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Optimizing Detection of Major Depression Among Patients with Coronary Artery Disease Using the Patient Health Questionnaire: Data from the Heart and Soul Study

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Clinical guidelines recommend depression screening in patients with coronary artery disease (CAD), but how to accomplish this is unclear.


We evaluated the test characteristics of the two-item Patient Health Questionnaire (PHQ-2), the nine-item Patient Health Questionnaire (PHQ-9), and a two-step screening approach (PHQ-2 then PHQ-9 if positive on PHQ-2), compared with the Computerized Diagnostic Interview Schedule (C-DIS) for major depression. We also evaluated a “PHQ diagnosis” of depression, requiring five of nine symptoms “more than half the days,” compared with the C-DIS.


Cross-sectional study of 1,024 outpatients with CAD.


Two hundred twenty-four patients (22%) had current major depression. Optimal cutpoints were ≥2 for the PHQ-2 (82% sensitive, 79% specific) and ≥6 for the PHQ-9 (83% sensitive, 76% specific). The two-step screening approach was less sensitive (75%), but more specific (84%), than the PHQ-2 or PHQ-9 alone. The “PHQ diagnosis” had low sensitivity (28%), but high specificity (96%).


Cutpoints of ≥2 on the PHQ-2 and ≥6 on the PHQ-9 had similar test characteristics. A two-step approach using the PHQ-2 followed by the PHQ-9 was no better than either instrument alone. A “PHQ diagnosis” of depression had high specificity, but poor sensitivity.

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The Heart and Soul Study was funded by the Department of Veterans Epidemiology Merit Review Program, the Department of Veterans Affairs Health Services Research and Development service, the National Heart Lung and Blood Institute (R01 HL079235), the American Federation for Aging Research (Paul Beeson Scholars Program), the Robert Wood Johnson Foundation (Generalist Physician Faculty Scholars Program), and the Ischemia Research and Education Foundation. Dr. Thombs is supported by a New Investigator Award from the Canadian Institutes of Health Research and an Établissement de Jeunes Chercheurs award from the Fonds de la Recherche en Santé Québec. Dr. Ziegelstein is supported by grant no. R24AT004641 from the National Center For Complementary and Alternative Medicine and by the Miller Family Scholar Program.

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Correspondence to Brett D. Thombs PhD.

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Thombs, B.D., Ziegelstein, R.C. & Whooley, M.A. Optimizing Detection of Major Depression Among Patients with Coronary Artery Disease Using the Patient Health Questionnaire: Data from the Heart and Soul Study. J GEN INTERN MED 23, 2014–2017 (2008).

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