Equivalency of the diagnostic accuracy of the PHQ-8 and PHQ-9: a systematic review and individual participant data meta-analysis.

BACKGROUND: Item 9 of the Patient Health Questionnaire-9 (PHQ-9) queries about thoughts of death and self-harm, but not suicidality. Although it is sometimes used to assess suicide risk, most positive responses are not associated with suicidality. The PHQ-8, which omits Item 9, is thus increasingly used in research. We assessed equivalency of total score correlations and the diagnostic accuracy to detect major depression of the PHQ-8 and PHQ-9. METHODS: We conducted an individual patient data meta-analysis. We fit bivariate random-effects models to assess diagnostic accuracy. RESULTS: 16 742 participants (2097 major depression cases) from 54 studies were included. The correlation between PHQ-8 and PHQ-9 scores was 0.996 (95% confidence interval 0.996 to 0.996). The standard cutoff score of 10 for the PHQ-9 maximized sensitivity + specificity for the PHQ-8 among studies that used a semi-structured diagnostic interview reference standard (N = 27). At cutoff 10, the PHQ-8 was less sensitive by 0.02 (-0.06 to 0.00) and more specific by 0.01 (0.00 to 0.01) among those studies (N = 27), with similar results for studies that used other types of interviews (N = 27). For all 54 primary studies combined, across all cutoffs, the PHQ-8 was less sensitive than the PHQ-9 by 0.00 to 0.05 (0.03 at cutoff 10), and specificity was within 0.01 for all cutoffs (0.00 to 0.01). CONCLUSIONS: PHQ-8 and PHQ-9 total scores were similar. Sensitivity may be minimally reduced with the PHQ-8, but specificity is similar.

The Accuracy of the Patient Health Questionnaire-9 Algorithm for Screening to Detect Major Depression: An Individual Participant Data Meta-Analysis.

BACKGROUND: Screening for major depression with the Patient Health Questionnaire-9 (PHQ-9) can be done using a cutoff or the PHQ-9 diagnostic algorithm. Many primary studies publish results for only one approach, and previous meta-analyses of the algorithm approach included only a subset of primary studies that collected data and could have published results. OBJECTIVE: To use an individual participant data meta-analysis to evaluate the accuracy of two PHQ-9 diagnostic algorithms for detecting major depression and compare accuracy between the algorithms and the standard PHQ-9 cutoff score of ≥10. METHODS: Medline, Medline In-Process and Other Non-Indexed Citations, PsycINFO, Web of Science (January 1, 2000, to February 7, 2015). Eligible studies that classified current major depression status using a validated diagnostic interview. RESULTS: Data were included for 54 of 72 identified eligible studies (n participants = 16,688, n cases = 2,091). Among studies that used a semi-structured interview, pooled sensitivity and specificity (95% confidence interval) were 0.57 (0.49, 0.64) and 0.95 (0.94, 0.97) for the original algorithm and 0.61 (0.54, 0.68) and 0.95 (0.93, 0.96) for a modified algorithm. Algorithm sensitivity was 0.22-0.24 lower compared to fully structured interviews and 0.06-0.07 lower compared to the Mini International Neuropsychiatric Interview. Specificity was similar across reference standards. For PHQ-9 cutoff of ≥10 compared to semi-structured interviews, sensitivity and specificity (95% confidence interval) were 0.88 (0.82-0.92) and 0.86 (0.82-0.88). CONCLUSIONS: The cutoff score approach appears to be a better option than a PHQ-9 algorithm for detecting major depression.

Shortening self-report mental health symptom measures through optimal test assembly methods: Development and validation of the Patient Health Questionnaire-Depression-4.

