Patient Health Questionnaire

Last updated
Patient Health Questionnaire
Synonyms PHQ
LOINC 69723-5

The Patient Health Questionnaire (PHQ) is a multiple-choice self-report inventory that is used as a screening and diagnostic tool for mental health disorders of depression, anxiety, alcohol, eating, and somatoform disorders. It is the self-report version of the Primary Care Evaluation of Mental Disorders (PRIME-MD), a diagnostic tool developed in the mid-1990s by Pfizer Inc. [1] The length of the original assessment limited its feasibility; consequently, a shorter version, consisting of 11 multi-part questions - the Patient Health Questionnaire was developed and validated. [2]

Contents

In addition to the PHQ, a nine-item version to assess symptoms of depression, a seven-item version to assess symptoms of anxiety (GAD-7), [3] and a 15-item version to detect somatic symptoms (PHQ-15) [4] have been developed and validated. The PHQ-9, GAD-7, and the PHQ-15 were combined to create the PHQ-somatic, anxiety, depressive symptoms (PHQ-SADS) [2] and includes questions regarding panic attacks (after the GAD-7 section). Though less commonly used, there are also brief versions of the PHQ-9 and GAD-7 that may be useful as screening tools in some settings. In recent years, the PHQ-9 has been validated for use in adolescents, [5] and a version for adolescents was also developed and validated (PHQ-A). [6] Although these tests were originally designed as self-report inventories they can also be administered by trained health care practitioners. [7]

The PHQ is available in over 20 languages, available on the PHQ website. Both the original Patient Health Questionnaire and later variants are public domain resources; no fees or permissions are required for using or copying the measures. [8] : 3, 7–8  Additionally, the measures have been validated in a number of different populations internationally. [9] [10] [11]

Versions

The original Patient Health Questionnaire contains five modules; these contain questions about depressive, anxiety, somatoform, alcohol, and eating disorders. [8] Designed for use in the primary care setting, it lacks coverage for disorders seen in psychiatric settings. [12] Some modules are used independently, and variants have been developed based on the original items.

9-item depression scale

The PHQ-9 (DEP-9 in some sources [13] ), a tool specific to depression, scores each of the 9 DSM-IV related criteria based on the mood module from the original PRIME-MD. [14] The PHQ-9 is both sensitive and specific in its diagnoses, which has led to its prominence in the primary care setting.[ citation needed ] This tool is used in a variety of different contexts, including clinical settings across the United States as well as research studies.

One study which used the PHQ-9, examined if college student displays of depression symptoms on Facebook were representative of offline symptoms. Results demonstrated that those who displayed depression symptoms on Facebook scored higher on the PHQ-9, suggesting that those who display depression symptoms on Facebook are experiencing them offline. [15]

2-item depression screener

Patient Health Questionnaire 2 item
Synonyms PHQ-2
LOINC 55757-9

The Patient Health Questionnaire 2 item (PHQ-2) is an ultra-brief screening instrument containing the first two questions from the PHQ-9. [8] : 3  Two screening questions to assess the presence of a depressed mood and a loss of interest or pleasure in routine activities, and a positive response to either question indicates further testing is required. [16] This version of the PHQ has been shown to have good diagnostic sensitivity but poor specificity. [16]

4-item depression and anxiety screener

Patient Health Questionnaire 4 item
Synonyms PHQ-4
LOINC 69724-3

The Patient Health Questionnaire 4 item (PHQ-4) combines the PHQ-2 with the Generalized Anxiety Disorder 2 (GAD-2), an ultra-brief anxiety screener containing the first two questions from the Generalized Anxiety Disorder 7 (GAD-7). [8] : 3 

15-item somatic scale

Patient Health Questionnaire 15 item
Synonyms PHQ-15, PHQ Somatic Symptom Scale
LOINC 69728-4

The Patient Health Questionnaire 15 item (PHQ-15) contains the PHQ's somatic symptom scale. [8] : 3  [17] It is a well-validated measure, which asks whether symptoms are present and about their severity. [18] A brief version, the Somatic Symptom Scale - 8 was derived from PHQ-15. [18] The development of the PHQ-15 helped address three main problems in the assessment and diagnosis of somatoform disorders. Firstly, traditional methods of diagnosing somatoform disorders would only capture about 20% of true cases due to the number of symptoms required to meet a diagnosis. [2] Secondly, in order to attain more reliable and valid data, assessments need to address more current rather than previous symptoms. [2] Thirdly, continuing to adhere to the "medically unexplained" requirement for symptoms makes it very difficult to make a diagnosis because it is extremely hard to ascertain if a symptom is or is not part of a larger medical condition (ex: chronic fatigue and depression). [2]

