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Patient Health Questionnaire

Patient Health Questionnaire (PHQ-9)

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Purpose

The PHQ-9 assesses the presence and intensity of depressive symptoms.

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Instrument Details

Acronym PHQ-9

Area of Assessment

Depression

Assessment Type

Patient Reported Outcomes

Administration Mode

Paper & Pencil

Cost

Free

CDE Status

Availability
Please visit this website for more information about the instrument:
Classification
Supplemental – Highly Recommended: Headache, Spinal Cord Injury (SCI) and SCI-Pediatric (ages 12 and older), and Stroke
 
Supplemental: Epilepsy, Sport-Related Concussion (SRC) Subacute (after 72 hours to 3 months) and Persistent/Chronic (3 months and greater post concussion), and Traumatic Brain Injury (TBI).
 
Exploratory: Unruptured Cerebral Aneurysms and Subarachnoid Hemorrhage (SAH)

Diagnosis/Conditions

  • Brain Injury
  • Cardiac Dysfunction
  • Parkinson's Disease + Neurologic Rehabilitation
  • Spinal Cord Injury
  • Stroke Recovery

Key Descriptions

  • A self-report questionnaire includes items from the original PHQ's mood module.
  • The PHQ-9 was designed to diagnose both the presence of depressive symptoms as well as to characterize the severity of depression.
  • 9 Items are rated based on frequency of occurrence in the past two weeks (responses in shaded areas of the scoresheet are associated with depression – generally scores of 2 or 3):
    0 = not at all
    1 = several days
    2 = more than half the days
    3 = nearly every day
  • A single question rates how difficult problems have made it to do work, take care of things at home or get along with other people using a 4-level scale ranging from not difficult at all to extremely difficult.

Number of Items

9

Time to Administer

1-3 minutes

1 to 3 minutes

Required Training

Reading an Article/Manual

Age Ranges

Adolescent

13 - 17

years

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

Initially reviewed by Jason Raad, MS and the Rehabilitation Measures Team; Updated with references from the Coronary Heart Disease population by Jon Walmsley, SPT and Mike Weiler, SPT; Updated with references for the TBI population by Erin Donnelly and the TBI EDGE task force of the Neurology Section of the APTA in 2012; Updated with references for Parkinson's Disease, dementia, and stroke by Rachel Mason, SPT and Lauren Nevoral, SPT in 4/2012.

Updated in 2019 by Crystle Grinen, BS, Karen Juarez, BS, Elizabeth Mooney, BS, and Alan Sadural, BS.

ICF Domain

Body Function

Measurement Domain

Emotion

Professional Association Recommendation

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (Vestibular EDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

For detailed information about how recommendations were made, please visit:  http://www.neuropt.org/go/healthcare-professionals/neurology-section-outcome-measures-recommendations

Abbreviations:

 

HR

Highly Recommend

R

Recommend

LS / UR

Reasonable to use, but limited study in target group  / Unable to Recommend

NR

Not Recommended

 

Recommendations based on level of care in which the assessment is taken:

 

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

TBI EDGE

LS

R

R

R

R

 

Recommendations for use based on ambulatory status after brain injury:

 

Completely Independent

Mildly dependant

Moderately Dependant

Severely Dependant

TBI EDGE

N/A

N/A

N/A

N/A

 

Recommendations for entry-level physical therapy education and use in research:

 

Students should learn to administer this tool? (Y/N)

Students should be exposed to tool? (Y/N)

Appropriate for use in intervention research studies? (Y/N)

Is additional research warranted for this tool (Y/N)

TBI EDGE

No

Yes

Yes

Not reported

Considerations

Using the PHQ-9 in clinical settings may result in a larger than acceptable number of false-positives because positive predictive value tends to be low (Wittkampf et al., 2009) 

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Older Adults and Geriatric Care

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Standard Error of Measurement (SEM)

Older Primary Care Patients: 

(Lowe, Unutzer, et al, 2004, n = 434, mean age = 71 (7.4) years, all participants enrolled in the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT), Older Primary Care Patients)

  • SEM for for change due to treatment and no control of prior depression = 2.44 
  • SEM for the the same number of DSM-IV depressive symptoms at both assessments = 1.32

Minimally Clinically Important Difference (MCID)

Older Primary Care Patients:

