Ultra-brief Measure Research Articles

An Initial Comparison of the Psychometric Properties of the Dark Triad Dirty Dozen in Spanish and Portuguese

Abstract. We tested the psychometric properties of the Dark Triad Dirty Dozen measure of psychopathy, narcissism, and Machiavellianism in Portugal ( n = 1,034) and Spain ( n = 386). Adult ( M = 43.40, SD = 14.81, range = 18–88) participants (1,113 women) completed the Dirty Dozen measure of each trait along with ultrabrief measures of extraversion, openness, neuroticism, agreeableness, conscientiousness, and religiousness and a lengthier measure of individual differences in depression, anxiety, and stress. Using confirmatory factor analysis and multigroup confirmatory factor analysis, we found evidence for measurement invariance for a 3-factor model of the Dirty Dozen in the sexes and countries. The Dark Triad traits and disagreeableness were present across the traits and countries. Across depression, anxiety, and stress, correlations with the Dark Triad traits were stronger in men than women. Our results suggest that the scale translations – in each country – are trustworthy paving the way for inter-Iberian and international collaborations.

The emoji current mood and experience scale: the development and initial validation of an ultra-brief, literacy independent measure of psychological health

Background There is increasing interest in measuring wellbeing and mental health in a range of settings and services outside conventional mental health care settings. However, ensuring that measurement does not intrude on the primary service activity whilst promoting inclusion through minimizing literacy demands, requires ultra-brief and easy to use tools. Aims To develop and test a brief emoji-based tool to assess mental health, wellbeing, resilience and community connection. Method In study 1, 672 adults completed an online questionnaire study comprising a new emoji measure and established questionnaires assessing mental health, resilience, community connection and wellbeing. In study 2, 415 participants completed a paper-and-pencil version of the emoji measure, mental health and community connection, with 212 individuals providing data at a second time point. Results Multidimensional scaling revealed a meaningful structure to the emoji measure with validity demonstrated through relationships to existing scales. Stability over time and sensitivity to change were also demonstrated. Conclusions The emoji-based measure presented here provides an ultra-brief measure of mood and current experience, with minimal literacy demands on participants. Further research is now needed to test the properties and utility of the scale with other participant groups.

Psychosocial factors and mental health in Mexican healthcare workers during the COVID-19 pandemic

Introduction. The World Health Organization has estimated a significant increase in mental disorders due to the COVID-19 pandemic and has identified healthcare workers as a vulnerable group. In Mexico, the impact of this pandemic on the mental health of healthcare workers and the psychosocial factors associated with it remain unknown. Objective. To identify levels of stress, burnout, anxiety, and depression and their relationship with negative psychosocial stressors and positive psychosocial resources in healthcare workers in Mexico during the COVID-19 pandemic. Method. As a part of a larger project in certain Latin American countries, 269 health workers from various Mexican clinics and hospital centers initially participated in a non-experimental, cross-sectional correlational design. Participants were recruited by targeted sampling. Various ultra-brief measures were used to measure symptoms of depression, anxiety, burnout, and stress and a mixed-methods exploration technique was used to identify associated psychosocial factors, which were also explored with cluster analysis. Results. We found high levels of depressive and anxiety symptoms (56.9% and 74.7%), as well as burnout and stress (49.8% and 46.8%). Although the stressors “infection of self” and “family infection” (38.3% and 30.9%) and the resources “family” and “personal protective equipment” (34.6% and 24.5%) were the most frequent, there were more than 20 factors in each category differentially associated with mental health. Cluster analysis made it possible to identify representative sets of psychosocial variables. Discussion and conclusion. The increased risk in mental health for health care workers is confirmed in a preliminary way and the stressors and resources to be considered in preventive strategies to address COVID-19 pandemic in Mexico are identified.

