The PHQ-9: validity of a brief depression severity measure

OBJECTIVE

While considerable attention has focused on improving the detection of depression, assessment of severity is also important in guiding treatment decisions. Therefore, we examined the validity of a brief, new measure of depression severity.

MEASUREMENTS

The Patient Health Questionnaire (PHQ) is a self-administered version of the PRIME-MD diagnostic instrument for common mental disorders. The PHQ-9 is the depression module, which scores each of the 9 DSM-IV criteria as "0" (not at all) to "3" (nearly every day). The PHQ-9 was completed by 6,000 patients in 8 primary care clinics and 7 obstetrics-gynecology clinics. Construct validity was assessed using the 20-item Short-Form General Health Survey, self-reported sick days and clinic visits, and symptom-related difficulty. Criterion validity was assessed against an independent structured mental health professional (MHP) interview in a sample of 580 patients.

RESULTS

As PHQ-9 depression severity increased, there was a substantial decrease in functional status on all 6 SF-20 subscales. Also, symptom-related difficulty, sick days, and health care utilization increased. Using the MHP reinterview as the criterion standard, a PHQ-9 score > or =10 had a sensitivity of 88% and a specificity of 88% for major depression. PHQ-9 scores of 5, 10, 15, and 20 represented mild, moderate, moderately severe, and severe depression, respectively. Results were similar in the primary care and obstetrics-gynecology samples.

CONCLUSION

In addition to making criteria-based diagnoses of depressive disorders, the PHQ-9 is also a reliable and valid measure of depression severity. These characteristics plus its brevity make the PHQ-9 a useful clinical and research tool.

Is food insufficiency associated with health status and health care utilization among adults with diabetes?

OBJECTIVES

Preliminary studies have shown that among adults with diabetes, food insufficiency has adverse health consequences, including hypoglycemic episodes and increased need for health care services. The purpose of this study was to determine the prevalence of food insufficiency and to describe the association of food insufficiency with health status and health care utilization in a national sample of adults with diabetes.

METHODS

We analyzed data from adults with diabetes ( n =1,503) interviewed in the Third National Health and Nutrition Examination Survey. Bivariate and multivariate analyses were used to examine the relationship of food insufficiency to self-reported health status and health care utilization.

RESULTS

Six percent of adults with diabetes reported food insufficiency, representing more than 568,600 persons nationally (95% confidence interval, 368,400 to 768,800). Food insufficiency was more common among those with incomes below the federal poverty level (17% vs 4%, P < or = .001). Adults with diabetes who were food insufficient were more likely to report fair or poor health status than those who were not (63% vs 43%; odds ratio, 2.2; P=.05). In a multivariate analysis, fair or poor health status was independently associated with poverty, nonwhite race, low educational achievement, and number of chronic diseases, but not with food insufficiency. Diabetic adults who were food insufficient reported more physician encounters, either in clinic or by phone, than those who were food secure (12 vs 7, P<.05). In a multivariate linear regression, food insufficiency remained independently associated with increased physician utilization among adults with diabetes. There was no association between food insufficiency and hospitalization in bivariate analysis.

CONCLUSIONS

Food insufficiency is relatively common among low-income adults with diabetes and was associated with higher physician utilization.

The effect of spirituality on health and healing: a critical review for athletic trainers

OBJECTIVE

To provide a comprehensive overview of the published literature regarding the effect of spirituality on health and healing.

DATA SOURCES

I searched MEDLINE from 1976 to 1999 using the terms "spirituality," "religion," "faith," "healing," and "health."

DATA SYNTHESIS

Strong scientific evidence suggests that individuals who regularly participate in spiritual worship services or related activities and who feel strongly that spirituality or the presence of a higher being or power are sources of strength and comfort to them are healthier and possess greater healing capabilities. Numerous research investigations have reported positive correlations between spirituality and decreased rates of stroke, cancer, cardiovascular disease, hypertension, drug abuse, suicide, and general mortality. It has been suggested that faith is beneficial for health and healing because it helps people avoid unhealthy behaviors such as smoking and excessive drinking. However, studies designed to statistically control for such factors also report positive associations between spirituality and health in individuals with unhealthy behaviors.

CONCLUSIONS/RECOMMENDATIONS

The impact of spirituality on health and healing is a topic that has been virtually ignored in the disciplines of athletic training and sports medicine. Because of their lack of exposure to this topic, most athletic trainers are unaware of the many positive associations that exist between spirituality and health and healing. The available literature base regarding this topic is quite large; its findings need to be explored and integrated into our profession.

