The Factor Reliability and Convergent Validity of the Patient Health Questionnaire-4 Among an International Sample of Pregnant Women

Factor structure and measurement invariance of the Patient Health Questionnaire-4 among the Chilean population

BACKGROUND

The PHQ-4 is an ultrabrief screening test for depression and anxiety symptoms. The psychometric properties of this test among the population in Chile are unknown. This study was aimed to determine the factor structure of the PHQ-4 in the adult population in Chile, and to assess its measurement invariance across different groups.

METHODS

The study considered a nationally representative sample of 10921 people aged 18 and above, in Chile in 2021. Exploratory and confirmatory factor analysis were conducted, and configural, metric, scalar, and strict measurement invariance were assessed.

RESULTS

The two-factor structure of the PHQ-4 supported the two underlying constructs of depression and anxiety. This model explained 67% of the variance and had excellent fit (CFI: 0.9999; TLI: 0.9994; RMSEA: 0.0107; SRMR: 0.0022). Strict measurement invariance held across gender, age, area of residence, household income quintile, immigrant or host population, and indigenous or non-indigenous population (ΔCFI<0.01).

CONCLUSION

The PHQ-4 can be used to assess depressive and anxiety symptoms in population studies, and as a screening test for depression and anxiety in public mental health programs in Chile.

Confirmatory validation of the patient health questionnaire - 4 (PHQ-4) for gastrointestinal disorders: A large-scale cross-sectional survey

OBJECTIVE

Using the large Rome Foundation Global Epidemiology Survey dataset, the aim of this study was to evaluate the construct and convergent validity and internal consistency of the PHQ-4 across both gastrointestinal and non-gastrointestinal condition cohorts. Another aim was to provide descriptive information about the PHQ-4 including means, confidence intervals and percentage of caseness using a large representative sample.

METHODS

A cross-sectional survey was conducted in 26 countries. Confirmatory factor and internal consistency analyses were conducted across subsamples of patients with gastrointestinal conditions (i.e., disorders of gut-brain interaction [DGBI; any DGBI, individual DGBI, and DGBI region], gastroesophageal reflux disease (GERD), coeliac disease, diverticulitis, inflammatory bowel disease (IBD), cancer anywhere in the gastrointestinal tract, peptic ulcer) and those without a gastrointestinal condition. Convergent validity was also assessed via a series of Pearson's correlation coefficients with PROMIS (physical and mental quality of life), and PHQ-12 (somatisation).

RESULTS

Based on 54,127 participants (50.9% male; mean age 44.34 years) confirmatory factor analysis indicated acceptable to excellent model fits for the PHQ-4 across all subsamples and individual DGBI and DGBI region (Comparative Fit Index >0.950, Tucker-Lewis Index >0.950, Root Mean Squared Error of Approximation <0.05, and Standardised Root Mean Square Residual <0.05). The PHQ-4 was found to demonstrate convergent validity (Pearson's correlation coefficients >±0.4), and good internal consistency (Cronbach's α > 0.75).

CONCLUSIONS

This study provides evidence that the PHQ-4 is a valid and reliable tool for assessing mental health symptomology in both gastrointestinal and non-gastrointestinal cohorts.

A Systematic Review of the Psychometric Properties of the Patient Health Questionnaire-4 in Clinical and Nonclinical Populations

BACKGROUND

The Patient Health Questionnaire-4 (PHQ-4) is an ultra-brief instrument that measures depressive and anxiety symptoms. Although it has been frequently used in the last 15 years, no research has systematically reviewed its psychometric properties.

OBJECTIVE

This systematic review summarized, for the first time, the available published evidence on the psychometric properties of the PHQ-4.

METHODS

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and was registered in the Prospective Register of Systematic Reviews, under the identification code CRD42022381809. The search strategy was applied in Medline, PsycINFO, Web of Science, and SCOPUS from 2009 (year of publication) to 2023 (present). Two independent reviewers performed screening, data extraction, and methodological quality assessment of the studies. The data was reported through a narrative synthesis.

RESULTS

In total, 26 studies involving 93,466 participants from 19 countries, with clinical and nonclinical samples, were included. The two-factor structure was the most frequent, being invariant according to gender, age, geographic location, income, educational level, and language. The internal consistency was adequate for distress (α from 0.72 to 0.88), as well as for depression (α from 0.65 to 0.81) and anxiety (α from 0.74 to 0.84). The temporal stability of the instrument was verified through test-retest reliability, reporting an acceptable connection between both measures. Correlations with related measures were significant and in the expected direction.

CONCLUSIONS

The PHQ-4 is a reliable and valid instrument for screening depressive and anxiety symptoms, both for the clinical and nonclinical populations. Due to the brevity of its administration, the PHQ-4 could be a clinical tool that contributes to optimizing health resources.

Factor structure of the patient health questionnaire-4 in adults with attention-deficit/hyperactivity disorder

Background

Persons with attention-deficit/hyperactivity disorder (ADHD) frequently experience symptoms of anxiety and depression. In this population, there is a need for validated brief self-report screening questionnaires to assess the severity of comorbid mental health problems. The Patient Health Questionnaire 4 (PHQ-4) is a self-report questionnaire that may contribute to this purpose as it can screen for both disorders efficiently. However, this will be the first study examining the factor structure of the PHQ-4 in samples of adults with ADHD, and also evaluating the validity of the Norwegian version of the PHQ-4.