Psychosocial factors and mental health in Mexican healthcare workers during the COVID-19 pandemic

Introduction. The World Health Organization has estimated a significant increase in mental disorders due to the COVID-19 pandemic and has identified healthcare workers as a vulnerable group. In Mexico, the impact of this pandemic on the mental health of healthcare workers and the psychosocial factors associated with it remain unknown. Objective. To identify levels of stress, burnout, anxiety, and depression and their relationship with negative psychosocial stressors and positive psychosocial resources in healthcare workers in Mexico during the COVID-19 pandemic. Method. As a part of a larger project in certain Latin American countries, 269 health workers from various Mexican clinics and hospital centers initially participated in a non-experimental, cross-sectional correlational design. Participants were recruited by targeted sampling. Various ultra-brief measures were used to measure symptoms of depression, anxiety, burnout, and stress and a mixed-methods exploration technique was used to identify associated psychosocial factors, which were also explored with cluster analysis. Results. We found high levels of depressive and anxiety symptoms (56.9% and 74.7%), as well as burnout and stress (49.8% and 46.8%). Although the stressors “infection of self” and “family infection” (38.3% and 30.9%) and the resources “family” and “personal protective equipment” (34.6% and 24.5%) were the most frequent, there were more than 20 factors in each category differentially associated with mental health. Cluster analysis made it possible to identify representative sets of psychosocial variables. Discussion and conclusion. The increased risk in mental health for health care workers is confirmed in a preliminary way and the stressors and resources to be considered in preventive strategies to address COVID-19 pandemic in Mexico are identified.

The Psychometric Properties of the Patient Health Questionnaire-4 for Pregnant Women.

Background: Perinatal anxiety and depression are common complications during pregnancy. The purpose of this study was to examine the item characteristics, reliability, validity, and factorial structure of the four-item Patient Health Questionnaire-4 (PHQ-4) and to determine the associations between scale scores and sociodemographic factors in a sample of pregnant women from Spain. Method: A total of 845 pregnant women were recruited from two public hospitals in Spain between 2014 and 2016. Participants completed a self-report questionnaire that included Patient Health Questionnaire-4, including the two-item Patient Health Questionnaire and the two-item Generalized Anxiety Disorder Screener. Results: Exploratory and confirmatory factor analysis and scale inter-correlations between the PHQ-4 and PHQ-9 revealed that the PHQ-4 has a bivariate structure and adequately assesses the dimensions of antenatal anxiety and depression. Conclusion: The PHQ-4 is a reliable and valid instrument to screen for depression and anxiety during pregnancy. The PHQ-4 is an ultra-brief measure that can be used to screen for antenatal depression and anxiety to prevent the negative consequences associated with these mental health conditions among mothers and infants.

Psychometric properties of the Session Rating Scale 3.0 in a Spanish clinical sample

ABSTRACT The Session Rating Scale 3.0 (SRS 3.0) is an ultra-brief measure of the therapeutic alliance, frequently used to provide feedback to the clinician during the therapeutic process (Prescott et al. [2017]. Feedback-informed treatment in clinical practice. Reaching for excellence. American Psychological Association (APA). http://www.apa.org/pubs/books/4317449.aspx). This study describes the psychometric properties of the SRS 3.0 in a Spanish clinical sample of 165 adult psychotherapy patients from different primary care centres of Barcelona (Spain). Results show the measure has good reliability and good convergent and predictive validity. The results are consistent with the findings from studies done in other countries. In summary, the instrument appears to be a valid and reliable tool for monitoring therapeutic alliance during the course of psychotherapy with Spanish-speaking patients. Additional research with the SRS 3.0 in Spanish could provide more evidence of its psychometric properties.

