Indiana University-Purdue University Indianapolis (IUPUI) / Importance: Despite its widespread use in clinical settings and in behavioral medicine research, little is known about the psychometric performance of the PHQ-9 across major U.S. sociodemographic groups. Thus, utilizing a large sample representative of the U.S. population and confirmatory factor analysis (CFA), we determine the factor structure and measurement invariance of the PHQ-9 across groups based on sex, race/ethnicity, and education level. Objective: Our objective was to address key knowledge gaps by definitively determining the factor structure and measurement invariance of the PHQ-9 across major U.S. sociodemographic groups based on sex, race/ethnicity, and education level. Design: The continuous National Health and Nutrition Examination Survey (NHANES) is a cross-sectional, epidemiologic study designed to assess the health and nutritional status of the U.S. population. We examined data from the 2005-2014 survey years. Setting: NHANES is uses a stratified multistage probability sampling approach to enroll civilian, non-institutionalized adults and children in the U.S. Participants: For our final sample, we selected the 26,202 adult respondents with no missing PHQ-9 data. The factors of interest were sex (49.3% men, 50.7% women), race/ethnicity (48.9% non-Hispanic White, 23.7% non-Hispanic Black, 17.8% Mexican American, 9.7% other Hispanic), and education level (9.9% less than 9th grade, 16.6% 9th-12th grade but no diploma, vii 23.7% high school graduate/GED or equivalent, 28.9% some college or Associate’s degree, 20/8% college graduate or above). Main Outcome(s) and Measure(s): The Patient Health Quessionnaire-9 (PHQ-9) Results: Results revealed that the best solution for the PHQ-9 consists of a cognitive/affective factor (items 1. anhedonia, 2. depressed mood, 6. feelings of worthlessness, 7. concentration difficulties, 8. psychomotor disturbances, and 9. thoughts of death) and a somatic factor (items 3. sleep disturbance, 4. fatigue, and 5. appetite changes; RMSEA = 0.034, RMSEA 90% CI = 0.032–0.036, TLI = 0.984, CFI = 0.988). To evaluate measurement invariance, we then conducted single-group and multiple-group CFAs to carry out the 5 steps of measurement invariance testing. Dimensional, configural, weak factorial, strong factorial, and strict factorial invariance was established for the PHQ-9 across the sex, race/ethnicity, and education level groups, as all models demonstrated close fit and the ΔCFI was < 0.010 for all steps. Conclusions and Relevance: Using a U.S. representative sample, we determined that a two-factor solution for the PHQ-9 with a cognitive/affective factor and a somatic factor is invariant across sex, race/ethnicity, and education level groups. Therefore, clinically, the PHQ-9 is an acceptable measure to utilize in major U.S. sociodemographic groups, extending the use of this depression screener from the primary care clinic to the community. Additionally, we show that PHQ-9 cognitive/affective and somatic subscale scores have the same meaning and can be compared across major U.S. sociodemographic groups and provide a consistent, evidence-based approach to computing PHQ-9 subscale scores to be used in future studies.

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Background Depression is a very common disorder that causes great suffering for the patient. Recognizing depressed patients in primary care (PC) settings is a challenge and only about half are identified as depressed by their general practitioner (GP). Among patients receiving antidepressants (AD) about 70 % are improved, but only about 35 % reach remission. Hence, there is a need to identify depressed patients and to develop optimal treatment strategies in PC. Self-rating scales can be helpful in assisting the recognition. Patients’ beliefs about the cause of depression and their attitudes towards treatment options have been found to influence their help-seeking behavior, coping strategies, treatment preferences and adherence. To increase depressed patients’ knowledge about their disorder and to help them reach and stay in remission, the “Contactus program” was launched in Sweden, containing patient education and group counseling, as supplement to the usual care in PC. Aims To explore patients’ beliefs about causes and improvement factors for depression, and evaluate if the Contactus program could help to improve treatment outcome. Also, to investigate the psychometrics of two commonly used self-rating scales for depression, HADS and PHQ-9. Methods Treatment outcome among patients participating in the Contactus program (N=205) was compared to a control group (N=114) treated as usual. The outcome was measured by HADS, GAF-self and by questionnaires. Both groups also answered an open-ended question about the cause of their depression at baseline and another question about improvement factors at follow-up after six weeks. To compare HADS and PHQ-9, patients (N=737) visiting their physician because of depression filled in both scales. The scales cut-offs were compared with Cohen’s Kappa, internal consistency was calculated and factor analysis was performed.  Results Depressed patients participating in the Contactus program had a response rate of 55 % compared to 29 % in the control group (p=0.006). Also, remission was reached among 42 % in the Contactus group and 21 % among the controls (p=0.02). The patient’s subjective evaluation of the outcome after six weeks showed that 72% of the Contactus patients considered themselves improved vs. 47% among controls (p=0.01). The most common described reason for depression was current stress, most often work related, and own personality traits. Very few mentioned biological factors. For improvement, the most commonly mentioned aspects were participation in the Contactus program and AD. When comparing HADS to PHQ-9 their agreement at recommended cut-offs, HADS-D≥11 and PHQ-9≥10, was low (k=0.35). The highest Kappa value (0.56) and also equal prevalence of depression were found at HADS-D≥8 and PHQ≥12. Both scales had a high internal consistency (α=0.9). Conclusions The results of this thesis indicate that patient education and group counseling are valuable supplements to usual treatment of depression in PC. It is also clear that patients and professionals often have different opinions about the causes of depression, at least concerning biological factors. The patients were generally positive to professional help. The patients’ own beliefs about their illness must be considered when developing new types of interventions and when trying to reach an understanding in the patient-doctor encounter. Finally, there are many self-rating scales for depression. Here two scales were compared and both showed good psychometric properties in terms of internal consistency and factor structure. However their optimal cut-offs were questioned. In conclusion, self-rating scales are useful in identifying depressed patients in PC and might also be apt for measuring treatment outcome. Offering the patient education about their disorder and possibility to share experiences seems to increase response and remission rates, substantially. More studies are needed to explore the effects of educational programs, group interventions, and how patients’ own believes interact with the choice of treatment, adherence and outcome.