7-item anxiety scale

The GAD-7 is a 7-item scale designed to assess symptoms of anxiety. Each item is scored on a 0-to-3 point scale ("not at all" to "nearly every day"). Cut points of 5, 10, and 15 correspond to mild, moderate, and severe anxiety. [19]

8-item depression scale

The PHQ-8 is an eight-item scale developed specifically to screen for depression in American epidemiological populations. [20]

Somatic, anxiety, and depressive symptoms

Patient Health Questionnaire - Somatic, Anxiety, and Depressive Symptoms
Synonyms PHQ-SADS
LOINC 69729-2

The Patient Health Questionnaire - Somatic, Anxiety, and Depressive Symptoms (PHQ-SADS) screens for somatic, anxiety, and depressive symptoms using PHQ-9, GAD-7, and PHQ-15, plus the panic symptoms question from the original PHQ. [8] : 3  [21]

Adolescent scale

The PHQ-A is a four module self-report to evaluate depression, anxiety, substance use and eating disorders in adolescent primary care patients. [6]

Reliability

MeasureCriterionRating* (adequate, good, excellent, too good)Explanation
PHQNormsExcellentMultiple convenience and random samples, as well as research studies in both clinical and nonclinical sample [22] [1] [23]
Internal consistency (Cronbach's alpha, split half, etc.)Good Cronbach's alpha reported at .88 for measuring depression [22]
Inter-rater reliability GoodKappas range from .64-.81 for depression. [24] Kappa for anxiety is .83 [24]
Test-retest reliability (stability)No published studies formally checking test-retest reliability
RepeatabilityNo published studies formally checking repeatability
PHQ-9NormsExcellentMultiple convenience and random samples, as well as research studies in both clinical and nonclinical samples. [25] [26]
Internal consistency (Cronbach's alpha, split half, etc.)Good Cronbach's alphas range from .83 to .89 [3] [27]
Inter-rater reliability GoodOne study in Nigerian university students with found ranges between .83 and .92 [11]
Test-retest reliability (stability)AdequateCorrelation between administrations done within 48 hours was .84. [3]
RepeatabilityNot publishedNo published studies formally checking repeatability.
GAD-7NormsExcellentMultiple convenience and random samples, as well as research studies in both clinical and nonclinical samples [14]
Internal consistency (Cronbach's alpha, split half, etc.)Good Cronbach's alpha reported at .92 [2]
Inter-rater reliability GoodThe interviewer vs. self-rated correlation ranges from .83 and .84 [2]
Test-retest reliability (stabilityGoodReported as .83 [2]
RepeatabilityNot publishedNo published studies formally checking repeatability
PHQ-15NormsExcellentTwo large studies with convenience and random samples used. One research studies (N=906) in clinical sample and one research study (N=6000) in nonclinical sample. [2]
Internal consistency (Cronbach's alpha, split half, etc.)Good Cronbach's alpha reported at .80 [2]
Inter-rater reliability No published studies formally checking inter-rater reliability
Test-retest reliability (stability)GoodKappa = .60 when administration was done within 2 weeks of first test [28] [2]
RepeatabilityNo published studies formally checking repeatability.

Validity

MeasureCriterionRating* (adequate, good, excellent, too good*)Explanation with references
PHQ Content validity GoodCovers DSM-IV criteria for major depressive disorder, panic disorder, other anxiety disorder, bulimia nervosa, other depressive disorder, probable alcohol abuse or dependence, and somatoform and binge eating disorders [1]
Construct validity (e.g., predictive, concurrent, convergent, and discriminant validity)AdequateConstruct validity has not been fully established, and more substantial evidence of convergent and discriminant validity would be helpful. [29] Validity is consistent with PRIME-MD. [1]
Discriminative validityExcellentAUCs range from .89 to .92 for detecting depression [22] [23]
Validity generalizationNo published studies formally checking validity generalization.
Treatment sensitivityNo published studies formally checking treatment sensitivity.
Clinical utilityGoodThe PHQ is free and can be completed independently by the patient; it assesses a wide array of mental health concerns. [1]
PHQ-9 Content validity ExcellentCovers the DSM-IV criteria for major depressive disorder. [3]
Construct validity (e.g., predictive, concurrent, convergent, and discriminant validity)GoodHigher PHQ-9 scores were correlated with greater self-reported disability days, clinic visits, health-care utilization, as well as difficulties in activities and relationships. [3]
Discriminative validityToo excellentAn average sensitivity of .77 and specificity of .94 (corresponding to an AUC .94) in primary care settings suggests good discriminative validity in populations that are generally not depressed, but it may not perform as well in clinical populations. [25]
Validity generalizationVariableA meta-analysis of 27 samples suggested that performance of the PHQ-9 is highly heterogeneous; pooled sensitivity is low and specificity is high. [26]
Treatment sensitivityGoodIn a treatment study using three medical outpatient cohorts, the PHQ-9 has been shown to be sensitive to change over time [30]