Ebola vaccine? Family first! Evidence from using a brief measure on Ebola vaccine demand in a national household survey during the outbreak in Sierra Leone

BackgroundVaccination against Ebolavirus is an emerging public health tool during Ebola Virus Disease outbreaks. We examined demand issues related to deployment of Ebolavirus vaccine during the 2014–2015 outbreak in Sierra Leone. MethodsA cluster survey was administered to a population-based sample in December 2014 (N = 3540), before any Ebola vaccine was available to the general public in Sierra Leone. Ebola vaccine demand was captured in this survey by three Likert-scale items that were used to develop a composite score and dichotomized into a binary outcome to define high demand. A multilevel logistic regression model was fitted to assess the associations between perceptions of who should be first to receive an Ebola vaccine and the expression of high demand for an Ebola vaccine. ResultsThe largest proportion of respondents reported that health workers (35.1%) or their own families (29.5%) should receive the vaccine first if it became available, rather than politicians (13.8%), vaccination teams (9.8%), or people in high risk areas (8.2%). High demand for an Ebola vaccine was expressed by 74.2% of respondents nationally. The odds of expressing high demand were 13 times greater among those who said they or their families should be the first to take the vaccine compared to those who said politicians should be the first recipients (adjusted odds ratio [aOR] 13.0 [95% confidence interval [CI] 7.8–21.6]). The ultra-brief measure of the Ebola vaccine demand demonstrated acceptable scale reliability (Cronbach’s α = 0.79) and construct validity (single-factor loadings > 0.50). ConclusionPerceptions of who should be the first to get the vaccine was associated with high demand for Ebola vaccine around the peak of the outbreak in Sierra Leone. Using an ultra-brief measure of Ebola vaccine demand is a feasible solution in outbreak settings and can help inform development of future rapid assessment tools.

Revalidation of Adjustment Disorder-New Module-4 screening of adjustment disorder in a non-clinical sample: Psychometric reevaluation and correlates with other ICD-11 mental disorders.

In line with the new conceptualization of adjustment disorder (AjD) in the 11th revision of the International Classification of Diseases (ICD-11), a new 20-item self-report questionnaire was developed and validated - the Adjustment Disorder-New Module (ADNM). However, such a long research tool has the potential to become problematic for use in epidemiological and clinical settings. Therefore, an ultra-brief measure for AjD (ADNM-4) was established and validated in a recent study conducted with a representative national sample. The aim of the present study was to revalidate the ultra-brief ADNM-4 Scale, as well as to reestablish cutoff scores for clinical use. An online survey was conducted with a convenience sample of 484 Israelis aged 18-65 years, who were recruited via social media. Participants filled out self-report questionnaires dealing with diagnostic criteria of stress-related disorders, that is, AjD (the original and ultra-brief modules), prolonged grief disorder, depression, anxiety, and hypochondriasis. Construct, discriminant, and convergent validity were assessed via confirmatory factor analysis and correlation coefficients, while cutoff scores were established through receiver-operating characteristic analysis. The findings confirmed the ultra-brief module's validity. The high fit indices indicated construct validity, and the correlations with the various stress-related disorders indicated good convergent and discriminant validity. Cutoff scores resembled earlier cutoff scores calculated with a representative national sample, indicating a consistent and accurate diagnostic ability. These findings provide additional evidence for the psychometric characteristics of the ADNM-4, which seems to be a suitable brief screening tool for assessing AjD symptoms according to the ICD-11 definition. Therefore, the ADNM-4 is recommended in cases where prompt screening is required, as well as for research purposes.

A Preliminary Validation Study of Two Ultra-Brief Measures of Suicide Risk: The Suicide and Perceived Burdensomeness Visual Analog Scales.

The advent of rapid-acting suicide-focused interventions and longitudinal research designs employing high-frequency, repeated measurement of suicide risk has resulted in a need to quantify suicide risk during very brief windows of time (e.g., minutes, hours, days). This has rapidly outpaced traditional methods for assessing suicide risk, which often focus on measuring indicators of suicide risk during much broader intervals of time (e.g., weeks to months). Valid and practical methods for rapidly assessing suicide risk during small time intervals are therefore needed. This study reports a preliminary examination of the Suicide Visual Analog Scale (S-VAS) and the Perceived Burdensomeness Visual Analog Scale (PB-VAS) in a clinical sample of suicidal adults. Results support the convergent validity, predictive validity, responsiveness, and clinical utility of both scales, suggesting the S-VAS and PB-VAS are valid methods for rapidly quantifying two dimensions of suicide risk.

