Skip to main content
×
×
Home

Case finding and screening clinical utility of the Patient Health Questionnaire (PHQ-9 and PHQ-2) for depression in primary care: a diagnostic meta-analysis of 40 studies

  • Alex J. Mitchell (a1), Motahare Yadegarfar (a2), John Gill (a2) and Brendon Stubbs (a3)
Abstract
Background

The Patient Health Questionnaire (PHQ) is the most commonly used measure to screen for depression in primary care but there is still lack of clarity about its accuracy and optimal scoring method.

Aims

To determine via meta-analysis the diagnostic accuracy of the PHQ-9-linear, PHQ-9-algorithm and PHQ-2 questions to detect major depressive disorder (MDD) among adults.

Method

We systematically searched major electronic databases from inception until June 2015. Articles were included that reported the accuracy of PHQ-9 or PHQ-2 questions for diagnosing MDD in primary care defined according to standard classification systems. We carried out a meta-analysis, meta-regression, moderator and sensitivity analysis.

Results

Overall, 26 publications reporting on 40 individual studies were included representing 26 902 people (median 502, s.d.=693.7) including 14 760 unique adults of whom 14.3% had MDD. The methodological quality of the included articles was acceptable. The meta-analytic area under the receiver operating characteristic curve of the PHQ-9-linear and the PHQ-2 was significantly higher than the PHQ-9-algorithm, a difference that was maintained in head-to-head meta-analysis of studies. Our best estimates of sensitivity and specificity were 81.3% (95% CI 71.6–89.3) and 85.3% (95% CI 81.0–89.1), 56.8% (95% CI 41.2–71.8) and 93.3% (95% CI 87.5–97.3) and 89.3% (95% CI 81.5–95.1) and 75.9% (95% CI 70.1–81.3) for the PHQ-9-linear, PHQ-9-algorithm and PHQ-2 respectively. For case finding (ruling in a diagnosis), none of the methods were suitable but for screening (ruling out non-cases), all methods were encouraging with good clinical utility, although the cut-off threshold must be carefully chosen.

Conclusions

The PHQ can be used as an initial first step assessment in primary care and the PHQ-2 is adequate for this purpose with good acceptability. However, neither the PHQ-2 nor the PHQ-9 can be used to confirm a clinical diagnosis (case finding).

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Case finding and screening clinical utility of the Patient Health Questionnaire (PHQ-9 and PHQ-2) for depression in primary care: a diagnostic meta-analysis of 40 studies
      Available formats
      ×
      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Case finding and screening clinical utility of the Patient Health Questionnaire (PHQ-9 and PHQ-2) for depression in primary care: a diagnostic meta-analysis of 40 studies
      Available formats
      ×
      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Case finding and screening clinical utility of the Patient Health Questionnaire (PHQ-9 and PHQ-2) for depression in primary care: a diagnostic meta-analysis of 40 studies
      Available formats
      ×
Copyright
This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Corresponding author
Alex J. Mitchell, Psycho-Oncology, Department of Cancer Studies, University of Leicester, Leicester LE1 5WW, UK. Email: ajm80@le.ac.uk
Footnotes
Hide All

Declaration of interest

None.

