Depression is a common mental health disorder and is a major contributor to the overall global burden of disease. Improving the instruments that are used to detect and assist in the diagnosis of depression is of importance due to the impact that the disorder has on the individual and society. The study aimed to explore and improve the measurement of depression. Seventy-one participants’ results on the PHQ-9 (that measures frequency of depressive symptoms) and the Borg CR scale® (measuring intensity of depressive symptoms) were analysed. It was also of interest to measure mental health patients’ (n = 16) self-rated depression and compare it to mental health staffs’ (n = 7) observer-rated depression. The overall correlation between intensity and frequency of depressive symptoms was found to be positively strong (r =. 695), the Borg CR scale showed high internal consistency when used for measuring intensity of depressive symptoms (.846), self-reported depression was lower than observer-rated depression (p = .167). In addition, inter-individual differences in frequency and intensity of depressive symptoms were also examined. Overall, the outcome of this study showed that intensity of depressive symptoms can differ considerably between individuals, despite similar overall depression scores.

Personer som drabbats av depression återfaller/återinsjuknar ofta en eller flera gånger i livet. Forskning har visat att b la demografiska faktorer, residualsymtom och insomni är prediktorer för återfall. Syftet med studien var därför att undersöka betydelsen av demografiska faktorer, residualsymtom och insomni för nivån av depression 6-12 månader efter avslutad behandling på en psykiatrisk specialistmottagning. Urvalet var alla patienter som diagnosticerats med depression eller recidiverande depression och genomgått KBT-terapi under perioden 2008 – september 2013, och som hade uppföljningsdata vid sex eller tolv-månader, vilket sammanlagt var 111 patienter. Beroendevariabel var resultat på formuläret Patient Health Questionnaire (PHQ-9). Resultaten visade att patienter med residualsymtom inte försämrades signifikant mellan eftermätningen och uppföjningsmätningen, ett fynd som inte överensstämmer med forskning på området. Regressionsanalyser visade ingen signifikant påverkan av kön, ålder och utbildningsnivå på senare nivå av depression vid uppföljningsmätning. Däremot visade regressionsanalyser att sömnbesvär, mätt med formuläret Insomnia Severity Index (ISI), vid framför allt eftermätning hade ett samband med senare nivå av depression vid uppföljningsmätningen. Resultaten indikerade att kvarstående sömnbesvär då behandlingen avslutades predicerade senare nivå av depression. Slutsatsen är att ett tillägg av en sömnintervention för de patienter som har insomni då behandlingen avslutas kan minska sannolikheten för återfall i depression. Då många patienter saknade uppföljningsdata kunde inga säkra slutsatser dras.

The lifetime prevalence of clinical depression in patients living with human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) is approximately 22% compared to 3% to 10% in the primary care population. The nursing practice problem at the project site concerned nurses' lack of knowledge and understanding of procedures to help ensure that all patients living with HIV/AIDS were properly screened for depression and referred for further evaluation and treatment. The purpose of this project was to implement a staff education module to address the use of the PHQ-9 screening tool to identify depression in people diagnosed with HIV/AIDS. The theoretical framework for this educational module was the theory of planned behavior. The practice-focused question explored the extent to which the implementation of an evidence-based practice education model in a primary care clinic treating patients living with HIV/AIDs would increase staff knowledge on the use of the PHQ-9 tool to screen for depression. A staff education project incorporating a pretest and posttest design was conducted to determine whether a significant change existed in the test scores of the participants between the pretest and the posttest. After completion, the posttest measures showed an improvement of 35%. The implications of this project for social change might include improvement in the knowledge, attitudes, and practices of the nurses in the treatment of depression in adults living with HIV/AIDS.

