Systematic review of the factor structure and measurement invariance of the patient health questionnaire-9 (PHQ-9) and validation of the Portuguese version in community settings

Measuring depression and anxiety in autistic college students: A psychometric evaluation of the PHQ-9 and GAD-7

LAY ABSTRACT

Anxiety, depression, and suicidality are major concerns among college students, though less is known about these constructs in autistic college students. Given the rising number of autistic individuals entering college, adequate screening and diagnosis of mental health difficulties is necessary to provide care to this population. For example, despite widespread usage of the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7), it is unknown if the two instruments accurately measure depression and anxiety the same way between non-autistic and autistic individuals. Thus, the current study was the first to examine how these instruments measure depression and anxiety symptoms in autistic versus non-autistic college students. Utilizing tests of construct measurement in a sample of autistic (n = 477) and non-autistic (n = 429) university students aged 18-29, results showed that while the GAD-7 and PHQ-9 appear to be accurately capturing anxiety and depression in autistic college students, the PHQ-9 item assessing suicidality was found to be measuring different things. This indicates that autistic college students are not interpreting this question the way non-autistic students are, and thus, the measure is failing to capture suicidality in autistic people. Future investigators should continue to assess the appropriateness of using common screening measures, originally created by non-autistic people, in autistic populations.

The effects of C-tactile stimulation on temporal summation of second pain: A study of the central and peripheral neural correlates

Affective touch is mediated by specialized receptors sensitive to gentle and slow touch called C-tactile afferents (CT). The activation of these receptors has shown promise in reducing subjective pain ratings, however, how this type of touch can affect central sensitization processes is poorly studied. This work aimed to investigate if affective touch is able to modulate pain sensitization and its electrophysiological correlates during Temporal Summation of Second Pain (TSSP), a phenomenon characterized by an increase in pain perception due to repeated noxious stimuli. Thirty-seven participants underwent a TSSP protocol involving three conditions: TSSP alone, TSSP during vibrotactile stimulation, and TSSP during CT stimulation (administered with a brush mounted in a robot arm). We measured subjective pain ratings, electroencephalographic (N2-P2 complex) and electrocardiographic activity during these conditions. Participants reported a significantly lower increase of pain during CT stimulation compared to vibrotactile stimulation, but not to TSSP alone. In addition, TSSP was reduced when administered in the ipsilateral arm compared to the other somatosensory stimulation. Subjective reports of attention towards painful stimuli, amplitude of the N2-P2 complex, and heart rate were also reduced during CT stimulation. Conclusion: Our results indicated that the activation of CT receptors may reduce sensitization compared to other types of somatosensory stimulation, which is possibly related to the reduction of the attention devoted to nociceptive stimulation. Our results suggest that activation of CT receptors may alleviate the occurrence of central pain sensitization.

Examining the psychometric properties of the Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7 among young urban South African women

BACKGROUND

Valid, reliable, and easy-to-administer scales are crucial for identifying mental health conditions, especially in LMICs where such scales tend not to be validated. This study aims to address this gap by investigating the psychometric properties and factorial structure of the PHQ-9 and GAD-7 in a sample of young women in Soweto, South Africa.

METHODS

The PHQ-9 and GAD-7 were administered to 6028 women aged 18-28 years old. Cronbach's alpha, Mokken scale analysis, and Confirmatory Factor Analysis were used to provide support for the internal consistency and construct validity of these scales.

RESULTS

Both scales demonstrated good internal consistency (α = 0.81 for PHQ-9 and α = 0.84 for GAD-7). Internal consistency reliability was further supported by positive inter-item correlations and item-by-scale correlations for all items on both measures. CFA of the PHQ-9 and GAD-7 showed a reasonable fit for the 1-factor model and 2-factor models (depression and anxiety with somatic and cognitive subtypes).

LIMITATIONS

This study was limited to young African women in urban Soweto who were proficient in English, which may affect generalizability. Differences in language or cultural context may impact the accuracy and applicability of these scales to other African populations.

CONCLUSION

The PHQ-9 and GAD-7 are valid and reliable for identifying psychological distress in the studied population. Despite showing good psychometric properties, further diagnostic assessment is needed to confirm clinical diagnoses. The scales are useful for identifying those at risk but not a substitute for comprehensive diagnostic evaluations.

Prevalence of anxiety and depression among patients with glaucoma

Purpose

This study aimed to determine the prevalence of anxiety and depression among patients with glaucoma compared to the average Brazilian prevalence (9.8% of anxiety and 5.8% of depression, according to the World Health Organization) and its correlation with the severity of the disease.

Methods

This was a transversal, single-arm trial of patients from four glaucoma centers in São Paulo and Curitiba-Brazil. Patients comprised adults at least 18 years of age with glaucoma diagnosis under treatment for at least 6 months. All subjects of the study answered two questionnaires (PHQ-9 and GAD-7) to evaluate the presence of anxiety and depression, and the results were analyzed accordingly to clinical and demographic characteristics.

Results

The protocol included a total of 210 patients. The average age was 61.6 ± 15.3 years, and the female gender was more common (68.86%). Primary open-angle glaucoma was the most common diagnosis (59.90%). The average IOP was 18.5 mmHg, and 1.5 anti-glaucoma drops were the mean treatment. The prevalence of depression and anxiety was 26.90 and 25.71%, respectively. Most patients with anxiety were classified as early glaucoma, while those with depression had severe glaucoma.

Conclusion

This study found that the prevalence of anxiety and depression among patients with glaucoma is higher than in the general population in our country.

Validity and internal consistency of four scales in patients with TMD: PHQ8, GAD7, PHQ15 and JFLS20

OBJECTIVES

The aim of this cross-sectional study was to explore the structural validity and internal consistency reliability of General Anxiety Disorder-7, Patient Health Questionnaire-8, 15 and Jaw Functional Limitation Scale-20 in patients with chronic pain of temporomandibular disorders.

MATERIALS AND METHODS

Validity and reliability were assessed in 129 patients diagnosed according to the diagnostic criteria for temporomandibular disorders. Structural validity was explored using factor analysis, and internal consistency by calculating Cronbach α.

RESULTS

Confirmatory factor analysis revealed a suitable 2-factor model for Patient Health Questionnaire-8, with Cronbach α of 0.89, and 0.86. One and 2-factor models were suitable for General Anxiety Disorder-7, with overall Cronbach α of 0.93 for the 1-factor model, and 0.91 and 0.84 for both factors in a 2-factor model. A 4-factor solution was appropriate for Patient Health Questionnaire-15, with Cronbach α of 0.72, 0.57, 0.71 and 0.73 for each factor separately. Exploratory factor analysis was conducted to explore the factor structure of Jaw Functional Limitation Scale 20, and a 3-factor solution was appropriate.

CONCLUSIONS

This study provides positive evidence of structural validity and internal consistency of these questionnaires in patients with pain of temporomandibular disorders. However, additional testing is required to explore further psychometric properties.

Psychometric Properties of the Patient Health Questionnaire-9 in Patients With Breast Cancer

OBJECTIVE

Due to the high frequency of depressive symptoms associated with breast cancer, it is crucial to screen for depression in breast cancer patients. While numerous screening tools are available for depression in this population, there is a need for a brief and convenient tool to enhance clinical use. This study aims to investigate the psychometric properties of the Patient Health Questionnaire-9 (PHQ-9) in patients with breast cancer.

METHODS

Patients with breast cancer (n=327) who visited the Breast Cancer Clinic were included in this study. The reliability of the PHQ-9 was analyzed by Cronbach's α, and the construct validity of the PHQ-9 was explored by factor analysis. The concurrent validity of the PHQ-9 was evaluated by Pearson correlation analysis with the Hospital Anxiety and Depression Scale (HADS) and Perceived Stress Scale (PSS).

RESULTS

The values of Cronbach's α ranged from 0.800 to 0.879 was acceptable. The exploratory factor analysis revealed that the one-factor model and two-factor model of the PHQ-9 explained 46% and 57% of the variance, respectively. The PHQ-9 were significantly correlated with those of HADS (r=0.702, p<0.001) and PSS (r=0.466, p<0.001). Consequently, the PHQ-9 demonstrated acceptable reliability and validity in breast cancer patients.