Major depressive disorder (MDD) is common among college students. The disease perpetuates depressive symptoms and potentially leads to chronic depressive episodes. Existing literature has shown that students who use both cognitive and behavioral maladaptive coping skills are more prone to endure depressive symptoms and poorer academic performance. Despite these known associations, little research has examined the relationship between coping skills and self-efficacy in response to warning signs of MDD in college students. This study sought to fill the gaps in the research of MDD related to precursors, predictors, and coping mechanisms among undergraduate students in a national sample of U.S. college students. Secondary data (N = 6,713) were analyzed from the Healthy Minds Study 2012, which used the Patient Health Questionnaire-9 (PHQ-9) with a test-retest reliability. Social learning and social cognitive theories were used as the theoretical frameworks to focus on problems such as management of life activities, academic success, and maladaptive beliefs. Analyses of the data from the cross-sectional survey using multiple linear and logistic regressions indicated a statistically significant relationship between depressive symptoms and the potential predictive factors of MDD. These findings contribute positively to social change by informing the work of therapists and program developers, who may use these results to create programs that reduce depressive symptoms among undergraduates.

This research was aimed at validating the PHQ–9 in an African context. This study forms part of the project of Psychosocial Health and Biomarkers in an African context (FORT3, Wissing, 2008). The Patient Health Questionnaire (PHQ–9) is a nine–item depression scale that has the potential of being a dual–purpose instrument to establish the diagnosis of a depressive disorder, as well as the grade of symptom severity (Kroenke, Spitzer & Williams, 2001). The PHQ–9 was administered with criterion related measures to a multicultural convenience sample of 2214 participants from the North West Province of South Africa, including two groups of adolescents (n1 = 1480 and n2 = 559) and an availability sample of adults (n3 = 185). Instruments to determine criterion validity were the General Health Questionnaire (GHQ), designed to detect symptoms of mental disorders; the Mental Health Continuum - Short Form for Adults (MHC–SF) which measures the degree of emotional, social and psychological well–being; and the New General Self–Efficacy Scale (NGSE) designed to measure an individual’s general self–efficacy. Descriptive statistics for the PHQ–9 including its reliability in the various groups is reported. The PHQ–9 manifested a Cronbach Alph are liability index of 0.86. Criterion–related validity was supported by significant correlations between the PHQ–9 and criterion measures. Confirmatory factor analysis for the PHQ–9 yielded a one–factor solution in all groups. The percentage variance explained ranged between 34.71% and 46.62%. Exploratory factor analyses yielded two factors in all groups with the second factor comprised of no more than 2 items and thus interpreted as a minor factor. The construct validity obtained in this research indicates that the PHQ–9 may be a valid measure to identify depression in a South African context. Based on the psychometric properties found in this study, it can be concluded that the PHQ–9 is a valid measure of depression in two of the samples selected for this study. Future studies may further validate this instrument in specific language and cultural groups, and explore the cross–cultural measurement equivalence. / Thesis (M.A. (Research Psychology))--North-West University, Potchefstroom Campus, 2011.

