Brief assessment of depression: Psychometric properties of the Portuguese version of the Patient Health Questionnaire (PHQ-9)

Tiago Ferreira, Marlene Sousa, João Salgado

Abstract

Background: The lack of knowledge regarding psychometric characteristics of brief scales for assessing the severity of symptoms of depression for the Portuguese population limits the ability of health professionals to signal clinically relevant situations, as well as the implementation of alternative forms of mental health care. The Patient Health Questionnaire (PHQ-9) is a scale whose usefulness in various professional contexts has been amply demonstrated by research. However, some of its psychometric qualities remain unknown for the Portuguese version.

Goals: The main objective of this study was to analyse the validity of the factorial structure and the psychometric characteristics of the PHQ-9 in two different clinical Portuguese contexts, namely in primary health care units and in a university clinic, also reflecting the similarities and differences found regarding the factorial structures.

Methods: The first study was carried out with 153 patients (83.66% females), with a mean age of 46.10 years (SD = 16.79), from eight health units of primary health care (non-probabilistic sampling). All participants underwent an initial screening for the detection of symptoms of depression and suicidal ideation, within the context of a regular family medicine appointment or nursing visit. Participants who scored positively for one of these symptoms were invited to participate in the study. The PHQ-9 and the Work and Social Adjustment Scale (WSAS) were used and exploratory and semi-confirmatory factor analyses of the PHQ-9 were performed. In the second study, 106 adults (70.78% females) participated in a psychological counselling session at a university clinic, with a mean age of 32.47 years (SD = 11.01), also constituting a non-probabilistic sample. As instruments, the PHQ-9, the Beck-II Depression Inventory and the State-Trait Anxiety Inventory were used, which participants completed before the beginning of the psychological treatment. As in the first study, exploratory and semi-confirmatory factor analyses of the PHQ-9 were conducted. 

Results: The results of the two studies revealed a factorial structure consisting of three factors. In the first study, the three factors were: (1) depressed mood and anhedonia; (2) self-devaluation and suicidal ideation; and (3) fatigue, psychomotor agitation/retardation, and changes in appetite, sleep problems or difficulty in concentration. In the second study, the three factors that were found were: (1) sleep problems and fatigue; (2) changes in appetite and difficulty in concentration, psychomotor agitation/retardation, and suicidal ideation; and (3) depressed mood, anhedonia, and self-devaluation. The factorial structure found in both studies revealed a good fit. The PHQ-9 also presented good internal consistency, convergent validity and criterion validity in both studies. The cut-off point of 9 emerged as an indicator of major depression.

Discussion: The results of this study enhance the use of this scale in different contexts of health care provision in Portugal, since it was possible to determine the cut-off point for the detection of cases with major depression, as well as the criteria for delimiting severity degrees of depression-related symptomatology.

Keywords: PHQ-9, Depression, Psychometric qualities, Primary health care, University clinic

Keywords

PHQ-9; Depression; Psychometric qualities; Primary health care; University clinic

References

Aaronson, N., Ahmedzai, S., Bergman, B., Bullinger, A., Cull, A., Duez, N., ...Takeda, F. (1993). The European Organization for Research and Treatment of Cancer QLQ – C30: A quality-of-life instrument for use in international clinical trials in oncology. Journal of the National Cancer Institute, 85(5), 365-376. doi:10.1093/jnci/85.5.365

Adewuya, A. O., Ola, B. A., & Afolabi, O. O. (2006). Validity of the Patient Health Question-naire (PHQ-9) as a screening tool for depression amongst Nigerian university students. Journal of Affective Disorders, 96(1-2), 89-93. doi:10.1016/j.jad.2006.05.021

Almeida, J. A. C., Xavier, A., Cardoso, G., Pereira, A., Gusmão, R., Corrêa, B., ... Silva, J. (2013). Estudo epidemiológico nacional de saúde mental: 1º relatório. Lisboa: Faculdade de Ciências Médicas, Universidade Nova de Lisboa.

American Psychiatric Association (2006). DSM-IV-TR: Manual de Diagnóstico das Perturbações Mentais (4ª Edição). Lisbon: Climepsi Editores.

Arrieta, J., Aguerrebere, A., Raviola, G., Flores, H., Elliott, P., Espinosa, A., ... Palazuelos, D. (2017). Validity and utility of the Patient Health Questionnaire (PHQ)â€2 and PHQâ€9 for screening and diagnosis of depression in rural Chiapas, Mexico: A crossâ€sectional study. Journal of Clinical Psychology, 73(9), 1076-1090. doi:10.1002/jclp.22390

Arroll, B., Goodyear-Smith, F., Crengle, S., Gunn, J., Kerse, N., Fishman, T., ... Hatcher, S. (2010). Validation of PHQ-2 and PHQ-9 to screen for major depression in the primary care population. Annals of Family Medicine, 8(4), 348 – 353. doi:10.1370/afm.1139.