CONCLUSION

The findings of this study indicate that the PHQ-9 exhibits acceptable reliability and validity in patients with breast cancer. The convenience of this brief self-report questionnaire suggests its potential as a reliable and valid tool for assessing depression in breast cancer clinics.

Enhancing mental health and well-being in adults from lower-resource settings: A mixed-method evaluation of the impact of problem management plus

Mental health conditions, recognised as a global crisis, were further exacerbated by the COVID-19 pandemic. Access to mental health services remains limited, particularly in low-income regions. Task-sharing interventions, exemplified by Problem Management Plus (PM+), have emerged as potential solutions to bridge this treatment gap. This study presents an evaluation of the PM+ scale-up in Sub-Saharan Africa (Ethiopia and Benin) and Eastern Europe (Croatia and Bosnia and Herzegovina) as part of a mental health and psychosocial support programming including 87 adult participants. A mixed-method approach assesses the impact of the intervention. Quantitative analyses reveal significant reductions in self-reported problems, depression, anxiety and improved functioning. Qualitative data highlight four main themes: general health, family relationships, psychosocial problems and daily activities. These thematic areas demonstrate consistent improvements across clients, irrespective of the region. The findings underscore the impact of PM+ in addressing a broad spectrum of client issues, demonstrating its potential as a valuable tool for mitigating mental health challenges in diverse settings. This study contributes to the burgeoning body of evidence supporting PM+ and highlights its promise in enhancing mental health outcomes on a global scale, particularly for vulnerable populations.

Analysis of the dimensional structure of the Patient Health Questionnaire-9 (PHQ-9) in undergraduate students at a public university in Brazil

BACKGROUND

The prevalence of mental health-related problems has increased in recent years, especially among young adults, such as university students. Several measurement instruments have been developed to identify individuals at risk for depression, such as the Patient Health Questionnaire-9 (PHQ-9). However, different dimensional structures of the PHQ-9 can make it difficult to interpret and compare research results. To analyze the dimensional structure and convergent validity of the PHQ-9 in university students.

METHODS

This is a cross-sectional study developed with 3163 students enrolled in different courses at a university in southern Brazil. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were performed to identify the most parsimonious and best-fitting model. Convergent validity was verified through the significant relationship (p < 0.05) between theoretically related constructs (sleep quality, alcohol consumption, and physical activity practice).

RESULTS

The EFA resulted in two models (unidimensional and two-dimensional), with better indices for the two-dimensional model. In the CFA, both the unidimensional and the two-dimensional models presented satisfactory fit indices that were higher for the unidimensional model.

LIMITATIONS

The analysis of convergent validity is limited by the absence of a gold standard for comparison.

CONCLUSIONS

This study provided support for the unidimensional structure of the PHQ-9, with adequate convergent validity, among university students.

Identifying a stable and generalizable factor structure of major depressive disorder across three large longitudinal cohorts

The Patient Health Questionnaire 9 (PHQ-9) is the current standard outpatient screening tool for measuring and tracking the nine symptoms of major depressive disorder (MDD). While the PHQ-9 was originally conceptualized as a unidimensional measure, it has become clear that MDD is not a monolithic construct, as evidenced by high comorbidities with other theoretically distinct diagnoses and common symptom overlap between depression and other diagnoses. Therefore, identifying reliable and temporally stable subfactors of depressive symptoms could allow research and care to be tailored to different depression phenotypes. This study improved on previous factor analysis studies of the PHQ-9 by leveraging samples that were clinical (participants with depression only), large (N = 1483 depressed individuals in total), longitudinal (up to 5 years), and from three diverse (matching racial distribution of the United States) datasets. By refraining from assuming the number of factors or item loadings a priori, and thus utilizing a solely data-driven approach, we identified a ranked list of best-fitting models, with the parsimonious one achieving good model fit across studies at most timepoints (average TLI >= 0.90). This model categorizes the PHQ-9 items into four factors: (1) Affective (Anhedonia + Depressed Mood), (2) Somatic (Sleep + Fatigue + Appetite), (3) Internalizing (Worth/Guilt + Suicidality), (4) Sensorimotor (Concentration + Psychomotor), which may be used to further precision psychiatry by testing factor-specific interventions in research and clinical settings.

Measurement invariance and differential item functioning of the PHQ-9 and GAD-7 between working age and older adults seeking treatment for common mental disorders

BACKGROUND

The nine-item Patient Health Questionnaire (PHQ-9) and seven-item Generalised Anxiety Disorder (GAD-7) scale are widely used clinically and within research, and so it is important to determine how the measures, and individual items within the measures, are answered by adults of differing ages. This study sought to evaluate measurement invariance and differential item functioning (DIF) of the PHQ-9 and GAD-7 between working age and older adults seeking routine psychological treatment.

METHODS

Data of working age (18-64 years old) and older (≥65) adults in eight Improving Access to Psychological Therapies (IAPT) services were used. Confirmatory factor analysis (CFA) was used to establish unidimensionality of the PHQ-9 and GAD-7, with multiple-group CFA to test measurement invariance and The Multiple Indicators, Multiple Causes Models approach to assess DIF. The employed methods were applied to a propensity score matched (PSM) sample in sensitivity analyses to control for potential confounding.

RESULTS

Data from 166,816 patients (159,325 working age, 7491 older) were used to show measurement invariance for the PHQ-9 and GAD-7, with limited evidence of DIF and similar results found with a PSM sample (n = 5868).

LIMITATIONS

The localised sample creates an inability to detect geographical variance, and the potential effect of unmeasured confounders cannot be ruled out.

CONCLUSIONS

The findings support the use of the PHQ-9 and GAD-7 measures for working age and older adults, both clinically and in research settings. This study validates using the measures for these age groups to assess clinically significant symptom thresholds, and monitor treatment outcomes between them.

The network structure of psychopathological and resilient responses to the pandemic: A multicountry general population study of depression and anxiety

Commonly identified patterns of psychological distress in response to adverse events are characterized by resilience (i.e., little to no distress), delayed (i.e., distress that increases over time), recovery (i.e., distress followed by a gradual decrease over time), and sustained (i.e., distress remaining stable over time). This study aimed to examine these response patterns during the COVID-19 pandemic. Anxiety and depressive symptom data collected across four European countries over the first year of the pandemic were analyzed (N = 3,594). Participants were first categorized into groups based on the four described patterns. Network connectivity and symptom clustering were then estimated for each group and compared. Two thirds (63.6%) of the sample displayed a resilience pattern. The sustained distress network (16.3%) showed higher connectivity than the recovery network (10.0%) group, p = .031; however, the resilient network showed higher connectivity than the delayed network (10.1%) group, p = .016. Regarding symptom clustering, more clusters emerged in the recovery network (i.e., three) than the sustained network (i.e., two). These results replicate findings that resilience was the most common mental health pattern over the first pandemic year. Moreover, they suggest that high network connectivity may be indicative of a stable mental health response over time, whereas fewer clusters may be indicative of a sustained distress pattern. Although exploratory, the network perspective provides a useful tool for examining the complexity of psychological responses to adverse events and, if replicated, could be useful in identifying indicators of protection against or vulnerability to future psychological distress.

Cultural adaptation to Bolivian Quechua and psychometric analysis of the Patient Health Questionnaire PHQ-9

OBJECTIVE

Cultural adaptation of the Patient Health Questionnaire-PHQ-9 to Bolivian Quechua and analysis of the internal structure validity, reliability, and measurement invariance by sociodemographic variables.

METHODS

The PHQ-9 was translated and back-translated (English-Quechua-English) to optimise translation. For the cultural adaptation, experts, and people from the target population (e.g., in focus groups) verified the suitability of the translated PHQ-9. For the psychometric analysis, we performed a Confirmatory Factor Analysis (CFA) to evaluate internal validity, calculated α and ω indices to assess reliability, and performed a Multiple Indicator, Multiple Cause (MIMIC) model for evaluating measurement invariance by sex, age, marital status, educational level and residence. We used standard goodness-of-fit indices to interpret both CFA results.