Differences in patient-reported processes and outcomes between men and women with myocardial infarction

OBJECTIVE

Previous research measuring differences in the care between men and women with myocardial infarction has focused on differences in procedure use and mortality. However, little is known about differences in processes and outcomes that are reported by patients, such as interpersonal processes of care and health status. Our goal was to measure differences in patient-reported measures for men and women who recently were hospitalized with myocardial infarction.

PARTICIPANTS AND SETTING

We surveyed by mail patients with myocardial infarction discharged to home from one of 27 Cleveland area hospitals 3 months following discharge; 502 (64%) of 783 patients responded. The mean age of subjects was 65 years and 40% were women.

MEASUREMENTS

Process measures included the quality of communication during the hospitalization and at time of discharge and reports of health education discussions during hospitalization. Outcome measures included physical and mental health component scores of the Medical Outcomes Study 36-Item Short-Form Health Survey, change in work status, and days spent in bed because of ill health. We compared processes and outcomes in men and women using multivariate analyses that adjusted for age, other demographic characteristics, comorbid conditions, severity of the myocardial infarction, and premorbid global health status.

MAIN RESULTS

In multivariate analyses, women were as likely as men to report at least one problem with communication during the hospitalization (odds ratio [OR] 0.86; 95% confidence interval [95% CI] 0.56 to 1. 33) or at time of discharge (OR 1.24; 95% CI, 0.82 to 1.89) and to report that they were given dietary advice before discharge (OR 0. 60; 95% CI, 0.36 to 1.01), were told what to do if they developed chest pain (OR 1.21; 95% CI, 0.66 to 2.23), or, if they smoked cigarettes, given advice about how to stop smoking (OR 0.64; 95% CI, 0.26 to 1.58). However, 3 months after discharge, women reported worse physical health (P <.05) and mental health (P <.05), were more likely to report spending time in bed because of ill health (OR 1. 80; 95% CI, 1.06, 3.05), and were more likely to report working less than before their myocardial infarction (OR 4.02; 95% CI, 1.58 to 10. 20).

CONCLUSIONS

In terms of processes of care measured with patient reports, women with myocardial infarction reported their quality of care to be similar to that of men. However, 3 months following myocardial infarction, women reported worse health status and were less likely to return to work than men.

Patient expectations and health-related quality of life

OBJECTIVE: The measurement of health-related quality of life (HRQL) has become increasingly common in health services research. Whilst useful, its focus on behaviour, capacities and activities means that it remains relatively specific. This paper explores the possibility of extending the evaluation of health by considering the concept of patients' expectations. DESIGN: In-depth and semi-structured interviews were used to explore the concept of expectations from the patients' perspective. Patients' expectations were then used in the construction of a two-part questionnaire. SETTINGS AND PARTICIPANTS: Expectations were explored with a group of 33 cardiac patients. The resulting questionnaire was given to 400 cardiac patients in a large teaching hospital in London. RESULTS: Patients identified a range of expectations which related to their health and seemed to represent the desired results of their hospital stay. Comparison of the content of patient expectations with a commonly used generic measure of HRQL, the Short-Form 36 (SF-36), found some overlap but indicated that patients seemed to adopt a broader approach to their health. Expectations that patients identified were used to construct two scales to measure expectations and their evaluation. The internal consistency of these scales was 0.82 and 0.88, respectively. CONCLUSION: The study indicates the potential complexity of the concept of expectations and the need for further exploration. It also demonstrates the feasibility of constructing standardized scales to measure patient expectations. Whilst conceptually different from HRQL such standardized expectations scales could provide a useful adjunct to HRQL measurement and provide a meaningful context for the interpretation of HRQL data.

Health status of male preparatory school students lodging at a dormitory in Japan

An investigation on the health status of 79 male preparatory school students lodging at a dormitory in Japan was carried out by questionnaire on lifestyles, subjective symptoms and mental status, as compared with two control groups: 73 medical students and 36 new employees. About 83 % of them slept less than 6 hours and 70 % of them did not exercise. Many students are troubled with back pain or lumbago(47%), sensation of incomplete bladder emptying(l6%), loss of visual acuity(55%) and eye fatigue(65%). Self-rating depression scale score of preparatory school students was not significantly higher than those of the control groups. The lifestyles of preparatory school students found to be very restricted and strained. However, no significant differences on mental adverse health effects was found among three groups.

Health characteristics and medical service use patterns of sheltered homeless and low-income housed mothers

OBJECTIVE

To compare the health characteristics and service utilization patterns of homeless women and low-income housed women who are heads of household.

