient Health Questionnaire-9.The Patient Health Questionnaire-9 (PHQ-9) is often used in research to estimate the prevalence of depression in a population. However, a meta-analysis in the Journal of Clinical Epidemiology suggests that using this common screening tool this way can lead to substantial overestimates when compared with diagnostic methods such as the Structured Clinical Interview (SCID) for the Diagnostic and Statistical Manual of Mental Disorders.The PHQ-9 is good for tracking depressive symptoms but is not designed to capture the prevalence of depression.—Brooke Levis, Ph.D.“Disease prevalence estimates have important implications for interpreting medical research, understanding disease burden, and making decisions about health care resource utilization,” wrote Brooke Levis, Ph.D., who conducted the research during her doctoral training at McGill University in Montreal, and colleagues. “Administering diagnostic interviews in large enough samples to estimate prevalence, however, is resource intensive. Thus, researchers sometimes use self-report depression symptom questionnaires or screening tools instead and label the percentage of participants scoring above a screening cutoff as depression prevalence.”The researchers analyzed data from 44 studies that included a total of 9,242 participants. They estimated the percentage of participants who scored at least 10 on the PHQ-9, the percentage of participants who were classified as having major depression based on the SCID, and the differences between the two estimates. The researchers found the prevalence of depression using the PHQ-9 to be 24.6%, compared with 12.1% using the SCID. This means that using PHQ-9 data more than doubles the estimate of depression compared with using SCID data.“We weren’t surprised [by the results] because theoretically, one would expect this. Screening tools are supposed to cast a wide net to find lots of people to examine, not to estimate disorder prevalence,” Levis told Psychiatric News. In other words, the true prevalence may be different from what PHQ-9 estimates suggest because many people who report depressive symptoms on the PHQ-9 do not meet the diagnostic criteria for deression when they are further evaluated with tools such as the SCID.“The message is simple: Researchers who want to estimate depression prevalence should use appropriate methods, not the PHQ-9,” Levis said. “It’s good for other things, such as monitoring depression symptom levels, but not for this.”“Although the finding is not surprising, given that the PHQ is a screening tool, it is good to see this quantified,” said APA Director of Research and Deputy Medical Director Nitin Gogtay, M.D. “Screening tools are to be taken as [such] and not to bypass a thorough clinical interview and the use of semi-structured interviews, which tend to be more thorough.”Some policymakers may interpret the results to mean that fewer people have depression than previously thought and attempt to allocate fewer resources to mental health care. That would be a mistake, said study co-author Brett Thombs, Ph.D., a professor in the Department of Psychiatry at McGill University. “Anybody who cares about mental health knows that many people with mental health conditions [already] can’t access the kind of care they need, when they need it, and the amount they need,” Thombs said. “We don’t need to exaggerate estimates of prevalence to make that clear.”In their conclusion, the researchers noted that although they looked at data from one only depression screening tool, the PHQ-9, they “expect that other [screening] tools would similarly exaggerate depression prevalence.” ■This study was funded by the Canadian Institutes of Health Research. “Patient Health Questionnaire-9 Scores Do Not Accurately Estimate Depression Prevalence: Individual Participant Data Meta-Analysis” is posted here. ISSUES NewArchived

Screening for anxiety and depression in dialysis patients: Comparison of the Hospital Anxiety and Depression Scale and the Beck Depression Inventory

Indigenous peoples’ worldviews are intricately interconnected and interrelated with their communities and the environments in which they live. Their worldviews also manifest in a holistic view of health and well-being, which contrasts with those of the dominant western biomedical model. However, screening depression and/or anxiety in Indigenous peoples often occurs using standard western tools. Understandably, the cultural appropriateness of these tools has been questioned. The purpose of this scoping review was to map the literature that used any type of tool to screen depression or anxiety in Indigenous adults globally. A systematic scoping review method was used to search databases including, but not limited to, CINAHL, PubMed, Scopus and Google. Database-specific search terms associated with Indigenous peoples, depression and anxiety, and screening tools were used to identify literature. In addition, citation searches of related systematic reviews and relevant websites were conducted. The data set was limited to English language publications since database inception. Fifty-four publications met the review's inclusion criteria. Most studies were completed in community settings using standard western depression and anxiety screening tools. Thirty-three different tools were identified, with the Patient Health Questionnaire-9 being the most frequently used. The review's findings are concerning given repeated calls for culturally appropriate screening tools to be used with Indigenous peoples. Although there has been some work to cross-culturally adapt depression screening tools for specific Indigenous populations, clearly more clinicians and researchers need to be aware of, and use, culturally appropriate approaches to screening.