Psychometric Properties of the Outcome Rating Scale (ORS) in a Spanish Clinical Sample.

The Outcome Rating Scale (ORS) is an ultra-brief measure of well-being designed to track outcome in psychotherapy. This research studied the psychometric properties of the ORS in a Spanish clinical sample. One-hundred and sixty-five adult participants from different primary care centers of the city of Barcelona were recruited. The psychometric properties of the ORS in the sample were explored and described, comparing them to the properties of other instruments already validated in Spain. Our results showed good reliability (α = .91 [.88, .93]; α = .96; test re-test correlations from .61 to .84), good validity (convergent validity correlations with distress and symptoms measures from -.32 to -.76), and good sensitivity to change (pre-post comparison through Wilcoxon signed-rank test, Mdnpre = 31.0, Mdnpost = 19.6, z = -7.38, p < .05, r = .42). These results are consistent with previous findings in other countries. We conclude suggesting that the instrument can be applied to monitor outcome in psychotherapy and to test the effectiveness of treatments imparted with Spanish speaking clients. However, further research with the ORS in Spanish could provide more evidence of its psychometric properties.

Brief report: How short is too short? An ultra-brief measure of the big-five personality domains implicates "agreeableness" as a risk for all-cause mortality.

Controversy exists over the use of brief Big Five scales in health studies. We investigated links between an ultra-brief measure, the Big Five Inventory-10, and mortality in the General Social Survey. The Agreeableness scale was associated with elevated mortality risk (hazard ratio = 1.26, p = .017). This effect was attributable to the reversed-scored item “Tends to find fault with others,” so that greater fault-finding predicted lower mortality risk. The Conscientiousness scale approached meta-analytic estimates, which were not precise enough for significance. Those seeking Big Five measurement in health studies should be aware that the Big Five Inventory-10 may yield unusual results.

Psychometric analysis of the Generalized Anxiety Disorder scale (GAD-7) in primary care using modern item response theory.

ObjectiveThe Generalized Anxiety Disorder scale (GAD-7) is one of the most frequently used diagnostic self-report scales for screening, diagnosis and severity assessment of anxiety disorder. Its psychometric properties from the view of the Item Response Theory paradigm have rarely been investigated. We aimed to close this gap by analyzing the GAD-7 within a large sample of primary care patients with respect to its psychometric properties and its implications for scoring using Item Response Theory.MethodsRobust, nonparametric statistics were used to check unidimensionality of the GAD-7. A graded response model was fitted using a Bayesian approach. The model fit was evaluated using posterior predictive p-values, item information functions were derived and optimal predictions of anxiety were calculated.ResultsThe sample included N = 3404 primary care patients (60% female; mean age, 52,2; standard deviation 19.2) The analysis indicated no deviations of the GAD-7 scale from unidimensionality and a decent fit of a graded response model. The commonly suggested ultra-brief measure consisting of the first two items, the GAD-2, was supported by item information analysis. The first four items discriminated better than the last three items with respect to latent anxiety.ConclusionThe information provided by the first four items should be weighted more heavily. Moreover, estimates corresponding to low to moderate levels of anxiety show greater variability. The psychometric validity of the GAD-2 was supported by our analysis.

Preliminary validation of the Rating of Outcome Scale and equivalence of ultra-brief measures of well-being.