RESULTS

The experts and focus groups improved the translated PHQ-9, making it clear and culturally equivalent. For the psychometric analysis, we included data from 397 participants, from which 73.3% were female, 33.0% were 18-30 years old, 56.7% reported primary school studies, 63.2% were single, and 62.0% resided in urban areas. In the CFA, the single-factor model showed adequate fit (Comparative Fit Index = 0.983; Tucker-Lewis Index = 0.977; Standardized Root Mean Squared Residual = 0.046; Root Mean Squared Error of Approximation = 0.069), while the reliability was optimal (α = 0.869-0.877; ω = 0.874-0.885). The invariance was confirmed across all sociodemographic variables (Change in Comparative Fit Index (delta) or Root Mean Square Error of Approximation (delta) < 0.01).

CONCLUSIONS

The PHQ-9 adapted to Bolivian Quechua offers a valid, reliable and invariant unidimensional measurement across groups by sex, age, marital status, educational level and residence.

Late life anxiety and depression symptoms, and suicidal behaviors in racial/ethnic minority older adults in community-based organizations and community clinics in the U.S

OBJECTIVE

Late life anxiety and depression represent a significant source of disability, with racial/ethnic minority older adults in the U.S. showing marked disparities in healthy aging. Community-based organizations (CBOs) and community clinics serve these populations for preventive care, yet few identify their mental health service needs. We examine the association between race/ethnicity and risk of mild-to-severe symptoms of anxiety and depression, and suicidal behaviors in minority older adults.

METHOD

Data come from the multisite randomized controlled trial Building Community Capacity for Disability Prevention for Minority Elders, which screened 1,057 adults (45.5% Asian, 26.8% Latinx, 15.0% non-Latinx Black, 8.5% non-Latinx White, and 4.2% American Indian) aged 60 + years at CBOs and clinics in Massachusetts, New York, Florida, and Puerto Rico. Screened participants completed the Generalized Anxiety Disorder-7 (GAD-7) for anxiety symptoms, the Geriatric Depression Scale-15 (GDS-15) for depression symptoms, and the Paykel Suicide Risk Questionnaire for suicidal behaviors.

RESULTS

28.1% of older adults reported mild-to-severe anxiety symptoms, 30.1% reported mild-to-severe depression symptoms, and 4.3% reported at least one suicidal behavior. Compared to non-Latinx Whites, Latinxs had higher odds of mild-to-severe anxiety and depression symptoms and one or more suicidal behaviors, and Asians had higher odds of mild-to-severe depression symptoms only.

CONCLUSIONS

There is an urgent need to improve outreach for screening and preventive mental health care for minority older adults. Expanding outreach and community-based capacity to identify and treat minority older adults with mental health conditions represents an opportunity to prevent disability. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Sensitivity and specificity of the Patient Health Questionnaire (PHQ-9, PHQ-8, PHQ-2) and General Anxiety Disorder scale (GAD-7, GAD-2) for depression and anxiety diagnosis: a cross-sectional study in a Peruvian hospital population

OBJECTIVES

The Patient Health Questionnaire (PHQ) and Generalised Anxiety Disorder Scale (GAD) are widely used screening tools, but their sensitivity and specificity in low-income and middle-income countries are lower than in high-income countries. We conducted a study to determine the sensitivity and specificity of different versions of these scales in a Peruvian hospital population.

DESIGN

Our study has a cross-sectional design.

SETTING

Our participants are hospitalised patients in a Peruvian hospital. The gold standard was a clinical psychiatric interview following ICD-10 criteria for depression (F32.0, F32.1, F32.2 and F32.3) and anxiety (F41.0 and F41.1).

PARTICIPANTS

The sample included 1347 participants. A total of 334 participants (24.8%) were diagnosed with depression, and 28 participants (2.1%) were diagnosed with anxiety.

RESULTS

The PHQ-9's≥7 cut-off point showed the highest simultaneous sensitivity and specificity when contrasted against a psychiatric diagnosis of depression. For a similar contrast against the gold standard, the other optimal cut-off points were: ≥7 for the PHQ-8 and ≥2 for the PHQ-2. In particular, the cut-off point ≥8 had good performance for GAD-7 with sensitivity and specificity, and cut-off point ≥10 had lower levels of sensitivity, but higher levels of specificity, compared with the cut-off point of ≥8. Also, we present the sensitivity and specificity values of each cut-off point in PHQ-9, PHQ-8, PHQ-2, GAD-7 and GAD-2. We confirmed the adequacy of a one-dimensional model for the PHQ-9, PHQ-8 and GAD-7, while all PHQ and GAD scales showed good reliability.

CONCLUSIONS

The PHQ and GAD have adequate measurement properties in their different versions. We present specific cut-offs for each version.

Measurement invariance of the patient health questionnaire-9 depression scale in a nationally representative population-based sample

The Patient Health Questionnaire-9 (PHQ-9) is widely used to measure the severity of depressive symptoms and to screen for depressive disorder, but its measurement invariance has received little research attention. The aim of this study was to assess the measurement invariance of the PHQ-9 across various sociodemographic and medical-condition groups. The structural validity and internal consistency of the PHQ-9 were also assessed as the prerequisite properties for measurement invariance. This study was conducted using data from the Korea National Health and Nutrition Examination Survey. The included participants comprised 5,347 people older than 19 years. Exploratory graph analysis (EGA) and confirmatory factor analysis (CFA) were performed to determine structural validity, and the omega coefficient (ω ) was used to determine internal consistency. Measurement invariance (configural, metric, and scalar invariance) was evaluated using multigroup confirmatory factor analysis (MGCFA). The single structural model of the PHQ-9 that was validated by EGA was also satisfactory with fit indices of χ2 = 770.765 (p < 0.001), CFI = 0.944, SRMR = 0.040, and RMSEA = 0.076 (90% CI = 0.072-0.081). The ω of the PHQ-9 was 0.812, implying satisfactory internal consistency. The one-factor PHQ-9 had equivalent overall structure, factor loadings, and item intercepts across age groups, suggesting invariance across ages. Partial scalar invariance was demonstrated across sex and marital-status groups. Partial metric and scalar invariance were supported across education groups. Scalar invariance was supported among all of the medical-condition (hypertension, diabetes, cancer, arthritis, asthma, and heart disease) groups. Overall, the measurement invariance of the one-factor PHQ-9 was empirically supported across sociodemographic and medical-condition groups. The PHQ-9 can be reliably used to compare the severity of depressive symptoms across these groups in research and practice.

New cut-off points of PHQ-9 and its variants, in Costa Rica: a nationwide observational study

The PHQ-9 questionnaire is a screening test worldwide used to measure depression. But it cannot be used in Costa Rica, due to the fact that it has not previously been validated for its population. The present study aims to show the validation of the PHQ-9 questionnaire and its variants (PHQ-2, PHQ-4, PHQ-8) in a population sample of adults residing in Costa Rica. A sample was collected (n = 1162) using a self-administered questionnaire. Confirmatory Factor Analysis (CFA), Receiver Operating Characteristic (ROC) curve, and Multiple Group Confirmatory Factor Analysis (MGCFA) were tested. One factor was found that explained 73.33% of the variance with excellent internal consistency (α = 0.928). Goodness-of-fit measures were adequate (RMSEA = 0.107; CFI = 0.948), as was diagnostic power at a cut-off of 10 (78.60 for Sensitivity and 27.95 for 1-Specificity). External validation indices were good (r = 0.843 with GAD-7, r = - 0.647 with RS14, and r = 0.301 with FCV19S), and the model showed invariance by sex (∆χ2 = 27.90; df = 27; p < 0.001). Additionally, new cut-off points were proposed for PHQ-9 and its variants for Costa Rican male, female, and general populations. The PHQ-9 and its variants (PHQ-2, 4, and 8) are valid tools for detecting depression (and anxiety for PHQ-4) in Costa Rican population. In addition, new cut-off points differentiated by sex are proposed.

Effectiveness of an Internet-Based Self-Guided Program to Treat Depression in a Sample of Brazilian Users: Randomized Controlled Trial

BACKGROUND

Depression is undertreated in Brazil. Deprexis is a self-guided internet-based program used to treat depressive symptoms based on empirically supported integrative and cognitive behavioral therapy. Evidence from a meta-analysis supports Deprexis' efficacy in German-speaking countries and the United States, but no study has been conducted using this program in countries with low literacy rates and large social disparities. Furthermore, few studies have investigated whether internet-based interventions ameliorate the psychological processes that might underlie depressive symptomatology, such as low perceived self-efficacy.