BACKGROUND: The objective of this study was to develop and validate a short form of the Patient Health Questionnaire-9 (PHQ-9), a self-report questionnaire for assessing depressive symptomatology, using objective criteria. METHODS: Responses on the PHQ-9 were obtained from 7,850 English-speaking participants enrolled in 20 primary diagnostic test accuracy studies. PHQ unidimensionality was verified using confirmatory factor analysis, and an item response theory model was fit. Optimal test assembly (OTA) methods identified a maximally precise short form for each possible length between one and eight items, including and excluding the ninth item. The final short form was selected based on prespecified validity, reliability, and diagnostic accuracy criteria. RESULTS: A four-item short form of the PHQ (PHQ-Dep-4) was selected. The PHQ-Dep-4 had a Cronbach's alpha of 0.805. Sensitivity and specificity of the PHQ-Dep-4 were 0.788 and 0.837, respectively, and were statistically equivalent to the PHQ-9 (sensitivity = 0.761, specificity = 0.866). The correlation of total scores with the full PHQ-9 was high (r = 0.919). CONCLUSION: The PHQ-Dep-4 is a valid short form with minimal loss of information of scores when compared to the full-length PHQ-9. Although OTA methods have been used to shorten patient-reported outcome measures based on objective, prespecified criteria, further studies are required to validate this general procedure for broader use in health research. Furthermore, due to unexamined heterogeneity, there is a need to replicate the results of this study in different patient populations.

"Not Just One, It's Both of Us": Low-Income Mothers' Perceptions of Structural Family Therapy Delivered in a Semi-rural Community Mental Health Center.

Qualitative methods were used to explore mothers' perceptions of structural family therapy (SFT) delivered in a semi-rural community mental health clinic. In-depth, semi-structured interviews were conducted with sixteen mothers who received SFT after seeking services for their children. Thematic analysis suggests mothers found SFT acceptable and valuable. Mothers reported using SFT strategies to regain parental authority, which they believed improved their ability to manage their child's needs and decreased their own stress. SFT also increased some mothers' receptivity to individual treatment. Mothers identified their low dose of treatment and lack of father involvement as impediments to improvement, raising concerns about intervention sustainability.

Probability of major depression diagnostic classification using semi-structured versus fully structured diagnostic interviews.

BACKGROUND: Different diagnostic interviews are used as reference standards for major depression classification in research. Semi-structured interviews involve clinical judgement, whereas fully structured interviews are completely scripted. The Mini International Neuropsychiatric Interview (MINI), a brief fully structured interview, is also sometimes used. It is not known whether interview method is associated with probability of major depression classification.AimsTo evaluate the association between interview method and odds of major depression classification, controlling for depressive symptom scores and participant characteristics. METHOD: Data collected for an individual participant data meta-analysis of Patient Health Questionnaire-9 (PHQ-9) diagnostic accuracy were analysed and binomial generalised linear mixed models were fit. RESULTS: A total of 17 158 participants (2287 with major depression) from 57 primary studies were analysed. Among fully structured interviews, odds of major depression were higher for the MINI compared with the Composite International Diagnostic Interview (CIDI) (odds ratio (OR) = 2.10; 95% CI = 1.15-3.87). Compared with semi-structured interviews, fully structured interviews (MINI excluded) were non-significantly more likely to classify participants with low-level depressive symptoms (PHQ-9 scores ≤6) as having major depression (OR = 3.13; 95% CI = 0.98-10.00), similarly likely for moderate-level symptoms (PHQ-9 scores 7-15) (OR = 0.96; 95% CI = 0.56-1.66) and significantly less likely for high-level symptoms (PHQ-9 scores ≥16) (OR = 0.50; 95% CI = 0.26-0.97). CONCLUSIONS: The MINI may identify more people as depressed than the CIDI, and semi-structured and fully structured interviews may not be interchangeable methods, but these results should be replicated.Declaration of interestDrs Jetté and Patten declare that they received a grant, outside the submitted work, from the Hotchkiss Brain Institute, which was jointly funded by the Institute and Pfizer. Pfizer was the original sponsor of the development of the PHQ-9, which is now in the public domain. Dr Chan is a steering committee member or consultant of Astra Zeneca, Bayer, Lilly, MSD and Pfizer. She has received sponsorships and honorarium for giving lectures and providing consultancy and her affiliated institution has received research grants from these companies. Dr Hegerl declares that within the past 3 years, he was an advisory board member for Lundbeck, Servier and Otsuka Pharma; a consultant for Bayer Pharma; and a speaker for Medice Arzneimittel, Novartis, and Roche Pharma, all outside the submitted work. Dr Inagaki declares that he has received grants from Novartis Pharma, lecture fees from Pfizer, Mochida, Shionogi, Sumitomo Dainippon Pharma, Daiichi-Sankyo, Meiji Seika and Takeda, and royalties from Nippon Hyoron Sha, Nanzando, Seiwa Shoten, Igaku-shoin and Technomics, all outside of the submitted work. Dr Yamada reports personal fees from Meiji Seika Pharma Co., Ltd., MSD K.K., Asahi Kasei Pharma Corporation, Seishin Shobo, Seiwa Shoten Co., Ltd., Igaku-shoin Ltd., Chugai Igakusha and Sentan Igakusha, all outside the submitted work. All other authors declare no competing interests. No funder had any role in the design and conduct of the study; collection, management, analysis and interpretation of the data; preparation, review or approval of the manuscript; and decision to submit the manuscript for publication.

