Prevalence of Depression Among the Adult Population in Southwestern Saudi Arabia: A Cross-Sectional, Community-Based Study

Background Depression is one of the most common mental disorders, which is increasing globally with higher prevalence among women. Many factors contribute to the etiology and risk factors for depression, including biological and psychosocial factors. This study aimed to assess the prevalence of depression among the adult population in Al-Qunfudah governorate, southwestern Saudi Arabia (SA). Methods A cross-sectional study was conducted on a sample of 1036 participants among adults in Al-Qunfudah governorate, southwestern SA, using a validated Arabic version of the Patient Health Questionnaire (PHQ-9) during the period from October 1st, 2022 to the end of December 2022. The PHQ-9 contains nine items, with a total score ranging from 0 to 27. A score of 1-4 represented minimal depression, while a score of 5, 10, 15, and 20 represented mild, moderate, moderately severe, and severe depression, respectively. The sample size was estimated to be 375 participants, by considering a margin of error of 5%, and a 95% confidence interval, calculated using Raosoft calculator (Raosoft Inc., Seattle, WA). Data collection was performed through an online survey of the PHQ-9 on a Google form and distributed using different social media platforms. The eligible participants' responses were kept confidential and analyzed using IBM SPSS Statistics for Windows, Version 22 (Released 2013; IBM Corp., Armonk, New York, United States). p-values of <0.05 were considered statistically significant.  Results The study showed that the overall prevalence of depression among the 1036 adult study participants was 68.1%. Mild, moderate, moderate to severe, and severe depression was diagnosed among 28.2%, 21.9%, 12%, and 6% of the participants, respectively. Several factors were significantly associated with PHQ-9 diagnosed depression including being younger (p<0.0001), a female (p<0.0001), single (p<0.0001), a student (p<0.0001), and non-employed (p<0.0001) and having a lower educational level (p<0.0001). Conclusions There is a high prevalence rate of depression among the adult population of Al-Qunfudah governorate in southwestern SA, which highlights the need for interventions to address this issue, and to reduce the incidence of depression in the region among the high-risk groups.

Analyzing the Prevalence of Depression and Anxiety Symptoms Among Relatives of Cancer Patients in Kuwait

INTRODUCTION

The mental health impact on relatives of cancer patients frequently goes unnoticed and is commonly undervalued. This study aimed to explore how personal factors such as the patient's degree of kin, marital status, cancer stage, and number of diagnosed family members are correlated with the severity of depression and anxiety among relatives of cancer patients.

METHOD

This self-administered cross-sectional survey was conducted in Kuwait, employing a random sampling method to recruit participants. Depression and anxiety symptoms were assessed using the validated Arabic versions of the Patient Health Questionnaire-9 (PHQ-9) and the Generalized Anxiety Disorder-7 (GAD-7) scale.

RESULTS

The mean age of the relatives of the cancer patients was 38.36 years (±13.44), with a female majority (59.72%). The prevalence of depression in the examined population was 60.1%, with the majority having mild depression (39.3%). On the other hand, the prevalence of anxiety in the same group was 51.2%, with the majority having mild disease (27.5%). Being female and having a cancer patient relative in the metastasis stage put patients' relatives at a greater risk of depression and anxiety.

CONCLUSION

The diagnosis of cancer necessitates mental health screenings for patients' relatives, as findings from our study indicate that these individuals are at a high risk of developing depression and anxiety. Targeted support and referrals to specialists are crucial for mitigating the impact on their well-being.

The Psychological Impact of Vitiligo in Saudi Arabia

Background Vitiligo, the most common pigment disorder, impacts 0.5-2% of the global population, often causing psychological distress due to appearance changes and potential discrimination. Existing data on depressive symptoms and quality of life (QoL) effects in Saudi Arabian vitiligo patients are limited and inconsistent. Hence, this multi-center investigation was conducted in Saudi Arabia to determine the prevalence of depressive symptoms and quality of life (QoL) impairment in patients with vitiligo and to identify factors linked to increased psychological distress in this population. Methods We conducted a multi-center cross-sectional study in Saudi Arabia, employing two validated Arabic questionnaires, the Dermatology Life Quality Index (DLQI) and the Patient Health Questionnaire-9 items (PHQ-9), along with demographic information. Appropriate statistical analyses were performed. Results In total, 204 patients completed the survey. The median DLQI was 4 (range: 25), while the median PHQ-9 was 5 (range: 27). Factors associated with worse QoL included an early age of onset (under 18 years) and a disease duration exceeding five years. Conversely, only disease duration correlated with worse PHQ-9 scores. Vitiligo lesions on the lower extremities, feet, and genitalia were linked to poorer DLQI scores, while only genitalia were associated with worse PHQ-9 scores. We recommend further social awareness campaigns emphasizing the role of supportive families to improve the well-being of vitiligo patients.

Patient Perception of Depressive Symptoms in Rheumatic Diseases: A Cross-sectional Survey

OBJECTIVES

The presented study aimed to explore the presence and the self-identification of depressive symptoms among patients with rheumatic musculoskeletal diseases (RMDs) through the use of the Patient Health Questionnaire (PHQ-9).

METHODS

Between June and October 2019, patients from the regional association for people with RMDs in Lombardy, Italy (ALOMAR), were invited to participate in a cross-sectional online survey. Participants completed PHQ-9 along with a survey about their perception of depressive symptoms. Patients were stratified according to PHQ-9 score as follows: not depressed (<4), subclinical or mild depression (5-9), moderate depression (10-14), moderately severe depression (10-14), and severe depression (20-27). Descriptive statistics and analyses of variance were used to explore data.