OBJECTIVE

The main objective of this study was to replicate in Brazil previously reported effects of Deprexis on depressive symptom reduction. Therefore, the main research question was whether Deprexis is effective in reducing depressive symptoms and the general psychological state in Brazilian users with moderate and severe depression in comparison with a control group that does not receive access to Deprexis. A secondary research question was whether the use of Deprexis affects perceptions of self-efficacy.

METHODS

We interviewed 312 participants recruited over the internet and randomized 189 participants with moderate to severe depression (according to the Patient Health Questionnaire-9 and a semistructured interview) to an intervention condition (treatment as usual plus immediate access to Deprexis for 90 days, n=94) or to a control condition (treatment as usual and delayed access to Deprexis, after 8 weeks, n=95).

RESULTS

Participants from the immediate access group logged in at Deprexis an average of 14.81 (SD 12.16) times. The intention-to-treat analysis using a linear mixed model showed that participants who received Deprexis improved significantly more than participants assigned to the delayed access control group on the primary depression self-assessment measure (Patient Health Questionnaire-9; Cohen d=0.80; P<.001) and secondary outcomes, such as general psychological state measure (Clinical Outcome in Routine Evaluation-Outcome Measurement; Cohen d=0.82; P<.001) and the perceived self-efficacy measure (Cohen d=0.63; P<.001). The intention-to-treat analyses showed that 21% (20/94) of the participants achieved remission compared with 7% (7/95) in the control group (P<.001). The deterioration rates were lower in the immediate access control group. The dropout rate was high, but no differences in demographic and clinical variables were found. Participants reported a medium to high level of satisfaction with Deprexis.

CONCLUSIONS

These results replicate previous findings by showing that Deprexis can facilitate symptomatic improvement over 3 months in depressed samples of Brazilian users. From a public health perspective, this is important information to expand the reach of internet-based interventions for those who really need them, especially in countries with less access to mental health care. This extends previous research by showing significant effects on perceived self-efficacy.

TRIAL REGISTRATION

Registro Brasileiro de Ensaios Clíncos (ReBec) RBR-6kk3bx UTN U1111-1212-8998; https://ensaiosclinicos.gov.br/rg/RBR-6kk3bx/.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1590/1516-4446-2019-0582.

Reliability and cross-country equivalence of the 8-item version of the Patient Health Questionnaire (PHQ-8) for the assessment of depression: results from 27 countries in Europe

Background

The 8-item version of the Patient Health Questionnaire (PHQ-8) is one of the self-reported questionnaires most frequently used worldwide for the screening and severity assessment of depression. However, in some European countries its reliability is unknown, and it is unclear whether its psychometric properties vary between European countries. Therefore, the aim of this study was to assess the internal structure, reliability and cross-country equivalence of the PHQ-8 in Europe.

Methods

All participants from the 27 countries included in the second wave of the European Health Interview Survey (EHIS-2) between 2014 and 2015 with complete information on the PHQ-8 were included (n = 258,888). The internal structure of the PHQ-8 was assessed using confirmatory factor analyses (CFA) for categorical items. Additionally, the reliability of the questionnaire was assessed based on the internal consistency, Item Response Theory information functions, and item-discrimination (using Graded Response Models), and the cross-country equivalence based on multi-group CFA.

Findings

The PHQ-8 shows high internal consistency for all countries. The countries in which the PHQ-8 was more reliable were Romania, Bulgaria and Cyprus and less reliable were Iceland, Norway and Austria. The PHQ-8 item with highest discrimination was item 2 (feeling down, depressed, or hopeless) in 24 of the 27 countries. Measurement invariance between countries in Europe was observed from multigroup CFA at the configural, metric and scalar levels.

Interpretation

The results from our study, likely the largest study to the date assessing the internal structure, reliability and cross-country comparability of a self-reported mental health assessment measure, shows that the PHQ-8 has an adequate reliability and cross-country equivalence across the 27 European countries included. These results highlight the suitability of the comparisons of the PHQ-8 scores in Europe. They could be helpful to improve the screening and severity assessment of depressive symptoms at the European level.

Funding

This work was partially funded by CIBER Epidemiology and Public Health (CIBERESP) as part of the Intramural call of 2021 (ESP21PI05).

Anxiety, depression, perceived executive function and sugar sweetened beverages: a causal mediation analysis in Mexican young adults

There is the notion that dysregulation of executive function (EF), which disrupts behavior and cognitive processes, may explain the emotional impairment which leads to increasing sugar sweetened beverages (SSBs) intake. We aimed to test whether anxiety and depression mediate the association between self-reported problems in EF and sugar sweetened beverage intake in Mexican adults between 18-40 years. An open survey advertised as a 'mental health and sugar sweetened beverages study' was conducted, participants were recruited through Facebook ads. Males and females, between 18-40 years, able to read and write, and currently residing in Mexico were included. We analyzed data using causal mediation analysis with latent variables using a structural equation modelling framework. Significant indirect effects were found for somatic symptoms of depression (β = 6.601, SE = 2.657, p < .05) and anxiety (β = .679, SE =.334, p < .05). In depression model no significant direct effects of EF were found in the depression model, however they were found in the anxiety model (β = 1.335 SE =.566, p < .05). Somatic symptoms of depression were a total mediator, and anxiety a partial mediator. The results suggest that EF increased the probability of emotional symptoms, which led to a higher consumption of SBBs.

The impact of employment stress on college students: psychological well-being during COVID-19 pandemic in China

Employment among final year college students in China has encountered unprecedented difficulties during the Coronavirus disease 2019 (COVID-19) pandemic, the high unemployment rate had led college graduates faced inadvertently mental health issues such as anxiety and depression. This study aims to investigate the impact of employment stress on college students' psychological well-being during the COVID-19 pandemic in China. An online survey consisting of demographic items (i.e., age, gender, subject major, type of university, and perceived severity of the current employment situation), Employment Stress scale, Employment Anxiety Scale, and Patient Health Questionnaire was employed for data collection. A total of 2,627 final year college students were recruited, with participants displayed below moderate levels of employment stress and anxiety. Approximately 13.2% of participants were depressed and 53.3% considered the current employment situation as severe. Female students were stressed by individual factors and anxious, whilst male students were more depressed. Arts students were less depressed and students from comprehensive universities were more depressed and anxious compared to other types of universities. Students who perceived the employment situation as very severe displayed the lowest level of employment stress and anxiety. Gender, university type, family stress, college stress, and individual stress are predictors of psychological well-being among college students. The family environment, female identity, and stress from university play a crucial role in college students' psychological well-being. The government should pay more attention to the psychological well-being of graduate students and develop feasible measures to help them secure a job during this unprecedented time.

Anxiety and Depression in the Initial Stage of the COVID-19 Outbreak in a Portuguese Sample: Exploratory Study

BACKGROUND

In previous studies, it was found that the confinement to which the population was subjected during the quarantine of the COVID-19 pandemic increased the risk of anxiety and depression.

OBJECTIVE

to analyze the levels of anxiety and depression symptoms in Portugal residents during the quarantine of the COVID-19 pandemic.

METHODS

This is a descriptive, transversal, and exploratory study of non-probabilistic sampling. Data collection was carried out between 6th and 31st of May 2020. Sociodemographic and health questionnaires PHQ-9 and GAD-7 were used.

RESULTS

The sample consisted of 920 individuals. The prevalence for depressive symptoms (PHQ-9 ≥ 5) was 68.2% and (PHQ-9 ≥ 10) was 34.8%, and for anxiety symptoms (GAD-7 ≥ 5) was 60.4% and (GAD-7 ≥ 10) was 20%. Depressive symptoms were moderately severe for 8.9% of the individuals, and 4.8% presented severe depression. Regarding the generalized anxiety disorder, we found that 11.6% of individuals present moderate symptoms, and 8.4% severe anxiety symptoms.

CONCLUSIONS

The prevalence of depressive and anxiety symptoms were substantially higher than those previously found for the Portuguese population and when compared with other countries during the pandemic. Younger individuals, female, with chronic illness and medicated, were more vulnerable to depressive and anxious symptoms. In contrast, participants who maintained frequent levels of physical activity during confinement had their mental health protected.