(Lowe, Unutzer, et al, 2004, Older Primary Care Patients)

  • MCID = 5 points

Test/Retest Reliability

Chronically Ill Elderly Patients:

(Lamars, et al., 2008; = 106; mean age = 71.4 (6.9); 51% diagnosed with DM, Chronically Ill Elderly Patients) 

  • Excellent Test-retest reliability (correlation = 0.91)

 

Older Primary Care Patients:

(Lowe, et al, 2004; at baseline and 6 months, Older Primary Care Patients)

  • Excellent test-retest reliability for change due to treatment and no control of prior depression (ICC = 0.81) 
  • Excellent test-retest reliability for same number of DSM-IV depressive symptoms at both assessments (ICC = 0.96)

Older Adults: (Chen et al., 2016; n=82)

  • Excellent test-retest reliability: (ICC = 0.79)

Internal Consistency

Older Adults

  • Adequate internal consistency (Cronbach’s alpha = 0.77) (Chen et al., 2016; n=634)
  • Adequate internal consistency (Cronbach’s alpha = 0.725) (Zhang et al., 2019; n= 1546)

New Nursing Home Admits (Belanger et al, 2019; n = 1,734,785; 65.09% were cognitively intact, 21.1% had mild impairment, 13.43% had moderate impairment, and .26 had severe impairment)

  • Excellent internal consistency: (McDonald’s omega = 0.87)

Long-Stay Nursing Home Cohort (Belanger et al., 2019; n = 122,949; 4.66% were cognitively intact, 20.7% had mild impairment, 38.95% had moderate impairment, and 32.51 had severe impairment)

  •  Excellent internal consistency: (McDonald’s omega = 0.87)

Criterion Validity (Predictive/Concurrent)

Concurrent Validity

Older Adults: (Chen et al., 2016; n=634)

Concurrent validity of the PHQ-9 with the Hamiltyom Rating Scale for Depression (HAMD-17) and Short Form of the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q-SF)

Measures

PHQ-9 Whole Scale

PHQ-9 Non-somatic component

PHQ-9 Somatic Component

Q-LES-Q-SF total score

-0.53

-0.47

-0.47

Q-LES-Q-SF psychosocial dimension

-0.47

-0.45

-0.40

Q-LES-Q-SF physical dimension

-0.48

-0.37

-0.46

HAMD-17

0.66

0.55

0.60

P Value <0.001

 

Criterion Validity

Older Adults (Chen et al., 2016; n=634)

  • Excellent criterion validity for major depressive disorder (AUC of ROC was 0.97)

New Nursing Home Admits (Belanger et al, 2019; n = 1,734,785)

  • Adequate criterion validity for depression for a PHQ-9 score of 10 or above (r= 0.54)

 

Long-Stay Nursing Home Cohort (Belanger et al., 2019; n = 122,949)

  • Excellent criterion validity for depression for a PHQ-9 score of 10 or above (r= 0.67)

Construct Validity

Construct Validity

Older Adults: (Chen et al., 2016; n=634)

Construct Validity of PHQ-9 individual item loadings for factor analysis (n=634)

 

Component

Items

Somatic Dimension

Non Somatic Dimension

3. Trouble falling or staying asleep or sleeping too much

0.471

 

4. Feeling tired or having little energy

0.640

 

5. Poor appetite or overeating

0.673

 

7. Trouble concentrating on things

0.711

 

8. Moving or speaking so slowly or the opposite

0.660

 

1. Little interes or pleasure in doing things

 

0.520

2. Feeling down, depressed, or hopes

 

0.666

6. Feeling bad about yourself

 

0.822

9. Thoughts that you would be better off dead

 

0.794

Non-Specific Patient Population

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Cut-Off Scores

Meta-analysis:

(Gilbody, et al, 2007; 14 validated studies reviewed; n = 5,026 participants, Meta-analysis)

  • Clinicians and researchers may elect to adjust cut-scores in response to clinical population characteristics

 

Coronary Heart Disease:

(Thombs, et al, 2008; n = 1024, Coronary Heart Disease) 

  • Cutoff score of > 6 for Major Depressive Disorder, with 83% sensitivity and 76% specificity

(McManus, et al, 2005; n = 1024, Coronary Heart Disease) 

  • Cutoff score of > 10 for Major Depressive Disorder with 54% sensitivity and 90% specificity

 

Patients with Mental Health or Somatic Complaints:

Wittkampf, et al, 2009; n = 664; mean age = 49.8; Diagnosed as depressed based on Structured Clinical Interview for DSM-IV Axis I Disorders = 12.3%; Dutch sample, Patients with Mental Health or Somatic Complaints) 

  • For screening a cutoff > 10 points demonstrated the highest sensitivity and specificity, however, the PHQ-9 was not found to be specific enough to be used for diagnostic purposes among populations at the highest risk.