RESULTS

Of the 192 RMD patients who completed PHQ-9, 35 (18.2%) were not depressed, 68 (35.4%) had subclinical or mild depression, 42 (21.9%) had moderate depression, 30 (15.6%) had moderately severe depression, and 17 (8.9%) had severe depression. Contrary to the above findings, only 16 respondents (8.3%) reported that they experienced depressive symptoms, and only 7 of the 16 were being followed by a psychiatrist. Respondents with higher PHQ-9 scores tended to have concomitant fibromyalgia, to be younger, and to be overweight.

CONCLUSIONS

The current results indicate the overall burden of depressive symptoms in RMD patients. While clinical depression (PHQ-9 >10) was detected in 41.2% of respondents, only 8.3% reported that they experience depressive symptoms. Routine screening of RMD patients for depression is therefore critical.

Depression Screening for the Geriatric Population Visiting Primary Healthcare Centers in the Eastern Region of Saudi Arabia

Background Depression is considered one of the most common psychiatric disorders that affects more than 260 million people in all age groups worldwide. Yet, among the geriatric population, in which it can show nonspecific symptoms, depression can be easily underdiagnosed. The objectives of this study are to assess the prevalence of depression among the geriatric population in primary healthcare centers and to estimate the effects of different sociodemographic and medical factors. Methodology A total of 408 patients aged 60 years or older were approached in the primary healthcare centers of the eastern region of Saudi Arabia. Using the Patient Health Questionnaire-9, patients were either interviewed or filled the questionnaire by themselves. Questions about sociodemographic data and medical and medication histories were included in the questionnaire. Results Of the 408 participants, 173 (42.4%) reported depressive symptoms; 115 (28.2%) of the participants had mild depression, 50 (12.3%) had moderate depression, and 8 (2%) reported moderately severe depression. Correlates of depression included elderly patients aged 75 years or more, of whom 78.9% showed depression compared to 39.3% of those who were 60-65 years old (P = 0.001). Furthermore, the female elderly showed higher rates of depression compared to males (52.8% vs. 35.7%; P = 0.001). A reported 81.1% of the elderly were diagnosed with chronic diseases; approximately half of them were depressed, while only 32.9% of the elderly free of diseases were depressed (P = 0.001). Conclusions The prevalence of depression is high among the elderly in the eastern province of Saudi Arabia, especially in those who complain of chronic diseases, older patients, and females. Screening for depression must be employed early to manage depressive symptoms and prevent further complications.

The Prevalence of Depression and Anxiety Among Sickle Cell Disease Patients in King Abdulaziz University Hospital

Background Sickle cell disease (SCD) is a recessive hereditary condition. The physical changes caused by SCD affect the quality of life (QoL) by negatively impacting psychological aspects. Objective This study aimed to assess the prevalence of depression and anxiety in SCD patients based on different sociodemographic characteristics in Jeddah, Saudi Arabia. Method A cross-sectional study was conducted at King Abdulaziz University Hospital (KAUH) in Jeddah from 13 July to 30 August 2021. The included patients were 18 years of age and above and affected with sickle cell disease. Medical staff interviewed the patients and filled the Patient Health Questionnaire (PHQ)-9 and General Anxiety Disorder (GAD)-7. Result One hundred nineteen (119) patients were included in this study. The median age of participants was 32 and mostly male (n=72, 60.5%). The rate of depression was 45.4%. On the other hand, the rate of anxiety was 22.7%. The median of the PHQ-9 score was 8±8 while the median of the GAD-7 score was 5±8. Moreover, the study showed that anxiety and depression in relation to sociodemographics were higher in the patient age groups of 30-34 years old, male, single, unemployed, and with higher education. There was a significant association between depression rate and the two variables: patient employment status (49.3%; p=0.047) and a family history of SCD (51%). Conclusion Depression in patients with sickle cell disease is prevalent and correlated to demographic and social factors.

Prevalence of Depression and Psychological Distress and Perturbations of Cortisol Dynamics in Attendants of Hospitalized Patients: An Observational Pilot Study

Background: Attendants of in-hospital patients are prone to undue stress resulting in depression, anxiety, melancholy and psychological distress. Hitherto available studies cater to attendants of patients admitted in critical care units and none have ventured to look into their cortisol dynamics. Herein, we have evaluated the magnitude of psychological distress and depression amongst ostensibly healthy attendants of non-critically ill patients and correlated them with cortisol dynamics. 

Methods: Non-critically ill patients admitted to the general medicine ward were chosen by purposive sampling and one attendant was selected from each patient. Those with known risk factors, psychiatric illnesses, chronic drug intake, addictions, and overweight/obesity were excluded. Psychological distress and depression were assessed using the General Health Questionnaire 12-items (GHQ-12) and the Patient Health Questionnaire (PHQ-9), respectively. Morning plasma cortisol, late-night plasma cortisol (LNPC), late-night salivary cortisol (LNSC), urinary free cortisol (UFC), and plasma cortisol after overnight 1 mg dexamethasone administration were measured. 

