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Validation of the patient health Questionnaire-9 (PHQ-9) for detecting depression among pregnant women in Lima, Peru

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Abstract

Depression during pregnancy is linked to adverse perinatal and offspring outcomes. The Patient Health Questionnaire-9 (PHQ-9) has been validated for identifying depression in pregnant women in limited cultural contexts. Construct validity and reliability have been assessed in Lima, Peru, but criterion validity has not. This study aimed to comprehensively evaluate the PHQ-9 among pregnant Peruvian women in the Pregnancy Outcomes, Maternal and Infant Study (PrOMIS). Using Composite International Diagnostic Interview (CIDI) criteria for past-12-month major depressive disorder as the reference standard, sensitivity, specificity, and predictive value of the PHQ-9 for detecting depression were assessed at various cutpoints of the PHQ-9. Confirmatory factor analysis (CFA) was used to evaluate one- and two-factor structures for the PHQ-9. Cronbach’s alpha was computed for the entire PHQ-9 scale and for subscales supported by CFA. A cutpoint of ≥8 maximized combined sensitivity (61%) and specificity (62%). At this cutpoint, positive predictive value was low (15%) and negative predictive values was high (93%). Reliability for the full scale was high (α = 0.80). Both one- and two-factor solutions were appropriate for this population, but a two-factor solution containing an affective/mood factor (α = 0.67) and a somatic factor (α = 0.75) was optimal (CFI = 0.93, RMSEA = 0.075). Among pregnant women in Lima, screening with the PHQ-9 can identify those in need of mental health care, but may identify a large number of false positive cases.

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References

  • Barthel, D., Barkmann, C., Ehrhardt, S., Schoppen, S., Bindt, C., Appiah-Poku, J., … Tannich, E. (2015). Screening for depression in pregnant women from Côte d’Ivoire and Ghana: Psychometric properties of the patient health Questionnaire-9. Journal of Affective Disorders, 187, 232–240. https://doi.org/10.1016/j.jad.2015.06.042.

  • Batmaz, G., Dane, B., Sarioglu, A., Kayaoglu, Z., & Dane, C. (2015). Can we predict postpartum depression in pregnant women? Clinical and Experimental Obstetrics & Gynecology, 42(5), 605–609.

    Article  Google Scholar 

  • Beard, C., Hsu, K. J., Rifkin, L. S., Busch, A. B., & Björgvinsson, T. (2016). Validation of the PHQ-9 in a psychiatric sample. Journal of Affective Disorders, 193, 267–273. https://doi.org/10.1016/j.jad.2015.12.075.

    Article  PubMed  Google Scholar 

  • Begg, C. B., & Greenes, R. A. (2009). Assessment of diagnostic tests when disease verification is subject to selection Bias. Biometrics Published by : International biometric society stable URL : http://www.jstor.org/stable/2530820, 39(1), 207–215.

    Article  Google Scholar 

  • Boothroyd, L., Dagnan, D., & Muncer, S. (2019). PHQ-9: One factor or two? Psychiatry Research, 271, 532–534. https://doi.org/10.1016/j.psychres.2018.12.048.

    Article  PubMed  Google Scholar 

  • Breedlove, G., & Fryzelka, D. (2011). Depression screening during pregnancy. Journal of Midwifery and Women’s Health, 56(1), 18–25. https://doi.org/10.1111/j.1542-2011.2010.00002.x.

    Article  PubMed  Google Scholar 

  • Bromet, E., Andrade, L. H., Hwang, I., Sampson, N. A., Alonso, J., de Girolamo, G., de Graaf, R., Demyttenaere, K., Hu, C., Iwata, N., Karam, A. N., Kaur, J., Kostyuchenko, S., Lépine, J. P., Levinson, D., Matschinger, H., Mora, M. E. M., Browne, M. O., Posada-Villa, J., Viana, M. C., Williams, D. R., & Kessler, R. C. (2011). Cross-national epidemiology of DSM-IV major depressive episode. BMC Medicine, 9(1), 90. https://doi.org/10.1186/1741-7015-9-90.