A new PHQ-2 for Chinese adolescents: identifying core items of the PHQ-9 by network analysis

BACKGROUND

The importance of preventing and treating adolescent depression has been gradually recognized in Chinese society, especially in the context of the COVID-19 pandemic. Early screening is the first step. The Patient Health Questionnaire-9 (PHQ-9) is a leading scale in the field of depression screening. To improve screening efficiency in large-scale screening, an even shorten scale is desirable. The PHQ-2, which only included two items measuring anhedonia and depressed mood, is an ultra-form of the PHQ-9. However, emerging evidence suggests that there may be a better short form for the PHQ-9, especially for adolescents. Therefore, using two large samples of Chinese adolescents, this study aimed to identify the core items of the PHQ-9 and examine the short form consisting of core items.

METHODS

Surveys were conducted among primary and middle school students in two Chinese cities with different economic levels during the COVID-19 pandemic. Two gender-balanced samples aged 10 to 17 (n_{Sample 1} = 67281, n_{Sample 2} = 16726) were collected. Network analysis was used to identify the core items of the PHQ-9, which were extracted to combine a short version. Reliability, concurrent validity, and the receiver operating characteristic curve (ROC) of the short form were examined. Analyses were gender-stratified.

RESULTS

Network analysis identified fatigue and depressed mood as core items in the PHQ-9 among Chinese adolescents. Items measuring Fatigue and Mood were combined to be a new PHQ-2 (PHQ-2 N). The PHQ-2 N displayed satisfactory internal consistency and current validity. Taking the PHQ-9 as a reference, the PHQ-2 N showed higher ROC areas and better sensitivity and specificity than the PHQ-2. The optimal cutoff score for the PHQ-2 N was 2 or 3.

CONCLUSIONS

Fatigue and depressed mood are the central symptoms of the depressive symptom network. The PHQ-2 N has satisfactory psychometric properties and can be used in rapid depression screening among Chinese adolescents.

Validation of the English and Swahili Adaptation of the Patient Health Questionnaire-9 for Use Among Adolescents in Kenya

PURPOSE

Our study aimed to validate culturally adapted English and Swahili versions of the Patient Health Questionnaire-9 (PHQ-9) for use with adolescents in Kenya. Criterion validity was determined with clinician-administered diagnostic interviews using the Kiddie Schedule of Affective Disorders and Schizophrenia.

METHODS

A total of 250 adolescents comprising 148 (59.2%) females and 102 (40.8%) males aged 10-19 years (mean = 14.76; standard deviation = 2.78) were recruited. The PHQ-9 was administered to all respondents concurrently in English and Swahili. Adolescents were later interviewed by clinicians using Kiddie Schedule of Affective Disorders and Schizophrenia to determine the presence or absence of current symptoms of major depressive disorder. Sensitivity specificity, positive predictive value (PPV) and negative predictive value (NPV), and likelihood ratios for various cut-off scores for PHQ-9 were analyzed using receiver operating characteristic curves.

RESULTS

The internal consistency (Cronbach's α) for PHQ-9 was 0.862 for the English version and 0.834 for Swahili version. The area under the curve was 0.89 (95% confidence interval, 0.84-0.92) and 0.87 (95% confidence interval, 0.82-0.90) for English and Swahili version, respectively, on receiver operating characteristic analysis. A cut-off of ≥ 9 on the English-language version had a sensitivity of 95.0%, specificity of 73.0%, PPV of 0.23, and NPV of 0.99; a cut-off of ≥ 9 on the Swahili version yielded a sensitivity of 89.0%, specificity of 70.0%, PPV of 0.20, and NPV of 0.90.

DISCUSSION

Psychometric properties were comparable across both English-adapted and Swahili-adapted version of the PHQ-9, are reliable, and valid instrument to detect major depressive disorder among adolescents which can be used in resource-limited settings for early identification of adolescents in need of mental health support.

A Cross-Sectional Study on the Prevalence of Depressive Symptoms and Its Associated Sociodemographic Factors in Peru during the COVID-19 Pandemic

The present study aims to analyze the prevalence of depressive symptoms and its sociodemographic-associated factors in Peruvian adults. Data was extracted from a nation-wide representative survey in which depression symptoms were measured with the PHQ-9 and sociodemographic information was extracted from household data. Depression severity rates were estimated for each symptom, and responses were modeled through the Rating Scale Model to obtain a depression measure used as dependent variable on a Generalized Mixed Linear Model. The most frequent depression symptoms were emotional, such as discouragement, sad mood, hopelessness, and lack of pleasure when doing activities. Our model showed that, after controlling the effects of all the variables considered, the most relevant predictors were gender, education level, physiographic region, age, marital status, and number of coresidents. Higher depression levels were found in women, people who did not complete higher education, participants living in the Highlands, older adults, single participants, and people living alone. Thus, interventions to promote or prevent depression severity during similar situations as the pandemic should focus on specific sociodemographic groups and their particular needs.

Are subtypes of affective symptoms differentially associated with change in cognition over time: A latent class analysis

BACKGROUND

In the absence of disease-modifying treatments, identifying potential psychosocial risk factors for dementia is paramount. Depression and anxiety have been identified as potential risk factors. Studies however have yielded mixed findings, lending possibility to the fact that potential constellations of co-occurring depression and anxiety symptoms may better explain the link between affective symptoms and cognitive decline.

METHODS

Data from participants (aged 50 and above) of the PROTECT study was used. Latent Class Analysis (LCA) was conducted on 21,684 participants with baseline anxiety and depression measures. Multiple linear regressions models, using a subset of these participants (N = 6136) who had complete cognition data at baseline and at 2-year follow-up, were conducted to assess for associations between class membership and longitudinal changes in cognition.

RESULTS

The LCA identified a 5-class solution: "No Symptoms", "Sleep", "Sleep and Worry", "Sleep and Anhedonia", and "Co-morbid Depression and Anxiety". Class membership was significantly associated with longitudinal change in cognition. Furthermore, this association differed across different cognitive measures.

LIMITATIONS

Limitations included significant attrition and a generally healthy sample which may impact generalisability.

CONCLUSIONS

Substantial heterogeneity in affective symptoms could explain previous inconsistent findings concerning the association between affective symptoms and cognition. Clinicians should not focus solely on total symptom scores on a single affective domain, but instead on the presence and patterns of symptoms (even if sub-clinical) on measures across multiple affective domains. Identifying particular subgroups that are at greater risk of poor cognitive outcomes may support targeted prevention work.

Factor structure, measurement invariance, and concurrent validity of the Patient Health Questionnaire-9 and the Generalized Anxiety Disorder scale-7 in a Norwegian psychiatric outpatient sample

OBJECTIVE

The aim of this study was to test factor structure, measurement invariance, and concurrent validity of the nine item Patient Health Questionnaire-9 (PHQ-9) and the seven item Generalized Anxiety Disorder scale-7 (GAD-7) in a heterogeneous outpatient sample.

METHOD

Outpatients completed the PHQ-9, GAD-7, and the Working Social Adjustment Scale (WSAS) before starting treatment. Study design was cross-sectional, with convenience sampling. The total sample consisted of 831 participants (61% women).

RESULTS

Both PHQ-9 and GAD-7 demonstrated better fit statistics with two-factor and bifactor solutions consisting of a cognitive and somatic factor. Omega hierarchical was .78 for PHQ-9 and .81 for GAD-7. Both instruments achieved scalar invariance across gender, diagnosis, and comorbidity. However, the somatic factors demonstrated poor discriminant validity. These factors are not well separatable and risks being too similar if used together. The general factors of both instruments were most associated with functional impairment, although PHQ-9 demonstrated a stronger association with WSAS (γ = .74, r² = .62) than GAD-7 (γ = .54, r² = .32). Using latent mean difference, women and patients with comorbidity had significantly higher scores of both depression and anxiety.

CONCLUSION

This study shows that the PHQ-9 and GAD-7 may be used as one-dimensional instruments in clinical settings. Tests for measurement invariance supported that both measures are understood and interpreted comparably across gender and diagnostic subgroups.