The PHQ-9 has been used in studies to effectively monitor change following cognitive behavioral treatment. [31]

A meta analysis stated that the PHQ-9 had good treatment sensitivity. [2]

Clinical utilityGoodThe PHQ-9 is brief, free to use, and easy to score. It has good specificity, but the poor sensitivity could lead to false negatives, [26] which is a problem for a screening tool. It is likely to perform best in samples where the prevalence of depressive disorders is high. [25] To improve clinical utility, meta-analyses suggest increasing cut score to 10 or higher to improve sensitivity. [25] [26]
GAD-7 Content validity GoodCovers seven of the core symptoms for generalized anxiety disorder. [32]
Construct validity (e.g., predictive, concurrent, convergent, and discriminant validity)GoodScores correlate with the Beck Anxiety Inventory (r= .72) and the anxiety subscale of the SCL-90 (r=.74). [2]
Discriminative validityToo excellent AUC for detecting generalized anxiety disorder was .91, for panic disorder AUC= .85 for panic disorder, AUC=.83 for social anxiety disorder, and AUC=.83 for PTSD. [2]
Validity generalizationGoodValidity has been established across multiple populations. [33] [34]
Treatment sensitivityGoodThe GAD-7 showed good sensitivity to treatment effects in two randomized-controlled trials. [35]
Clinical utilityExcellentThe GAD-7 is brief, free to use, and easy to score. [19] It is sensitive to change following treatment. [35] There is some evidence that elderly people may require some help to complete the scale accurately. [33]
PHQ-15 Content validity GoodScores correspond well to DSM-IV somatoform diagnoses from the SCID [28] and General Health Questionnaire-15. [36]
Construct validity (e.g., predictive, concurrent, convergent, and discriminant validity)AdequatePHQ-15 scores correlated with medically unexplained symptom counts (r=.52) measured via an independent psychiatric review [2] and with the General Health Questionnaire-15. [36]
Discriminative validityExcellentSensitivity was 78% and specificity was 71% for a DSM-IV diagnosis of somatoform disorder, [28] corresponding to an AUC of .76. [28]
Validity generalizationAlthough the PHQ-15 is currently being used in major studies in several European countries and Australia. [2] there is evidence that it does not perform as well in Hispanic populations. [37]
Treatment sensitivityUnknown Meta-analysis states that the treatment sensitivity for the PHQ-15 has not been researched much, but there is some support that the PHQ-15 is sensitive to treatment. [2]
Clinical utilityGoodThe PHQ-15 is easy to use, free, and has a high discriminant and convergent validity, [2] it has also been validated in many different clinical populations. [2]

Limitations

All versions of the PHQ are self reports and, consequently, are subject to inherent biases, including social desirability [38] and poor retrospective recall. [39]

The influence of these biases can mitigated by following up with a structured or semi-structured interview, the gold standard for diagnostic assessment. [40]

The time period assessed by each scale could also be a limitation; the PHQ-9 asks about the last four weeks, whereas the GAD-7 focuses on the past two weeks, and the PHQ asks about various time periods from the last two weeks to the last six months. Depending on the time period in question, this may or may not require a revision (i.e., if you are interested in depression over the last six months, you might alter the instructions), which could impact the validity of the measure.

The scoring thresholds recommended are influenced by the samples in which they were validated and correspond with different levels of sensitivity and specificity, [41] which may or may not match well with the intended use of the scale.

See also

Related Research Articles

Psychological testing refers to the administration of psychological tests. Psychological tests are administered or scored by trained evaluators. A person's responses are evaluated according to carefully prescribed guidelines. Scores are thought to reflect individual or group differences in the construct the test purports to measure. The science behind psychological testing is psychometrics.