 

General Medical Population:(Lowe et al, 2004, n = 501; mean age = 41.7 (13.8) years; participants were recruited from outpatient clinics and 12 family practices; German sample, General Medical Population) 

  • The PHQ-9 was found to be more accurate in diagnosing ‘major depressive disorder’ than either the Hospital Anxiety and Depression Scale (HADS) or the Well Being Index (WBI-5) 
  • Suggested cut-off to indicate depression is PHQ-9 > 11 

General Medical Population

  • Suggested cut-off to indicate depression is PHQ-9 > 10 (sensitivity 0.88; specificity 0.85) (Levis et al, 2019; Studies n=29; participants n=6725; major depression n=924)
  • Optimal cut-off score of 10 (Sensitivity = 81%; specificity = 79%; PPV = 59% and NPV = 92%) (Daray, F. M. et. al, 2019; n = 257)

Test/Retest Reliability

Primary Care Patients:

(Zuithoff, et al., 2010; n = 1338; mean age = 51, Primary Care Patients) 

  • Excellent Test-retest reliability (Correlation = 0.94) 

 

Primary Care Patients:

(Kroenke, et al, 2001; n = 3000; mean age = 46 (17) years; most common medical conditions = Hypertension (25%) and Arthritis (11%), Primary Care Patients)

  • Excellent test-retest reliability over a 48 hour period (r = 0.84)

Internal Consistency

Coronary Heart Disease:

(Stafford, et al, 2007; = 193, Coronary Heart Disease)

  • Excellent internal consistency (Chronbach's alpha = 0.90) 

 

Outpatients:

(Lowe, Spitzer, et al, 2004; n = 501; mean age = 41.7 (13.8) years; German sample, Outpatients)

  • Excellent internal consistency (Cronbach’s alpha = 0.88)

 

Primary Care Patients:

(Kroenke, et al, 2001, Primary Care Patients)

  • Excellent internal consistency (Chronbach's alpha > 0.86)

 

(Zuithoff, et al. 2010, Primary Care Patients) 

  • Excellent internal Consistency (ICC = 0.88)

General Medical Population (Daray, F. M. et. al, 2019; n = 257)

  • Excellent internal consistency (Cronbach's α value of 0.86)

Undergraduate University Students: (McCord et al., 2020; n = 231)

  • Adequate internal consistency (Cronbach's α value of 0.76)\
  • Poor internal consistency (inter-item correlation coefficient = 0.27)

Criterion Validity (Predictive/Concurrent)

Primary Health Care (with Full PHQ):

(Löwe et al 2004, n = 501, mean age = 41.7 (13.8) years; German sample); common health complaints included: diseases of the musculoskeletal system and connective tissue (21%), endocrine, nutritional and metabolic diseases (16%), cardiovascular/circulatory diseases (10%), Primary Health Care (with Full PHQ))

 

Concurrent Validity Using the International Diagnostic Checklists (IDCL) for ICD-10 to Assess Severity of Depression:

 

 

 

 

 

 

 

PHQ

 

HADS

 

WBI-5

 

Level of Depression

mean

SD

mean

SD

mean

SD

No depressive episode

6.6

4.7

5.4

3.8

13.0

5.7

Mild depressive episode

13.9

5.2

10.1

3.3

6.7

4.2

Moderate depressive episode

17.8

4.7

12.7

4.0

3.6

2.6

Severe depressive episode

19.2

3.9

14.3

4.3

3.6

2.9

PHQ = (full) Patient Health Questionnaire
HADS = Hospital Anxiety and Depression Scale
WBI-5 = WHO Well-Being Index 5

 

 

 

 

 

 

 

General Medical Population (Daray, F. M. et. al, 2019; n = 257)