Beck, A.T., Steer, R.A., & Brown, G. (1996). BDI-II: Beck Depression Inventory-II Manual. New York: Psychological Corporation.

Cameron, I. A., Crawford, J. R., Lawton, K., & Reid, I. C. (2008). Psychometric comparison of PHQ-9 and HADS for measuring depression severity in primary care. British Journal of General Practice, 58(546), 32 – 36. doi:10.3399/bjgp08X263794.

Chen, S., Chiu, H., Xu, B., Ma, Y., Jin, T., Wu, A., & Conwell, Y. (2010). Reliability and validity of the PHQâ€9 for screening lateâ€life depression in Chinese primary care. International Journal of Geriatric Psychiatry, 25(11), 1127-1133. doi:10.1002/gps.2442

Campos, R. C., & Gonçalves, B. (2011). The Portuguese version of the Beck Depression Inventory-II (BDI-II). European Journal of Psychological Assessment, 27, 258-264. http://dx.doi.org/10.1027/1015-5759/a000072

Campos, R. C., & Gonçalves, B. (2011). The Portuguese version of the Beck Depression Inventory-II (BDI-II): Preliminary psychometric data with two nonclinical samples. European Journal of Psychological Assessment, 27(4), 258-264. doi:10.1027/1015-5759/a000072

Chilcot, J., Rayner, L., Lee, W., Price, A., Goodwin, L., Monroe, B., ... Hotopf, A. (2013). The factor structure of the PHQ-9 in palliative care. Journal of Psychosomatic Research, 75(1), 60 – 64. doi: 10.1016/j.jpsychores.2012.12.012

Coelho, R., Martins, A., & Barros, H. (2002). Clinical profiles relating gender and depressive symptoms among adolescents ascertained by the Beck Depression Inventory II. European Psychiatry, 17(4), 222 – 226. https://doi.org/10.1016/S0924-9338(02)00663-6

Costello, A. B., & Osborne, J. W. (2005). Best practices in exploratory factor analysis: Four recommendations for getting the most from your analysis. Practical assessment, research & evaluation, 10(7), 1-9.

Elhai, J. D., Contractor, A. A., Tamburrino, A., Fine, T. H., Prescott, A. R., Shirley, E., ... Calabrese, J. R. (2012). The factor structure of major depression symptoms: A test of four com-peting models using the Patient Health Questionnaire-9. Psychiatry Research, 199(3), 169-173. doi:10.1016/j.psychres. 2012.05.018

Epskamp, S., Borsboom, D., & Fried, E. I. (2018). Estimating psychological networks and their stability: A tutorial paper. Behav Res Methods, 50(1), 195-212. doi: 10.3758/s13428-017-0862-1.

Fiest, K. A., Patten, S. B., Wiebe, S., Bulloch, A. G., Maxwell, C. J., & Jetté, N. (2014). Vali-dating screening tools for depression in epilepsy. Epilepsia, 55(10), 1642-1650. doi:10.1111/epi.12754.

Fried, E. I., & Nesse, R. A. (2015). Depression sum-scores don’t add up: Why analyzing specific depression symptoms is essential. BMC Medicine, 13(1), 72. doi:10.1186/s12916-015-0325-4

Fried, E. I., van Borkulo, C. D., Epskamp, S., Schoevers, R. A., Tuerlinckx, F., & Borsboom, D. (2016). Measuring depression over time... Or not? Lack of unidimensionality and longitudinal measurement invariance in four common rating scales of depression. Psychological Assessment, 28(11), 1354 – 1367. doi:10.1037/pas0000275

Fortunato, S. (2010). Community detection in graphs. Physics reports, 486(3), 75 – 174. doi:10.1016/j.physrep.2009.11.002

Foygel, R., & Drton, A. (2010). Extended Bayesian information criteria for Gaussian graphical models. In J.D. Lafferty, C.K.I. Williams, J. Shawe-Taylor, R.S. Zemel, & A. Culotta (Eds.), Advances in Neural Information Processing Systems 23 (NIPS 2010) (pp. 604 – 612). Curran Associates, Inc.

Fruchterman, T., & Reingold, E. (1991). Graph drawing by force-directed placement. Software: Practice and Experience, 21(11), 1129–1164. doi:10.1002/spe.4380211102

Garrido, L. E., Abad, F. J., & Ponsoda, V. (2013). A new look at Horn’s parallel analysis with ordinal variables. Psychological Methods, 18(4), 454 – 474. doi:10.1037/a0030005.

