Trends in Psychiatry and Psychotherapy
https://trends.org.br/article/doi/10.1590/2237-6089-2017-0116
Trends in Psychiatry and Psychotherapy
Original Article

Reliability and validity of the Farsi version of the Patient Health Questionnaire-9 (PHQ-9) with Iranian psychiatric outpatients

Confiabilidade e validade da versão persa do Patient Health Questionnaire-9 (PHQ-9) em pacientes psiquiátricos ambulatoriais iranianos

Mahboubeh Dadfar; Zornitsa Kalibatseva; David Lester

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Abstract

Abstract Introduction: The Patient Health Questionnaire-9 (PHQ-9) is a brief screening and diagnostic tool for depression. It has been used in research and clinical practice in primary care and other clinical and non-clinical settings. The PHQ-9 has not had its validity examined in psychiatric and psychological settings in Iran. Methods: A cross-sectional study was conducted to investigate the validation of the Farsi version of the PHQ-9. A convenience sample of 130 Iranian volunteer psychiatric outpatients was selected from psychiatric and psychological clinics. They completed the PHQ-9, the Patient Health Questionnaire-15 (PHQ-15), the World Health Organization-five Well-Being Index (WHO-5), and the short form of the Beck Depression Inventory-13 (BDI-13). Data were analyzed by descriptive statistics, Cronbach's α, Pearson correlation coefficient, principal component analysis, exploratory factor analysis, and confirmatory factor analysis. Results: Mean score of the PHQ-9 was 12.83 (standard deviation = 6.25), indicating moderately severe depression in the sample. Cronbach's α coefficient for PHQ-9 was 0.88, and one-week test-retest reliability 0.79. The PHQ-9 correlated 0.64 with PHQ-15, −0.35 with WHO-5, and 0.70 with BDI-13, indicating good construct and criterion-related validity. The results of the factor analysis of PHQ-9 items identified and confirmatory factor analysis confirmed a single factor labeled general depression. Conclusions: The PHQ-9 appears to have a unidimensional structure, adequate validity and reliability, and can be useful in epidemiological/research settings. Based on previous literature and on the present findings, the PHQ-9 may have applicability to other contexts in the studied population, but this needs to be confirmed by other studies.

Keywords

Depression, validity, reliability, factorial structure, Patient Health Questionnaire-9, psychiatric outpatients, Iran

Resumo

Resumo Introdução: O Patient Health Questionnaire-9 (PHQ-9) é uma ferramenta breve de triagem e diagnóstico para depressão. Tem sido usado em pesquisa e na prática clínica primária e em outros contextos clínicos e não clínicos. O PHQ-9 não teve sua validade examinada em contextos psiquiátricos e psicológicos no Irã. Métodos: Um estudo transversal foi conduzido para investigar a validação da versão persa do PHQ-9. Uma amostra de conveniência de 130 pacientes psiquiátricos ambulatoriais iranianos foi selecionada em clínicas psiquiátricas e psicológicas. Os pacientes completaram o PHQ-9, Patient Health Questionnaire-15 (PHQ-15), the World Health Organization-five Well-Being Index (WHO-5) e a forma abreviada do Beck Depression Inventory-13 (BDI-13). Os dados foram analisados por estatística descritiva, α de Cronbach, coeficiente de correlação de Pearson, análise de componentes principais e análise fatorial exploratória e confirmatória. Resultados: O escore médio do PHQ-9 foi 12,83 (desvio padrão=6,25), indicando depressão moderadamente severa na amostra. O α de Cronbach para PHQ-9 foi 0,88, e a confiabilidade teste-reteste de uma semana 0,79. O PHQ-9 apresentou correlação de 0,64 com PHQ-15, −0,35 com WHO-5 e 0,70 com BDI-13, indicando boa validade do construto e dos critérios relacionados. Os resultados da análise fatorial dos itens do PHQ-9 identificaram, e a análise fatorial confirmatória confirmou, um único fator, chamado depressão geral. Conclusões: O PHQ-9 parece ter uma estrutura unidimensional, validade e confiabilidade adequadas, e pode ser útil em contextos epidemiológicos e de pesquisa. Com base na literatura prévia e neste estudo, o PHQ-9 pode ter aplicabilidade em outros contextos na população estudada, mas isso precisa ser confirmado.