  • Adequate criterion validity for major depressive episode (AUC of ROC was 0.87)

Construct Validity

Coronary Heart Disease:

(Stafford et al, 2007; n = 193, Coronary Heart Disease)

  • Moderate correlation between PHQ-9 and Hospital Anxiety Depression Scale with cutoff score > 6 for major depressive disorder (= 0.72)

 

General Population:

(Martin, et al; 2006; mean age = 48.8 (18.1); 53% female and 47% male, General Population) 

  • Excellent correlations between PHQ-9 and BDI (= 0.73, p < 0.001) 
  • Excellent correlations between PHQ-9 and GHQ-12 (r = 0.59, p < 0.001) 

 

Patients with Mental Health or Somatic Complaints:

(Wittkampf et al, 2009, Patients with Mental Health or Somatic Complaints)

  • Adequate correlations between PHQ-9 total score & Hamilton Depression Rating Scale (HDRS-17) score (r = 0.52, two tailed P < 0.01)

Undergraduate University Students: (McCord et al., 2020; n = 231)

  • Adequate Convergent Validity between PHQ-9 scores and Emotional/Internalizing Dysfunction subscale of Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) (r = .48)
  • Poor Convergent Validity between PHQ-9 scores and Thought Dysfunction subscale of MMPI-2-RF (r = .25)
  • Poor Convergent Validity between PHQ-9 scores and Behavioral/Externalizing Dysfunction subscale of MMPI-2-RF (r = .24)
  • Adequate convergent validity between PHQ-9 and MMPI-2-RF RCd-Demoralization (r = 0.59), RC2-Low Positive Emotions (r = 0.33), and RC7-Dysfunctional Negative Emotions (r = 0.44)

Content Validity

  • The PHQ-9 is derived from the Primary Care Evaluation of Mental Disorders interview schedule which utilizes criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) to diagnose depression

  • Rasch analysis suggests the PHQ-9 is a unidimensional measure of depression (Williams, et al, 2009)

  • The PHQ-9 has been found to be accurate in medical settings (Thompson et al, 2011)

Responsiveness

Depression:

(Lowe, et al, 2006; n = 1,788 (diagnosed with: Major Depressive Disorder (MDD) n = 757, minor depression n= 543, other depressive disorders  n = 438 patients); Mean age 50.3 (14.7) years, Depression)

  • On the 0 to 27 scale, the mean change of for this population was 10.3 (5.6) points over a 12 week period.

Responsiveness of the PHQ-9 to Sertraline (antidepressant) Treatment:

 

 

 

 

 

 

 

 

 

Baseline

 

12 week follow-up

 

 

 

 

n

mean

SD

mean

SD

Strength

Effect Size*

Total sample

1788

16.04

4.87

5.76

4.20

Large

-1.85

Comorbid physical illness (Yes)

535

16.00

4.54

6.75

4.43

Large

-1.71

Comorbid physical illness (No)

1253

16.06

5.00

5.33

4.02

Large

-1.93

*Standardized response mean

 

 

 

 

 

 

 

Alzheimer's Disease and Progressive Dementia

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Cut-Off Scores

Dementia:

(Hanock et al, 2009; = 113; mean age = 69 (11.7) years, Dementia)

  • Cut off point of 9 which coincides with the threshold between mild and moderate depression

Normative Data

Dementia:

(Hanock et al, 2009, Dementia)

  • Demented group PHQ-9 scores:
    • Mode = 0
    • Median = 2
    • Mean = 4.1 +/- 5.4
  • Non demented group PHQ-9 scores:
    • Mode = 0 
    • Median = 3.5 
    • Mean = 7.8 +/- 7.9

Criterion Validity (Predictive/Concurrent)

Dementia:

(Hanock et al, 2009, Dementia)

  • Area under the receive operating characteristic curve (ROC) = 0.63
  • Shows that this test has poor diagnostic accuracy

Floor/Ceiling Effects

Dementia:

(Hanock et al, 2009, Dementia)

  • Floor effects = 30%, participants reported no depressive symptoms

Parkinson's Disease

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Cut-Off Scores

Parkinson’s Disease:

(Williams et al, 2012; = 229; mean age = 66.0 (10.8) years, Parkinson's Disease)

