Archives of Women's Mental Health

, Volume 15, Issue 5, pp 367–374 | Cite as

Validation of the Patient Health Questionnaire (PHQ)-9 for prenatal depression screening

  • Abbey C. SidebottomEmail author
  • Patricia A. Harrison
  • Amy Godecker
  • Helen Kim
Original Article


The study was designed to validate the Patient Health Questionnaire (PHQ-9) for depression risk identification among pregnant women. Pregnant women were routinely administered the Prenatal Risk Overview, a comprehensive psychosocial screening interview, which included the PHQ-9, at their prenatal intake appointment at three community clinics. Study participants completed the Structured Clinical Interview for DSM-IV (SCID) at a later appointment. PHQ-9 risk classifications were cross-tabulated with SCID diagnostic categories to examine concordance, sensitivity, specificity, and positive and negative predictive values. The study sample included 745 women. Prevalence of a current major depressive episode was 3.6 %; an additional 7.0 % were classified as meeting subdiagnostic criteria of three or more depressive symptoms. A PHQ-9 score cutoff of 10 yielded sensitivity and specificity rates of 85 and 84 %, respectively, for a depression diagnosis and 75 and 88 % for a subdiagnosis, respectively. Positive predictive value was higher for the expanded group (43 %) than that of the diagnosis-only group (17 %). The PHQ-9, embedded within a multidimensional risk screening interview, effectively identified pregnant women who met criteria for current depression. The moderate risk score cutoff also identified women with subdiagnostic symptom levels who may benefit from interventions to alleviate their distress and improve pregnancy outcomes.


Depression Risk screening Prenatal care Healthy Start 



This research was funded by grant number R40MC07840 from the Department of Health and Human Services, Health Resources and Services Administration. The authors acknowledge Stacye Ballard for conducting the diagnostic interviews at study sites and Carol B. Peterson for providing SCID training to the research team. The Community University Health Care Center and NorthPoint Health and Wellness Center in Minneapolis and West Side Community Health Services East Side Family Clinic in St. Paul served as study sites.

Conflicts of interest

The authors have no financial conflicts of interest.