Copyright and usage

© The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

Footnotes
References
Hide All
1 Mitchell, AJ, Vaze, A, Rao, S. Clinical diagnosis of depression in primary care: a meta-analysis. Lancet 2009; 374: 609–19.
2 National Collaborating Centre for Mental Health. Depression in Adults with a Chronic Physical Health Problem: The NICE Guideline on Treatment and Management 2010. British Psychological Society & Royal College of Psychiatrists.
3 Moussavi, S, Chatterji, S, Verdes, E, Tandon, A, Patel, V, Ustun, B. Depression, chronic diseases, and decrements in health: results from the World Health Surveys. Lancet 2007; 370: 851–8.
4 Whiteford, HA, Degenhardt, L, Rehm, J, Baxter, AJ, Ferrari, AJ, Erskine, HE, et al. Global burden of disease attributable to mental and substance use disorders: findings from the global burden of disease study 2010. Lancet 2013; 382: 1575–86.
5 Harman, JS, Veazie, PJ, Lyness, JM. Primary care physician office visits for depression by older Americans. J Gen Intern Med 2006; 21: 926–30.
6 Shah, A. The burden of psychiatric disorder in primary care. Int Rev Psychiatry 1992; 4: 243–50.
7 Zastrow, A, Faude, V, Seyboth, F, Niehoff, D, Herzog, W, Löwe, B. Risk factors of symptom underestimation by physicians. J Psychosom Res 2008; 64: 543–51.
8 Duhoux, A, Fournier, L, Gauvin, L, Roberge, P. Quality of care for major depression and its determinants: a multilevel analysis. BMC Psychiatry 2012; 12: 142.
9 Druss, BG, Wang, PS, Sampson, NA, Olfson, M, Pincus, HA, Wells, KB, et al. Understanding mental health treatment in persons without mental diagnoses: results from the National Comorbidity Survey replication. Arch Gen Psychiatry 2007; 64: 1196–203.
10 Takayanagi, Y, Spira, A, Bienvenu, O, Hock, RS, Carras, MC, Eaton, WW, et al. Antidepressant use and lifetime history of mental disorders in a community sample: results from the Baltimore Epidemiologic Catchment Area Study. J Clin Psychiatry 2015; 76: 40–4.
11 Duhoux, A, Fournier, L, Menear, M. Quality indicators for depression treatment in primary care: a systematic literature review. Curr Psychiatry Rev 2011; 7: 104–37.
12 Mojtabai, R. Clinician-identified depression in community settings: concordance with structured-interview diagnoses. Psychother Psychosom 2013; 82: 161–9.
13 Dowrick, C, Frances, A. Medicalising unhappiness: new classification of depression risks more patients being put on drug treatment from which they will not benefit. BMJ 2013; 347: 7140.
14 Jerant, A, Kravitz, RL, Fernandez, Y, Garcia, E, Feldman, MD, Cipri, C, et al. Potential antidepressant overtreatment associated with office use of brief depression symptom measures. J Am Board Fam Med 2014; 27: 611–20.
15 Mitchell, AJ, Meader, N, Davies, E, Clover, K, Carter, GL, Loscalzo, MJ, et al. Meta-analysis of screening and case finding tools for depression in cancer: evidence based recommendations for clinical practice on behalf of the Depression in Cancer Care consensus group. J Affect Disord 2012; 140: 149–60.
17 Mitchell, AJ, Coyne, JC. Do ultra-short screening instruments accurately detect depression in primary care? A pooled analysis and meta-analysis of 22 studies. Br J Gen Pract 2007; 57: 144–51.
18 Mitchell, AJ, Vahabzadeh, A, Magruder, K. Screening for distress and depression in cancer settings: 10 lessons from 40 years of primary-care research. Psychooncology 2011; 20: 572–84.
19 Kroenke, K, Spitzer, RL, Williams, JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001; 16: 606–13.
20 Kroenke, K, Spitzer, RL, Williams, JB. The patient health questionnaire-2: validity of a two-item depression screener. Med Care 2003; 41: 1284–92.