Results: After exclusion, 39 participants were recruited (M:F=2.3:1.6). The mean age was 34.1±11.4 years. The mean duration of stay in hospital ambience prior to recruitment was 16.2±1.2 days. Based on the PHQ-9 score, 55% of the participants had depression. Psychological distress prevailed in 13% of participants as per the GHQ-12 score. The median LNPC/LNSC was higher in participants with depression compared to those with no depression, however, there was no statistically significant difference. There was no significant correlation between GHQ-12/PHQ-9 scores and cortisol dynamics. 

Conclusions: Although depression is prevalent in about half of the patient attendants, cortisol dynamics remain largely unaltered over a short period of two to three weeks.

Efficacy of a Multimodal Online Lifestyle Intervention for Depressive Symptoms and Quality of Life in Individuals With a History of Major Depressive Disorder

Background

Major depressive disorder (MDD) is a complex bio-psycho-social syndrome that affects millions of individuals and is one of the leading causes of impaired quality of life (QOL). In addition to the symptoms of depression and low mood, many individuals with MDD also suffer from isolation without the sense of a supportive, surrounding community. Given the challenges of treating individuals with MDD, social isolation and a lack of communal connection, this randomized controlled trial was designed to determine the efficacy of a multimodal, online and community-based lifestyle intervention for improving depressive symptoms and QOL in individuals with a history of MDD.

Materials and methods

The study enrolled 71 female or male participants between the ages of 20 and 64 with a self-reported BMI between 18.4 and 34.9 kg/m² and a history of MDD. Individuals were randomized to either participate in a 44-day multimodal, online, community-based lifestyle intervention or placed on a wait list where they would complete the intervention at a later date. The multimodal intervention involved a self-directed learning program where individuals were guided to make lifestyle changes including adopting a whole-foods diet, increasing movement, and adopting stress management and mindfulness practices. All participants completed the 36-Item Short Form Health Survey (SF-36), the Cleveland Clinic Center for Functional Medicine's Medical Symptoms Questionnaire (MSQ), and the Patient Health Questionnaire-9 (PHQ-9) before and after the online program to assess health-related QOL, overall symptom burden, and depressive symptom burden, respectively. 

Results

A total of 37 participants were randomized to participate in the multimodal intervention with 26 completing all three study questionnaires at both study time points; 34 participants were randomized to the wait list control group with 27 completing all three study questionnaires at both study time points. There were no clinically or statistically significant differences between the control group or the intervention group at baseline. The control group showed no clinically nor statistically significant changes in the MSQ, PHQ-9 or any of the eight subdomains of the SF-36 from the beginning to the end of the 10-week study period. When compared to the control group, the intervention group showed statistically and clinically significant improvements in median (M) scores of the SF-36 subdomains of vitality and mental health, and clinically but not statistically significant improvements in the subdomain of emotional role functioning. There were additional statistically and clinically significant improvements in the mean score of the MSQ and M scores of the PHQ-9 (treatment pre-intervention M = 10.5, inter-quartile range [IQR] = 14, to treatment post-intervention M = 5, IQR = 8.25; control pre-intervention M = 15, IQR = 8, to control post-intervention M = 13.5, IQR = 12.5).

Conclusions 

Our randomized controlled study provides evidence for the role of a multimodal, online and community-based lifestyle intervention to improve depressive symptoms, QOL, and total symptom burden in individuals with a history of MDD. Given the growing challenges of effectively supporting individuals suffering with MDD, it appears critical to further explore the utilization of novel, multimodal and self-directed lifestyle interventions.

Incidence of depression in patients with hepatitis C treated with direct-acting antivirals

OBJECTIVE

Depression has been associated with hepatitis C, as well as with its treatment with proinflammatory cytokines (i.e., interferon). The new direct-acting antiviral agents (DAAs) have minimal adverse effects and high potency, with a direct inhibitory effect on non-structural viral proteins. We studied the incidence and associated factors of depression in a real-life prospective cohort of chronic hepatitis C patients treated with the new DAAs.

METHODS

The sample was recruited from a cohort of 91 patients with hepatitis C, of both sexes, with advanced level of fibrosis and no HIV coinfection, consecutively enrolled during a 6-month period for DAA treatment; those euthymic at baseline (n=54) were selected. All were evaluated through the depression module of the Patient Health Questionnaire (PHQ-9-DSM-IV), at three time points: baseline, 4 weeks, and end-of-treatment.

RESULTS

The cumulative incidence (95%CI) of major depression and any depressive disorder during DAA treatment was 13% (6.4-24.4) and 46.3% (33.7-59.4), respectively. No differences were observed between those patients with and without cirrhosis or ribavirin treatment (p > 0.05). Risk factors for incident major depression during DAA treatment included family depression (relative risk 9.1 [1.62-51.1]), substance use disorder (11.0 [1.7-73.5]), and baseline PHQ-9 score (2.1 [1.1-3.1]).

CONCLUSIONS

The findings of this study highlight the importance of screening for new depression among patients receiving new DAAs, and identify potential associated risk factors.

Physical Activity and Its Association with Depression in the Diabetic Hispanic Population

Introduction

Hispanics are the largest ethnic minority group in the United States. The prevalence of depression and co-morbid depression in the Hispanic population is well-recognized. The positive association between physical activity and psychological health improves mood, emotional well-being, and prognostic outcome.

Objectives

There are two aspects of our research paper. First, it critically reviews the available literature showing the correlation between physical exercise and depression. Second, it analyzes the association between exercise and depression in uncontrolled diabetic Hispanics using data collected from the local community intervention program.