This research was aimed at validating the PHQ–9 in an African context. This study forms part of the project of Psychosocial Health and Biomarkers in an African context (FORT3, Wissing, 2008). The Patient Health Questionnaire (PHQ–9) is a nine–item depression scale that has the potential of being a dual–purpose instrument to establish the diagnosis of a depressive disorder, as well as the grade of symptom severity (Kroenke, Spitzer & Williams, 2001). The PHQ–9 was administered with criterion related measures to a multicultural convenience sample of 2214 participants from the North West Province of South Africa, including two groups of adolescents (n1 = 1480 and n2 = 559) and an availability sample of adults (n3 = 185). Instruments to determine criterion validity were the General Health Questionnaire (GHQ), designed to detect symptoms of mental disorders; the Mental Health Continuum - Short Form for Adults (MHC–SF) which measures the degree of emotional, social and psychological well–being; and the New General Self–Efficacy Scale (NGSE) designed to measure an individual’s general self–efficacy. Descriptive statistics for the PHQ–9 including its reliability in the various groups is reported. The PHQ–9 manifested a Cronbach Alph are liability index of 0.86. Criterion–related validity was supported by significant correlations between the PHQ–9 and criterion measures. Confirmatory factor analysis for the PHQ–9 yielded a one–factor solution in all groups. The percentage variance explained ranged between 34.71% and 46.62%. Exploratory factor analyses yielded two factors in all groups with the second factor comprised of no more than 2 items and thus interpreted as a minor factor. The construct validity obtained in this research indicates that the PHQ–9 may be a valid measure to identify depression in a South African context. Based on the psychometric properties found in this study, it can be concluded that the PHQ–9 is a valid measure of depression in two of the samples selected for this study. Future studies may further validate this instrument in specific language and cultural groups, and explore the cross–cultural measurement equivalence. / Thesis (M.A. (Research Psychology))--North-West University, Potchefstroom Campus, 2011.

Introducción: En la actualidad, existen instrumentos que permiten realizar pruebas de tamizaje de depresión como el Patient Health Questionnaire 9 (PHQ-9). El PHQ-9 es un cuestionario rápido y práctico, siendo utilizado en la población general. En el 2019, se realizó la validación del PHQ-9 en el Perú. Objetivos: Adaptar culturalmente y validar la versión en español del PHQ-9 en la comunidad nativa Shipibo-Konibo Metodología: Se realizó un juicio de expertos para analizar si los nueve ítems del cuestionario PHQ-9 eran adecuados para emplearse en la población nativa. Se realizó el análisis de fiabilidad utilizando los coeficientes alfa de cronbach y omega de mcdonald, la estabilidad con el test-retest a través del r de Pearson y finalmente el análisis factorial exploratorio. Resultados: Los ítems siete y ocho del PHQ-9 obtuvieron valores inferiores a 0.80 según el índice de validez de contenido por ítem (I-CVI). En el análisis de fiabilidad, se obtuvieron los valores alfa de cronbach y omega de mcdonald de 0.720 y 0.748 respectivamente. El r de Pearson fue de 0.315, con un valor p de 0.007. El análisis factorial exploratorio mostró la presencia de dos factores dentro del cuestionario. El primer factor está compuesto por los ítems uno, dos y tres; mientras que el segundo factor está compuesto por los ítems cuatro, cinco y seis. Conclusiones: Los seis primeros ítems del PHQ-9 son las preguntas más adecuadas para realizar un correcto tamizaje de depresión en la comunidad nativa Shipibo-Konibo. / Introduction: Nowadays, there are instruments that allow to realize depression screening tests, such as the Patient Health Questionnaire 9 (PHQ-9). The PHQ-9 is a quick and practical questionnaire, being used in general population. In 2019, the validation of the PHQ-9 was carried out in Peru. Objectives: Culturally adapt and validate the Spanish version of the PHQ-9 in the native Shipibo-Konibo community. Methodology: An expert judgment was carried out to analyze whether the nine items of the PHQ-9 questionnaire were adequate to be used in the native population. The reliability analysis was performed using the Cronbach's alpha and McDonald's omega coefficients, the stability with the test-retest through Pearson's r and finally the exploratory factorial analysis was performed. Results: Items seven and eight of the PHQ-9 obtained values ​​lower than 0.80 according to the item content validity index (I-CVI). In the reliability analysis, the Cronbach's alpha and McDonald's omega values ​​were 0.720 and 0.748 respectively. Pearson's r was 0.315, with a p-value of 0.007. The exploratory factor analysis showed the presence of two factors within the questionnaire. The first factor is composed of items one, two and three; while the second factor is composed of items four, five and six. Conclusions: The first six items of the PHQ-9 are the most appropriate questions to perform depression screening in the native Shipibo-Konibo community. / Tesis

Diss. (sammanfattning) Umeå : Umeå universitet, 2010.