Three brief psychotherapy outcome measures were assessed for equivalence. The Rating of Outcome Scale (ROS), a 3-item patient-reported outcome measure, was evaluated for interitem consistency, test-retest reliability, discriminant validity, repeatability, sensitivity to change, and agreement with the Outcome Rating Scale (ORS) and Outcome Questionnaire (OQ) in 1 clinical sample and 3 community samples. Clinical cutoffs, reliable change indices, and Bland-Altman repeatability coefficients were calculated. Week-to-week change on each instrument was compared via repeated-measures-corrected effect size. Community-normed T scores and Bland-Altman plots were generated to aid comparisons between instruments. The ROS showed good psychometric properties, sensitivity to change in treatment, and discrimination between outpatients and nonpatients. Agreement between the ROS and ORS was good, but neither the agreement between these nor that between ultrabrief instruments and the OQ were as good as correlations might suggest. The ROS showed incremental advantages over the ORS: improvements in concordance with the OQ, better absolute reliability, and less oversensitivity to change. The ROS had high patient acceptance and usability, and scores showed good reliability, cross-instrument validity, and responsiveness to change for the routine monitoring of clinical outcomes. (PsycINFO Database Record

The Development and Validation of Brief and Ultrabrief Measures of Values

ABSTRACTValues are a central personality construct and the importance of studying them has been well established. To encourage researchers to integrate measures of values into their studies, brief and ultrabrief instruments were developed to recapture the 10 values measured by the 40-item Portrait Values Questionnaire (PVQ; Schwartz, 2003). Rigorous psychometric procedures based on separate derivation (N = 38,049) and evaluation (N = 29,143) samples yielded 10- and 20-item measures of values, which proved to be successful at capturing the patterns and magnitude of correlations associated with the original PVQ. These instruments should be useful to researchers who would like to incorporate a values scale into their study but do not have the space to administer a longer measure.

Detecting Delirium Superimposed on Dementia: Evaluation of the Diagnostic Performance of the Richmond Agitation and Sedation Scale

ObjectivesDelirium disproportionately affects patients with dementia and is associated with adverse outcomes. The diagnosis of delirium superimposed on dementia (DSD), however, can be challenging due to several factors, including the absence of caregivers or the severity of preexisting cognitive impairment. Altered level of consciousness has been advocated as a possible useful indicator of delirium in this population. Here we evaluated the performance of the Richmond Agitation and Sedation Scale (RASS) and the modified-RASS (m-RASS), an ultra-brief measure of the level of consciousness, in the diagnosis of DSD. DesignMulticenter prospective observational study. RASS and m-RASS results were analyzed together, labeled RASS/m-RASS. SettingAcute geriatric wards, in-hospital rehabilitation, emergency department. ParticipantsPatients 65 years and older with dementia. MeasurementsDelirium was diagnosed with the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) or with the Delirium Rating Scale-Revised (DRS-R-98), or with the 4 A's Test (4AT). Dementia was detected with the Clinical Dementia Rating (CDR) Scale, the Short Form–Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) or via the clinical records. ResultsOf the 645 patients included, 376 (58%) had delirium. According to the instrument used to evaluate delirium, the prevalence was 66% with the 4AT, 23% with the DSM, and 100% with the DRS-R-98. Overall a RASS/m-RASS score other than 0 was 70.5% sensitive (95% confidence interval [CI] 65.9%–75.1%) and 84.8% (CI 80.5%–89.1%) specific for DSD. Using a RASS/m-RASS value greater than +1 or less than −1 as a cutoff, the sensitivity was 30.6% (CI 25.9%–35.2%) and the specificity was 95.5% (CI 93.1%–98.0%). The sensitivity and the specificity did not greatly vary according to the method of delirium diagnosis and the dementia ascertainment, although the specificity was slightly higher when the DSM and the IQCODE were used. ConclusionIn older patients admitted to different clinical settings, the RASS and m-RASS analyzed as a single group had moderate sensitivity and very high specificity for the detection of DSD. Level of consciousness is therefore a valuable clinical indicator that should form part of delirium screening strategies, although for higher sensitivity other methods of assessment should be used.

Operating characteristics of PROMIS four-item depression and anxiety scales in primary care patients with chronic pain.

