Abstract
Background
Depression greatly burdens sub-Saharan Africa, especially populations living with HIV/AIDS, for whom few validated depression scales exist. Patient Health Questionnaire-9 (PHQ-9), a brief dual-purpose instrument yielding DSM-IV diagnoses and severity, and PHQ-2, an ultra-brief screening tool, offer advantages in resource-constrained settings.
Objective
To assess the validity/reliability of PHQ-9 and PHQ-2.
Design
Observational, two occasions 7 days apart.
Participants
A total of 347 patients attending psychosocial support groups.
Measurements
Demographics, PHQ-9, PHQ-2, general health perception rating and CD4 count.
Results
Rates for PHQ-9 DSM-IV major depressive disorder (MDD), other depressive disorder (ODD) and any depressive disorder were 13%, 21% and 34%. Depression was associated with female gender, but not CD4. Construct validity was supported by: (1) a strong association between PHQ-9 and general health rating, (2) a single major factor with loadings exceeding 0.50, (3) item-total correlations exceeding 0.37 and (4) a pattern of item means similar to US validation studies. Four focus groups indicated culturally relevant content validity and minor modifications to the PHQ-9 instructions. Coefficient alpha was 0.78. Test-retest reliability was acceptable: (1) intraclass correlation 0.59 for PHQ-9 total score, (2) kappas 0.24, 0.25 and 0.38 for PHQ-9 MDD, ODD and any depressive disorder and (3) weighted kappa 0.53 for PHQ-9 depression severity categories. PHQ-2 ≥3 demonstrated high sensitivity (85%) and specificity (95%) for diagnosing any PHQ-9 depressive disorder (AUC, 0.97), and 91% and 77%, respectively, for diagnosing PHQ-9 MDD (AUC, 0.91). Psychometrics were also good within four gender/age (18–35, 36–61) subgroups.
Conclusions
PHQ-9 and PHQ-2 appear valid/reliable for assessing DSM-IV depressive disorders and depression severity among adults living with HIV/AIDS in western Kenya.
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Acknowledgements
This project was sponsored in part by funding provided by the Presidential Emergency Plan for AIDS Relief to the USAID-AMPATH® partnership. AMPATH is a registered trademark of the Trustees of Indiana University, Moi University and Moi Teaching and Referral Hospital. This project was also supported by funding from the School of Health, Physical Education, and Recreation and the Department of Applied Health Science at Indiana University-Bloomington.
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Appendix. PHQ-9 with Modified Instructions for Western Kenyan Culture
Appendix. PHQ-9 with Modified Instructions for Western Kenyan Culture
Over the last 2 weeks, how often have you been bothered by any of the following problems? | ||||
Not at all | Several days | More than half the days | Nearly every day | |
1. Little interest or pleasure in doing things............ | 0 | 1 | 2 | 3 |
2. Feeling down, depressed or hopeless.............. | 0 | 1 | 2 | 3 |
3. Trouble falling or staying asleep, or sleeping too much................................................................... | 0 | 1 | 2 | 3 |
4. Feeling tired or having little energy..................... | 0 | 1 | 2 | 3 |
5. Poor appetite or overeating................................ | 0 | 1 | 2 | 3 |
6. Feeling bad about yourself — or that you are a failure or have let yourself or your family down... | 0 | 1 | 2 | 3 |
7. Trouble concentrating on things, such as reading the newspaper or watching television.................................................... | 0 | 1 | 2 | 3 |
8. Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual.............................. | 0 | 1 | 2 | 3 |
9. Thoughts that you would be better off dead or of hurting yourself in some way........................... | 0 | 1 | 2 | 3 |
Based upon our focus groups, there are two minor modifications to the instructions that might be considered when administering the PHQ-9 in Western Kenya. First, some patients might benefit from being reminded that questions 3, 5, and 8 refer to changes in symptoms in either direction. Second, patients confused by the response options could be instructed that “not at all” refers to 0–1 days in the past 2 weeks, “several days” refers to 2–6 days, “more than half the days” refers to 7–11 days, and “nearly every day” refers to 12–14 days. This alternative number of days response set has been previously validated in a large population-based study of nearly 200,000 individuals.102
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Monahan, P.O., Shacham, E., Reece, M. et al. Validity/Reliability of PHQ-9 and PHQ-2 Depression Scales Among Adults Living with HIV/AIDS in Western Kenya. J GEN INTERN MED 24, 189–197 (2009). https://doi.org/10.1007/s11606-008-0846-z
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DOI: https://doi.org/10.1007/s11606-008-0846-z