  • Cut off score of ≥6 for PHQ-9, with 66% sensitivity and 80% specificity 

(Thompson et al, 2011; = 214; mean age = 72.5 (9.6) years, Parkinson's Disease)

  • Cut off score of ≥ 5 for major depression for PHQ-9 
  • Cut off score of 2-4 for minor depression for PHQ-9

Patient with Parkinson’s Disease: (Chagas et al., June 2013; n=110)

  • Cut-off score of 9 for major depressive disorder (sensitivity of 100% and specificity of 83.1%)

Normative Data

Parkinson’s Disease:

(Williams et al, 2012, Parkinson's Disease)

  • Active depressive disorder is probable with PHQ-9 scores of 8.9 (5.2)
  • No active depressive disorder is probable with a PHQ-9 score of 3.8 (3.8)

Interrater/Intrarater Reliability

Parkinson’s Disease:

(Thompson et al, 2011, Parkinson's Disease)

  • Adequate interrater reliability 95%CI = 0.4 (0.26, 0.54) between PHQ-9 and SCID

Internal Consistency

Parkinson’s Disease:

(Williams et al, 2012, Parkinson's Disease)

  • Excellent internal consistency (Cronbach’s alpha = 0.85)

Patient with Parkinson’s Disease: (Chagas et al., June 2013; n=110)

  • Excellent: Cronbach's alpha of 0.83

Criterion Validity (Predictive/Concurrent)

Predictive Validity:

Parkinson’s Disease: (Chagas et al., June 2013; n=110)

  • Excellent criterion validity for depression for PHQ-9 (AUC of ROC was 0.94)

 

Concurrent validity:

  • Excellent: the PHQ-9 correlated with the Zung Self-rating Depression Scale (SDS) and the 15-item Geriatric Depression Scale (GDS-15) with Spearman’s coefficient of 0.630 (p<0.001) for both scales

Stroke

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Cut-Off Scores

Stroke:

(de Man-Van Ginkel et al, 2012; = 55; mean age = 65.09 (15.03) years; mean time since stroke onset = 59.82 (77.43) days, Stroke)

  • The optimum cut-off value for the PHQ-9 was 10 with 100% sensitivity and 86% specificity 

(de Man-Van Ginkel et al, 2012; = 164; mean age = 70.6 (13.99) years; mean time since stroke onset = 6.7 (0.9) weeks, Stroke)

  • Accuracy of the PHQ-9 was best at a cutoff score of greater than or equal to 10 with a sensitivity of 0.80 and specificity of 0.78

(Prisnie et al., 2016; n= 122; mean age = 60.1 (15.6) years; mean time since stroke onset = 0.3 years [0.18-0.88])

  • > 13 indicates risk of depression (sensitivity 81.8%; specificity 97.1%)

Test/Retest Reliability

Stroke:

(de Man-Van Ginkel et al, 2012, Stroke)

  • Excellent test-retest reliability for the agreement between the pairs of nurses on the sum score level (ICC = 0.98)

Interrater/Intrarater Reliability

Stroke:

(de Man-Van Ginkel et al, 2012, Stroke)

  • Excellent interrater reliability (ICC = 0.98)

Internal Consistency

Stroke:

(de Man-Van Ginkel et al, 2012, Stroke)

  • Excellent internal consistency (Chronbach’s alpha = 0.79)

Criterion Validity (Predictive/Concurrent)

Stroke:

(de Man-Van Ginkel et al, 2012, Stroke)

  • Concurrent validity between PHQ-9 and Geriatric Depression Scale (GDS-15) was excellent with r = 0.7 and P < 0.001 
  • Area under the receive operating characteristic curve (ROC) = 0.87 (95%CI 0.80-0.93)
  • Discriminatory power for the PHQ-9 was adequate

(Prisnie et al., 2016; n= 122; mean age = 60.1 (15.6) years; mean time since stroke onset = 0.3 years [0.18-0.88])

  • Adequate criterion validity for depression at cut-off point of 13 (AUC of ROC was 0.895)

Brain Injury

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Cut-Off Scores

Traumatic Brain Injury:

(Fann, et al, 2005; n = 478; mean age = 42 (17.9) years; mean time since TBI = 3.8 (2.8) months, TBI) 

  • PHQ-9 cutoff > 12 was the best screening criteria for Major Depressive Disorder (MDD) 