Method

A chi-square analysis was conducted to examine whether levels of physical activity reported at the baseline were associated with the frequency of depressed mood and anhedonia self-reported for the previous two weeks. This study utilized the use of the PHQ-2 scale for the assessment of depressive symptoms. The PHQ-2 scale is a useful tool to screen for depression in the integrated care setting. Participants from a local community intervention program were stratified on the basis of their gender and preferred language. Data were collected and represented in tables according to demographic characteristics.

Results

Our study established a statistically significant association between the levels of physical activity and the frequency of depression symptoms among Spanish speaking participants from the local community intervention program. These results provide convincing evidence that biological, developmental, social, and psychological factors facilitate the association between physical activity and depression.

Oral health condition and occurrence of depression in the elderly

Depression is a common disorder among the elderly; however, it is not a standard element of the ageing process. Depression can affect oral health as a result of neglecting oral hygiene procedures, cariogenic nutrition, avoidance of necessary dental care which leads to an increased risk of dental caries and periodontal disease.Assessment of the relationship of oral health parameters with depression.500 subjects aged ≥65 (mean 74.4 ± 7.4) were involved in the study. Dental condition (decay-missing-filled index [DMFT], number of missing teeth [MT], removable denture wearing, teeth mobility), periodontal condition (bleeding on probing [BoP], pocket depth [PD], loss of attachment), oral dryness (the Challacombe Scale) and depression according to the Patient Health Questionnaire-9 (PHQ-9) scale were assessed.Depression on a minimal level was detected in 60.2% of the subjects, mild-in 22.2%, moderate-in 6.0% and moderately-in 2.6%. The mean of the PHQ-9 scale was 3.56 ± 4.07. Regression analysis showed a positive relationship of the PHQ-9 value with DMFT, the number of MT, oral dryness and with age. No correlation was observed between other examined oral health indicators, such as periodontal condition (BoP, PD, clinical attachment level), periodontitis, removable denture wearing a PHQ-9.The results of our study have shown that among people aged 65 and over, the severity of depression increases with a higher number of MT, the number of decayed teeth, as well as prevalence of oral dryness.

Study protocol on criterion validation of Edinburgh Postnatal Depression Scale (EPDS), Patient Health Questionnaire (PHQ-9) and Centre for Epidemiological Studies-Depression (CES-D) screening tools among rural postnatal women; a cross-sectional study

BACKGROUND

Screening women for postnatal depression (PND) provides an opportunity to reach undetected cases and enhance pregnancy outcomes. In Zimbabwe, no validation of depression screening tools has been done on postnatal women in rural settings.

OBJECTIVES

This study aims to determine criterion validity of the Edinburgh Postnatal Depression Scale (EPDS), the Patient Health Questionnaire (PHQ-9) and the Center for Epidemiological Studies-Depression (CES-D) scale using the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) criteria as the reference standard.

METHODS

Women (n=462) attending postnatal care at 7 or 42 days at two rural district hospitals in Zimbabwe will be assessed for depressive symptoms using the EPDS, PHQ-9 and CES-D. The women will be interviewed by a clinical psychologist using DSM-5 criteria. Sensitivities, specificities, positive predictive values, negative predictive values and test efficiencies will be calculated for each of the three tools. The area under the receiver operating curve will quantify the overall ability of the three tests to discriminate between those mothers with PND and those without.

DISCUSSION

Findings from this study will add to the body of knowledge on PND among women in resource-limited settings. Identifying women with PND will enable healthcare providers to link them with care, which will ultimately improve maternal and child health outcomes. Furthermore, this study will provide evidence on which screening tool would be best for screening PND in rural settings of Zimbabwe.

Effect of early palliative care on quality of life in patients with non-small-cell lung cancer

Background

Patients with metastatic non-small-cell lung cancer (nsclc) experience great pain and stress. Our study aimed to explore the effect of early palliative care on quality of life in patients with nsclc.

Methods

A total of 150 patients were randomly divided into two groups: control group with conventional care and study group with early palliative care. The quality of life (qol) rating scale and self-rating scale of life quality (sslq) were used to analyze the patients' quality of life. The Hospital Anxiety and Depression Scale-D/A (hads-d/a) and Patient Health Questionnaire 9 (phq-9) were used to analyze the patients' mood. Pulmonary function indexes of peak expiratory flow (pef), functional residual capacity (frc), and trachea-esophageal fistula 25% (tef 25%) were analyzed using the lung function detector.

Results

The qol and sslq scales scores of patients receiving early palliative care were significantly higher than those in the control group (p < 0.05). Moreover, the questionnaire results of the hads-d/a and phq-9 were better in patients receiving palliative care than in the control group (p < 0.05 or p < 0.01). In addition, analytical results of pulmonary function showed that the levels of pef, frc, and tef 25% in patients assigned to early palliative care were remarkably higher than those in the control group (p < 0.01 or p < 0.001).

Conclusions

These data demonstrate that early palliative care improves life quality, mood, and pulmonary function of nsclc patients, indicating that early palliative care could be used as a clinically meaningful and feasible care model for patients with metastatic nsclc.