Validity and reliability of the Patient Health Questionnaire scale (PHQ-9) among university students of Bangladesh

This study investigated the reliability and factorial validity of Patient Health Questionnaire-9 (PHQ-9) in the context of university students in Bangladesh. The research aimed to assess whether the original one-dimensional model or a model containing both somatic and cognitive-emotional factors is appropriate in the case of a sample of university students. A repeated cross-sectional survey design based on convenience sampling was used to collect data from 677 university students from both public and private universities. The factor structure of the PHQ-9 was assessed using confirmatory factor analysis (CFA). Measurement invariances were assessed across gender, type of university, level of education and victim of domestic violence. Its convergent validity was determined by investigating its correlations with Generalized Anxiety Disorder-7 (GAD-7) and Patient Health Questionnaire Anxiety-Depression Scale (PHQ-ADS). Results showed excellent reliability of PHQ-9 as measured by both Cronbach's α and McDonald's ω. CFA suggested that a modified one-factor model where the error variances between item-3 ('sleeping difficulties') and item-6 ('feeling as a failure'), item-6 and item-9 ('suicidal thoughts'), item-4 ('feeling tired') and item-9, item-3 and item-9 were allowed to covary is appropriate for the sample. This model provided high values of comparative fit index (CFI), goodness of fit index (GFI), and Tucker Lewis Index (TLI), low value of standardized root mean square residual (SRMR) and a non-significant root mean square error of approximation (RMSEA) as well as a high Factor Determinacy Score Coefficient. Correlation between PHQ-9 and GAD-7 was 0.751 and 0.934 between PHQ-9 and PHQ-ADS. Finally, the model is strictly invariant across gender and university type. Overall, the study provided support for modified unidimensional structure for PHQ-9 and showed high internal consistency along with good convergent validity.

Psychometric properties of screening questionnaires to detect depression in primary healthcare setting in rural Ethiopia

BACKGROUND

Much of the research about the validity of depression screening questionnaires is on criterion validity. Evidence is scarce on the concurrent, convergent and construct validity of these measures, particularly from low-income countries. This study aimed to evaluate the psychometric properties of depression screening questionnaires in primary healthcare (PHC) in rural Ethiopia.

METHODS

A facility-based cross-sectional study was conducted with 587 participants recruited from patients attending three PHC facilities and two 'Holy water sites' (places where religious treatment is being provided). The psychometric properties of five mental health screening questionnaires were evaluated: the nine item Patient Health Questionnaire (PHQ-9), the two item version of PHQ-9 (PHQ-2), a version of PHQ-9 with two added items of irritability and noise intolerance (PHQ-11), the Patient Health Questionnaire-15 (PHQ-15), and the World Health Organization-Five Well-being Index (WHO-5). Clinical diagnosis of depression was ascertained by psychiatrists. We analyzed data using exploratory factor analysis, Spearman's rank order correlation coefficient (Rho), the Mann Whitney test of the equality of medians, univariate logistic regression and Cronbach's alpha.

RESULTS

PHQ-9, PHQ-11 and WHO-5 were found to be unidimensional, with items in each scale highly loading onto one factor (factor loadings ranging from 0.64 to 0.87). The items of each instrument were internally consistent, with Cronbach's alpha ranging from 0.72 (PHQ-2) to 0.89 (PHQ-11). Scores for all screening scales were moderately or highly correlated with each other (Rho = 0.58 to 0.98) and moderately correlated with anxiety and disability scores. Median scores of all screening scales were significantly higher in those diagnosed with depression. The association of items measuring emotional and cognitive symptoms with the diagnosis of depression was stronger than the association with items measuring somatic symptoms. Irritability and noise intolerance had higher association with depression diagnosis than PHQ-9 items.

CONCLUSION

Emotional and cognitive symptoms are more useful than somatic symptoms to predict the diagnosis of depression in the PHC context in Ethiopia. Future research should focus on testing the unidimensionality of PHQ-9, PHQ-11 and WHO-5 using confirmatory factor analysis; establishing the criterion validity of PHQ-11 and WHO-5; and on assessing test-retest reliability of all the measures.

The effects of survey mode on self-reported psychological functioning: Measurement invariance and latent mean comparison across face-to-face and web modes

Despite the increasing popularity of mixed-mode approaches to data collection, studies examining measurement equivalence across different survey modes in representative samples of the general population, particularly focusing on measures of socially sensitive psychological constructs, are sparse. In this study, we used data from a large representative sample of the Slovenian population (N = 9,900) collected as part of the third wave of the European Health Interview Survey (EHIS) to examine mode-inherent effects (i.e., measurement effects that cannot be neutralized by clever survey design) of the traditional interviewer-mediated face-to-face mode and the increasingly popular self-administered web mode on three measures of psychological functioning, namely the Patient Health Questionnaire Depression Scale (PHQ-8), the Satisfaction with Life Scale (SWLS), and the Mental Health Continuum - Short Form (MHC-SF). After controlling for self-selection propensities, our results showed strict measurement invariance for all three scales across the two survey modes, but statistically significant and notable differences in latent means, suggesting that individuals who respond face-to-face systematically report better psychological functioning than individuals who respond over the web. These results suggest significant mode inherent effects that cannot be attributed to measurement non-invariance of the scales between face-to-face and web survey modes, but most likely to social desirability bias in responses achieved in the presence of an interviewer. Administration mode effects must be considered when interpreting and comparing results obtained through different survey modes, particularly interviewer-mediated versus self-administered modes, especially when using measures of culturally desirable traits and behaviors, such as mental health and well-being.

Psychometric Properties and Factor Structure of the Patient Health Questionnaire-9 as a Screening Tool for Depression Among Ecuadorian College Students

Background

The Patient Health Questionnaire-9 (PHQ-9) is the most well-known self-report measure to screen for depressive symptomatology, although discerning which is the factor structure that represents the best fit remains a challenge.

Objective

The aim of this study was to analyze the psychometric properties and factorial structure of the Spanish version of the PHQ-9 in a large sample of Ecuadorian college students.

Methods

A total of 5,394 students (M = 22.03 years; SD = 3.05; 54.8% female) from three Ecuadorian universities were surveyed using a computerized questionnaire within a 4-week assessment period. The PHQ-9 was tested for factorial structure, reliability, and correlations with other mental health-related measures.

Results

The hierarchical model that included a general factor and three nested factors had a better fit, and such a hierarchical structure remained invariant across sex and age. Total omega value (ω) was 0.90 for the total scale and hierarchical omega values (ωh) were 0.68 for the general factor, as well as 0.34, 0.38, and 0.44 for the respective nested factors (somatic, cognitive/affective, concentration/motor). Moreover, PHQ-9 scores were significantly higher among women, although effect sizes of comparison of those sex differences were very small. Finally, the PHQ-9 scores correlated with multiple mental health indicators (psychological inflexibility, loneliness, stress, and satisfaction with life).

Discussion

The Spanish version of the PHQ-9 showed good psychometric properties among Ecuadorian college students. The hierarchical structure showed the best fit for the data, including not only a dominant general factor, but also the somatic, cognitive/affective and concentration/motor subcomponents. In conclusion, the PHQ-9 tool seems to represent an easy-to-implement screening questionnaire to design preventive programs for those Ecuadorian college students at risk of developing depressive disorders.

Measurement invariance of the Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder scale (GAD-7) across four European countries during the COVID-19 pandemic

BACKGROUND

The Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder scale (GAD-7) are self-report measures of major depressive disorder and generalised anxiety disorder. The primary aim of this study was to test for differential item functioning (DIF) on the PHQ-9 and GAD-7 items based on age, sex (males and females), and country.

METHOD

Data from nationally representative surveys in UK, Ireland, Spain, and Italy (combined N = 6,054) were used to fit confirmatory factor analytic and multiple-indictor multiple-causes models.

RESULTS

Spain and Italy had higher latent variable means than the UK and Ireland for both anxiety and depression, but there was no evidence for differential items functioning.

CONCLUSIONS

The PHQ-9 and GAD-7 scores were found to be unidimensional, reliable, and largely free of DIF in data from four large nationally representative samples of the general population in the UK, Ireland, Italy and Spain.