Objectives

The aim of the current cross-sectional study was to examine the factor structure and validity of the Norwegian version of the PHQ-4 in a sample of adults who reported having been diagnosed with ADHD.

Methods

Of 496 invited, a total of 326 participants (66%) completed the PHQ-4, The World Health Organization Five Well-Being Index, the Oslo Social Support Scale and the 4-item Perceived Stress Scale electronically in a web-portal between the 9th and 30th of June 2020.

Results

Confirmatory factor analysis of the PHQ-4 supported a two-factor structure [RMSEA = 0.038 (90% CI 0.000-0.159), CFI = 1.00, TLI = 0.999, SRMR = 0.004], consisting of a depression factor and an anxiety factor. Standardized factor loadings were 0.79 to 0.97. The PHQ-4 was negatively correlated with well-being and social support and positively correlated with perceived level of stress.

Conclusion

This study indicates promising psychometric properties of the PHQ-4 as a measure of anxiety and depressive symptoms in adults with self-reported ADHD who are fluent in Norwegian. The questionnaire's brevity makes it a valuable resource in research and clinical settings. However, more studies are needed to test the instrument in a clinical sample.

Maternal prenatal psychological distress and vitamin intake with children's neurocognitive development

BACKGROUND

Maternal prenatal psychological distress (PPD) is increasingly linked to sub-optimal child neurodevelopment. Daily intake of prenatal vitamin during pre-conception and early pregnancy may ameliorate the effects of PPD on cognition in the offspring.

METHODS

PPD was assessed in early (12-16 weeks) and late (28-32 weeks) gestation in the Ontario Birth Study. Prenatal vitamin supplement intake information was collected in early gestation. Child cognition at 4 years was assessed using the NIH Toolbox. Poisson regression was used to investigate associations between PPD and/or prenatal vitamin intake and child cognition.

RESULTS

Four hundred and eighteen mother-child dyads were assessed. Moderate-severe PPD experienced during early gestation was associated with reduced cognition (adjusted incidence rate ratio (IRR_adj) = 3.71, 95% confidence interval (CI): 1.57-8.77, P = 0.003). Daily intake of prenatal vitamins was not associated with cognition (IRR_adj = 1.34, 95% CI: 0.73-2.46, P = 0.34). Upon stratification, the experience of mild-severe PPD with daily intake of prenatal vitamins was associated with higher incident rates of suboptimal cognition compared to children of women with daily prenatal vitamin intake without any episode of PPD (IRR_adj = 2.88, 95% CI: 1.1-7.4).

CONCLUSIONS

Moderate-severe PPD in early pregnancy is associated with poor cognition in children and daily intake of prenatal vitamin did not ameliorate this association.

IMPACT

Our findings expand on existing literature by highlighting that exposure to prenatal psychological distress (PPD), in moderate-to-severe form, in the early stages of pregnancy, can have detrimental effects on the offspring's cognitive development at 4 years. Overall, prenatal vitamin intake did not ameliorate the effects of PPD. Early screening and treatment of prenatal maternal mental illness is crucial.

Post-Traumatic Growth and Resilience among Hospitalized COVID-19 Survivors: A Gendered Analysis

The literature on behavioral outcomes associated with the COVID-19 pandemic is inundated with mental health burdens such as depression and stress disorders. The current study investigated gender invariance on resilience and post-traumatic growth (PTG) as positive psychological changes associated with the COVID-19 pandemic. A total of 381 survivors of the COVID-19 infection completed measurements of resilience, PTG, violence and stigma experience, and mental health problems like post-traumatic stress disorder (PTSD). The data were analyzed using descriptive statistics, correlation, multivariate regression, and a latent profile analysis. The results revealed that more than half of the participants had high scores on resilience (53.6%) and PTG (60.9%). The positive psychological changes, although independent of each other, were moderated by gender, and influenced by the negative experiences of participants such as stigma, violence, and PTSD. Latent profile analyses revealed three classes of participants, two of which were characterized by high scores on mental health problems and PTG. The clusters were invariant across gender. Surviving COVID-19 contributed to resilience and PTG. These can be targeted for intervention programs to mitigate the mental health burden occasioned by the pandemic.