(Cook, et al. 2011; = 365; mean age: 43 (17.7); 1 year post-injury, TBI) 

  • Minimal: 0-4 
  • Mild: 5-9 
  • Moderate: 10-14 
  • Moderately severe: 15-19 
  • Severe: >20

TBI Patients: (Donders & Pendery, 2017; n = 137; mean age = 40.42 (15.03) years; Median PHQ-9 score = 9 (IQR = 0 to 25); assessed within 1 to 12 months post TBI)

  • Cut off score of 10 demonstrated best sensitivity and specificity (sensitivity = .917, specificity =.602)

Test/Retest Reliability

Traumatic Brain Injury:

(Fann, et al, 2005, TBI)

  • Excellent test-retest reliability within 7 of initial assessment (r = 0.76)

Interrater/Intrarater Reliability

TBI Patients: (Dyer et al., 2016; n = 100)

  • Excellent person separation reliability (0.78)

Internal Consistency

TBI Patients: (Dyer et al., 2016; n = 100)

  • Excellent internal consistency (Cronbach’s alpha = 0.82-0.84)

Criterion Validity (Predictive/Concurrent)

TBI Patients: (Donders & Pendery, 2017; n = 137)

  • Adequate criterion validity for diagnosis of major depression (AUC of ROC was 0.759)

TBI Patients

  • Excellent convergent validity between the PHQ-9 and the Symptom Checklist-20 (r = 0.85) (Dyer et al., 2016; n = 100)
  • Excellent convergent validity between the PHQ-9 and the Hamilton Depression Rating Scale (HAM-D) (r = 0.81) (Dyer et al., 2016; n = 100)
  • Excellent convergent validity between the PHQ-9 and the Maier subscale of HAM-D (r = 0.82) (Dyer et al., 2016; n = 100)
  • Excellent convergent validity between the PHQ-9 and the Bech subscale of HAM-D (r = 0.80) (Dyer et al., 2016; n = 100)
  • Adequate convergent validity between the PHQ-9 and the Patient Global Impression scale - improvement (r = 0.49) (Dyer et al., 2016; n = 100)
  • Excellent convergent validity between the PHQ-9 and the Structured Clinical Interview for DSM-IV (r = 0.78) (Dyer et al., 2016; n = 100)
  • Excellent convergent validity between the PHQ-9 and the Minnesota Multiphasic Personality Inventory-2-Restructured Form Demoralization (r = 0.64) (Donders & Pendery, 2017; n = 137)
  • Adequate convergent validity between the PHQ-9 and the Minnesota Multiphasic Personality Inventory-2-Restructured Form Low Positive Emotions (r = 0.48) (Donders & Pendery, 2017; n = 137)

 

(Donders & Pendery, 2017; n = 137)

Logistic Regression Model for PHQ-9 Elevations

Parameter

B

SE

β

P

Years of education

-0.05

0.09

-0.06

0.59

Prior outpatient psychiatric treatment

1.23

0.38

0.34

0.002

Prior substance abuse

0.19

0.50

0.04

0.71

Prior mild TBI

-0.38

0.55

-0.07

0.50

Uncomplicated mild TBI

0.83

0.43

0.21

0.05

Comorbid orthopedic injury

0.24

0.43

0.06

0.58

Time since injury

-0.01

0.01

-0.12

0.27

Construct Validity

Traumatic Brain Injury:

(Fann, et al, 2005, TBI)

  • Excellent convergent validity between the PHQ-9 and SCL-20 (Hopkins Symptom Checklist depression subscale; r = 0.90)
  • Excellent convergent validity between the PHQ-9 and HAM-D (Hamilton Rating Scale for Depression; r= 0.78)
  • Excellent discriminant validity between the PHQ-9 and SCL-20 (r = 0.84)
  • Excellent discriminant validity between the PHQ-9 and HAM-D (= 0.67, p < 0.001)

Spinal Injuries

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Normative Data

SCI:

(Krause, et al, 2009; n = 727, 53.3% had cervical injuries; mean age 47.9 years, time since injury 18.2 years, Chronic SCI)

  • Mean PHQ-9 score = 5.57 (5.74)
  • Mean Older Adult Health and Mood Questionnaire (OAHMQ) score =  6.0 (5.0)

(Bombardier, et al, 2004; Norms based on Kroenke, et al. 2001, Chronic SCI)