Mental Health Impact in Latin American Pediatric Rheumatologists During the COVID-19 Pandemic

OBJECTIVE

The aim of this study was to assess mental health in Latin American pediatric rheumatologists (LAPRs) during the COVID-19 pandemic.

METHODS

A cross-sectional study was performed with 318 LAPRs based on an online, self-rated survey about clinical practice/mental health impacts during the COVID-19 pandemic. Validated self-reported scales for anxiety (Generalized Anxiety Disorder [GAD-7]) and depression (Patient Health Questionnaire [PHQ-9]) were evaluated.

RESULTS

The response rate was 126 of 318 (40%), including 13 of 20 (65%) Latin American countries. Working on the COVID-19 frontline was reported by 27% of LAPRs. Anxiety and moderate/severe depression were observed in 49% and 25%, respectively. No LAPRs reported previous mental health disorders. Deaths of childhood-onset systemic lupus erythematosus and juvenile idiopathic arthritis patients with confirmed/suspected COVID-19 were reported by 8% and 2% of LAPRs, respectively. Further analysis of LAPRs revealed that the median current age was significantly lower in LAPRs with anxiety than in those without anxiety (39 [29-43] vs 45 [30-70] years, p = 0.029). Working on the frontline of COVID-19 (37% vs 17%, p = 0.015), feeling helpless (39% vs 17%, p = 0.009), and experiencing burnout (39% vs 11%, p = 0.0001) were factors significantly higher in LAPRs with anxiety. Median nighttime sleep abnormalities measured by the visual analog scale (VAS) (8 [0-10] vs 4 [0-10], p = 0.009) were significantly higher in the anxiety group, whereas the physical activity VAS was lower (0.5 [0-10] vs 3 [0-10], p = 0.005). A positive Spearman correlation was shown between the GAD-7 score and nighttime sleep abnormality VAS score (r = +0.348, p < 0.001), and a negative correlation was shown between the GAD-7score and physical activity VAS score (r = -0.192, p = 0.031).

CONCLUSIONS

Anxiety and depression were relevant to the experience of LAPRs during the COVID-19 pandemic, impacting their mental health. Reporting information about mental health is essential to planning future preventive and health promotion strategies.

Mental health impacts in pediatric nurses: a cross-sectional study in tertiary pediatric hospital during the COVID-19 pandemic

Objective:

to assess mental health issues in pediatric nurses during coronavirus pandemic in 2019.

Method:

cross-sectional study was conducted with pediatric nurses at the Instituto da Criança e do Adolescente based on online self-rated survey about clinical practice and mental health impact during COVID-19 pandemic. Validated self-reported scales for anxiety, depression and burnout were used for assessing these professionals.

Results:

107/298 (36%) nurses answered, 90% were female, median age was 41(23-64) years, 68% worked with adolescents, 66% in frontline. Burnout, anxiety and moderate/severe depression occurred in 65%, 72% and 74%, respectively. Lack of standardized treatment protocol for nurses (27%vs.10%, p=0.049), moderate/severe depression (74% vs. 16%, p=0.002) and burnout (82% vs. 58%, p=0.01) were significantly higher in pediatric nurses with anxiety compared to those without. Pediatric nurses that worked with adolescents compared to those that did not showed higher frequency of burnout in the former group (77% vs. 32%, p=0.0001). Multivariable analysis revealed that adequate quarantine adherence increased the presence of anxiety in 4.6 times [OR4.6(CI 1.1-20.2), p=0.04].

Conclusion:

most pediatric nurses who had worked in the frontline of COVID-19 were under precarious conditions, working with reduced team, and with an expressive changes in their monthly income. Current anxiety was a relevant issue, burnout was also an important mental condition for these professionals, reinforcing culture of good teamwork, collaboration practices and psychological/psychiatric approach.

Associations between depressive symptom clusters and care utilization and costs among community-dwelling older adults

OBJECTIVES

Whether and how symptom clusters are associated with care utilization remains understudied. This study aims to investigate the economic impact of symptom clusters.

METHODS

We conducted cross-sectional analyses of data collected from 3255 older adults aged 60 years and over in Hong Kong using the Patient Health Questionnaire-9 and the Client Service Receipt Inventory to measure depressive symptoms and service utilization to calculate 1-year care expenditure. Based on Research Domain Criteria framework, we categorized depressive symptoms into four clusters: Negative Valance Systems and Externalizing (NVSE; anhedonia and depression), Negative Valance Systems and Internalizing (guilt and self-harm), Arousal and Regulatory Systems (sleep, fatigue, and appetite), and Cognitive and Sensorimotor Systems (CSS; concentration and psychomotor). Two-part models were used with four symptom clusters to estimate economic impacts on care utilization.

RESULTS

Core affective symptoms had the largest economic impact on non-psychiatric care expenditure; a one-point increase in NVSE was associated with USD$ 571 additional non-psychiatric care expenditure. The economic impacts of CSS on non-psychiatric care expenditure was attenuated when the severity level of NVSE was higher.

CONCLUSIONS

Our findings highlight the importance of understanding economic impacts on care utilization based on symptom profiles with a particular emphasis on symptom combinations. Policymakers should optimize care allocation based on older adults' depressive symptom profiles rather than simply considering their depression sum-score or the severity defined by cut-off points.

Impacto en la salud mental de enfermeros pediátricos: un estudio transversal en un hospital pediátrico de tercer nivel durante la pandemia de COVID-19

Resumen Objetivo: evaluar los problemas de salud mental en enfermeros pediátricos durante la pandemia del coronavirus 2019. Método: estudio transversal realizado con enfermeros pediátricos del Instituto da Criança e do Adolescente mediante una encuesta de autoevaluación en línea sobre la práctica clínica y el impacto en la salud mental durante la pandemia de COVID-19. Se evaluaron escalas de autoevaluación validadas para ansiedad, depresión y burnout. Resultados: respondieron 107/298 (36%) de los enfermeros, de los cuales 90% eran del sexo femenino, la mediana de edad actual fue de 41 (23-64) años, 68% trabajaban con adolescentes, 66% trabajaban en primera línea. Burnout, ansiedad y depresión moderada/grave ocurrieron en 65%, 72% y 74% de los enfermeros, respectivamente. Falta de protocolo de tratamiento estandarizado en las enfermerías (27% vs. 10%, p=0,049), depresión moderada/grave (74% vs. 16%, p=0,002) y burnout (82% vs. 58%, p=0,01) fueron significativamente mayores en enfermeros pediátricos con ansiedad en comparación con enfermeros sin esta condición. Los enfermeros pediátricos que trabajaban con adolescentes presentaron mayor frecuencia de burnout en comparación con los que no trabajaban con adolescentes (77% vs. 32%, p=0,0001). El análisis multivariado reveló que el adecuado cumplimiento de la cuarentena aumentó 4,6 veces la presencia de ansiedad [OR 4.6(IC 1,1-20,2), p=0,04]. Conclusión: La mayoría de los enfermeros pediátricos trabajaban en la primera línea de la COVID-19, en condiciones precarias, trabajando con un equipo reducido y enfrentando importantes pérdidas de ingresos. La ansiedad actual fue un tema relevante y el burnout también fue una condición mental importante para estos profesionales, reforzando la cultura del buen trabajo en equipo, las prácticas colaborativas y la atención psicológica/psiquiátrica.