Community Behavioral Health Service Use and Criminal Recidivism of People With Mental, Substance Use, and Co-occurring Disorders.

OBJECTIVE: This study assessed the relationship between community behavioral health service (CBHS) use and criminal recidivism in a broad sample of potential beneficiaries and by diagnostic group. METHODS: Among a cohort of people on probation with any mental and/or substance use disorder (N=772), the study estimated the effect of CBHS use on rearrest with Cox proportional hazards models. RESULTS: Service use significantly predicted reduced recidivism among people with any mental disorder (hazard rate=0.36, p=0.008), but not among those with any substance use disorder or co-occurring disorders. CONCLUSIONS: CBHS use in a given week predicted a 64% reduced recidivism risk during the following week among people with any mental disorder. However, CBHS use had no clear relationship with recidivism among people with co-occurring disorders or any substance use disorder. CBHS use may reduce recidivism, depending on recipient and service characteristics.

Patient Health Questionnaire-9 scores do not accurately estimate depression prevalence: individual participant data meta-analysis.

OBJECTIVES: Depression symptom questionnaires are not for diagnostic classification. Patient Health Questionnaire-9 (PHQ-9) scores ≥10 are nonetheless often used to estimate depression prevalence. We compared PHQ-9 ≥10 prevalence to Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (SCID) major depression prevalence and assessed whether an alternative PHQ-9 cutoff could more accurately estimate prevalence. STUDY DESIGN AND SETTING: Individual participant data meta-analysis of datasets comparing PHQ-9 scores to SCID major depression status. RESULTS: A total of 9,242 participants (1,389 SCID major depression cases) from 44 primary studies were included. Pooled PHQ-9 ≥10 prevalence was 24.6% (95% confidence interval [CI]: 20.8%, 28.9%); pooled SCID major depression prevalence was 12.1% (95% CI: 9.6%, 15.2%); and pooled difference was 11.9% (95% CI: 9.3%, 14.6%). The mean study-level PHQ-9 ≥10 to SCID-based prevalence ratio was 2.5 times. PHQ-9 ≥14 and the PHQ-9 diagnostic algorithm provided prevalence closest to SCID major depression prevalence, but study-level prevalence differed from SCID-based prevalence by an average absolute difference of 4.8% for PHQ-9 ≥14 (95% prediction interval: -13.6%, 14.5%) and 5.6% for the PHQ-9 diagnostic algorithm (95% prediction interval: -16.4%, 15.0%). CONCLUSION: PHQ-9 ≥10 substantially overestimates depression prevalence. There is too much heterogeneity to correct statistically in individual studies.