<span class="mw-page-title-main">Generalized anxiety disorder</span> Long-lasting anxiety not focused on any one object or situation

Generalized anxiety disorder (GAD) is a mental and behavioral disorder, specifically an anxiety disorder characterized by excessive, uncontrollable and often irrational worry about events or activities. Worry often interferes with daily functioning, and individuals with GAD are often overly concerned about everyday matters such as health, finances, death, family, relationship concerns, or work difficulties. Symptoms may include excessive worry, restlessness, trouble sleeping, exhaustion, irritability, sweating, and trembling.

<span class="mw-page-title-main">Depression (mood)</span> State of low mood and aversion to activity

Depression is a mental state of low mood and aversion to activity. It affects more than 280 million people of all ages. Depression affects a person's thoughts, behavior, feelings, and sense of well-being. Depressed people often experience loss of motivation or interest in, or reduced pleasure or joy from, experiences that would normally bring them pleasure or joy. Depressed mood is a symptom of some mood disorders such as major depressive disorder and dysthymia; it is a normal temporary reaction to life events, such as the loss of a loved one; and it is also a symptom of some physical diseases and a side effect of some drugs and medical treatments. It may feature sadness, difficulty in thinking and concentration and a significant increase or decrease in appetite and time spent sleeping. People experiencing depression may have feelings of dejection or hopelessness and may experience suicidal thoughts. It can either be short term or long term.

The Beck Depression Inventory, created by Aaron T. Beck, is a 21-question multiple-choice self-report inventory, one of the most widely used psychometric tests for measuring the severity of depression. Its development marked a shift among mental health professionals, who had until then, viewed depression from a psychodynamic perspective, instead of it being rooted in the patient's own thoughts.

A major depressive episode (MDE) is a period characterized by symptoms of major depressive disorder. Those affected primarily exhibit a depressive mood for at least two weeks or more, and a loss of interest or pleasure in everyday activities. Other symptoms can include feelings of emptiness, hopelessness, anxiety, worthlessness, guilt, irritability, changes in appetite, difficulties in concentration, difficulties remembering details, making decisions, and thoughts of suicide. Insomnia or hypersomnia and aches, pains, or digestive problems that are resistant to treatment may also be present.

Somatosensory amplification (SSA) is a tendency to perceive normal somatic and visceral sensations as being relatively intense, disturbing and noxious. It is a common feature of hypochondriasis and is commonly found with fibromyalgia, major depressive disorder, some anxiety disorders, Asperger syndrome, and alexithymia. One common clinical measure of SSA is the Somatosensory Amplification Scale (SSAS).

The Beck Anxiety Inventory (BAI), created by Aaron T. Beck and other colleagues, is a 21-question multiple-choice self-report inventory that is used for measuring the severity of anxiety in adolescents and adults ages 17 and older. The questions used in this measure ask about common symptoms of anxiety that the subject has had during the past week. It is designed for individuals who are of 17 years of age or older and takes 5 to 10 minutes to complete. Several studies have found the Beck Anxiety Inventory to be an accurate measure of anxiety symptoms in children and adults.

A depression rating scale is a psychometric instrument (tool), usually a questionnaire whose wording has been validated with experimental evidence, having descriptive words and phrases that indicate the severity of depression for a time period. When used, an observer may make judgements and rate a person at a specified scale level with respect to identified characteristics. Rather than being used to diagnose depression, a depression rating scale may be used to assign a score to a person's behaviour where that score may be used to determine whether that person should be evaluated more thoroughly for a depressive disorder diagnosis. Several rating scales are used for this purpose.

Somatic symptom disorder, also known as somatoform disorder, is defined by one or more chronic physical symptoms that coincide with excessive and maladaptive thoughts, emotions, and behaviors connected to those symptoms. The symptoms are not purposefully produced or feigned, and they may or may not coexist with a known medical ailment.

The Generalized Anxiety Disorder 7 (GAD-7) is a self-reported questionnaire for screening and severity measuring of generalized anxiety disorder (GAD). The GAD-7 is normally used in outpatient and primary care settings for referral to a psychiatrist pending outcome.

Antenatal depression, also known as prenatal or perinatal depression, is a form of clinical depression that can affect a woman during pregnancy, and can be a precursor to postpartum depression if not properly treated. It is estimated that 7% to 20% of pregnant women are affected by this condition. Any form of prenatal stress felt by the mother can have negative effects on various aspects of fetal development, which can cause harm to the mother and child. Even after birth, a child born from a depressed or stressed mother feels the affects. The child is less active and can also experience emotional distress. Antenatal depression can be caused by the stress and worry that pregnancy can bring, but at a more severe level. Other triggers include unplanned pregnancy, difficulty becoming pregnant, history of abuse, and economic or family situations.