Golino, H. F., & Demetriou, A. (2017). Estimating the dimensionality of intelligence like data using Exploratory Graph Analysis. Intelligence, 62, 54-70. doi:10.1016/j.intell.2017. 02.007

Golino, H. F., & Epskamp, S. (2017). Exploratory graph analysis: A new approach for estimating the number of dimensions in psychological research. PLoS One, 8;12(6):e0174035. doi: 10.1371/journal.pone.0174035.

Hutchinson, S. R., & Olmos, A. (1998). Behaviour of descriptive fit indices in confirmatory factor analysis using ordered categorical data. Structural Equation Modelling, 5, 344 – 364. doi:10.1080/10705519809540111

Jaccard, J., & Wan, C. K. (1996). LISREL approaches to interaction effects in multiple regression. Thousand Oaks, CA: Sage Publications.

Keith, T. Z., Caemmerer, J. A., & Reynolds, A. R. (2016). Comparison of methods for factor extraction for cognitive test-like data: Which overfactor, which underfactor?. Intelligence, 54, 37-54. doi:10.1016/j.intell.2015.11.003

Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQâ€9. Journal of General Internal Medicine, 16(9), 606 – 613. doi:10.1046/j.1525-1497.2001.016009606.x

Kroenke, K., Spitzer, R. L., & Williams, J. B. (2003). The Patient Health Questionnaire-2: Validity of a two-item depression screener. Medical Care, 41(11), 1284-1292. doi:10.1097/01. MLR.0000093487.78664.3C

Lorenzo-Seva, U., & Ferrando, P. J. (2013). Factor 9.2: A comprehensive program for fitting exploratory and semiconfirmatory factor analysis and IRT models. Applied Psychological Measurement, 37(6), 497-498. doi: 10.1177/0146621613487794

Lorenzo-Seva, U. & ten Berge, J.A.F. (2006). Tucker's congruence coefficient as a meaningful index of factor similarity. Methodology, 2, 57 – 64. doi:10.1027/1614-2241.2.2.57

Löwe, B., Schenkel, I., Carney-Doebbeling, C., & Göbel, C. (2006). Responsiveness of the PHQ-9 to psychopharmacological depression treatment. Psychosomatics, 47(1), 62 – 67. doi:10.1176/appi.psy.47.1.62

MacCallum, R. C., Widaman, K. F., Zhang, S. B., & Hong, S. H. (1999). Sample size in factor analysis. Psychological Methods, 4(1), 84-99. doi:10.1037/1082-989X.4.1.84

Manea, L., Gilbody, S., & McMillan, D. (2012). Optimal cut-off score for diagnosing depression with the Patient Health Questionnaire (PHQ-9): A meta-analysis. Canadian Medical Association Journal, 184(3), E191 – E196. doi:10.1503/ cmaj.110829

Martin, A., Rief, W., Klaiberg, A., & Braehler, E. (2006). Validity of the brief Patient Health Questionnaire mood scale (PHQ-9) in the general population. General Hospital Psychiatry, 28, 71–77. doi:10.1016/j.genhosppsych.2005.07.003

McKnight, P. E., Monfort, S. S., Kashdan, T. B., Blalock, D. V., & Calton, J. A. (2016). Anxiety symptoms and functional impairment: A systematic review of the correlation between the two measures. Clinical Psychology Review, 45, 115 – 130. doi:10.1016/j.cpr.2015.10.005

Monteiro, S., Torres, A., Pereira, A., Albuquerque, E., & Morgadinho, R. (2013). Preliminary validation study of a Portuguese version of the Patient Health Questionnaire (PHQ-9). Eu-ropean Psychiatry, 28, Supplemment, 1. doi:10.1016/S0924-9338(13)76982-7

Mundt, J., Marks, I., Shear, A., & Greist, J. (2002). The Work and Social Adjustment Scale: A simple measure of impairment in functioning. British Journal of Psychiatry, 180, 461 – 464. doi:10.1192/bjp.180.5.461

National Institute for Health and Clinical Excellence (2009). Depression in adults: The treatment and management of depression in adults. NICE Clinical Guideline 90. London: NICE.

Pais-Ribeiro, J., Pinto, C., & Santos, C. (2008). Validation study of the Portuguese version QLC-C30- V.3. Psicologia, Saúde & Doenças, 9(1), 89-102.