  1. Adewuya AO, Ola BA, Afolabi OO (2006) Validity of the patient health questionnaire (PHQ-9) as a screening tool for depression amongst Nigerian university students. J Affect Disord 96(1–2):89–93. doi: 10.1016/j.jad.2006.05.021 PubMedCrossRefGoogle Scholar
  2. American Psychiatric Association (2000) Diagnostic and statistical manual of mental disorders, 4th edn. APA, Washington DC, DSM-IVGoogle Scholar
  3. Bennett HA, Einarson A, Taddio A, Koren G, Einarson TR (2004) Prevalence of depression during pregnancy: systematic review. Obstet Gynecol 103(4):698–709. doi: 10.1097/01.AOG.0000116689.75396.5f PubMedCrossRefGoogle Scholar
  4. Bonari L, Bennett H, Einarson A, Koren G (2004) Risks of untreated depression during pregnancy. Can Fam Physician 50:37–39PubMedGoogle Scholar
  5. Chung TK, Lau TK, Yip AS, Chiu HF, Lee DT (2001) Antepartum depressive symptomatology is associated with adverse obstetric and neonatal outcomes. Psychosom Med 63(5):830–834PubMedGoogle Scholar
  6. Committee opinion no. 453 (2010) Screening for depression during and after pregnancy. Obstet Gynecol 115(2 Pt 1):394–395. doi: 10.1097/AOG.0b013e3181d035aa Google Scholar
  7. Cox JL, Holden JM, Sagovsky R (1987) Detection of postnatal depression. Development of the 10-item Edinburgh postnatal depression scale. Br J Psychiatry 150:782–786PubMedCrossRefGoogle Scholar
  8. Damus K (2008) Prevention of preterm birth: a renewed national priority. Curr Opin Obstet Gynecol 20(6):590–596. doi: 10.1097/GCO.0b013e3283186964 PubMedCrossRefGoogle Scholar
  9. Davalos DB, Yadon CA, Tregellas HC (2012) Untreated prenatal maternal depression and the potential risks to offspring: a review. Arch Womens Ment Health 15(1):1–14. doi: 10.1007/s00737-011-0251-1 PubMedCrossRefGoogle Scholar
  10. Dayan J, Creveuil C, Herlicoviez M, Herbel C, Baranger E, Savoye C, Thouin A (2002) Role of anxiety and depression in the onset of spontaneous preterm labor. Am J Epidemiol 155(4):293–301PubMedCrossRefGoogle Scholar
  11. Evans J, Heron J, Francomb H, Oke S, Golding J (2001) Cohort study of depressed mood during pregnancy and after childbirth. BMJ 323(7307):257–260PubMedCrossRefGoogle Scholar
  12. First MS, Spitzer RL, Gibbon M, Williams J (2005) Structured clinical interview for DSM-IV-TR axis I disorders, research version-patient edition (SCID-I/P). Biometrics Research Department, New York State Psyciatric Institute, New YorkGoogle Scholar
  13. Flynn HA, Sexton M, Ratliff S, Porter K, Zivin K (2011) Comparative performance of the Edinburgh Postnatal Depression Scale and the Patient Health Questionnaire-9 in pregnant and postpartum women seeking psychiatric services. Psychiatry Res 187(1–2):130–134. doi: 10.1016/j.psychres.2010.10.022 PubMedCrossRefGoogle Scholar
  14. Gilbody S, Richards D, Brealey S, Hewitt C (2007) Screening for depression in medical settings with the Patient Health Questionnaire (PHQ): a diagnostic meta-analysis. J Gen Intern Med 22(11):1596–1602. doi: 10.1007/s11606-007-0333-y PubMedCrossRefGoogle Scholar
  15. Gjerdingen D, Crow S, McGovern P, Miner M, Center B (2009) Postpartum depression screening at well-child visits: validity of a 2-question screen and the PHQ-9. Ann Fam Med 7(1):63–70. doi: 10.1370/afm.933 PubMedCrossRefGoogle Scholar
  16. Goldenberg RL, Culhane JF (2007) Low birth weight in the United States. Am J Clin Nutr 85(2):584S–590SPubMedGoogle Scholar
  17. Hanusa BH, Scholle SH, Haskett RF, Spadaro K, Wisner KL (2008) Screening for depression in the postpartum period: a comparison of three instruments. J Womens Health (Larchmt) 17(4):585–596. doi: 10.1089/jwh.2006.0248 CrossRefGoogle Scholar
  18. Harrison PA, Sidebottom AC (2008) Systematic prenatal screening for psychosocial risks. J Health Care Poor Underserved 19(1):258–276. doi: 10.1353/hpu.2008.0003 PubMedCrossRefGoogle Scholar
  19. Harrison PA, Godecker A, Sidebottom AC (2011a) Psychosocial risk screening during pregnancy: additional risks identified during a second interview. J Health Care Poor Underserved 22(4):1344–1357. doi: 10.1353/hpu.2011.0122 PubMedCrossRefGoogle Scholar
  20. Harrison PA, Godecker A, Sidebottom AC (2011b) Validation of the alcohol use module from a multidimensional prenatal psychosocial risk screening instrument. Matern Child Health J. doi: 10.1007/s10995-011-0926-2
  21. Hobfoll SE, Ritter C, Lavin J, Hulsizer MR, Cameron RP (1995) Depression prevalence and incidence among inner-city pregnant and postpartum women. J Consult Clin Psychol 63(3):445–453PubMedCrossRefGoogle Scholar
  22. Huang FY, Chung H, Kroenke K, Delucchi KL, Spitzer RL (2006) Using the Patient Health Questionnaire-9 to measure depression among racially and ethnically diverse primary care patients. J Gen Intern Med 21(6):547–552. doi: 10.1111/j.1525-1497.2006.00409.x PubMedCrossRefGoogle Scholar
  23. Kotelchuck M (1994) The Adequacy of Prenatal Care Utilization Index: its US distribution and association with low birthweight. Am J Public Health 84(9):1486–1489PubMedCrossRefGoogle Scholar
  24. Kroenke K, Spitzer RL, Williams JB (2001) The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 16(9):606–613PubMedCrossRefGoogle Scholar
  25. Kroenke K, Spitzer RL, Williams JB, Lowe B (2010) The Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales: a systematic review. Gen Hosp Psychiatry 32(4):345–359. doi: 10.1016/j.genhosppsych.2010.03.006 PubMedCrossRefGoogle Scholar