DESIGN

Case-control study.

SETTING

Community of Worcester, Massachusetts.

PARTICIPANTS

A sample of 220 homeless mothers and 216 low-income housed mothers receiving welfare.

MEASUREMENTS AND MAIN RESULTS

Outcome measures included health status, chronic conditions, adverse lifestyle practices, outpatient and emergency department use and hospitalization rates, and use of preventive screening measures. Both homeless mothers and housed mothers demonstrated low levels of physical and role functioning and high levels of bodily pain. Prevalence rates of asthma, anemia, and ulcer disease were high in both groups. More than half of both groups were current smokers. Compared with the housed mothers, homeless mothers reported more HIV risk behaviors. Although 90% of the homeless mothers had been screened for cervical cancer, almost one third had not been screened for tuberculosis. After controlling for potential confounding factors, the homeless mothers, compared with the housed mothers, had more frequent emergency department visits in the past year (adjusted mean, homeless vs housed, 1.41 vs .95, p = .10) and were significantly more likely to be hospitalized in the past year (adjusted odds ratio 2.22; 95% confidence interval 1.13, 4.38).

CONCLUSIONS

Both homeless mothers and low-income housed mothers had lower health status, more chronic health problems, and higher smoking rates than the general population. High rates of hospitalization, emergency department visits, and more risk behaviors among homeless mothers suggest that they are at even greater risk of adverse health outcomes. Efforts to address gaps in access to primary care and to integrate psychosocial supports with health care delivery may improve health outcomes for homeless mothers and reduce use of costly medical care services.

Health status and mammography use among older women

OBJECTIVE

To assess the extent to which an age-associated reduction in mammography use can be explained by declining self-reported health status.

DESIGN

We analyzed data from the 1992 National Health Interview Survey (NHIS) and Cancer Control Supplement. Logistic regression analysis was used to evaluate the association between age, health status (self-reported health and limitations in major activity), and other variables potentially related to mammography use within the past 1 year (recent mammography).

PARTICIPANTS

Of 12,035 NHIS respondents we restricted our analysis to the 1,772 women aged 50 years or older who reported one or more lifetime mammograms. We excluded women without a mammogram (n = 937) because we were interested in factors related to recent use versus past use of mammography.

MEASUREMENTS AND MAIN RESULTS

The percentage of women with a recent mammogram declined with increasing age, and the age association was independent of other factors including health status (adjusted odds ratio [OR] comparing women aged 75 years or older with those aged 50 to 64 years was 0.54; 95% confidence interval [CI] 0.41, 0.70). This age effect persisted in an analysis restricted to women reporting good or better health (adjusted OR was 0.60, 95% CI 0.44, 0.80).

CONCLUSION

The observed decline in recent mammography use with advancing age was not explained by variation in health status. Because healthy elderly women may live long enough to realize the potential benefit of screening mammography, factors responsible for its reduced use should be identified. Doing so will allow for the selective promotion of screening mammography among those older women most likely to benefit.

The relation between health status changes and patient satisfaction in older hospitalized medical patients

OBJECTIVE

To examine the relation between two patient outcome measures that can be used to assess the quality of hospital care: changes in health status between admission and discharge, and patient satisfaction.

DESIGN

Prospective cohort study.

SETTING AND PATIENTS

Subjects were 445 older medical patients (aged > or =70 years) hospitalized on the medical service of a teaching hospital.

MEASUREMENTS AND MAIN RESULTS

We interviewed patients at admission and discharge to obtain two measures of health status: global health and independence in five activities of daily living (ADLs). At discharge, we also administered a 5-item patient satisfaction questionnaire. We assessed the relation between changes in health status and patient satisfaction in two sets of analyses, that controlled for either admission or discharge health status. When controlling for admission health status, changes in health status between admission and discharge were positively associated with patient satisfaction (p values ranging from .01 to .08). However, when controlling for discharge health status, changes in health status were no longer associated with patient satisfaction. For example, among patients independent in ADLs at discharge, mean satisfaction scores were similar regardless of whether patients were dependent at admission (i.e., had improved) or independent at admission (i.e., remained stable) (79.6 vs 81.2, p = .46). Among patients dependent in ADLs at discharge, mean satisfaction scores were similar regardless of whether they were dependent at admission (i.e., remained stable) or independent at admission (i.e., had worsened) (74.0 vs 75.7, p = .63). These findings were similar using the measure of global health and in multivariate analyses.