  • Mean PHQ-9 score = 5.48 (95% CI = 5.07–5.88)
  • Major Depressive Disorder (MDD) is probable with PHQ-9 scores > 18.1 (3.9)

PHQ-9 SCI Norms:

 

Diagnostic Catagory

Total Score

No depressive symptoms

0

Minimal depressive symptoms

1 to 4

Mild depressive symptoms

5 to 9

Moderate depressive symptoms

10 to 14

Moderate/severe depressive symptoms

15 to 19

Severe depressive symptoms

20 to 27

Test/Retest Reliability

Spinal Cord Injury: (Summaka et al., 2019; n=51)

  • Excellent Reliability test-retest reliability (ICC = 0.88)

Internal Consistency

SCI:

(Bombardier, et al, 2004, Chronic SCI)

  • Excellent internal consistency (Chronbach's alpha = 0.87)
  • First assessment completed by the patient, while the second was conducted over the phone 48 hours later

Spinal Cord Injury

  • Adequate: Cronbach's alpha of 0.71 (Summaka et al., 2019; n=51)
  • Excellent: Cronbach’s alpha of 0.87 (Dorstyn et al., 2019; n=48 mean age= 42)
  • Excellent: Cronbach’s alpha of 0.82 (Williams et al., 2016; n=133)

Construct Validity

SCI:

(Krause et al, 2009, Chronic SCI)

  • Excellent correlations between the PHQ-9 and Older Adult Health and Mood Questionnaire (OAHMQ) scale (r = 0.78)
  • Adequate correlations between PHQ-9 & prevalence of Major Depressive Disorder (r = 0.530)

 

(Bombardier et al, 2004, Chronic SCI)

  • Adequate convergent validity between PHQ-9 scores and:
    • Life satisfaction (r = -0.51, p < 0.001) 
    • Subjective health (r = -0.50, p < 0.001)

Convergent Validity:

Spinal Cord Injury:

  • Excellent convergent validity between the PHQ-9A total scale and the (HDRS-A) Hamilton Depression Rating Scale Arabic version (r=0.713, p<0.001). (Summaka et al., 2019; n=51)
  • Excellent convergent validity between the PHQ-9 and the Hopkins Symptom Checklist-20 (r = 0.78) (Williams et al., 2016; n=133)
  • Excellent convergent validity between the PHQ-9 and the Hamilton Depression Rating Scale (HAM-D) (r = 0.68) (Williams et al., 2016; n=133)
  • Excellent convergent validity between the PHQ-9 and the Maier subscale of HAM-D (r = 0.67) (Williams et al., 2016; n=133)
  • Excellent convergent validity between the PHQ-9 and the Bech subscale of HAM-D (r = 0.69) (Williams et al., 2016; n=133)
  • Adequate convergent validity between the PHQ-9 and the Patient Global Impression scale - improvement (r = 0.66) (Williams et al., 2016; n=133)
  • Excellent convergent validity between the PHQ-9 and the Structured Clinical Interview for DSM-IV (r = 0.79) (Williams et al., 2016; n=133)
  •  

Discriminatory Validity

Spinal Cord Injury: (Summaka et al., 2019; n=51)

  • Adequate discriminatory validity between the PHQ-9A total scale and the (HDRS-A) Hamilton Depression Rating Scale Arabic version indicating that the PHQ-9-A has greater discriminatory power (AUC of ROC was 0.83)

Floor/Ceiling Effects

SCI:

(Williams, et al, 2009; n = 202; mean age = 42.6 (13.9) years; > 1 (Range = 1 to 44) years post injury, Chronic SCI) 

  • 22% of participants reported no depressive symptoms

Spinal Cord Injury: (Williams et al., 2016; n=133)

  • Adequate floor effects = 5% reported no depressive symptoms

Responsiveness

Spinal Cord Injury: (Williams et al., 2016; n=133)

●  Williams et al., stated that the comparison of the PHQ-9 to the Hopkins Symptom Checklist-20 (HSCL-20), and the Hamilton Depression Rating Scale (HAM-D) in people with SCI diagnosed with major depressive disorder, the PHQ-9 detected a small effect size change over the 12 weeks of the randomized controlled trial.

  • Effect Size: Small Change: effect size= -.06

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