21 MacMillan, HL, Patterson, CJ, Wathen, CN, Feightner, JW, Bessette, P, Elford, RW, et al. Canadian Task Force on Preventive Health Care: screening for depression in primary care: recommendation statement from the Canadian Task Force on Preventive Health Care. CMAJ 2005; 172: 33–5.
22 U.S. Preventive Services Task Force. Screening for depression: recommendations and rationale. Ann Intern Med 2002; 136: 760–4.
23 Siu, AL; US Preventive Services Task Force. Screening for depression in adults: US Preventive Services Task Force Recommendation Statement. JAMA 2016; 315: 380–7.
24 National Collaborating Center for Mental Health. The NICE Guideline on The Management and Treatment of Depression in Adults (Updated Edition). National Institute for Health and Clinical Excellence, 2010.
25 Allaby, M. Screening for Depression: A Report for the UK National Screening Committee (Revised Report). UK National Screening Committee, 2010.
26 Shaw, EJ, Sutcliffe, D, Lacey, T, Stokes, T. Assessing depression severity using the UK Quality and Outcomes Framework depression indicators: a systematic review. Br J Gen Pract 2013; 63: e30917.
27 Joffres, M, Jaramillo, A, Dickinson, J, Lewin, G, Pottie, K, Shaw, E, et al. Canadian Task Force on Preventive Health Care: recommendations on screening for depression in adults. CMAJ 2013; 185: 775–82.
28 Goodyear-Smith, FA, van Driel, ML, Arroll, B, Del Mar, C. Analysis of decisions made in meta-analyses of depression screening and the risk of confirmation bias: acase study. BMC Med Res Methodol 2012; 12: 76.
29 Gilbody, S, Richards, D, Brealey, S, Hewitt, C. Screening for depression in medical settings with the patient health questionnaire (PHQ): a diagnostic meta-analysis. J Gen Intern Med 2007; 22: 1596–602.
30 Wittkampf, KA, Naeije, L, Schene, A, Huyser, J, van Weert, HC. Diagnostic accuracy of the mood module of the Patient Health Questionnaire: a systematic review. Gen Hosp Psychiatry 2007; 29: 388–95.
31 Manea, L, Gilbody, S, McMillan, D. Optimal cut-off score for diagnosing depression with the Patient Health Questionnaire (PHQ-9): a meta-analysis. CMAJ 2012; 184: 191–6.
32 Manea, L, Gilbody, S, McMillan, D. A diagnostic meta-analysis of the Patient Health Questionnaire-9 (PHQ-9) algorithm scoring method as a screen for depression. Gen Hosp Psychiatry 2015; 37: 6775.
33 Löwe, B, Spitzer, RL, Gräfe, K, Kroenke, K, Quenter, A, Zipfel, S, et al. Comparative validity of three screening questionnaires for DSM-IV depressive disorders and physicians' diagnoses. J Affect Disord 2004; 78: 131–40.
34 Lowe, B, Kroenke, K, Kerstin, G. Detecting and monitoring depression with a two-item questionnaire (PHQ-2). J Psychosom Res 2005; 58: 163–71.
35 Cholera, R, Gaynes, BN, Pence, BW, Bassett, J, Qangule, N, Macphail, C, et al. Validity of the Patient Health Questionnaire-9 to screen for depression in a high-HIV burden primary healthcare clinic in Johannesburg, South JAfrica. J Affect Disord 2014; 167: 160–6.
36 Whiting, PF, Rutjes, AW, Westwood, ME, Mallett, S, Deeks, JJ, Reitsma, JB, et al. QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med 2011; 155: 529–36.
37 Mitchell, AJ. Sensitivity x PPV is a recognized test called the clinical utility index (CUI +). Eur J Epidemiol 2011; 26: 251–2.
38 Mitchell, AJ. The clinical significance of subjective memory complaints in the diagnosis of mild cognitive impairment and dementia: a meta-analysis. Int J Geriatr Psychiatry 2008; 23: 1191–202.