Case managers' perspectives on what they need to do their job.

OBJECTIVE: The purpose of this brief report is to identify the perceived training needs of case managers working on community support teams in a community mental health center serving a semi-rural/suburban area. METHODS: Semi-structured interviews were conducted with 18 case managers and 3 supervisors to inquire about areas of training need in case management. Interviews were coded and analyzed for common themes regarding training needs and methods of training improvement. RESULTS: Identified training needs called for a hands-on, back-to-basics approach that included education on the symptoms of severe mental illness, co-morbid substance use problems, and methods of engaging consumers. A mentoring model was proposed as a potential vehicle for disseminating knowledge in these domains. CONCLUSIONS: Case managers identify significant training needs that would address their basic understanding of severe mental illness. Programs targeting these needs may result in improved outcomes for case managers and the individuals with psychiatric disabilities they serve.

The relationship between maternal and child symptom change in community mental health.

The mental health of mothers and children are closely linked. This study examined the relationship between child and maternal symptom change during a period in which children participated in community mental health treatment. Symptom change was measured using the Child Behavior Checklist for children and the Beck Depression Inventory for Mothers. Results indicate that mothers whose children improve in community mental health treatment are significantly more likely to report a reduction in maternal depressive symptoms than mothers whose children do not improve. Implications of these findings for mental health service settings are discussed.

Screening for anxiety and depression in community mental health: the beck anxiety and depression inventories.

Accurate diagnosis is key to providing quality services in community mental health. This research examined the ability of the Beck Anxiety and Depression Inventories to identify anxiety and depression in community settings. The diagnostic accuracy of these instruments was compared with the Structured Clinical Interview for DSM-IV in a sample of 288 distressed women seeking treatment for their children. Operating characteristic curves indicated the Beck Anxiety and Depression Inventories hold utility as screens for panic and major depressive disorder, respectively. Deploying these instruments as initial screens in a tiered diagnostic system may improve diagnostic accuracy in community settings.

Motivation deficits and use of alcohol and illicit drugs among individuals with schizophrenia.

This study examined the impact of substance use on intrinsic motivation and evaluated the association between intrinsic motivation and substance use recovery among individuals with schizophrenia. Alcohol and illicit drug use and intrinsic motivation were evaluated at baseline and 6-months for 1434 individuals with schizophrenia from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) using self-rated substance use assessments and a derived motivation measure from the Heinrichs-Carpenter Quality of Life Scale. Results revealed patients had moderate motivation deficits overall and a considerable number were using alcohol or illicit drugs at baseline (n=576; 40.2%). Regression models at baseline showed patients with low levels of motivation had higher odds of substance use and those who were using substances had greater motivation deficits. At 6-months, substance using patients continued to demonstrate greater motivation deficits; however, those with high levels of motivation exhibited a greater reduction in their use of substances. Findings remained significant after adjusting for clinical confounds and were consistent across any substance, alcohol, and cannabis use. Our results emphasize concerns about substance use compounding motivation deficits in schizophrenia, and suggest that disentangling the motivation-substance use relationship in schizophrenia may facilitate efforts aimed at ameliorating these challenges and improving outcomes.

Effect of maternal mental health problems on child treatment response in community-based services.

OBJECTIVE: Many mothers bringing children for community mental health treatment need mental health services themselves. Moreover, children of mothers with mental health problems enter treatment with more severe symptomatology than do other children. However, little is known about how maternal mental health problems affect children's response to treatment. This study examined the impact of maternal mental health status on the child's treatment response. METHODS: The mental health of 272 mother-child pairs was assessed twice, when children entered treatment at three community mental health clinics and again three months later. Analysis of variance was used to examine the impact of maternal mental health status on children's rate of improvement. RESULTS: Children of mothers with mental health problems had significantly greater behavior problems (F=34.54, p<.001) and demonstrated less improvement over time (F=4.44, p=.04) than children of mentally healthy mothers. CONCLUSION: These findings suggest that treatment for mothers as well as children could be beneficial for this population.