Anxiety and depression are common comorbidities in chronic obstructive pulmonary disease (COPD) patients but are often under-diagnosed. We aimed to assess the suitability of the COPD Assessment Test (CAT) in screening anxiety and depression in patients with COPD. Stable COPD patients from a cross-sectional observational study were assessed by CAT. Anxiety and depression were identified using the Generalized Anxiety Disorder questionnaire (GAD-7) and Patient Health Questionnaire (PHQ-9), respectively. Logistic regression analysis and receiver operating characteristic curve analysis were used to identify factors associated with anxiety or depression and to calculate the predictive values. A total of 530 stable COPD patients were enrolled and of those, the proportions of anxiety and depression were 17.0% and 21.5%, respectively. The adjusted odds ratios of the CAT for the presence of anxiety and depression were 1.094 (95%CI: 1.057–1.131) and 1.143 (95%CI: 1.104–1.183), respectively. The CAT score had a significant predictive value for the presence of anxiety (AUC = 0.709) and depression (AUC = 0.791) with an optimum cutoff score of 15. However, the psychometric properties of CAT were undesirable, presenting high negative predictive value (NPV) but low positive predictive value (PPV). Among CAT items, analysis further showed that non-respiratory CAT components were superior to respiratory components in identifying both anxiety and depression. Our results indicated that CAT is more useful to exclude anxiety and depression rather than detect them.

The purpose of this project was to educate staff on screening tools for anxiety and depression, to consistently use these tools amongst chronic pain patients, and to examine the impact their use has on referrals to mental health. Chronic pain is a wide spread problem and is the leading chronic health care condition in the United States, greater than heart disease, cancer, and diabetes combined (AAPM, 2011). The plan was to implement a practice change to include the consistent use of measurement tools to screen for anxiety and depression and to examine their effect on the number of mental health referrals. Symptom clusters of anxiety and depression are often associated with chronic pain and one pertinent study revealed that out of 250 veterans with chronic pain that 45% screened positive for one or more of the five types of common anxiety disorders and those with anxiety disorders and had significantly higher levels of pain (Pedersen, 2013). One study took place in Michigan through telephone inquiry which determined that 21.9% of participants had chronic pain and 35% of those also had depression, amongst those were younger participants who were more likely to have both depression and chronic pain compared to just having chronic pain alone (Miller & Cano, 2009). The use of reliable tools to screen for anxiety and depression were reviewed and it was determined that when completed correctly the General Anxiety Disorder -7 (GAD-7) is deemed to be highly reliable for screening of anxiety disorders (Spitzer, Kroenke, Williams, & Lowe, 2006). Also deemed reliable for determining the severity of depression is the commonly used patient health questionnaire (PHQ-9) (Kroenke, Spitzer, & Williams, 2001). The concept is that once the standardized use of the screening tools are implemented, referrals to mental health will increase.

Implementation of Depression Screening with the Patient Health Questionnaire-9 (PHQ-9) at a Radiation Oncology Department.

Introduction: Chest pain in patients with non-obstructive coronary artery disease (NO-CAD) is a major clinical problem impacting the quality of life and can present a therapeutic challenge for providers. The objective of this study was to identify clinical factors associated with chest pain frequency in NO-CAD patients. Mainly, we investigated the hypothesis that increased body mass index (BMI) and depression are associated with increased chest pain frequency in NO-CAD patients. Methods: We identified a sample of 439 patients with NO-CAD (mean age 55.3 years, 50% women, 72% white) in the Emory Cardiovascular Biobank, a database of patients who underwent coronary angiography for suspected myocardial ischemia. Sociodemographic variables, clinical risk factors like BMI, and Patient Health Questionnaire 9 (PHQ9) results - a depression screening tool - were collected. We measured chest pain frequency through a questionnaire that asked patients how many times they had chest pain, chest tightness, or angina over the preceding four weeks. Within the sample, 180 patients (41%) reported no chest pain, chest tightness, or angina, and 259 patients (69%) reported one or more instances of chest pain, chest tightness, or angina in the preceding four weeks. We compared these two groups using t-test, Mann-Whitney U test, and multivariate logistic regression analyses. Results: The sample mean BMI was 30.6 ± 6.6 kg/m 2 . The median PHQ9 score was 3.0, with scores ranging from 0 to 27 and 34% having minimal to major depressive symptoms. Compared to those with no chest pain, patients with chest pain had higher BMI (31.5 ± 7.1 vs 29.4 ± 5.6 kg/m 2 , p=0.001) and higher PHQ9 scores (median [interquartile range]: 4 [1,8] vs 1 [0,3], p<0.001). Furthermore, higher BMI and PHQ9 scores were associated with higher odds of chest pain (odds ratio [95% confidence interval]: 1.041 [1.004-1.079] and 1.104 [1.044-1.168], respectively). Conclusions: In patients with NO-CAD, higher BMI and PHQ9 scores were associated with higher chest pain frequency. Thus, weight and depression optimization could reduce symptoms and improve quality of life in NO-CAD patients; however, this needs further study.