Prevalence and Predictors of Depression Amongst Hypertensive Individuals in Karachi, Pakistan

Objective

While studies evaluating the prevalence of depression and hypertension have been extensively carried out in high income countries, there is a paucity of information assessing the prevalence of depression within hypertensive patients in low income nations. The primary objective of this study was to investigate the prevalence of undiagnosed depression in hypertensive patients within a tertiary care facility in Karachi, Pakistan. The secondary objective was to assess factors associated with undiagnosed depression in this group.

Methods

A cross-sectional study was conducted at the Civil Hospital Karachi Outpatient Department from January 2017 to April 2017. The sample population was composed of 411 hypertensive patients. Interviews were conducted after taking informed consent, with data concerning basic demographic details and lifestyle habits gathered. Blood pressure was recorded and its severity was classified as per the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7) guidelines. Depression was evaluated and its severity classified as per the Patient Health Questionnaire-9 (PHQ-9) scale, with a score of 10 or above set as the cut-off point. Data were entered and analyzed using the IBM Statistical Package for the Social Sciences 23.0. (IBM, NY, USA)

Results

The prevalence of depression within 411 hypertensive patients was 40.1% (n = 165). The mean age of the sample was 45.7 ± 11.2 years, and the majority were females (72%, n = 295), unemployed (72%, n = 296), had primary or no education (67%, n = 277), and were of low socioeconomic status (78%, n = 321). The average systolic and diastolic blood pressures were 143.8 ± 21.7 and 93.3 ± 15.5 mm Hg, respectively. Factors which had a significant association with depression were gender (p = 0.009), age class (p = 0.035), educational status (p = 0.000), employment status (p = 0.003), socioeconomic status (p = 0.008), physical activity (p = 0.025), smoking (p = 0.017), and family history of hypertension (p = 0.022).

Conclusion

With such a high prevalence rate of undiagnosed depression within hypertensive patients, it is pertinent to establish screening programs for early detection and community programs to raise awareness regarding long-term complications of untreated depression.

The diagnostic accuracy of the Patient Health Questionnaire-2 (PHQ-2), Patient Health Questionnaire-8 (PHQ-8), and Patient Health Questionnaire-9 (PHQ-9) for detecting major depression: protocol for a systematic review and individual patient data meta-analyses

BACKGROUND

Major depressive disorder (MDD) may be present in 10%-20% of patients in medical settings. Routine depression screening is sometimes recommended to improve depression management. However, studies of the diagnostic accuracy of depression screening tools have typically used data-driven, exploratory methods to select optimal cutoffs. Often, these studies report results from a small range of cutoff points around whatever cutoff score is most accurate in that given study. When published data are combined in meta-analyses, estimates of accuracy for different cutoff points may be based on data from different studies, rather than data from all studies for each possible cutoff point. As a result, traditional meta-analyses may generate exaggerated estimates of accuracy. Individual patient data (IPD) meta-analyses can address this problem by synthesizing data from all studies for each cutoff score to obtain diagnostic accuracy estimates. The nine-item Patient Health Questionnaire-9 (PHQ-9) and the shorter PHQ-2 and PHQ-8 are commonly recommended for depression screening. Thus, the primary objectives of our IPD meta-analyses are to determine the diagnostic accuracy of the PHQ-9, PHQ-8, and PHQ-2 to detect MDD among adults across all potentially relevant cutoff scores. Secondary analyses involve assessing accuracy accounting for patient factors that may influence accuracy (age, sex, medical comorbidity).

METHODS/DESIGN

Data sources will include MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, PsycINFO, and Web of Science. We will include studies that included a Diagnostic and Statistical Manual or International Classification of Diseases diagnosis of MDD based on a validated structured or semi-structured clinical interview administered within 2 weeks of the administration of the PHQ. Two reviewers will independently screen titles and abstracts, perform full article review, and extract study data. Disagreements will be resolved by consensus. Risk of bias will be assessed with the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Bivariate random-effects meta-analysis will be conducted for the full range of plausible cutoff values.

DISCUSSION

The proposed IPD meta-analyses will allow us to obtain estimates of the diagnostic accuracy of the PHQ-9, PHQ-8, and PHQ-2.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42014010673.

Adult depression screening in Saudi primary care: prevalence, instrument and cost

BACKGROUND

By the year 2020 depression would be the second major cause of disability adjusted life years lost, as reported by the World Health Organization. Depression is a mental illness which causes persistent low mood, a sense of despair, and has multiple risk factors. Its prevalence in primary care varies between 15.3-22%, with global prevalence up to 13% and between 17-46% in Saudi Arabia. Despite several studies that have shown benefit of early diagnosis and cost-savings of up to 80%, physicians in primary care setting continue to miss out on 30-50% of depressed patients in their practices.

METHODS

A cross sectional study was conducted at three large primary care centers in Riyadh, Saudi Arabia aiming at estimating point prevalence of depression and screening cost among primary care adult patients, and comparing Patient Health Questionnaires PHQ-2 with PHQ-9. Adult individuals were screened using Arabic version of PHQ-2 and PHQ-9. PHQ-2 scores were correlated with PHQ-9 scores using linear regression. A limited cost-analysis and cost saving estimates of depression screening was done using the Human Capital approach.

RESULTS

Patients included in the survey analysis were 477, of whom 66.2% were females, 77.4% were married, and nearly 20% were illiterate. Patients exhibiting depressive symptoms on the basis of PHQ9 were 49.9%, of which 31% were mild, 13.4% moderate, 4.4% moderate-severe and 1.0% severe cases. Depression scores were significantly associated with female gender (p-value 0.049), and higher educational level (p-value 0.002). Regression analysis showed that PHQ-2 & PHQ-9 were strongly correlated R = 0.79, and R2 = 0.62. The cost-analysis showed savings of up to 500 SAR ($133) per adult patient screened once a year.