    Article  PubMed  PubMed Central  Google Scholar 

  • Brosseau-Liard, P. E., Savalei, V., & Li, L. (2012). An investigation of the sample performance of two nonnormality corrections for RMSEA. Multivariate Behavioral Research, 47(6), 904–930. https://doi.org/10.1080/00273171.2012.715252.

    Article  PubMed  Google Scholar 

  • Brown, T. A. (2015). Confirmatory factor analysis for applied research, 2nd edn. New York: The Guilford Press.

  • Chung, T. K., Lau, T. K., Yip, A. S., Chiu, H. F., & Lee, D. T. (2001). Antepartum depressive symptomatology is associated with adverse obstetric and neonatal outcomes. Psychosomatic Medicine, 63(5), 830–834. https://doi.org/10.1097/00006842-200109000-00017.

    Article  PubMed  Google Scholar 

  • Cripe, S. M., Sanchez, S. E., Perales, M. T., Lam, N., Garcia, P., & Williams, M. A. (2008). Association of intimate partner physical and sexual violence with unintended pregnancy among pregnant women in Peru. International Journal of Gynecology & Obstetrics, 100(2), 104–108. https://doi.org/10.1016/j.ijgo.2007.08.003.

    Article  Google Scholar 

  • Dadi, A. F., Miller, E. R., Bisetegn, T. A., & Mwanri, L. (2020). Global burden of antenatal depression and its association with adverse birth outcomes: An umbrella review. BMC Public Health, 20(1), 173. https://doi.org/10.1186/s12889-020-8293-9.

    Article  PubMed  PubMed Central  Google Scholar 

  • Davalos, D. B., Yadon, C. A., & Tregellas, H. C. (2012). Untreated prenatal maternal depression and the potential risks to offspring: A review. Archives of Women's Mental Health, 15(1), 1–14. https://doi.org/10.1007/s00737-011-0251-1.

    Article  PubMed  Google Scholar 

  • Elhai, J. D., Contractor, A. A., Tamburrino, M., Fine, T. H., Prescott, M. R., Shirley, E., Chan, P. K., Slembarski, R., Liberzon, I., Galea, S., & Calabrese, J. R. (2012). The factor structure of major depression symptoms: a test of four competing models using the patient health Questionnaire-9. Psychiatry Research, 199(3), 169–173. https://doi.org/10.1016/j.psychres.2012.05.018.

    Article  PubMed  Google Scholar 

  • Familiar, I., Ortiz-Panozo, E., Hall, B., Vieitez, I., Romieu, I., Lopez-Ridaura, R., & Lajous, M. (2015). Factor structure of the Spanish version of the patient health Questionnaire-9 in Mexican women. International Journal of Methods in Psychiatric Research, 24(1), 74–82. https://doi.org/10.1002/mpr.1461.

    Article  PubMed  Google Scholar 

  • First, M. B. (2014). Structured clinical interview for the DSM (SCID). In: The Encyclopedia of Clinical Psychology, (pp. 1–6). Hoboken, NJ, USA: John Wiley & Sons, Inc. https://doi.org/10.1002/9781118625392.wbecp351.

  • Gallis, J. A., Maselko, J., O’Donnell, K., Song, K., Saqib, K., Turner, E. L., & Sikander, S. (2018). Criterion-related validity and reliability of the Urdu version of the patient health questionnaire in a sample of community-based pregnant women in Pakistan. PeerJ., 6, e5185. https://doi.org/10.7717/peerj.5185.

    Article  PubMed  PubMed Central  Google Scholar 

  • Gelaye, B., Rondon, M., Araya, R., & Williams, M. (2016). Epidemiology of maternal depression, risk factors, and child outcomes in low-income and middle-income countries. Lancet Psychiatry, 3(10), 973–982. https://doi.org/10.1016/S2215-0366(16)30284-X.Epidemiology.