Cortisolkonzentrationen steigen während der Schwangerschaft und sind essentiell für die Organogenese und Einleitung der Geburt (Smith & Shearman, 1974). In dieser Studie haben wir einen Anstieg der HCC und HCNC vom 2. zum 3. Trimester in der Schwangerschaft nachgewiesen. Dabei stieg die HCC um den Faktor 1,3 und die HCNC um den Faktor 1,5. Frühere Studien konnten bereits einen ähnlich hohen physiologischen Anstieg von Cortisol nachweisen um den Faktor 1,5 im Haar und Speichel (D’Anna- Hernandez et al., 2011) und um den Faktor 3 im Urin und Plasma (Jung et al., 2011). Nach bestem Wissen wird in dieser Dissertation zum ersten Mal ein Anstieg der HCNC in der Schwangerschaft beschrieben. Dabei war die HCNC um das Dreifache höher als die HCC in beiden Trimestern, welches die Bedeutung der Inaktivierung von Cortisol zu Cortison durch das Enzym 11B- HSD Typ 2 hervorhebt. Höhere Werte für die HCNC wurden auch in nichtschwangeren Probanden beschrieben (Ullmann et al., 2016). In unserer Studie ergaben sich negative Assoziationen mit den PHQ- Subscores und der HCNC und dem Verhältnis von HCNC/HCC jedoch nie mit der HCC allein. Die gleichzeitige Bestimmung beider Steroide ist somit sinnvoll, gerade im Hinblick auf deren Verhältnis, welches ein indirekter Marker für die 11B- HSD Typ 2 Aktivität ist (Ghaemmaghami et al., 2014, Wilson & Thayer, 2017). Der Zusammenhang zwischen steigenden Stressscores und sinkender HCNC sowie sinkendem Verhältnis von HCNC/HCC lässt vermuten, dass Schwangere mit steigenden Stresssymptomen eine geringere Cortisonkonzentration aufweisen, möglicherweise durch niedrigere Aktivität der 11B- HSD Typ 2, und damit eine geringere Umwandlung von Cortisol zu Cortison. Als einziger Einflussfaktor auf die Konzentration der Steroide im Haar konnte häufiges Haarewaschen identifiziert werden (signifikant niedrigere Konzentrationen beider Steroide). Dies unterstreicht die Bedeutung einer genauen Datensammlung bei Probenabnahme durch gezieltes Erfragen der Haarbehandlung, nicht nur über Manipulation durch Haarfärbung und -tönung, sondern auch über alltägliche Handhabung des Waschens. Das Verhältnis HCNC/HCC wurde weder signifikant durch häufiges Haarewaschen noch durch andere untersuchte potentielle Einflussfaktoren beeinflusst und stellt daher einen robusteren Messparameter auch für zukünftige Studien dar.:I. Abkürzungsverzeichnis 1. Vorbemerkung ……………………………………………………………....…….. 1 2. Einführung in die Thematik 2.1 Definition Stress ……………………………………………………………....... 3 2.2 Physiologische Stressreaktion ……………………………………………....... 3 2.3 Modulation der Stresshormone durch das Enzym 11β- Hydroxysteroid-Dehydrogenase Typ 2 ……………………………………………………...........…… 5 2.4 Messung von Stress ……………………………………………………..……... 6 2.4.1 Messung von Stress durch Biomarker ………………………………..... 6 2.4.2 Messung von Stress durch Fragebögen ……………………………….. 8 2.5 Stress in der Schwangerschaft ………………………………………………... 9 3. Fragestellung …………………………………………………………………….... 11 4. Publikation …………………………………………………………………………. 13 5. Zusammenfassung der Arbeit ……………………………………………………. 21 6. Literaturverzeichnis ………………………………………………………………... 27 II. Anlagen II.A Tabellen ………………………………………………………………………........ 37 II.B Ergänzungsunterlagen zur wissenschaftlichen Publikation …………………. 41 III. Darstellung des eigenen Beitrags ……………………………...……………….. 46 IV. Erklärung über die eigenständige Abfassung der Arbeit ……….…………….. 47 V. Danksagung …..……………………………………………………....................... 48

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.

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.