CONCLUSION

The point prevalence of screened depression is high in primary care visitors in Saudi Arabia. Gender and higher level of education were found to be significantly associated with screened depression. Majority of cases were mild to moderate, PHQ-2 was equivocal to PHQ 9 in utility and that screening for depression in primary care setting is cost saving.

Establishing a common metric for depressive symptoms: linking the BDI-II, CES-D, and PHQ-9 to PROMIS depression

Interest in measuring patient-reported outcomes has increased dramatically in recent decades. This has simultaneously produced numerous assessment options and confusion. In the case of depressive symptoms, there are many commonly used options for measuring the same or a very similar concept. Public and professional reporting of scores can be confused by multiple scale ranges, normative levels, and clinical thresholds. A common reporting metric would have great value and can be achieved when similar instruments are administered to a single sample and then linked to each other to produce cross-walk score tables (e.g., Dorans, 2007; Kolen & Brennan, 2004). Using multiple procedures based on item response theory and equipercentile methods, we produced cross-walk tables linking 3 popular "legacy" depression instruments-the Center for Epidemiologic Studies Depression Scale (Radloff, 1977; N = 747), the Beck Depression Inventory-II (Beck, Steer, & Brown, 1996; N = 748), and the 9-item Patient Health Questionnaire (Kroenke, Spitzer, & Williams, 2001; N = 1,120)-to the depression metric of the National Institutes of Health (NIH) Patient-Reported Outcomes Measurement Information System (PROMIS; Cella et al., 2010). The PROMIS Depression metric is centered on the U.S. general population, matching the marginal distributions of gender, age, race, and education in the 2000 U.S. census (Liu et al., 2010). The linking relationships were evaluated by resampling small subsets and estimating confidence intervals for the differences between the observed and linked PROMIS scores; in addition, PROMIS cutoff scores for depression severity were estimated to correspond with those commonly used with the legacy measures. Our results allow clinicians and researchers to retrofit existing data of 3 popular depression measures to the PROMIS Depression metric and vice versa.

Prevalence of depression and its associated factors among patients attending primary care settings in the post-conflict Northern Province in Sri Lanka: a cross-sectional study

BACKGROUND

In Sri Lanka, civilians in the Northern Province were affected by a long-term armed conflict that ended in 2009. This study aims to describe the prevalence of depression and its associated factors among adult patients attending primary care settings in the Northern Province in Sri Lanka.

METHODS

We report data from a cross-sectional patient morbidity registry established in 16 primary care facilities (12 Divisional Hospitals and 4 Primary Medical Care Units) in four districts of the Northern Province. The Patient Health Questionnaire-9 (PHQ-9) was used to assess depression among all patients aged ≥ 18 years, between March and May 2013. A sample of 12,841 patient records was included in the analysis. A total score of ≥ 10 in the PHQ-9 was considered as major depression. Factors associated with major depression were tested using multivariable logistic regression analysis.

RESULTS

The prevalence of major depression was 4.5% (95% CI: 4.1-4.9) and mild depression was 13.3% (95% CI: 12.7-13.9). The major depression was significantly higher in females than males (5.1% vs. 3.6%) and among unpaid family workers (6.0%) than any other category who earned an income (varied between 1.2% and 3.2%). The prevalence was rising significantly with advancing age, and ranged from 0.3% in the youngest to 11.6% in the elderly.Multivariable regression analysis revealed that the females have a higher risk for major depression than males (OR = 1.4; 95% CI: 1.1-1.7). Older patients were more likely to be depressed than younger patients, OR (95% CI) were 4.9 (1.9-12.5), 5.6 (2.2-14.0), 5.7 (2.3-14.2) and 4.7 (1.8-11.9) for the age groups 25-34, 35-49, 50-64, and ≥ 65 years respectively, in contrast to 18-24 year group. Disability in walking (OR = 7.5; 95% CI: 5.8-9.8), cognition (OR = 4.5; 95% CI: 3.6-5.6), self-care (OR = 2.6; 95% CI: 1.7-4.0), seeing (OR = 2.3; 95% CI: 1.8-3.0), and hearing (OR = 2.0; 95% CI: 1.5-2.5) showed significant associations with depression.

CONCLUSIONS

Depression is a common issue at primary care settings in a post-conflict population, and the elders, women and persons with disability are at a greater risk. Strengthening capacity of primary care facilities and community mental health services is necessary for early detection and management.

Longitudinal comparison of three depression measures in adult cancer patients

CONTEXT

Although a number of depression measures have been used with cancer patients, longitudinal comparisons of several measures in the same patient population have been infrequently reported.

OBJECTIVES

To compare the Hopkins Symptom Checklist 20-item depression scale, Short-Form 36 Mental Health Inventory five-item distress scale, and Patient Health Questionnaire nine-item depression scale in adults with cancer.

METHODS

Of the 309 cancer patients enrolled in a telecare management trial for depression, 247 completed the three depression measures at both baseline and at three months and a retrospective assessment of global rating of change in depression at three months. Internal consistency and construct validity of each measure were evaluated. Responsiveness was compared by calculating standardized response means and receiver operating characteristic area under the curve, using global rating of change as the external comparator measure. Differences between intervention and control groups in depression change scores were compared by calculating standardized effect sizes (SESs).