Pais-Ribeiro, J., Silva, I., Ferreira, T., Martins, A., Meneses, R., & Baltar, A. (2007). Validation study of a Portuguese version of the Hospital Anxiety and Depression Scale. Psychology, Health & Medicine, 12(2), 225-237. doi:10.1080/ 13548500500524088

Perkins, N. J., & Schisterman, E. F. (2006). The inconsistency of “optimal†cutpoints obtained using two criteria based on the Receiver Operating Characteristic Curve. American Journal of Epidemiology, 163(7), 670–675. doi:10.1093/aje/kwj063

Pettersson, A., Boström, K. B., Gustavsson, P., & Ekselius, L. (2015). Which instruments to support diagnosis of depression have sufficient accuracy? A systematic review. Nordic Journal of Psychiatry, 69(7), 497-508. doi: 10.3109/08039488. 2015.1008568

Pons, P., & Latapy, A. (2005). Computing communities in large networks using random walks. In Computer and Information Sciences-ISCIS 2005 (pp. 284 – 293). Springer Berlin Heidelberg.

R Core Team (2017). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. URL http://www.R-project.org/. [Computer software]

Richards, D. (2011). Prevalence and clinical course of depression: A review. Clinical Psychology Review, 31, 1117–1125. doi:10.1016/j.cpr.2011.07.004

Schmittmann, V. D., Cramer, A. O., Waldorp, L. J., Epskamp, S., Kievit, R. A., & Borsboom, D. (2013). Deconstructing the construct: A network perspective on psychological phenomena. New Ideas in Psychology, 31(1), 43-53. doi:10.1016/ j.newideapsych.2011.02.007

Shafer, A. B. (2006), Metaâ€analysis of the factor structures of four depression questionnaires: Beck, CESâ€D, Hamilton, and Zung. Journal of Clinical Psychology, 62, 123-146. doi:10.1002/jclp.20213

Silva, D. R. (2003). O Inventário de Estado-Traço de Ansiedade (S.T.A.I.). In A. A. Gonçalves, A. R. Simões, L. S. Almeida, & C. Machado (Eds.), Avaliação Psicológica: Instrumentos validados para a população portuguesa (vol. 1, pp. 45-63). Coimbra: Quarteto.

Sivo, S. A., Fan, X., Witta, E. L., & Willse, J. T. (2006). The search for "optimal" cutoff properties: Fit index criteria in structural equation modelling. The Journal of Experimental Education, 74(3), 267-288. https://doi.org/10.3200/JEXE.74.3.267-288

Spielberger, C. D. (1983). Manual for the State-Trait Anxiety Inventory (STAI). Palo Alto, CA: Consulting Psychologists Press.

Stewart, A. L., Hays, R. D., & Ware, J. E. (1988). The MOS short-form general health survey: Reliability and validity in a patient population. Medical Care, 26(7), 724 – 735.

Streiner, D. L., & Cairney, J. (2007). What’s under the ROC? An introduction to receiver operating characteristics curves. Canadian Journal of Psychiatry, 52, 121–128. doi:10.1177/ 070674370705200210

Torres, A., Monteiro, S., Pereira, A., & Albuquerque, E. (2016). Reliability and validity of the PHQ-9 in Portuguese women with breast cancer. In 2nd International Conference on Health and Health Psychology Reliability. doi:10.15405/ epsbs.2016.07.02.38

Tucker, L. R. (1951). A method for synthesis of factor analysis studies. Personnel Research Section Report, 984. Washington, D. C.: Department of the Army.

Van Loo, H. A., De Jonge, P., Romeijn, J. W., Kessler, R. C., & Schoevers, R. A. (2012). Data-driven subtypes of major depressive disorder: A systematic review. BMC Medicine, 10(1), 156. doi:10.1186/1741-7015-10-156

Van Straten, A., Hill, J., Richards, D. A., & Cuijpers, P. (2014). Stepped care treatment delivery for depression: A systematic review and meta-analysis. Psychological Medicine, 45, 1-16. doi:10.1017/S0033291714000701

Wang, Y. P., & Gorenstein, C. (2013). Psychometric properties of the Beck Depression Inventory-II: A comprehensive review. Revista Brasileira de Psiquiatria, 35(4), 416-431. doi:10.1590/1516-4446-2012-1048

World Health Organization (2017). Depression and other common mental disorders: Global health estimates. From http://apps.who.int/iris/bitstream/10665/254610/1/WHO-MSD-MER-2017.2-eng.pdf?ua=1

Wright, A. F. (1994). Should general practitioners be testing for depression? British Journal of General Practice, 144, 132–135. doi: 10.4324/9780203408582_chapter_20

Yang-Wallentin, F., Jöreskog, K. G., & Luo, H. (2010). Confirmatory factor analysis of ordinal variables with misspecified models. Structural Equation Modelling, 17(3), 392 – 423. doi:10.1080/10705511.2010.489003

Zigmond, A. S., & Snaith, R. P. (1983). The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavia, 67, 361-370. doi:10.1111/j.1600-0447.1983.tb09716.x.


DOI: https://doi.org/10.33525/pprj.v1i2.36

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