  26. Lee AM, Lam SK, Sze Mun Lau SM, Chong CS, Chui HW, Fong DY (2007) Prevalence, course, and risk factors for antenatal anxiety and depression. Obstet Gynecol 110(5):1102–1112. doi: 10.1097/01.AOG.0000287065.59491.70 PubMedCrossRefGoogle Scholar
  27. Lotrakul M, Sumrithe S, Saipanish R (2008) Reliability and validity of the Thai version of the PHQ-9. BMC Psychiatry 8:46. doi: 10.1186/1471-244X-8-46 PubMedCrossRefGoogle Scholar
  28. Lusskin SI, Pundiak TM, Habib SM (2007) Perinatal depression: hiding in plain sight. Can J Psychiatry 52(8):479–488PubMedGoogle Scholar
  29. MacDorman MF (2011) Race and ethnic disparities in fetal mortality, preterm birth, and infant mortality in the United States: an overview. Semin Perinatol 35(4):200–208. doi: 10.1053/j.semperi.2011.02.017 PubMedCrossRefGoogle Scholar
  30. Marcus SM, Flynn HA, Blow FC, Barry KL (2003) Depressive symptoms among pregnant women screened in obstetrics settings. J Womens Health (Larchmt) 12(4):373–380. doi: 10.1089/154099903765448880 CrossRefGoogle Scholar
  31. Martin A, Rief W, Klaiberg A, Braehler E (2006) Validity of the Brief Patient Health Questionnaire Mood Scale (PHQ-9) in the general population. Gen Hosp Psychiatry 28(1):71–77. doi: 10.1016/j.genhosppsych.2005.07.003 PubMedCrossRefGoogle Scholar
  32. Melville JL, Gavin A, Guo Y, Fan MY, Katon WJ (2010) Depressive disorders during pregnancy: prevalence and risk factors in a large urban sample. Obstet Gynecol 116(5):1064–1070. doi: 10.1097/AOG.0b013e3181f60b0a PubMedCrossRefGoogle Scholar
  33. Miller LJ (2002) Postpartum depression. JAMA 287(6):762–765PubMedCrossRefGoogle Scholar
  34. Monahan PO, Shacham E, Reece M, Kroenke K, Ong'or WO, Omollo O, Yebei VN, Ojwang C (2009) Validity/reliability of PHQ-9 and PHQ-2 depression scales among adults living with HIV/AIDS in western Kenya. J Gen Intern Med 24(2):189–197. doi: 10.1007/s11606-008-0846-z PubMedCrossRefGoogle Scholar
  35. Murray DM, Cox JL (1990) Screening for depression during pregnancy with the Edinburgh Scale (EPDS). J Reprod Infant Psychol 8:99–107CrossRefGoogle Scholar
  36. Orr ST, James SA, Blackmore Prince C (2002) Maternal prenatal depressive symptoms and spontaneous preterm births among African-American women in Baltimore, Maryland. Am J Epidemiol 156(9):797–802PubMedCrossRefGoogle Scholar
  37. Preti A, Cardascia L, Zen T, Pellizzari P, Marchetti M, Favaretto G, Miotto P (2000) Obstetric complications in patients with depression—a population-based case-control study. J Affect Disord 61(1–2):101–106PubMedCrossRefGoogle Scholar
  38. Saenger P, Czernichow P, Hughes I, Reiter EO (2007) Small for gestational age: short stature and beyond. Endocr Rev 28(2):219–251. doi: 10.1210/er.2006-0039 PubMedCrossRefGoogle Scholar
  39. Scholle SH, Haskett RF, Hanusa BH, Pincus HA, Kupfer DJ (2003) Addressing depression in obstetrics/gynecology practice. Gen Hosp Psychiatry 25(2):83–90PubMedCrossRefGoogle Scholar
  40. Smith MV, Gotman N, Lin H, Yonkers KA (2010) Do the PHQ-8 and the PHQ-2 accurately screen for depressive disorders in a sample of pregnant women? Gen Hosp Psychiatry 32(5):544–548. doi: 10.1016/j.genhosppsych.2010.04.011 PubMedCrossRefGoogle Scholar
  41. Spitzer RL, Kroenke K, Williams JB (1999) 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 282(18):1737–1744PubMedCrossRefGoogle Scholar
  42. Steer RA, Scholl TO, Hediger ML, Fischer RL (1992) Self-reported depression and negative pregnancy outcomes. J Clin Epidemiol 45(10):1093–1099PubMedCrossRefGoogle Scholar
  43. Weobong B, Akpalu B, Doku V, Owusu-Agyei S, Hurt L, Kirkwood B, Prince M (2009) The comparative validity of screening scales for postnatal common mental disorder in Kintampo, Ghana. J Affect Disord 113(1–2):109–117. doi: 10.1016/j.jad.2008.05.009 PubMedCrossRefGoogle Scholar
  44. Wisner KL, Parry BL, Piontek CM (2002) Clinical practice. Postpartum depression. N Engl J Med 347(3):194–199. doi: 10.1056/NEJMcp011542 PubMedCrossRefGoogle Scholar
  45. Wittkampf KA, Naeije L, Schene AH, Huyser J, van Weert HC (2007) Diagnostic accuracy of the mood module of the Patient Health Questionnaire: a systematic review. Gen Hosp Psychiatry 29(5):388–395. doi: 10.1016/j.genhosppsych.2007.06.004 PubMedCrossRefGoogle Scholar
  46. Yeung A, Fung F, Yu SC, Vorono S, Ly M, Wu S, Fava M (2008) Validation of the Patient Health Questionnaire-9 for depression screening among Chinese Americans. Compr Psychiatry 49(2):211–217. doi: 10.1016/j.comppsych.2006.06.002 PubMedCrossRefGoogle Scholar
  47. Yonkers KA, Ramin SM, Rush AJ, Navarrete CA, Carmody T, March D, Heartwell SF, Leveno KJ (2001) Onset and persistence of postpartum depression in an inner-city maternal health clinic system. Am J Psychiatry 158(11):1856–1863PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2012

Authors and Affiliations

  • Abbey C. Sidebottom
    • 1
    Email author
  • Patricia A. Harrison
    • 2
  • Amy Godecker
    • 2
  • Helen Kim
    • 3
  1. 1.Allina Hospitals & ClinicsMinneapolisUSA
  2. 2.Minneapolis Department of Health and Family SupportMinneapolisUSA
  3. 3.Hennepin Women’s Mental Health Program, Department of PsychiatryHennepin County Medical CenterMinneapolisUSA

Personalised recommendations