The Somatic Symptom Scale - 8 (SSS-8) is a brief self-report questionnaire used to assess somatic symptom burden. It measures the perceived burden of common somatic symptoms. These symptoms were originally chosen to reflect common symptoms in primary care but they are relevant for a large number of diseases and mental disorders. The SSS-8 is a brief version of the popular Patient Health Questionnaire - 15 (PHQ-15).

The Screen for Child Anxiety Related Emotional Disorders (SCARED) is a self-report screening questionnaire for anxiety disorders developed in 1997. The SCARED is intended for youth, 9–18 years old, and their parents to complete in about 10 minutes. It can discriminate between depression and anxiety, as well as among distinct anxiety disorders. The SCARED is useful for generalized anxiety disorder, social anxiety disorder, phobic disorders, and school anxiety problems. Most available self-report instruments that measure anxiety in children look at general aspects of anxiety rather than Diagnostic and Statistical Manual of Mental Disorders (DSM) categorizations. The SCARED was developed as an instrument for both children and their parents that would encompass several DSM-IV and DSM-5 categorizations of the anxiety disorders: somatic/panic, generalized anxiety, separation anxiety, social phobia, and school phobia.

The Weinberg Screen Affective Scale (WSAS) is a free scale designed to screen for symptoms of depression in children and young adults ages 5–21. It can be used as an initial treatment scale and can be used to follow up on treatment efficacy. There are 56 self-report questions that screen for symptoms in 10 major categories of depression: dysphoric mood, low self-esteem, agitation, sleep disturbance, change in school performance, diminished socialization, change in attitude towards school, somatic complaints, loss of usual energy, and unusual change in weight and/or appetite. The scale is based on previously proposed criteria for depression in children. A study looking at the agreement between scales for depression diagnosis found 79.4% agreement between the DSM-III and the WSAS in a sample of 107 children.

The Mood Disorder Questionnaire (MDQ) is a self-report questionnaire designed to help detect bipolar disorder. It focuses on symptoms of hypomania and mania, which are the mood states that separate bipolar disorders from other types of depression and mood disorder. It has 5 main questions, and the first question has 13 parts, for a total of 17 questions. The MDQ was originally tested with adults, but it also has been studied in adolescents ages 11 years and above. It takes approximately 5–10 minutes to complete. In 2006, a parent-report version was created to allow for assessment of bipolar symptoms in children or adolescents from a caregiver perspective, with the research looking at youths as young as 5 years old. The MDQ has become one of the most widely studied and used questionnaires for bipolar disorder, and it has been translated into more than a dozen languages.

<span class="mw-page-title-main">MindSpot Clinic</span>

MindSpot Clinic (MindSpot) is Australia's first free national online mental health clinic which launched in December 2012. It provides screening assessments and internet-delivered cognitive behavioural therapy (ICBT) courses for Australians troubled by stress, worry, anxiety and depression.

The nine-item Patient Health Questionnaire (PHQ-9) is a depressive symptom scale and diagnostic tool introduced in 2001 to screen adult patients in primary care settings. The instrument assesses for the presence and severity of depressive symptoms and a possible depressive disorder. The PHQ-9 is a component of the larger self-administered Patient Health Questionnaire (PHQ), but can be used as a stand-alone instrument. The PHQ is part of Pfizer's larger suite of trademarked products, called the Primary Care Evaluation of Mental Disorders (PRIME-MD). The PHQ-9 takes less than three minutes to complete. It is scored by simply adding up the individual items' scores. Each of the nine items reflects a DSM-5 symptom of depression. Primary care providers can use the PHQ-9 to screen for possible depression in patients.

Goldberg test may refer to any of various psychiatric tests used to assess mental health in general or as screening tools for specific mental disorders e.g. depression or bipolar disorder. Goldberg, after whom some psychiatric tests are named, might be one of two psychiatrists who share the same last name: Ivan Goldberg, an American psychiatrist, and Sir David Goldberg, a British psychiatrist. Psychiatric screening tests generally don't substitute getting help from professionals.

The Somatic Symptom Disorder - B Criteria Scale (SSD-12) is a brief self-report questionnaire used to assess the B criteria of DSM-5 somatic symptom disorder, i.e. the patients’ perceptions of their symptom-related thoughts, feelings, and behaviors.

References

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