Using the Patient Health Questionnaire-9 to measure depression among racially and ethnically diverse primary care patients.
Journal: 2006/September - Journal of General Internal Medicine
ISSN: 1525-1497
Abstract:
OBJECTIVE
The Patient Health Questionnaire depression scale (PHQ-9) is a well-validated, Diagnostic and Statistical Manual of Mental Disorders- Fourth Edition (DSM-IV) criterion-based measure for diagnosing depression, assessing severity and monitoring treatment response. The performance of most depression scales including the PHQ-9, however, has not been rigorously evaluated in different racial/ethnic populations. Therefore, we compared the factor structure of the PHQ-9 between different racial/ethnic groups as well as the rates of endorsement and differential item functioning (DIF) of the 9 items of the PHQ-9. The presence of DIF would indicate that responses to an individual item differ significantly between groups, controlling for the level of depression.
METHODS
A combined dataset from 2 separate studies of 5,053 primary care patients including non-Hispanic white (n=2,520), African American (n=598), Chinese American (n=941), and Latino (n=974) patients was used for our analysis. Exploratory principal components factor analysis was used to derive the factor structure of the PHQ-9 in each of the 4 racial/ethnic groups. A generalized Mantel-Haenszel statistic was used to test for DIF.
RESULTS
One main factor that included all PHQ-9 items was found in each racial/ethnic group with alpha coefficients ranging from 0.79 to 0.89. Although endorsement rates of individual items were generally similar among the 4 groups, evidence of DIF was found for some items.
CONCLUSIONS
Our analyses indicate that in African American, Chinese American, Latino, and non-Hispanic white patient groups the PHQ-9 measures a common concept of depression and can be effective for the detection and monitoring of depression in these diverse populations.
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J Gen Intern Med 21(6): 547-552

Using the Patient Health Questionnaire-9 to Measure Depression among Racially and Ethnically Diverse Primary Care Patients

Department of Psychiatry, University of California, San Francisco, CA, USA
Charles B. Wang Community Health Center, New York, NY, USA
New York University, New York, NY, USA
Indiana University School of Medicine, Indianapolis, IN, USA
Regenstrief Institute, Inc., Indianapolis, IN, USA
Biometrics Research Department, New York Psychiatric Institute, New York, NY, USA
Department of Psychiatry, Columbia University, New York, NY, USA
Address correspondence and requests for reprints to Dr. Huang: UCSF, Department of Psychiatry, 1001 Potrero Ave., Suite 7M, San Francisco, CA 94110 (e-mail: ude.dravrah.tsop@ydderf).
The authors have no conflicts of interest to declare.
This paper was presented at the 2005 American Psychiatric Association Annual Meeting in Atlanta, GA, on May 23, 2005.
The authors have no conflicts of interest to declare.
This paper was presented at the 2005 American Psychiatric Association Annual Meeting in Atlanta, GA, on May 23, 2005.
Received 2005 Jun 20; Revised 2005 Sep 9; Accepted 2005 Dec 8.

Abstract

OBJECTIVE

The Patient Health Questionnaire depression scale (PHQ-9) is a well-validated, Diagnostic and Statistical Manual of Mental Disorders— Fourth Edition (DSM-IV) criterion-based measure for diagnosing depression, assessing severity and monitoring treatment response. The performance of most depression scales including the PHQ-9, however, has not been rigorously evaluated in different racial/ethnic populations. Therefore, we compared the factor structure of the PHQ-9 between different racial/ethnic groups as well as the rates of endorsement and differential item functioning (DIF) of the 9 items of the PHQ-9. The presence of DIF would indicate that responses to an individual item differ significantly between groups, controlling for the level of depression.

MEASUREMENTS

A combined dataset from 2 separate studies of 5,053 primary care patients including non-Hispanic white (n =2,520), African American (n =598), Chinese American (n =941), and Latino (n =974) patients was used for our analysis. Exploratory principal components factor analysis was used to derive the factor structure of the PHQ-9 in each of the 4 racial/ethnic groups. A generalized Mantel-Haenszel statistic was used to test for DIF.

RESULTS

One main factor that included all PHQ-9 items was found in each racial/ethnic group with α coefficients ranging from 0.79 to 0.89. Although endorsement rates of individual items were generally similar among the 4 groups, evidence of DIF was found for some items.

CONCLUSIONS

Our analyses indicate that in African American, Chinese American, Latino, and non-Hispanic white patient groups the PHQ-9 measures a common concept of depression and can be effective for the detection and monitoring of depression in these diverse populations.

Keywords: depression, diagnosis, screening, ethnicity
Abstract

Major depression is 1 of the most common psychiatric disorders. The National Comorbidity Survey Replication estimates the lifetime prevalence of major depressive disorder to be 16% among adults in the United States. 1 Moreover, depressive illness is projected to have significant public health and economic costs: major depression is expected to be the second leading cause of death and disability and to impose the greatest burden of ill health worldwide by 2020. 2 Depression, however, is frequently unrecognized and not treated. 3 The U.S. Preventive Services Task Force (USPSTF) has therefore recommended systematic screening of depression in clinical settings with appropriate systems in place to ensure effective treatment and follow-up. 4

The PHQ-9 is the depression module of the self-administered version of the PRIME-MD diagnostic instrument, called the Patient Health Questionnaire (PHQ). 5 The PHQ-9 is an instrument whose 9 items are based on the DSM-IV diagnostic criteria. Each of the 9 items can be scored from 0 (not at all) to 3 (nearly every day). Its validity and reliability as a diagnostic measure as well as its utility in assessing depression severity and monitoring treatment response are well-established. 512

No studies, however, have yet examined the factor structure and differential functioning of the PHQ-9 in different racial/ethnic minority groups. In fact, relatively few studies have systematically investigated racial/ethnic differences in the function of other depression screening instruments. 1321 Assessing the performance of the PHQ-9 and other depression measures in different racial/ethnic groups is of growing concern because of the increasing diversity in the United States. According to the U.S. Census Bureau, Latinos are the largest racial/ethnic minority group in the country, numbering more than 35 million, whereas African Americans have historically constituted a numerically important minority group in the United States, currently numbering 34 million persons. 22 Asian Americans are a fast-growing racial/ethnic group, increasing 44% from 1990 to 2000. 23 It is projected that by the year 2020 the Asian American population will reach approximately 20 million. 24 This growing diversity in the United States makes the need for diagnostic instruments that can provide accurate, clinically relevant information for depression across racial/ethnic groups an urgent public health priority, especially in light of the USPSTF recommendation for screening of depression in routine care.

In this paper, data from the original PHQ Primary Care and Obstetrics/Gynecology validation studies were combined with PHQ-9 screening data collected from Chinese American patients attending a large urban primary care clinic. We compared the factor structure as well as the individual items of the PHQ-9 in 4 racial/ethnic subgroups: African American, Chinese American, Latino, and non-Hispanic whites.

Non-Hispanic white was the referent group. All tests 1 degree-of-freedom.

P-values in bold type significant at P < .05/9 = .0055.

Acknowledgments

We would like to thank Sarah Yip, BA, for her technical assistance, and Diane M. Davis, BS, and Scott Bilder, MS, for their statistical expertise. This study was supported by grants from the National Institute of Mental Health: T32 MH16242 (Dr. Huang) and P60 MD000538 (Drs. Huang and Chung).

Acknowledgments

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