Palavras-chave

Depressão, validade, confiabilidade, estrutura fatorial, Patient Health Questionnaire-9, pacientes psiquiátricos ambulatoriais, Irã

References

Screening for depression in adults. 2017.

Diagnostic and Statistical Manual of Mental Disorders. 2017.

Maurer DM. Screening for depression. Am Fam Physician. 2012;85:139-44.

Ahmadvand A, Sepehrmanesh Z, Ghoreishi FS, Afshinmajd S. Prevalence of psychiatric disorders in the general population of Kashan, Iran. Arch Iran Med. 2012;15:205-9.

Bakhtar M, Rezaeian M. The prevalence of suicide thoughts and attempted suicide plus their risk factors among Iranian students: a systematic review study. J Rafsanjan Uni Med Sci. 2017;15:1061-76.

Dadfar M, Lester D. Prevalence of personality disorders and clinical syndromes using the Millon Clinical Multiaxial Inventory III (MCMI-III) in an Iranian clinical sample. Int J Biomed Engin Clin Sci. 2016;1:17-28.

Nease Jr DE, Maloin JM. Depression screening: a practical strategy. J Fam Pract. 2003;52:118-24.

Spitzer RL, Williams JBW, Kroenke K, Linzer M, deGruy FV, Hahn SR. Utility of a new procedure for diagnosing mental disorders in primary care: the PRIME-MD 1000 study. JAMA. 1994;272:1749-56.

Spitzer RL, Kroenke K, Williams JBW. Validation and utility of a self-report version of PRIME-MD: the PHQ Primary Care Study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA. 1999;282:1737-44.

Kroenke K, Spitzer RL, Williams JBW. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16:606-13.

Kroenke K, Spitzer RL, Williams JBW, Löwe B. The Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales: a systematic review. Gen Hosp Psychiatry. 2010;32:345-59.

Yazici Güleç M, Güleç H, Simşek G, Turhan M, Aydin Sünbül E. Psychometric properties of the Turkish version of the Patient Health Questionnaire-Somatic, Anxiety, and Depressive Symptoms. Compr Psychiatry. 2012;53:623-9.

Kroenke K, Spitzer RL. The PHQ-9: a new depression diagnostic and severity measure. Psychiatric Ann. 2002;32:509-21.

Williams JW, Noel PH, Cordes JA, Ramirez G, Pignone M. Is this patient clinically depressed?. JAMA. 2002;287:1160-70.

Eack SM, Greeno CG, Lee BJ. Limitations of the Patient Health Questionnaire in identifying anxiety and depression: many cases are undetected. Res Soc Work Pract. 2006;16:625-31.

Meader N, Mitchell AJ, Chew-Graham C, Goldberg D, Rizzo M, Bird V. Case identification of depression in patients with chronic physical health problems: a diagnostic accuracy meta-analysis of 113 studies. Br J Gen Pract. 2011;61:808-20.

Choi SW, Schalet B, Cook KF, Cella D. Establishing a common metric for depressive symptoms: linking the BDI-II, CES-D, and PHQ-9 to PROMIS depression. Psychol Assess. 2014;26:513-27.

Löwe B, Unützer J, Callahan CM, Perkins AJ, Kroenke K. Monitoring depression treatment outcomes with the Patient Health Questionnaire-9. Med Care. 2004;42:1194-201.

Ell K, Quon B, Quinn DI, Dwight-Johnson M, Wells A, Lee PJ. Improving treatment for depression among low-income patients with cancer: the design of the ADAPt-C study. Gen Hosp Psychiatry. 2007;29:223-31.