RESULTS

Internal reliability coefficients for the three measures were ≥0.77 at baseline and ≥0.84 at three months. Construct validity was supported with strong correlations of the depression measures among themselves, moderately strong correlations with other measures of mental health, and moderate correlations with vitality and disability. In terms of responsiveness, standardized response means for all measures significantly differentiated between three groups (improved, unchanged, and worse) as classified by patient-reported global rating of change in depression at three months. The three measures were able to detect a modest treatment effect in the intervention group compared with the control group (SES ranging from 0.21 to 0.43) in the full sample, whereas detecting a greater treatment effect in depressed participants with comorbid pain (SES ranging from 0.30 to 0.58). Finally, the three measures performed similarly in detecting patients with improvement.

CONCLUSION

The Hopkins Symptom Checklist 20-item depression scale, Mental Health Inventory five-item distress scale, and Patient Health Questionnaire nine-item depression scale were established as reliable, valid, and responsive depression measures in adults with cancer. Given the current recommendations for measurement-based care, our study shows that clinicians treating depressed cancer patients have several measures from which to choose.

Depressive symptoms in people with chronic physical conditions: prevalence and risk factors in a Hong Kong community sample

BACKGROUND

Depression is predicted to become one of the two most burdensome diseases worldwide by 2020 and is common in people with chronic physical conditions. However, depression is relatively uncommon in Asia. Family support is an important Asian cultural value that we hypothesized could protect people with chronic physical conditions from developing depression. We investigated depressive symptom prevalence and risk factors in a Chinese sample with chronic medical conditions, focusing on the possible protective role of family relationships.

METHODS

Data were obtained from the Hong Kong Jockey Club FAMILY Project cohort study in 2009-2011, which included 6,195 participants (age ≥15) with self-reported chronic conditions. Depressive symptoms were recorded using the Patient Health Questionnaire-9 (PHQ-9). Demographic and lifestyle variables, stressful life events, perceived family support and neighborhood cohesion were assessed. Factors associated with a non-somatic (PHQ-6) depression score were also examined.

RESULTS

The prevalence of depressive symptoms (PHQ-9 scores ≥5) was 17% in those with one or more chronic conditions, and was more prevalent in women than in men (19.7% vs. 13.9%; p < 0.001). In multilevel analyses, life stress, number of chronic conditions and satisfaction with family support explained 43% of the variance in PHQ-9 scores (standardized regression coefficients of 0.46, 0.15, and -0.12 respectively, all p <0.001). Body mass index, problem alcohol drinking, physical activity, and unmarried status were significantly associated with PHQ-9 scores, although these associations were weak. Variables associated with depression explained 35% of the variance in non-somatic (PHQ-6) depression scores. Satisfaction with family support played a stronger protective role against depressive symptoms (both PHQ-9 and PHQ-6 scores) among women than men (p < 0.05).

CONCLUSIONS

Acute life stress and the number of chronic conditions, together with socio-demographic factors, explain most variance in depressive symptoms among chronically ill Chinese individuals. Somatic items in the PHQ-9 increased the depression scores but they did not alter the pattern of predictors. Family support appears to be an important protective factor in Chinese cultures for individuals with chronic conditions.

A multigroup confirmatory factor analysis of the Patient Health Questionnaire-9 among English- and Spanish-speaking Latinas

Depression is a significant problem for ethnic minorities that remains understudied partly due to a lack of strong measures with established psychometric properties. One screening tool, the Patient Health Questionnaire-9 (PHQ-9), which was developed for use in primary care has also gained popularity in research settings. The reliability and validity of the PHQ-9 has been well established among predominantly Caucasian samples, in addition to many minority groups. However, there is little evidence regarding its utility among Hispanic Americans, a large and growing cultural group in the United States. In this study, we investigated the reliability and structural validity of the PHQ-9 in Hispanic American women. A community sample of 479 Latina women from southern California completed the PHQ-9 in their preferred language of English or Spanish. Cronbach's alphas suggested that there was good internal consistency for both the English- and Spanish-language versions. Structural validity was investigated using multigroup confirmatory factor analysis. Results support a similar one-factor structure with equivalent response patterns and variances among English- and Spanish-speaking Latinas. These results suggest that the PHQ-9 can be used with confidence in both English and Spanish versions to screen Latinas for depression.

Prevalence, treatment, and control of depressive symptoms in the United States: results from the National Health and Nutrition Examination Survey (NHANES), 2005-2008

BACKGROUND

depression remains a major public health problem that is most often evaluated and treated in primary care settings. The objective of this study was to examine the prevalence, treatment, and control of depressive symptoms in a national data sample using a common primary care screening tool for depression.

METHODS

we analyzed a sample of adults (n = 4836) from 2005 to 2008 National Health and Nutrition Examination Survey data. Depressive symptoms were assessed using the Patient Health Questionnaire (PHQ-9) to determine the overall prevalence, rates of treatment, and antidepressant control of mild, moderate, moderately severe, and severe depressive symptoms.

RESULTS

of the sample, 20.1% reported significant depressive symptoms (PHQ-9) score, ≥ 5), the majority of whom had mild depressive symptoms (PHQ-9) score, 5-9). Even among individuals with severe depressive symptoms, a large percentage (36.9%) received no treatment from a mental health professional or with antidepressant medication. Of those taking antidepressants, 26.4% reported mild depressive symptoms and 18.8% had moderate, moderately severe, or severe depressive symptoms.