Depression is a psychiatric disorder associated with severe impairment in physical, social and role functioning, and with higher health care utilization. Experiencing an event that causes physical or psychological stress may substantially increase a person's chances of developing depression. Coping has been defined as a response aimed at diminishing the physical, emotional and psychological burden that is associated with stressful life events. Coping is considered one of the core concepts in health psychology and is strongly associated with the regulation of emotions throughout the stress period and thus it is important that it is understood, especially in the South African context of future morbidity. The purpose of this study was to determine whether there is a relationship between coping self–efficacy strategies and depression in an African context. Participants consisted of a convenience sample of 2 198 participants from both rural and urban areas. The rural group consisted of 182 adolescent Further Education and Training (FET) students between the ages of 16 and 21 years, and the urban group consisted of another 2 016 adolescent FET students between the ages of 16 and 21 years. Participants from both groups completed measurements on coping and depression. Two self–report measures were used: the Coping Self–Efficacy Scale (CSE) to determine a person's confidence or perceived self–efficacy in performing coping behaviors when facing life challenges or threats and the Patient Health Questionnaire (PHQ9) to measure depression severity. Descriptive analysis results indicated that a relationship existed between coping selfefficacy strategies and depression and that levels of depression were very similar for both rural (9.23) and urban (9.25) groups. Coping strategies were very different in rural and urban areas; rural participants only used problem–focused coping and stop unpleasant thoughts and emotions, while urban participants used all three coping self–efficacy strategies: problemfocused coping, stopping unpleasant thoughts and emotions and support from friends and family. Rural participants did not use support from friends and family as a coping selfefficacy strategy; possibly due to the different relationships people living in rural areas have with one another, as opposed to the relationships of people living in urban areas. Rural people may not deem it socially acceptable to ask friends or family members or help when struggling with various stressors. Alternatively, rural areas may be more depleted of personal resources due to the strong urbanization process going on. It was concluded that there is an important relationship between coping strategies and level of depression, and in this study this relationship was found to be different in some ways for rural and urban groups. The results of this study have great implications for further research and clinical practice. / 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.

Depression is a psychiatric disorder associated with severe impairment in physical, social and role functioning, and with higher health care utilization. Experiencing an event that causes physical or psychological stress may substantially increase a person's chances of developing depression. Coping has been defined as a response aimed at diminishing the physical, emotional and psychological burden that is associated with stressful life events. Coping is considered one of the core concepts in health psychology and is strongly associated with the regulation of emotions throughout the stress period and thus it is important that it is understood, especially in the South African context of future morbidity. The purpose of this study was to determine whether there is a relationship between coping self–efficacy strategies and depression in an African context. Participants consisted of a convenience sample of 2 198 participants from both rural and urban areas. The rural group consisted of 182 adolescent Further Education and Training (FET) students between the ages of 16 and 21 years, and the urban group consisted of another 2 016 adolescent FET students between the ages of 16 and 21 years. Participants from both groups completed measurements on coping and depression. Two self–report measures were used: the Coping Self–Efficacy Scale (CSE) to determine a person's confidence or perceived self–efficacy in performing coping behaviors when facing life challenges or threats and the Patient Health Questionnaire (PHQ9) to measure depression severity. Descriptive analysis results indicated that a relationship existed between coping selfefficacy strategies and depression and that levels of depression were very similar for both rural (9.23) and urban (9.25) groups. Coping strategies were very different in rural and urban areas; rural participants only used problem–focused coping and stop unpleasant thoughts and emotions, while urban participants used all three coping self–efficacy strategies: problemfocused coping, stopping unpleasant thoughts and emotions and support from friends and family. Rural participants did not use support from friends and family as a coping selfefficacy strategy; possibly due to the different relationships people living in rural areas have with one another, as opposed to the relationships of people living in urban areas. Rural people may not deem it socially acceptable to ask friends or family members or help when struggling with various stressors. Alternatively, rural areas may be more depleted of personal resources due to the strong urbanization process going on. It was concluded that there is an important relationship between coping strategies and level of depression, and in this study this relationship was found to be different in some ways for rural and urban groups. The results of this study have great implications for further research and clinical practice. / Thesis (M.A. (Research Psychology))--North-West University, Potchefstroom Campus, 2011.