Cannon DS, Tiffany ST, Coon H, Scholand MB, McMahon WM, Leppert MF. The PHQ-9 as a brief assessment of lifetime major depression. Psychol Assess. 2007;19:247-51.

Rooney AG, McNamara S, Mackinnon M, Fraser M, Rampling R, Carson A. Screening for major depressive disorder in adults with glioma using the PHQ-9: a comparison of patient versus proxy reports. J Neurooncol. 2013;113:49-55.

Santos IS, Tavares BF, Munhoz TN, Almeida LS, Silva NT, Tams BD. Sensitivity and specificity of the Patient Health Questionnaire-9 (PHQ-9) among adults from the general population. Cad Saúde Pública. 2013;29:1533-43.

Thombs BD, Benedetti A, Kloda LA, Levis B, Nicolau I, Cuijpers P. The diagnostic accuracy of the Patient Health Questionnaire-2 (PHQ-2), Patient Health Questionnaire-8 (PHQ-8), and Patient Health Questionnaire-9 (PHQ-9) for detecting major depression: protocol for a systematic review and individual patient data metaanalyses. Syst Rev. 2014;3:124.

Poots AJ, Green SA, Honeybourne E, Green J, Woodcock T, Barnes R. Improving mental health outcomes: achieving equity through quality improvement. Int J Qual Health Care. 2014;26:198-204.

Li CM, Zhang X, Hoffman HJ, Cotch MF, Themann CL, Wilson MR. Hearing impairment associated with depression in US adults, National Health and Nutrition Examination Survey 2005-2010. JAMA Otolaryngol Head Neck Surg. 2014;140:293-302.

Kiely KM, Butterworth P. Validation of four measures of mental health against depression and generalized anxiety in a community based sample. Psychiatry Res. 2015;225:291-8.

Loeb D, Sieja A, Corral J, Zehnder NG, Guiton G, Nease DE. Evaluation of the role of training in the implementation of a depression screening and treatment protocol in 2 academic outpatient internal medicine clinics utilizing the electronic medical record. Am J Med Qual. 2015;30:359-66.

Pinto-Meza A, Serrano-Blanco A, Peñarrubia MT, Blanco E, Haro JM. Assessing depression in primary care with the PHQ-9: can it be carried out over the telephone?. J Gen Intern Med. 2005;20:738-42.

Cameron IM, Crawford JR, Lawton K, Reid IC. Psychometric comparison of PHQ-9 and HADS for measuring depression severity in primary care. Br J Gen Pract. 2008;58:32-6.

Diez-Quevedo C, Rangil T, Sanchez-Planell L, Kroenke K, Spitzer RL. Validation and utility of the Patient Health Questionnaire in diagnosing mental disorders in 1003 General Hospital Spanish Inpatients. Psychosom Med. 2001;63:679-86.

Liu SI, Yeh ZT, Huang HC, Sun FJ, Tjung JJ, Hwang LC. Validation of Patient Health Questionnaire for depression screening among primary care patients in Taiwan. Compr Psychiatry. 2011;52:96-101.

de Lima Osório F, Vilela Mendes A, Crippa JA, Loureiro SR. Study of the discriminative validity of the PHQ-9 and PHQ-2 in a sample of Brazilian women in the context of primary health care. Perspect Psychiatr Care. 2009;45:216-27.

Yu X, Tam WW, Wong PT, Lam TH, Stewart SM. The Patient Health Questionnaire-9 for measuring depressive symptoms among the general population in Hong Kong. Compr Psychiatry. 2012;53:95-102.

Adewuya AO, Ola BA, Afolabi OO. Validity of the Patient Health Questionnaire (PHQ-9) as a screening tool for depression amongst Nigerian university students. J Affect Disord. 2006;96:89-93.

Han C, Jo SA, Kwak JH, Pae CU, Steffens D, Jo I. Validation of the Patient Health Questionnaire-9 Korean version in the elderly population: the Asian geriatric study. Compr Psychiatry. 2008;49:218-23.