Association between SARS-CoV-2 infection during pregnancy and postpartum depressive and anxiety symptoms: finding from the International Registry of Coronavirus Exposure in Pregnancy (IRCEP) study

While there has been concern over the perinatal mental health implications of the COVID-19 outbreak, evidence on the risk of postpartum depression and anxiety following SARS-CoV-2 infection is limited. We studied this question using the International Registry of Coronavirus Exposure in Pregnancy, which included both a prospective and retrospective cohort. Study participants were required to have been tested for SARS-CoV-2 between the date of last menstrual period and delivery. The exposure of interest was SARS-CoV-2 infection during pregnancy, as well as COVID-19 severity (severe, moderate, mild, and asymptomatic). The outcome was postpartum depression and anxiety symptoms, assessed by the 4-item Patient Health Questionnaire. The final analytic cohort consisted of 3819 participants (COVID-19 positive: 771; COVID-19 negative: 3048). After adjusting for confounding by socio-demographics, prior obstetric and maternal health comorbidities, mothers with severe COVID-19 had an increased risk of depressive (aRR: 1.72; 95%CI: 1.18-2.52) and anxiety (aRR: 1.40; 0.98-2.00) symptoms. The strength of the association was attenuated for women with moderate COVID-19 (aRR = 1.12; 0.86-1.44 for depressive symptoms; aRR = 1.18; 0.96-1.44 for anxiety symptoms). No increased risk was observed for mild or asymptomatic illness. The findings can inform targeted interventions to minimize the risk of adverse COVID-19-related mental health outcomes for pregnant women.

Levels of depression, anxiety, and psychological distress among Ugandan adults during the first wave of the COVID-19 pandemic: cross-sectional evidence from a mobile phone-based population survey

OBJECTIVES

Policy measures to slow the spread of coronavirus disease 2019 (COVID-19), such as curfews and business closures, may have negative effects on mental health. Populations in low- and middle-income countries (LMICs) may be particularly affected due to high rates of poverty and less comprehensive welfare systems, but the evidence is scarce. We evaluated predictors of depression, anxiety, and psychological distress in Uganda, which implemented one of the world's most stringent lockdowns.

METHODS

We conducted a mobile phone-based cross-sectional survey from December 2020 through April 2021 among individuals aged 18 years or over in Uganda. We measured depression, anxiety, and psychological distress using the Patient Health Questionnaire (PHQ)-2, the Generalized Anxiety Disorder (GAD)-2, and the PHQ-4. We applied linear regression to assess associations between experiences of COVID-19 (including fear of infection, social isolation, income loss, difficulty accessing medical care, school closings, and interactions with police) and PHQ-4 score, adjusted for sociodemographic characteristics.

RESULTS

29.2% of 4066 total participants reported scores indicating moderate psychological distress, and 12.1% reported scores indicating severe distress. Distress was most common among individuals who were female, had lower levels of education, and lived in households with children. Related to COVID-19, PHQ-4 score was significantly associated with difficulty accessing medical care, worries about COVID-19, worries about interactions with police over lockdown measures, and days spent at home.

CONCLUSIONS

There is an urgent need to address the significant burden of psychological distress associated with COVID-19 and policy responses in LMICs. Pandemic mitigation strategies must consider mental health consequences.

Screening for perinatal depression with the Patient Health Questionnaire depression scale (PHQ-9): A systematic review and meta-analysis

OBJECTIVES

Perinatal depression (PND) is a prevalent and disabling problem both during pregnancy and the postpartum period. The legacy screening measure has been the Edinburgh Postnatal Depression Scale (EPDS). This systematic review examines the validity of the PHQ-9 as a screener for PND.

METHODS

The following databases were searched from January 2001 (when the PHQ-9 was first published) through June 2020: MEDLINE, Embase, and PsychInfo. Studies that compared the PHQ-9 to a criterion standard psychiatric interview were used to determine the operating characteristics of sensitivity, specificity and area under the curve (AUC). Studies comparing the PHQ-9 to the EPDS and other depression scales evaluated convergent validity.

RESULTS

A total of 35 articles were eligible for criterion (n = 10) or convergent (n = 25) validity. Meta-analysis of the 7 criterion validity studies using the standard PHQ-9 cut point ≥10 showed a pooled sensitivity, specificity and AUC of 0.84, 0.81 and 0.89, respectively. Operating characteristics of the PHQ-9 and EPDS were nearly identical in head-to-head comparison studies. The median correlation between the PHQ-9 and EPDS was 0.59, and categorical agreement was moderate.

CONCLUSIONS

The PHQ-9 appears to be a viable option for perinatal depression screening with operating characteristics similar to the legacy EPDS.

The Psychometric Properties of the Patient Health Questionnaire-4 for Pregnant Women

Background: Perinatal anxiety and depression are common complications during pregnancy. The purpose of this study was to examine the item characteristics, reliability, validity, and factorial structure of the four-item Patient Health Questionnaire-4 (PHQ-4) and to determine the associations between scale scores and sociodemographic factors in a sample of pregnant women from Spain. Method: A total of 845 pregnant women were recruited from two public hospitals in Spain between 2014 and 2016. Participants completed a self-report questionnaire that included Patient Health Questionnaire-4, including the two-item Patient Health Questionnaire and the two-item Generalized Anxiety Disorder Screener. Results: Exploratory and confirmatory factor analysis and scale inter-correlations between the PHQ-4 and PHQ-9 revealed that the PHQ-4 has a bivariate structure and adequately assesses the dimensions of antenatal anxiety and depression. Conclusion: The PHQ-4 is a reliable and valid instrument to screen for depression and anxiety during pregnancy. The PHQ-4 is an ultra-brief measure that can be used to screen for antenatal depression and anxiety to prevent the negative consequences associated with these mental health conditions among mothers and infants.