Adaptation and initial validation of the Patient Health Questionnaire – 9 (PHQ-9) and the Generalized Anxiety Disorder – 7 Questionnaire (GAD-7) in an Arabic speaking Lebanese psychiatric outpatient sample

BackgroundThe Patient Health Questionnaire—9 (PHQ-9) and the Generalized Anxiety Disorder Questionnaire– 7 (GAD-7) are short screening instruments used for detection of depression and anxiety symptoms in various settings, including general and mental health care as well as the general population. The aim of this study is to evaluate psychometric properties and factorial structure of the PHQ-9 and the GAD-7 in a sample of Lithuanian university students.Methods1368 students (mean age 22.5±4.8) completed the PHQ-9 and the GAD-7 questionnaires online; after the completion of the survey, students were asked to provide phone contact for an additional interview. Eligible students were approached later by trained interviewers and completed The Clinical Interview Schedule-Revised for assessment of depressive and anxiety disorders.ResultsResults showed that the PHQ-9 and the GAD-7 are reliable screening tools for depression and anxiety (Cronbach alpha 0.86 and 0.91, respectively). The one-factor structure of the PHQ-9 and the GAD-7 was confirmed by the Confirmatory Factor Analysis. A cut-off of ≥10 for the PHQ-9 resulted in 71% sensitivity and 66% specificity recognizing students with increased risk for mood or anxiety disorder. For the GAD-7, a cut-off ≥9 resulted in 73% sensitivity and 70% specificity recognizing students at risk. The PHQ-9 was sensitive but not specific in recognizing students with depressive disorders. The sensitivity and specificity of the GAD-7 in differentiating students with generalized anxiety disorders were low.ConclusionsThe PHQ-9 and the GAD-7 have sufficient formal psychometric properties, but their clinical utility as diagnostic tools for recognition of depressive and anxiety disorders in students is limited. Due to low specificity and high false positive rates, both scales are recommended only as an initial screening tool for recognition of subjects with increased risk of mental disorders, however positive cases should be later assessed using more comprehensive instruments.

Background/Objective:The prevalence of anxiety and depression in adults in the United States is high with many experiencing ≥1 episode of anxiety or depression over a given year. Despite this, diagnoses of anxiety and depression in patients presenting to the ED for somatic complaints are seldom, relative to the population prevalence. Current fixed-item anxiety and depression screening tools have variable specificity and sensitivity, but adaptive screening tools such as the Computerized Adaptive Testing-Mental Health tool (CAT-MH) are thought to provide improved diagnostic characteristics and precision over fixed item tools. Our objective is to establish the reliability ofits depression and anxiety severity assessments in patients initially screened in an ED setting and reassessed over 30 days. Methods:We are conducting a longitudinal observational study among adult ED patients presenting with somatic, non-mental health complaints. The CAT-MH, Generalized Anxiety Disorder-7 (GAD-7), and Patient Health Questionnaire-8 (PHQ-8), are administered to randomly selected patients meeting enrollment criteria after informed consent. Participants are reassessed at 1-, 2-, and 4 weeks after ED discharge and analyzed for longitudinal test-retest reliability and sensitivity to change in score severity over time. Results:In this ongoing study, we present baseline anxiety and depression severity assessments for the first 49 enrolled patients (Mean age of 37, 73% female, 49% white, 47% black). Fixed item tools (GAD-7 and PHQ-8) categorized 16% and 6% of patients as moderate and severe anxiety respectively vs 19% and 15% as moderate, and moderately-severe/severe depression. In comparison, CAT-MH categorized 8% and 10% as moderate and severe anxiety.10% and 6% were categorized as moderate and severe depression. Conclusion:In this longitudinal observational study, we present baseline data for the first 49 out of 100 planned patients. Upon completion of the study, we hope to find that the severity assessments from CAT-MH remain stable over 30 days.