    Article  PubMed  PubMed Central  Google Scholar 

  • Gomez-Beloz, A., Williams, M. A., Sanchez, S. E., & Lam, N. (2009). Intimate partner violence and risk for depression among postpartum women in Lima, Peru. Violence and Victims, 24(3), 380–398. https://doi.org/10.1891/0886-6708.24.3.380.

    Article  PubMed  Google Scholar 

  • González-Blanch, C., Medrano, L. A., Muñoz-Navarro, R., Ruíz-Rodríguez, P., Moriana, J. A., Limonero, J. T., … Cano-Vindel, A. (2018). Factor structure and measurement invariance across various demographic groups and over time for the PHQ-9 in primary care patients in Spain. PLoS One, 13(2), 1–16. https://doi.org/10.1371/journal.pone.0193356.

  • Granillo, M. T. (2012). Structure and function of the patient health Questionnaire-9 among Latina and non-Latina white female college students. Journal of the Society for Social Work and Research, 3(2), 80–93.

    Article  Google Scholar 

  • Gulseren, L., Erol, A., Gulseren, S., Kuey, L., Kilic, B., & Ergor, G. (2006). From antepartum to postpartum: a prospective study on the prevalence of peripartum depression in a semiurban Turkish community. The Journal of Reproductive Medicine, 51(12), 955–960.

    PubMed  Google Scholar 

  • Hoffman, S., & Hatch, M. C. (2000). Depressive symptomatology during pregnancy: Evidence for an association with decreased fetal growth in pregnancies of lower social class women. Health Psychology, 19(6), 535–543.

    Article  Google Scholar 

  • Hu, L.T., & Bentler, P.M. (1999) Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Struct Equ Model A Multidiscip Journal, 6,1–55.

  • Huang, F. Y., Chung, H., Kroenke, K., Delucchi, K. L., & Spitzer, R. L. (2006). Using the patient health Questionnaire-9 to measure depression among racially and ethnically diverse primary care patients. Journal of General Internal Medicine, 21(6), 547–552. https://doi.org/10.1111/j.1525-1497.2006.00409.x.

    Article  PubMed  PubMed Central  Google Scholar 

  • Kessler, R. C., & Ustun, T. B. (2004). The world mental health (WMH) survey initiative version of the World Health Organization (WHO) composite international diagnostic interview (CIDI). International Journal of Methods in Psychiatric Research, 13(2), 93–121.

    Article  Google Scholar 

  • Kocalevent, R. D., Hinz, A., & Brähler, E. (2013). Standardization of the depression screener patient health questionnaire (PHQ-9) in the general population. General Hospital Psychiatry, 35(5), 551–555. https://doi.org/10.1016/j.genhosppsych.2013.04.006.

    Article  PubMed  Google Scholar 

  • Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606–613.

    Article  Google Scholar 

  • Larsson, C., Sydsjö, G., & Josefsson, A. (2004). Health, sociodemographic data, and pregnancy outcome in women with antepartum depressive symptoms. Obstetrics and Gynecology, 104(3), 459–466. https://doi.org/10.1097/01.AOG.0000136087.46864.e4.

    Article  PubMed  Google Scholar 

  • Levey, E. J., Gelaye, B., Koenen, K., Zhong, Q. Y., Basu, A., Rondon, M. B., Sanchez, S., Henderson, D. C., & Williams, M. A. (2018). Trauma exposure and post-traumatic stress disorder in a cohort of pregnant Peruvian women. Archives of Women's Mental Health, 21(2), 193–202. https://doi.org/10.1007/s00737-017-0776-z.

    Article  PubMed  Google Scholar 

  • Levis, B., Benedetti, A., & Thombs, B. D. (2019). Accuracy of patient health Questionnaire-9 (PHQ-9) for screening to detect major depression: Individual participant data meta-analysis. BMJ (Online), 365, l1476. https://doi.org/10.1136/bmj.l1476.

    Article  Google Scholar 

  • Li, C. H. (2016). Confirmatory factor analysis with ordinal data: Comparing robust maximum likelihood and diagonally weighted least squares. Behavior Research Methods, 48(3), 936–949. https://doi.org/10.3758/s13428-015-0619-7.

