Abstract
OBJECTIVE: The Patient Health Questionnaire depression scale (PHQ-9) is a well-validated, Diagnostic and Statistical Manual of Mental Disorders—Fourth Edition (DSM-IV) criterion-based measure for diagnosing depression, assessing severity and monitoring treatment response. The performance of most depression scales including the PHQ-9, however, has not been rigorously evaluated in different racial/ethnic populations. Therefore, we compared the factor structure of the PHQ-9 between different racial/ethnic groups as well as the rates of endorsement and differential item functioning (DIF) of the 9 items of the PHQ-9. The presence of DIF would indicate that responses to an individual item differ significantly between groups, controlling for the level of depression.
MEASUREMENTS: A combined dataset from 2 separate studies of 5,053 primary care patients including non-Hispanic white (n=2,520), African American (n=598), Chinese American (n=941), and Latino (n=974) patients was used for our analysis. Exploratory principal components factor analysis was used to derive the factor structure of the PHQ-9 in each of the 4 racial/ethnic groups. A generalized Mantel-Haenszel statistic was used to test for DIF.
RESULTS: One main factor that included all PHQ-9 items was found in each racial/ethnic group with α coefficients ranging from 0.79 to 0.89. Although endorsement rates of individual items were generally similar among the 4 groups, evidence of DIF was found for some items.
CONCLUSIONS: Our analyses indicate that in African American, Chinese American, Latino, and non-Hispanic white patient groups the PHQ-9 measures a common concept of depression and can be effective for the detection and monitoring of depression in these diverse populations.
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References
Kessler RC, Berglund P, Demler O, et al. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). JAMA. 2003;289:3095–105.
Murray CJ, Lopez AD. Global mortality, disability, and the contribution of risk factors: global burden of disease study. Lancet. 1997;349:1436–42.
Simon GE, VonKorff M. Recognition, management, and outcomes of depression in primary care. Arch Fam Med. 1995;4:99–105.
Pignone MP, Gaynes BN, Rushton JL, et al. Screening for depression in adults: a summary of the evidence for the US. Preventive Services Task Force. Ann Intern Med. 2002;136:765–76.
Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16:606–13.
Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. JAMA. 1999;282:1737–44.
Spitzer RL, Williams JB, Kroenke K, et al. Validity and utility of the PRIME-MD patient health questionnaire in assessment of 3000 obstetric-gynecologic patients: the PRIME-MD patient health questionnaire obstetrics-gynecology study. Am J Obstet Gynecol. 2000;183:759–69.
Lowe B, Unutzer J, Callahan CM, et al. Identifying depression in primary care: a literature synthesis of case-finding instruments. Gen Hosp Psychiatry. 2002;24:225–37.
Williams JW Jr., Pignone M, Ramirez G, et al. Identifying depression in primary care: a literature synthesis of case-finding instruments. Gen Hosp Psychiatry. 2002;24:225–37.
Williams JW Jr., Noel PH, Cordes JA, et al. Is this patient clinically depressed? JAMA. 2002;287:1160–70.
Lowe B, Spitzer RL, Grafe K, et al. Comparative validity of three screening questionnaires for DSM-IV depressive disorders and physicians’ diagnoses. J Affect Disord. 2004;78:131–40.
MacArthur Foundation Depression in Primary Care Initiative, www.depression-primarycare.org.
Ying YW. Depressive symptomatology among Chinese-Americans as measured by the CES-D. J Clin Psychol. 1988;44:739–46.
Posner SF, Stewart AL, Marin G, et al. Factor variability of the Center for Epidemiological Studies Depression Scale (CES-D) among urban Latinos. Ethn Health. 2001;6:137–44.
Penley JA, Wiebe JS, Nwosu A. Psychometric properties of the Spanish Beck Depression Inventory-II in a medical sample. Psychol Assess. 2003;15:569–77.
Roberts RE. Manifestation of depressive symptoms among adolescents. A comparison of Mexican Americans with the majority and other minority populations. J Nerv Mental Dis. 1992;180:627–33.
Hsiao-Rei Hicks M. Validity of the CIDI Probe flow chart for depression in Chinese American Women. Transcultural Psychiatry. 2002;39:434–51.