Lotrakul M, Sumrithe S, Saipanish R. Reliability and validity of the Thai version of the PHQ-9. BMC Psychiatry. 2008;8:46.

Karekla M, Pilipenko N, Feldman J. Patient Health Questionnaire: Greek language validation and subscale factor structure. Compr Psychiatry. 2012;53:1217-26.

Becker S, Zaid KA, Faris EAF. Screening for somatization and depression in Saudi Arabia: a validation study of the PHQ in primary care. Int J Psychiatry Med. 2002;32:271-83.

Yeung A, Fung F, Yu SC, Vorono S, Ly M, Wu S. Validation of the Patient Health Questionnaire-9 for depression screening among Chinese Americans. Compr Psychiatry. 2008;49:211-7.

Donlan W, Lee J. Screening for depression among indigenous Mexican migrant farmworkers using the Patient Health Questionnaire-9. Psychol Rep. 2010;106:419-32.

Carballeira Y, Dumont P, Borgacci S, Rentsch D, de Tonnac N, Archinard M. Criterion validity of the French version of Patient Health Questionnaire (PHQ) in a hospital department of internal medicine. Psychol Psychother. 2007;80:69-77.

Yazici Güleç M, Güleç H, Simşek G, Turhan M, Aydin Sünbül E. Psychometric properties of the Turkish version of the Patient Health Questionnaire-Somatic, Anxiety, and Depressive Symptoms. Compr Psychiatry. 2012;53:623-9.

Omoro SA, Fann JR, Weymuller EA, Macharía IM, Yueh B. Swahili translation and validation of the Patient Health Questionnaire-9 depression scale in the Kenyan head and neck cancer patient population. Int J Psychiatry Med. 2006;36:367-81.

Rogers KD, Young A, Lovell K, Campbell M, Scott PR, Kendal S. The British sign language versions of the Patient Health Questionnaire, the Generalized Anxiety Disorder 7-Item Scale, and the Work and Social Adjustment Scale. J Deaf Stud Deaf Educ. 2013;18:110-22.

Brown AD, Mentha R, Rowley KG, Skinner T, Davy C, O'Dea K. Depression in Aboriginal men in central Australia: adaptation of the Patient Health Questionnaire 9. BMC Psychiatry. 2013;13:271.

Hanwella R, Ekanayake S, de Silva VA. The validity and reliability of the Sinhala translation of the Patient Health Questionnaire (PHQ-9) and PHQ-2 screener. Dep Res Treat. 2014;2014:768978.

Gothwal VK, Bagga DK, Bharani S, Sumalini R, Reddy SP. The Patient Health Questionnaire-9: validation among patients with glaucoma. PLoS One. 2014;9:101295.

Torres A, Monteiro S, Pereira A, Albuquerque E. Reliability and validity of the PHQ-9 in Portuguese women with breast cancer. EpSBS. 2016;2016:411-23.

Khamseh ME, Baradaran HR, Javanbakht A, Mirghorbani M, Yadollahi Z, Malek M. Comparison of the CES-D and PHQ-9 depression scales in people with type 2 diabetes in Tehran, Iran. BMC Psychiatry. 2011;16:61.

Kroenke K, Spitzer RL, Williams JBW. The Patient Health Questionnaire-2: validity of a two-item depression screener. Med Care. 2003;41:1284-92.

Patient Health Questionnaire (PHQ-9 & PHQ-2) construct: depressive symptoms. 2015.

Xiong N, Fritzsche K, Wei J, Hong X, Leonhart R, Zhao X. Validation of patient health questionnaire (PHQ) for major depression in Chinese outpatients with multiple somatic symptoms: a multicenter cross-sectional study. J Affect Disord. 2015;174:636-43.

Solem S, Thunes SS, Hjemdal O, Hagen R, Wells A. A metacognitive perspective on mindfulness: an empirical investigation. BMC Psychol. 2015;3:24.