    Article  PubMed  Google Scholar 

  • Luna Matos, M. L., Salinas Pielago, J., & Luna Figueroa, A. (2009). Major depression in pregnant women served by the National Materno-Perinatal Institute in Lima, Peru. Revista Panamericana de Salud Publica = Pan American Journal of Public Health, 26(4), 310–314.

    PubMed  Google Scholar 

  • Manea, L. M., Gilbody, S., & McMilian, D. (2012). Optimal cut-off score for diagnosing depression with the patient health questionnaire (PHQ-9): a meta-analysis. Canadian Medical Association, 184(3), E191–E196. https://doi.org/10.1503/cmaj.112004.

    Article  Google Scholar 

  • Manea, L., Gilbody, S., & McMillan, D. (2015). A diagnostic meta-analysis of the patient health Questionnaire-9 (PHQ-9) algorithm scoring method as a screen for depression. General Hospital Psychiatry, 37(1), 67–75. https://doi.org/10.1016/j.genhosppsych.2014.09.009.

    Article  PubMed  Google Scholar 

  • Miranda, C. A. C., & Scoppetta, O. (2018). Factorial structure of the patient health Questionnaire-9 as a depression screening instrument for university students in Cartagena, Colombia. Psychiatry Research, 269(February), 425–429. https://doi.org/10.1016/j.psychres.2018.08.071.

    Article  PubMed  Google Scholar 

  • Nasreen, H. E., Pasi, H. B., Rifin, S. M., Aris, M. A. M., Rahman, J. A., Rus, R. M., & Edhborg, M. (2019). Impact of maternal antepartum depressive and anxiety symptoms on birth outcomes and mode of delivery: A prospective cohort study in east and west coasts of Malaysia. BMC Pregnancy and Childbirth, 19(1), 1–11. https://doi.org/10.1186/s12884-019-2349-9.

    Article  Google Scholar 

  • Ongeri, L., Wanga, V., Otieno, P., Mbui, J., Juma, E., Stoep, A. V., & Mathai, M. (2018). Demographic, psychosocial and clinical factors associated with postpartum depression in Kenyan women. BMC Psychiatry, 18(1), 1–9. https://doi.org/10.1186/s12888-018-1904-7.

    Article  Google Scholar 

  • Perales, M. T., Cripe, S. M., Lam, N., Sanchez, S. E., Sanchez, E., & Williams, M. A. (2009). Prevalence, types, and pattern of intimate partner violence among pregnant women in Lima, Peru. Violence Against Women, 15(2), 224–250. https://doi.org/10.1177/1077801208329387.

  • Richardson, E. J., & Richards, J. S. (2008). Factor structure of the PHQ-9 screen for depression across time since injury among persons with spinal cord injury. Rehabilitation Psychology, 53(2), 243–249.

    Article  Google Scholar 

  • Satorra, A. (2000). Scaled and adjusted restricted tests in multi-sample analysis of moment structures. In R. Heijmans, D. Pollack, & A. Satorra (Eds.), Innovations in multivariate statistical analysis. A Festschrift for Heinz Neudecker (pp. 233–247). London: Kluwer Academic Publishers.

    Chapter  Google Scholar 

  • Satorra, A., & Bentler, P. M. (2010). Ensuring positiveness of the scaled difference chi-square test statistic. Psychometrika, 75(2), 243–248. https://doi.org/10.1007/s11336-009-9135-y.

    Article  PubMed  PubMed Central  Google Scholar 

  • Schaffir, J. (2018). Consequences of antepartum depression. Clinical Obstetrics and Gynecology, 61(3), 533–543. https://doi.org/10.1097/GRF.0000000000000374.

    Article  PubMed  Google Scholar 

  • Sidebottom, A. C., Harrison, P. A., Godecker, A., & Kim, H. (2012). Validation of the patient health questionnaire (PHQ)-9 for prenatal depression screening. Archives of Women's Mental Health, 15(5), 367–374. https://doi.org/10.1007/s00737-012-0295-x.