39 Mitchell, AJ. A meta-analysis of the accuracy of the mini-mental state examination in the detection of dementia and mild cognitive impairment. J Psychiatr Res 2009; 43: 411–31.
40 Reeve, JL, Lloyd-Williams, M, Dowrick, C. Revisiting depression in palliative care settings: the need to focus on clinical utility over validity. Palliat Med 2008; 22: 383–91.
41 Li, J, Fine, JP. Assessing the dependence of sensitivity and specificity on prevalence in meta-analysis. Biostatistics 2011; 12: 710–22.
42 Swets, JA. Measuring the accuracy of diagnostic systems. Science 1988; 240: 1285–93.
43 Higgins, JPT, Thompson, SG, Deeks, JJ, Altman, DG. Measuring inconsistency in meta-analyses. BMJ 2003; 327: 557–60.
44 Harbord, RM, Egger, M, Sterne, JA. A modified test for small-study effects in meta-analyses of controlled trials with binary endpoints. Stat Med 2006; 25: 3443–57.
45 Thompson, SG, Higgins, JPT. How should meta-regression analyses be undertaken and interpreted? Stat Med 2002; 21: 1559–73.
46 Arroll, B, Goodyear-Smith, F, Crengle, S, Gunn, J, Kerse, N, Fishman, T, et al. Validation of PHQ-2 and PHQ-9 to screen for major depression in the primary care population. Ann Fam Med 2010; 8: 348–53.
47 Ayalon, L, Goldfracht, M, Bech, P. ‘Do you think you suffer from depression?’ Reevaluating the use of a single item question for the screening of depression in older primary care patients. Int J Geriatr Psychiatry 2010; 25: 497502.
48 Azah, N., Shah, M, Juwita, S, et al. Validation of the Malay version brief Patient Health Questionnaire (PHQ-9) among adult attending family medicine clinics. Int Med J 2005; 12: 259–64.
49 Cannon, DS, Tiffany, ST, Coon, H, Scholand, MB, McMahon, WM, Leppert, MF. The PHQ-9 as a brief assessment of lifetime major depression. Psychol Assess 2007; 19: 247–51.
50 Chen, S, Fang, Y, Chiu, H, Fan, H, Jin, T, Conwell, Y. Validation of the nine-item Patient Health Questionnaire to screen for major depression in a Chinese primary care population. Asia Pac Psychiatry 2013; 5: 61–8.
51 Chen, S, Chiu, H, Xu, B, Ma, Y, Jin, T, Wu, M, et al. Reliability and validity of the PHQ-9 for screening late-life depression in Chinese primary care. Int J Geriatr Psychiatry 2010; 25: 1127–33.
52 de Lima Osório, F, Vilela Mendes, A, Crippa, JA, Loureiro, SR. Study of the discriminative validity of the PHQ-9 and PHQ-2 in a sample of Brazilian women in the context of primary health care. Perspect Psychiatr Care 2009; 45: 216–27.
53 Gelaye, B, Williams, MA, Lemma, S, Deyessa, N, Bahretibeb, Y, Shibre, T, et al. Validity of the Patient Health Questionnaire-9 for depression screening and diagnosis in East Africa. Psychiatry Res 2013; 210: 653–61.
54 Gilbody, S, Richards, D, Barkham, M. Diagnosing depression in primary care using self-completed instruments: UK validation of PHQ-9 and CORE-OM. Br J Gen Pract 2007; 57: 835–6.
55 Henkel, V, Mergl, R, Kohnen, R, Allgaier, AK, Moller, HJ, Hegerl, U. Use of brief depression screening tools in primary care: consideration of heterogeneity in performance in different patient groups. Gen Hosp Psychiatry 2004; 26: 190–8.
56 Lamers, F, Jonkers, CC, Bosma, H, Penninx, BW, Knottnerus, JA, van Eijk, JT. Summed score of the Patient Health Questionnaire-9 was a reliable and valid method for depression screening in chronically ill elderly patients. J Clin Epidemiol 2008; 61: 679–87.
57 Liu, SI, Yeh, ZT, Huang, HC, Sun, FJ, Tjung, JJ, Hwang, LC, et al. Validation of Patient Health Questionnaire for depression screening among primary care patients in Taiwan. Compr Psychiatry 2011; 52: 96101.
58 Lotrakul, M, Sumrithe, S, Saipanish, R. Reliability and validity of the Thai version of the PHQ-9. BMC Psychiatry 2008; 8: 46.