Impacto na saúde mental de enfermeiros pediátricos: um estudo transversal em hospital pediátrico terciário durante a pandemia de COVID-19

Resumo Objetivo: avaliar problemas de saúde mental em enfermeiros pediátricos durante a pandemia causada pelo coronavírus 2019. Método: estudo transversal realizado com enfermeiros pediátricos do Instituto da Criança e do Adolescente, por meio de uma pesquisa online de autoavaliação sobre prática clínica e impacto na saúde mental, durante a pandemia de COVID-19. Foram avaliadas escalas de autoavaliação validadas para ansiedade, depressão e burnout. Resultados: 107/298(36%) enfermeiros responderam, dos quais 90% eram do sexo feminino, a mediana de idade atual era 41(23-64) anos, 68% trabalhavam com adolescentes, 66% trabalhavam na linha de frente. Burnout, ansiedade e depressão moderada/grave ocorreram em 65%, 72% e 74% dos enfermeiros, respectivamente. Falta de protocolo de tratamento padronizado nas enfermarias (27% vs. 10%, p=0,049), depressão moderada/grave (74% vs. 16%, p=0,002) e burnout (82% vs. 58%, p=0,01) foram significativamente maiores em enfermeiros pediátricos com ansiedade, em comparação com enfermeiros sem essa condição. Os enfermeiros pediátricos que trabalhavam com adolescentes apresentaram maior frequência de burnout, quando comparados aos que não trabalhavam com esse grupo (77% vs. 32%, p=0,0001). A análise multivariada revelou que o cumprimento adequado da quarentena aumentou a presença de ansiedade em 4,6 vezes [OR 4.6(IC 1,1-20,2), p=0,04]. Conclusão: a maioria dos enfermeiros pediátricos atuava na linha de frente da COVID-19, em condições precárias, trabalhando com equipe reduzida e enfrentando perdas expressivas de renda. A ansiedade atual foi um tema relevante e o burnout também foi uma condição mental importante para esses profissionais, reforçando a cultura do bom trabalho em equipe, das práticas de colaboração e do cuidado psicológico/psiquiátrico.

Longitudinal measurement invariance of the patient health questionnaire in a German sample

BACKGROUND

The Patient Health Questionnaire-8 (PHQ-8) is a screening questionnaire of depressive symptoms. However, it is unknown whether it is equivalent across time and between groups of individuals. The aim of our paper was to test whether the PHQ-8 has the same meaning in two groups of individuals over time.

METHODS

Primary care patients were proactively recruited from three German cities. PHQ-8 data from a baseline assessment (n = 588), two assessments during the intervention (n = 246/225), and a six (n = 437) and 12 months (n = 447) follow-up assessment were first used to examine the factor structure of the PHQ-8 by confirmatory factor analysis (CFA). The best fitting factor solution was then used to test longitudinal invariance across time and between intervention and control group by Multiple Group CFA.

RESULTS

A two-factor structure consistently showed the best model fit. Only configural longitudinal invariance was evidenced when the baseline assessment was included in the analysis. Without the baseline assessment, strict longitudinal invariance was shown across the intervention and the follow-up assessments. Scalar invariance was established between the intervention and control group for the baseline assessment and strict invariance between groups and across the 6- and 12-month follow-up assessments.

CONCLUSIONS

The lack of longitudinal invariance might be attributed to various differences between the baseline assessments and all following assessments, e.g., assessment mode (iPad vs telephone), potential changes in symptom perception, and setting.

TRIAL REGISTRATION

DRKS0001163 5, date of trial registration: 20.01.2017; DRKS00011637 , date of trial registration: 25.01.2017.

Are the PHQ-9 and GAD-7 Suitable for Use in India? A Psychometric Analysis

BACKGROUND

Cross-cultural evidence on the factorial structure and invariance of the PHQ-9 and the GAD-7 is lacking for South Asia. Recommendations on the use of unit-weighted scores of these scales (the sum of items' scores) are not well-founded. This study aims to address these contextual and methodological gaps using data from a rural Indian population.

METHODS

The study surveyed 1,209 participants of the Kerala Diabetes Prevention Program aged 30-60 years (n at risk of diabetes = 1,007 and n with diabetes = 202). 1,007 participants were surveyed over 2 years using the PHQ-9 and the GAD-7. Bifactor-(S - 1) modeling and multigroup confirmatory factor analysis were used.

RESULTS

Factor analysis supported the existence of a somatic and cognitive/affective subcomponent for both scales, but less explicitly for the GAD-7. Hierarchical omega values were 0.72 for the PHQ-9 and 0.76 for the GAD-7. Both scales showed full scalar invariance and full or partial residual invariance across age, gender, education, status of diabetes and over time. Effect sizes between categories measured by unit-weighted scores versus latent means followed a similar trend but were systematically higher for the latent means. For both disorders, female gender and lower education were associated with higher symptom severity scores, which corresponds with regional and global trends.

CONCLUSIONS

For both scales, psychometric properties were comparable to studies in western settings. Distinct clinical profiles (somatic-cognitive) were supported for depression, and to a lesser extent for anxiety. Unit-weighted scores of the full scales should be used with caution, while scoring subscales is not recommended. The stability of these scales supports their use and allows for meaningful comparison across tested subgroups.

CLINICAL TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Registry: ACTRN12611000262909http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=336603&isReview=true.

Bidimensional structure and measurement equivalence of the Patient Health Questionnaire-9: sex-sensitive assessment of depressive symptoms in three representative German cohort studies

BACKGROUND

The Patient Health Questionnaire-9 (PHQ-9) has been proposed as a reliable and valid screening instrument for depressive symptoms with one latent factor. However, studies explicitly testing alternative model structures found support for a two-dimensional structure reflecting a somatic and a cognitive-affective dimension. We investigated the bidimensional structure of the PHQ-9, with a somatic (sleeping problems, fatigability, appetitive problems, and psychomotor retardation) and a cognitive-affective dimension (lack of interest, depressed mood, negative feelings about self, concentration problems, and suicidal ideation), and tested for sex- and regional-differences.

METHODS

We have included data from the GEnder-Sensitive Analyses of mental health trajectories and implications for prevention: A multi-cohort consortium (GESA). Privacy-preserving analyses to provide information on the overall population and cohort-specific information and analyses of variance to compare depressive, somatic and cognitive-affective symptoms between sexes and cohorts were executed in DataSHIELD. In order to determine the dimensionality and measurement invariance of the PHQ-9 we tested three models (1 factor, 2 correlated factors, and bifactor) via confirmatory analyses and performed multi-group confirmatory factor analysis.

RESULTS

Differences between sex and cohorts exist for PHQ-9 and for both of its dimensions. Women reported depressive symptoms in general as well as somatic and cognitive-affective symptoms more frequently. For all tested models an acceptable to excellent fit was found, consistently indicating a better model fit for the two-factor and bifactor model. Scalar measurement invariance was established between women and men, the three cohorts, and their interaction.

CONCLUSIONS

The two facets of depression should be taken into account when using PHQ-9, while data also render support to a general factor. Somatic and cognitive-affective symptoms assessed by the PHQ-9 can be considered equivalent across women and men and between different German populations from different regions.

The factor structure of major depressive symptoms in a sample of Chinese earthquake survivors

BACKGROUND

Experiencing natural disasters is associated with common mental disorders including major depressive disorder (MDD). However, the latent structure of MDD is widely debated, and few studies tested the MDD factor structure in Chinese natural disaster survivors. Therefore, the aim of the current study was to evaluate the factorial validity of the Patient Health Questionnaire-9 (PHQ-9) for DSM-5 major depressive disorder (MDD) symptoms in Chinese earthquake survivors.

METHOD

Participants were 1058 Chinese earthquake survivors. Self-reported measures included the PHQ-9 and the Short-Form Health Survey (SF-36). Confirmatory factor analysis (CFA) and structural equation modelling (SEM) was used to examine the latent structure of MDD and the associations between latent factors of MDD and different domains of health-related quality of life (HRQoL), respectively.

RESULTS

In the current sample, the model consisted of somatic and cognitive/affective (non-somatic) factors demonstrated significantly better fit than the other competing MDD models (χ² = 173.89, df = 26, CFI = 0.986, TLI = 0.981, RMSEA = 0.073, BIC = 18,091.13). Further SEM analyses indicated that the non-somatic factor was significantly related to both physical (β = - 0.362, p < .01) and psychosocial HRQoL (β = - 0.773, p < .01), while the somatic factor was a uniquely predictor of physical HRQoL (β = - 0.336, p < .01). Furthermore, we found the somatic factor partially mediated the relationship between the cognitive/affective factor and physical HRQoL (all ps < .05).

CONCLUSIONS

The MDD symptoms was best captured by a two-factor model comprised of somatic and cognitive/affective factors in Chinese natural disaster survivors. The two MDD factors were differentially associated with physical and psychosocial HRQoL, and the cognitive/affective factor associated physical HRQoL partially through the somatic factor. The current findings increase our understanding of latent structure of MDD symptoms, and carry implications for assessment and intervention of post-disaster mental health problems.