Han C, Pae CU, Patkar AA, Masand PS, Kim KW, Joe SH. Psychometric properties of the Patient Health Questionnaire-15 (PHQ-15) for measuring the somatic symptoms of psychiatric outpatients. Psychosomatics. 2009;50:580-5.

Ros Montalbán S, Comas Vives A, Garcia-Garcia M. Validation of the Spanish Version of the PHQ-15 Questionnaire for the evaluation of physical symptoms in patients with depression and/ or anxiety disorders: DEPRE-SOMA study. Actas Esp Psiquiatr. 2010;38:345-57.

Lee S, Ma YL, Tsang A. Psychometric properties of the Chinese 15-item Patient Health Questionnaire in the general population of Hong Kong. J Psychosom Res. 2011;71:69-73.

Körber S, Frieser D, Steinbrecher N, Hiller W. Classification characteristics of the Patient Health Questionnaire-15 for screening somatoform disorders in a primary care setting. J Psychosom Res. 2011;71:142-7.

de Vroege L, Hoedeman R, Nuyen J, Sijtsma K, van der Feltz-Cornelis CM. Validation of the PHQ-15 for somatoform disorder in the occupational health care setting. J Occup Rehabil. 2012;22:51-8.

Kocalevent RD, Hinz A, Brähler E. Standardization of a screening instrument (PHQ-15) for somatization syndromes in the general population. BMC Psychiatry. 2013;13:91.

Qian J, Ren ZQ, Yu DH, He XY, Li CB. The value of the Patient Health Questionnaire-15 (PHQ-15) for screening somatic symptoms in general hospital. Chin Ment Health J. 2014;28:173-8.

Gierk B, Kohlmann S, Toussaint A, Wahl I, Brünahl CA, Murray AM. Assessing somatic symptom burden: a psychometric comparison of the Patient Health Questionnaire-15 (PHQ-15) and the Somatic Symptom Scale-8 (SSS-8). J Psychosom Res. 2015;78:352-5.

Zhang L, Fritzsche K, Liu Y, Wang J, Huang M, Wang Y. Validation of the Chinese version of the PHQ-15 in a tertiary hospital. BMC Psychiatry. 2016;16:89.

Topp CW, Østergaard SD, Søndergaard S, Bech P. The WHO-5 WellBeing Index: a systematic review of the literature. Psychother Psychosom. 2015;84:167-76.

de Wit M, Pouwer F, Gemke RJ, Delemarre-van de Waal HA, Snoek FJ. Validation of the WHO-5 Well-Being Index in adolescents with type 1 diabetes. Diabetes Care. 2007;30:2003-6.

Hajos TR, Pouwer F, Skovlund SE, Den Oudsten BL, Geelhoed-Duijvestijn PH, Tack CJ. Psychometric and screening properties of the WHO-5 Well-Being Index in adult outpatients with Type 1 or Type 2 diabetes mellitus. Diabet Med. 2013;30:63-9.

Saipanish R, Lotrakul M, Sumrithe S. Reliability and validity of the Thai version of the WHO-Five Well-Being Index in primary care patients. Psychiatry Clin Neurosc. 2009;63:141-6.

Wu SFV. Rapid screening of psychological well-being of patients with chronic illness: reliability and validity test on WHO-5 and PHQ-9 scales. Dep Res Treat. 2014;2014:239490.

Dadfar M, Momeni Safarabad N, Asgharnejad Farid AA, Nemati Shirzy M, Ghazie pour Abarghouie F. Reliability, validity, and factorial structure of the World Health Organization-5 WellBeing Index (WHO-5) in Iranian psychiatric outpatients. Trends Psychiatry Psychother. 2018;40(2).

Dadfar M, Kalibatseva Z. Psychometric properties of the Persian version of the short Beck Depression Inventory with Iranian psychiatric outpatients. Scientifica. 2016;2016:8196463.