Depression and anxiety are prevalent in patients with chronic pain and adversely affect pain, quality of life, and treatment response. The purpose of this psychometric study was to determine the reliability and validity of the four-item Patient Reported Outcomes Measurement Information System (PROMIS) depression and anxiety scales in patients with chronic pain. Secondary analysis of data from the Stepped Care to Optimize Pain care Effectiveness study, a randomized clinical trial of optimized analgesic therapy. Five primary care clinics at the Roudebush VA Medical Center (RVAMC) in Indianapolis, Indiana. Two hundred forty-four primary care patients with chronic musculoskeletal pain. All patients completed the four-item depression and anxiety scales from the PROMIS 29-item profile, as well as several other validated psychological measures. The minimally important difference (MID) using the standard error of measurement (SEM) was calculated for each scale, and convergent validity was assessed by interscale correlations at baseline and 3 months. Operating characteristics of the PROMIS measures for detecting patients who had probable major depression or were anxiety-disorder screen-positive were calculated. The PROMIS scales had good internal reliability, and the MID (as represented by two SEMs) was 2 points for the depression scale and 2.5 points for the anxiety scale. Convergent validity was supported by strong interscale correlations. The optimal screening cutpoint on the 4- to 20-point PROMIS scales appeared to be 8 for both the depression and anxiety scales. The PROMIS four-item depression and anxiety scales are reasonable options as ultra-brief measures for screening in patients with chronic pain.

Monitoring Alliance and Outcome with Client Feedback Measures

The therapeutic alliance is foundational to counseling practice and has amassed strong empirical support as being essential for successful counseling. Counselors generally rely on their own perspective when assessing the quality of the alliance, though the client's perspective has been found to be a better predictor of outcome. Formal methods for eliciting client feedback about the alliance and counseling outcomes have been strongly supported in the literature, yet such limitations as time constraints hinder counselor efforts to gather formal client feedback. Two ultra-brief measures of alliance and outcome, the Session Rating Scale and the Outcome Rating Scale, are feasible methods for counselors to secure client feedback. This article reviews the two measures and makes a case for using empirical means to understand adult clients' views of the therapeutic alliance.

Comparative Responsiveness of Pain Measures in Cancer Patients

Brief measures to assess and monitor pain in cancer patients are available, but few head-to-head psychometric comparisons of different measures have been reported. Baseline and 3-month data were analyzed from 274 patients enrolled in the Indiana Cancer Pain and Depression (INCPAD) trial. Participants completed the Brief Pain Inventory (BPI), the PEG (a 3-item abbreviated version of the BPI), the short form (SF)-36 pain scale, and a pain global rating of change measure. The global rating was used as the criterion for standardized response mean and receiver operating characteristic curve analyses. To assess responsiveness to the trial intervention, we evaluated standardized effect size statistics stratified by trial arm. All measures were responsive to global improvement, discriminated between participants with and without improvement, and detected a significant intervention treatment effect. Short and longer measures were similarly responsive. Also, composite measures that combined pain severity and interference into a single score (BPI total, PEG, SF-36 pain) performed comparably to separate measures of each domain (BPI severity and BPI interference). PerspectivePain measures as brief as 2 or 3 items that provide a single score are responsive in patients with cancer-related pain. Ultra-brief measures offer a valid and efficient means of assessing and monitoring pain for the clinical management as well as research of cancer-related pain.