59 Patel, V, Araya, R, Chowdhary, N, King, M, Kirkwood, B, Nayak, S, et al. Detecting common mental disorders in primary care in India: a comparison of five screening questionnaires. Psychol Med 2008; 38: 221–8.
60 Phelan, E, Williams, B, Meeker, K, Bonn, K, Frederick, J, Logerfo, J, et al. A study of the diagnostic accuracy of the PHQ-9 in primary care elderly. BMC Fam Pract 2010; 11: 63.
61 Richardson, LP, Rockhill, C, Russo, JE, Grossman, DC, Richards, J, McCarty, C, et al. Evaluation of the PHQ-2 as a brief screen for detecting major depression among adolescents. Pediatrics 2010; 125: e1097103.
62 Sherina, MS, Arroll, B, Goodyear-Smith, F. Criterion validity of the PHQ-9 (Malay version) in a primary care clinic in Malaysia. Med J Malaysia 2012; 67: 309–15.
63 Spitzer, RL, Kroenke, K, Williams, JBW. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. JAMA 1999; 282: 1737–44.
64 Sung, SC, Low, CC, Fung, DS, Chan, YH. Screening for major and minor depression in a multiethnic sample of Asian primary care patients: a comparison of the nine-item Patient Health Questionnaire (PHQ-9) and the 16-item Quick Inventory of Depressive Symptomatology – Self-Report (QIDS-SR16). Asia Pac Psychiatry 2013; 5: 249–58.
65 Whooley, MA, Avins, AL, Miranda, J, Browner, WS. Case-finding instruments for depression: two questions are as good as many. J Gen Intern Med 1997; 12: 439–45.
66 Wittkampf, K, van Ravesteijn, H, Baas, K, van de Hoogen, H, Schene, A, Bindels, P, et al. The accuracy of Patient Health Questionnaire-9 in detecting depression and measuring depression severity in high-risk groups in primary care. Gen Hosp Psychiatry 2009; 31: 451–9.
67 Yeung, A, Fung, F, Yu, SC, Vorono, S, Ly, M, Wu, S, et al. Validation of the Patient Health Questionnaire-9 for depression screening among Chinese Americans. Compr Psychiatry 2008; 49: 211–7.
68 Zuithoff, NP, Vergouwe, Y, King, M, Nazareth, I, van Wezep, MJ, Moons, KG, et al. The Patient Health Questionnaire-9 for detection of major depressive disorder in primary care: consequences of current thresholds in a crosssectional study. BMC Fam Pract 2010; 11: 98.
69 Maxwell, M, Harris, F, Hibberd, C, Donaghy, E, Pratt, R, Williams, C, et al. A qualitative study of primary care professionals' views of case finding for depression in patients with diabetes or coronary heart disease in the UK. BMC Fam Pract 2013; 14: 46.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

BJPsych Open
  • ISSN: -
  • EISSN: 2056-4724
  • URL: /core/journals/bjpsych-open
Please enter your name
Please enter a valid email address
Who would you like to send this to? *
×
Type Description Title
PDF
Supplementary materials

Mitchell et al. supplementary material
Supplementary Material

 PDF (163 KB)
163 KB

Metrics

Altmetric attention score

Full text views

Total number of HTML views: 1
Total number of PDF views: 187 *
Loading metrics...

Abstract views

Total abstract views: 409 *
Loading metrics...

* Views captured on Cambridge Core between 2nd January 2018 - 25th June 2018. This data will be updated every 24 hours.

Case finding and screening clinical utility of the Patient Health Questionnaire (PHQ-9 and PHQ-2) for depression in primary care: a diagnostic meta-analysis of 40 studies

  • Alex J. Mitchell (a1), Motahare Yadegarfar (a2), John Gill (a2) and Brendon Stubbs (a3)
Submit a response

eLetters

No eLetters have been published for this article.

×

Reply to: Submit a response


Your details


Conflicting interests

Do you have any conflicting interests? *