Lee PW, Schulberg HC, Raue PJ, Kroenke K. Concordance between the PHQ-9 and the HSCL-20. J Affect Disord. 2007;99:139-45.

Cameron IM, Crawford JR, Lawton K, Reid IC. Psychometric comparison of PHQ-9 and HADS for measuring depression severity in primary care. Br J Gen Pract. 2008;58:32-6.

van Steenbergen-Weijenburg KM, de Vroege L, Ploeger RR, Brals JW, Vloedbeld MG, Veneman TF. Validation of the PHQ-9 as a screening instrument for depression in diabetes patients in specialized outpatient clinics. BMC Health Serv Res. 2010;10:235.

Hyphantis T, Kotsis K, Voulgari PV, Tsifetaki N, Creed F, Drosos AA. Diagnostic accuracy, internal consistency, and convergent validity of the Greek version of the patient health questionnaire 9 in diagnosing depression in rheumatologic disorders. Arthritis Care Res (Hoboken). 2011;63:1313-21.

Zhong Q, Gelaye B, Fann JR, Sanchez SE, Williams MA. Crosscultural validity of the Spanish version of PHQ-9 among pregnant Peruvian women: a Rasch item response theory analysis. J Affect Disord. 2014;158:148-53.

Dum M, Pickren J, Sobell LC, Sobell MB. Comparing the BDI-II and the PHQ-9 with outpatient substance abusers. Addict Behav. 2008;33:381-7.

Zuithoff NP, Vergouwe Y, King M, Nazareth I, van Wezep MJ, Moons KG, Geerlings MI. The Patient Health Questionnaire-9 for detection of major depressive disorder in primary care: consequences of current thresholds in a cross sectional study. BMC Fam Pract. 2010;11:98.

Monteiro S, Torres A, Pereira A, Albuquerque E, Morgadinho R. 2077- Preliminary validation study of a Portuguese version of the patient health questionnaire (PHQ-9). Eur Psychiatry. 2013;28:12-9.

Torres A, Venâncio J. Effects of an innovative group program of multisensory stimulation of older adults. EpSBS. 2016;2016:387-96.

Zhong Q, Gelaye B, Rondon M, Sánchez SE, García PJ, Sánchez E. Comparative performance of Patient Health Questionnaire-9 and Edinburgh Postnatal Depression Scale for screening antepartum depression. J Affect Disord. 2014;162:1-7.

Dadfar M, Lester D. Psychometric characteristics of Patient Health Questionnaire-2 (PHQ-2) in Iranian psychiatric outpatients. Austin J Psychiatry Behav Sci. 2017;4:1059.

Huang FY, Chung H, Kroenke K, Delucchi KL, Spitzer RL. Using the Patient Health Questionnaire-9 to measure depression among racially and ethnically diverse primary care patients. J Gen Intern Med. 2006;21:547-52.

Graves DE, Bombardier CH. Improving the efficiency of screening for major depression in people with spinal cord injury. J Spinal Cord Med. 2008;31:177-84.

Hansson M, Chotai J, Nordstom A, Bodlund O. Comparison of two self rating scales to detect depression: HADS and PHQ-9. Br J Genl Pract. 2009;59:283-8.

Kalpakjian CZ, Toussaint LL, Albright KJ, Bombardier CH, Krause JK, Tate DG. Patient Health Questionnaire-9 in spinal cord injury: an examination of factor structure as related to gender. J Spinal Cord Med. 2009;32:147-56.

Krause JS, Reed KS, McArdle JJ. Factor structure and predictive validity of somatic and nonsomatic symptoms from the Patient Health Questionnaire-9: a longitudinal study after spinal cord injury. Arch Phys Med Rehabil. 2010;91:1218-24.

Richardson EJ, Richards JS. Factor structure of the PHQ-9 screen for depression across time since injury among persons with spinal cord injury. Rehabil Psychol. 2008;53:243-9.

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