Azocar F, Arean P, Miranda J, et al. Differential item functioning in a Spanish translation of the Beck Depression Inventory. J Clin Psychol. 2001;57:355–65.
Brown C, Schulberg HC, Madonia MJ. Clinical presentations of major depression by African Americans and whites in primary medical care practice. J Affect Disord. 1996;41:181–91.
Cho MJ, Moscicki EK, Narrow WE, et al. Concordance between two measures of depression in the Hispanic Health and Nutrition Examination Survey. Soc Psychiatry Psychiatr Epidemiol. 1993;28:156–63.
Zung WW, MacDonald J, Zung EM. Prevalence of clinically significant depressive symptoms in black and white patients in family practice settings. Am J Psychiatry. 1988;145:882–3.
U.S. Census Bureau. Overview of Race and Hispanic Origin: Census 2000 Brief. Washington, DC: U.S. Census Bureau; 2002.
U.S. Census Bureau. The Asian and Pacific Islander Population in the United States: March 2000 (Update). Washington, DC: U.S. Census Bureau; 2001.
U.S. Census Bureau. Projections of the resident population by race, Hispanic origin, and nativity: Middle series, 2001 to 2005. Washington, DC: U.S. Census Bureau; 2000.
Shumaker SA, Berzon RA. The International Assessment of Health-related Quality of Life: Theory, Translation, Measurement, and Analysis. Oxford: Rapid Communications; 1995.
Mantel N. Chi-Square tests with one degree of freedom; extensions of the mantel-haenszel procedure. J Am Stat Assoc. 1963;58:690–700.
Muthen BO, Kao CF, Burstein L. Instructionally sensitive psychometrics: application of a new IRT-based detection technique to mathematics achievement test items. J Educ Meas. 1991;28:1–22.
Kaiser HF. The application of electronic computers to factor analysis. Educ Psychol Meas. 1960;20.
Muthen LK, Muthen BO. Mplus User’s Guide. Los Angeles, CA: Muthen & Muthen; 1998–2004.
Aneshensel CS, Clark VA, Frerichs RR. Race, ethnicity, and depression: a confirmatory analysis. J Pers Soc Psychol. 1983;44:385–98.
Golding JM, Lipton RI. Depressed mood and major depressive disorder in two ethnic groups. J Psychiatr Res. 1990;24:65–82.
Dressler WM, Badger LW. Epidemiology of depressive symptoms in black communities. A comparative analysis. J Nerv Mental Dis. 1985;173:212–20.
Linzer M, Spitzer R, Kroenke K, et al. Gender, quality of life, and mental disorders in primary care: results from the PRIME-MD 1000 study. Am J Med. 1996;101:526–33.
Takeuchi DT, Chung RC, Lin KM, et al. Lifetime and twelve-month prevalence rates of major depressive episodes and dysthymia among Chinese Americans in Los Angeles. Am J Psychiatry. 1998;155:1407–14.
Weissman MM, Bland RC, Canino GJ, et al. Cross-national epidemiology of major depression and bipolar disorder. JAMA. 1996;276:293–9.
Ballenger JC, Davidson JR, Lecrubier Y, et al. Consensus statement on transcultural issues in depression and anxiety from the International Consensus Group on Depression and Anxiety. J Clin Psychiatry. 2001;13(suppl 62):47–55.
Kleinman A, Kleinman J. Somatization: the interconnections in Chinese society among culture, depressive experiences, and the meanings of pain In: Kleinman A, Good B, eds. Culture and Depression: Studies in the Anthropology and Cross-Cultural Psychiatry of Affect and Disorder. Berkeley: University of California Press; 1985.
Yen S, Robins CJ, Lin N. A cross-cultural comparison of depressive symptom manifestation: china and the United States. J Consult Clin Psychol. 2000;68:993–9.
Huang FY, Chung H, Kroenke K, et al. Racial/ethnic differences in the relationship between depression severity and functional status using the PHQ-9. Psychiatric Services. 2006 (In press).
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Huang, F.Y., Chung, H., Kroenke, K. et al. Using the patient health questionnaire-9 to measure depression among racially and ethnically diverse primary care patients. J Gen Intern Med 21, 547–552 (2006). https://doi.org/10.1111/j.1525-1497.2006.00409.x
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DOI: https://doi.org/10.1111/j.1525-1497.2006.00409.x