CONCLUSIONS

despite greater awareness and treatment of depression in primary care settings, the prevalence of depressive symptoms remains high, treatment levels remain low, and control of depressive symptoms are suboptimal. Primary care providers need to continue to focus their efforts on diagnosing and effectively treating this important disease.

Predictors of depressive symptomatology among rural stimulant users

This study examined sociodemographic and drug-related predictors of depressive symptoms among a rural, multistate sample of not-in-treatment stimulant drug users (n=710). Participants were recruited using respondent-driven sampling in Ohio, Arkansas, and Kentucky. The Patient Health Questionnaire (PHQ-9) was used to measure symptoms of depression. Moderate to severe depressive symptomatology was reported by 43.0% of the sample. Cumulative logistic regression analysis showed that daily and nondaily crack use as well as the daily use of cocaine HCl increased the odds of depressive symptoms. Methamphetamine use had no significant association with depression. The daily use of marijuana, the illicit use of tranquilizers, light/moderate cigarette smoking, and injection drug use also increased the risk of depressive symptoms. Living in Kentucky or Ohio (compared to Arkansas), having unstable living arrangements, and being White, female, and older were related to higher odds of depressive symptoms. These results suggest that a host of drug and nondrug factors need to be considered when addressing depressive symptoms in stimulant users.

Validity/reliability of PHQ-9 and PHQ-2 depression scales among adults living with HIV/AIDS in western Kenya

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 > or =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.

Postpartum depression screening at well-child visits: validity of a 2-question screen and the PHQ-9

PURPOSE

Postpartum depression affects up to 22% of women who have recently given birth. Most mothers are not screened for this condition, and an ideal screening tool has not been identified. This study investigated (1) the validity of a 2-question screen and the 9-item Patient Health Questionnaire (PHQ-9) for identifying postpartum depression and (2) the feasibility of screening for postpartum depression during well-child visits.

METHODS

Study participants were English-literate mothers registering their 0- to 1-month-old infants for well-child visits at 7 family medicine or pediatric clinics. They were asked to complete questionnaires during well-child visits at 0 to 1, 2, 4, 6, and 9 months postpartum. Each questionnaire included 2 depression screens: the 2-question screen and the PHQ-9. The mothers also completed the depression component of the Structured Clinical Interview for DSM-IV (SCID) initially, and again at a subsequent interval if either screening result was positive for depression.

RESULTS

The response rate was 33%. Of the 506 women who participated, 45 (8.9%) had major depression (ie, they had a positive result on the SCID). The screen sensitivities/specificities over the course of the study were 100%/44% with the 2-question screen, 82%/84% with the PHQ-9 using simple scoring, and 67%/92% with the PHQ-9 using complex scoring. In addition, the corresponding values for the first 2 items of the PHQ-9 (ie, the 2-item Patient Health Questionnaire or PHQ-2) were 84%/79%. Some 38% of women completed their 2- to 6-month questionnaires during well-child visits; the rest completed them by mail (29%) or telephone (33%).

CONCLUSIONS

The 2-question screen was highly sensitive and the PHQ-9 was highly specific for identifying postpartum depression. These results suggest the value of a 2-stage procedure for screening for postpartum depression, whereby a 2-question screen that is positive for depression is followed by a PHQ-9. These screens can be easily administered in primary care clinics; feasibility of screening during well-child visits was moderate but may be better in clinics using a mass-screening approach.

Assessing depression in primary care with the PHQ-9: can it be carried out over the telephone?

BACKGROUND

Telephone assessment of depression for research purposes is increasingly being used. The Patient Health Questionnaire 9-item depression module (PHQ-9) is a well-validated, brief, self-reported, diagnostic, and severity measure of depression designed for use in primary care (PC). To our knowledge, there are no available data regarding its validity when administered over the telephone.

OBJECTIVE

The aims of the present study were to evaluate agreement between self-administered and telephone-administered PHQ-9, to investigate possible systematic bias, and to evaluate the internal consistency of the telephone-administered PHQ-9.

METHODS

Three hundred and forty-six participants from two PC centers were assessed twice with the PHQ-9. Participants were divided into 4 groups according to administration procedure order and administration procedure of the PHQ-9: Self-administered/Telephone-administered; Telephone-administered/Self-administered; Telephone-administered/Telephone-administered; and Self-administered/Self-administered. The first 2 groups served for analyzing the procedural validity of telephone-administered PHQ-9. The last 2 allowed a test-retest reliability analysis of both self- and telephone-administered PHQ-9. Intraclass correlation coefficient (ICC) and weighted kappa (for each item) were calculated as measures of concordance. Additionally, Pearson's correlation coefficient, Student's t-test, and Cronbach's alpha were analyzed.

RESULTS

Intraclass correlation coefficient and weighted kappa between both administration procedures were excellent, revealing a strong concordance between telephone- and self-administered PHQ-9. A small and clinically nonsignificant tendency was observed toward lower scores for the telephone-administered PHQ-9. The internal consistency of the telephone-administered PHQ-9 was high and close to the self-administered one.

CONCLUSIONS

Telephone and in-person assessments by means of the PHQ-9 yield similar results. Thus, telephone administration of the PHQ-9 seems to be a reliable procedure for assessing depression in PC.