A 4-item measure of depression and anxiety: Validation and standardization of the Patient Health Questionnaire-4 (PHQ-4) in the general population

Background The 4-item Patient Health Questionnaire-4 (PHQ-4) is an ultra-brief self-report questionnaire that consists of a 2-item depression scale (PHQ-2) and a 2-item anxiety scale (GAD-2). Given that PHQ-4, PHQ-2, and GAD-2 have not been validated in the general population, this study aimed to investigate their reliability and validity in a large general population sample and to generate normative data. Methods A nationally representative face-to-face household survey was conducted in Germany in 2006. The survey questionnaire consisted of the PHQ-4, other self-report instruments, and demographic characteristics. Results Of the 5030 participants (response rate = 72.9%), 53.6% were female and mean (SD) age was 48.4 (18.0) years. The sociodemographic characteristics of the study sample closely match those of the total populations in Germany as well as those in the United States. Confirmatory factor analyses showed very good fit indices for a two-factor solution (RMSEA .027; 90% CI .023–.032). All models tested were structurally invariant between different age and gender groups. Construct validity of the PHQ-4, PHQ-2, and GAD-2 was supported by intercorrelations with other self-report scales and with demographic risk factors for depression and anxiety. PHQ-2 and GAD-2 scores of 3 corresponded to percentile ranks of 93.4% and 95.2%, respectively, whereas PHQ-2 and GAD-2 scores of 5 corresponded to percentile ranks of 99.0% and 99.2%, respectively. Limitation A criterion standard diagnostic interview for depression and anxiety was not included. Conclusions Results from this study support the reliability and validity of the PHQ-4, PHQ-2, and GAD-2 as ultra-brief measures of depression and anxiety in the general population. The normative data provided in this study can be used to compare a subject's scale score with those determined from a general population reference group.

PHQ-9 and PHQ-2 in Western Kenya

The Authors Reply: Coyne and colleagues cite one meta-analysis of diagnostic validation studies but proffer a more negative interpretation than the authors who concluded that “the PHQ9 has good diagnostic properties, and was able to correctly diagnose major depression (sensitivity 92%) while being able to exclude this condition with some certainty (specificity 80%)”1. A second PHQ-9 meta-analysis found 77% sensitivity and 94% specificity2. In a review of case-finding instruments in primary care, the PHQ-9 had operating characteristics comparable to longer depression measures3. Other features of the PHQ-9 have contributed to its popularity, including its brevity, its focus on the nine core symptoms of DSM-IV depressive disorders, its sensitivity to change, its robust performance across different race/ethnic groups, its translation into more than 70 languages, and its nonproprietary nature. We agree with the authors on several points. First, by using the PHQ-9 diagnostic algorithm to determine sensitivity and specificity, the operating characteristics of the PHQ-2 in our particular study may have been inflated. It should be noted, however, that agreement even among mental health professionals using criterion standard diagnostic interviews is only modest4. Second, we agree that the use of the PHQ-9 or any depression measure must be coupled with a clinical interview to confirm diagnosis of a depressive disorder and to assess severity, duration, and functional impairment. Third, we agree that depression detection is warranted only if systems are in place to assure effective treatment and follow-up5. However, this is no different than any other chronic disease: measuring serum glucose, blood pressure, or lipids in the absence of effective diagnosis, treatment and follow-up would be a fruitless endeavor. Our AMPATH clinics in western Kenya provide comprehensive services. Fourth, we concur that ultra-brief measures like the PHQ-2 should not be used in isolation: a high score on the PHQ-2 should trigger completion of the full PHQ-9 as well as a clinical interview. While PHQ-9 test-retest reliability (0.59) was moderate, we stated this “may be acceptable” because two major events occurring during the interval could have slightly affected “true” depression scores for some participants—a tumultuous national two-day holiday to allow travel to a national election with several reports of civil unrest—and some (not all) participants attended a support group therapy session. Finally, we acknowledged that future psychometric studies are needed in this population, including comparisons of PHQ-9 and PHQ-2 with gold standard diagnostic interviews. However, given that our study showed construct validity with general health ratings, content validity in which focus groups indicated the PHQ-9 was generally well understood but might benefit from two potential minor modifications to its instructions, high factor loadings, a pattern of item means similar to US validation samples, high internal consistency, and moderate test-retest reliability, we believe our conclusion that the PHQ-9 and PHQ-2 “appear to be” valid and reliable is warranted.