CONCLUSIONS

Patients with similar discharge health status have similar satisfaction regardless of whether that discharge health status represents stable health, improvement, or a decline in health status. The previously described positive association between patient satisfaction and health status more likely represents a tendency of healthier patients to report greater satisfaction with health care, rather than a tendency of patients who improve following an interaction with the health system to report greater satisfaction. This suggests that changes in health status and patient satisfaction are measuring different domains of hospital outcomes and quality. Comprehensive efforts to measure the outcomes and quality of hospital care will need to consider both patient satisfaction and changes in health status during hospitalization.

A prediction rule for the use of postdischarge medical services

OBJECTIVE

To develop and validate a prediction rule screening instrument, easily incorporated into the routine hospital admission assessment, that could facilitate discharge planning by identifying patients at the time of admission who are most likely to need postdischarge medical services.

DESIGN

Prospective cohort study with separate phases for prediction rule development and validation.

SETTING

Urban teaching hospital.

PATIENTS/PARTICIPANTS

General medical service patients, 381 in the derivation phase and 323 in the validation phase, who provided self-reported medical history, health status, and demographic data as a part of their admission nursing assessment, and were subsequently discharged alive.

MEASUREMENTS AND MAIN RESULTS

Use of postdischarge medical services such as visiting nurse or physical therapy, medical equipment, or placement in a rehabilitation or long-term care facility was determined. A prediction rule based on a patient's age and Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) physical function and social function scores stratified patients with regard to their risk of using postdischarge medical services. In the validation set, the rate of actual postdischarge medical service use was 15% (15 of 97), 36% (39 of 107), and 58% (57 of 98) among patients characterized by the prediction rule as being at "low", "intermediate," and "high" risk of using postdischarge medical services, respectively.

CONCLUSIONS

This prediction rule stratified general medical patients with regard to their likelihood of needing discharge planning to arrange for postdischarge medical services. Further research is necessary to determine whether prospective identification of patients likely to need discharge planning will make the hospital discharge planning process more efficient.

Measuring symptomatic and functional recovery in patients with community-acquired pneumonia

OBJECTIVE

To determine the rates of resolution of symptoms and return to premorbid health status and assess the association of these outcomes with health care utilization in patients with community-acquired pneumonia.

DESIGN

A prospective, multicenter cohort study.

SETTING

Inpatient and outpatient facilities at three university hospitals, one community hospital, and one staff-model health maintenance organization.

PATIENTS

Five hundred seventy-six adults (aged > or = 18 years) with clinical and radiographic evidence of pneumonia, judged by a validated pneumonia severity index to be at low risk of dying.

MEASUREMENTS AND MAIN RESULTS

The presence and severity of five symptoms (cough, fatigue, dyspnea, sputum, and chest pain) were recorded through questionnaires administered at four time points: 0, 7, 30, and 90 days from the time of radiographic diagnosis of pneumonia. A summary symptom score was tabulated as the sum of the five individual severity scores. Patients also provided responses to the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) and reported the number of and reason for outpatient physician visits. Symptoms and health status 30 days before pneumonia onset (prepneumonia) were obtained at the initial interview. All symptoms, except pleuritic chest pain, were still commonly reported at 30 days, and the prevalence of each symptom at 90 days was still nearly twice prepneumonia levels. Physical health measures derived from the SF-36 Form declined significantly at presentation but continued to improve over all three follow-up time periods. Patients with elevated symptom scores at day 7 or day 30 were significantly more likely to report pneumonia-related ambulatory care visits at the subsequent day 30 or day 90 interviews, respectively.

CONCLUSIONS

Disease-specific symptom resolution and recovery of the premorbid physical health status requires more than 30 days for many patients with pneumonia. Delayed resolution of symptoms is associated with increased utilization of outpatient physician visits.

Right-Handedness: A Preliminary Survey of Health Status and Health Care Utilization

Left-handedness has been linked to dyslexia, migraines, autoimmune disease and early-onset dementia. A pilot study to investigate further the association among handedness, health status and health-care utilization was carried out in a group family practice setting. Variables included frequency of types of medical problems, frequency of visits to the physician, number of referrals to specialists, and number of laboratory and radiographical investigations. A short questionnaire assessing handedness was distributed to 613 randomly selected patients visiting the family practice clinic over a one-month period. Twenty-eight left-handers were identified among 520 patients. These were matched with 28 controls, after which charts for all subjects were reviewed to evaluate the study variables. No statistical differences were found between the two groups. Methodological problems included determining true handedness (as distinct from mixed), reviewing of charts for data, and coding and assessing the data. Suggestions are made for improving and facilitating further research in this area for family practice.