    Article  PubMed  Google Scholar 

  • Spitzer, R., Kroenke, K., Williams, J. B. W., & Patient Health Questionnaire Primary Care Study Group. (1999). Validation and utility of a self-report version of PRIME-MD. Journal of the American Medical Association, 282(18), 1737–1744. https://doi.org/10.1001/jama.282.18.1737.

    Article  PubMed  Google Scholar 

  • Venkatesh, K. K., Riley, L., Castro, V. M., Perlis, R. H., & Kaimal, A. J. (2016). Association of antenatal depression symptoms and antidepressant treatment with preterm birth. Obstetrics and Gynecology, 127(5), 926–933. https://doi.org/10.1097/AOG.0000000000001397.

    Article  PubMed  Google Scholar 

  • Woldetensay, Y. K., Belachew, T., Tesfaye, M., Spielman, K., Biesalski, H. K., Kantelhardt, E. J., & Scherbaum, V. (2018). Validation of the patient health questionnaire (PHQ-9) as a screening tool for depression in pregnant women: Afaan Oromo version. PLoS One, 13(2), 1–15. https://doi.org/10.1371/journal.pone.0191782.

    Article  Google Scholar 

  • Zhong, Q.-Y., Gelaye, B., Rondon, M., Sanchez, S. E., Garcia, P. J., Sanchez, E., … Williams, M. A. (2014). Comparative performance of patient health Questionnaire-9 and Edinburgh postnatal depression scale for screening antepartum depression. Journal of Affective Disorders, 162, 1–7. https://doi.org/10.1016/j.jad.2014.03.028.

  • Zhong, Q.-Y., Gelaye, B., Zaslavsky, A. M., Fann, J. R., Rondon, M. B., Sánchez, S. E., & Williams, M. A. (2015). Diagnostic validity of the generalized anxiety disorder - 7 (GAD-7) among pregnant women. PLoS One, 10(4), 1–17. https://doi.org/10.1371/journal.pone.0125096.

    Article  Google Scholar 

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Acknowledgments

The authors wish to thank Ms. Elena Sanchez and the dedicated staff members of Asociación Civil Proyectos en Salud (PROESA), Perú and Instituto Materno Perinatal, Perú for their expert technical and administrative assistance with this research.

This research was supported by awards from the National Institutes of Health (NIH), the Eunice Kennedy Shriver Institute of Child Health and Human Development (R01-HD-059835), and the National Institute of Mental Health (R01MH110453, PI: Gradus). The NIH had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.

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Authors and Affiliations

  1. Department of Epidemiology, Boston University School of Public Health, 715 Albany St, Boston, MA, 02118, USA

    Meghan L. Smith & Jaimie L. Gradus

  2. Instituto de Investigación, Facultad de Medicina, Universidad de San Martin de Porres, Lima, Peru

    Sixto E. Sanchez

  3. Asociación Civil Proyectos en Salud, Lima, Peru

    Sixto E. Sanchez

  4. Universidad Peruana Cayetano Heredia, Lima, Peru

    Marta Rondon

  5. Instituto Nacional Materno Perinatal, Lima, Peru

    Marta Rondon

  6. Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA

    Jaimie L. Gradus

  7. Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA

    Bizu Gelaye

  8. The Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital, Boston, MA, USA

    Bizu Gelaye

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  1. Meghan L. Smith
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Correspondence to Meghan L. Smith.

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All procedures were approved by the institutional review boards of the Instituto Nacional Materno Perinatal, Lima, Peru, and the Harvard School of Public Health Office of Human Research Administration, Boston, USA.

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Smith, M.L., Sanchez, S.E., Rondon, M. et al. Validation of the patient health Questionnaire-9 (PHQ-9) for detecting depression among pregnant women in Lima, Peru. Curr Psychol 41, 3797–3805 (2022). https://doi.org/10.1007/s12144-020-00882-2

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