Why lower income mothers do not engage with the formal mental health care system: perceived barriers to care.

Lower income mothers who bring their children for mental health services also have high rates of depression and anxiety, yet few seek help. Maternal and child mental health are intimately intertwined; thus, the distress of both is likely to continue if the mother's needs are unaddressed. Because mothers overcome numerous instrumental challenges to help their children, the authors identify potential perceptual barriers to mothers' help seeking. An ethnographic analysis of in-depth qualitative interviews with 127 distressed mothers suggests several critical perceptual factors. For example, mothers attributed their distress to external causes (e.g., poverty, negative life stressors), which they believed individually focused mental health services could not affect. Interviewees also anticipated negative ramifications for seeking care, including being labeled unfit mothers, and thus potentially losing custody of their children. The authors discuss the implications of these and other key themes for engaging lower income mothers and their children.

Limitations of the Patient Health Questionnaire in Identifying Anxiety and Depression: Many Cases Are Undetected.

OBJECTIVE: To determine the concordance between the Structured Clinical Interview for DSM-IV (SCID) and the Patient Health Questionnaire (PHQ) in diagnosing anxiety and depressive disorders. METHOD: Fifty women seeking psychiatric services for their children at two mental health centers in Western Pennsylvania were assessed for anxiety and depressive disorders using the SCID and the PHQ. RESULTS: Twenty-five women met SCID criteria for at least one anxiety disorder, 11 (44%) of whom the PHQ failed to identify. The PHQ was particularly limited in identifying individuals with anxiety disorders other than panic disorder. Seventeen women met SCID criteria for at least one major depressive disorder, 6 (35%) of whom the PHQ failed to identify. The PHQ was particularly limited in identifying depressed individuals with dysthymia. CONCLUSIONS: Caution should be used when screening for anxiety and depression with the PHQ. Implications for improving diagnostic accuracy in social work practice are discussed.

Behavioral treatment of obesity in patients taking antipsychotic medications.

OBJECTIVE: Antipsychotic medications are associated with weight gain and metabolic dysregulation, yet little is known about the management of obesity among individuals with severe and persistent mental illness. Thus we sought to evaluate the potential utility of a behavioral weight control program for this population. METHOD: Outpatients receiving psychiatric care at a university medical center who had a body mass index (BMI; weight in kg/[height in m](2)) >or= 30 and were currently taking antipsychotic medication participated in a 12-week group behavioral weight control program. A medical chart review was conducted for each participant's body weight over the 10 months prior to beginning the program. A multiple baseline design was used to determine the impact of the intervention on BMI through 12-month posttreatment follow-up. We also assessed self-reported eating behavior, physical activity, and health-related quality of life. Data were collected from October 2000 to July 2003. RESULTS: Among 35 patients who began the program, 29 (83%) completed treatment, with mean (+/- SD) weight loss of 5.04 (+/- 7.52) pounds (p = .001) and improvements in eating, activity, and quality of life. At 3-month posttreatment follow-up (N = 27; 77%), total mean weight loss was 7.14 (+/- 11.47) pounds (p = .003). Results of a longitudinal model based on general estimating equations indicated that, relative to the pretreatment period, BMI decreased significantly during treatment and remained stable through 12-month posttreatment follow-up. CONCLUSION: Behavioral weight control is a promising approach to the treatment of obesity among outpatients taking antipsychotic medications, but longer and more robust interventions are needed.

Depression and anxiety among mothers who bring their children to a pediatric mental health clinic.

OBJECTIVE: Maternal psychiatric illness is a potent risk factor for child psychiatric disorders, but little is known about rates of psychiatric diagnoses among mothers who bring their children to pediatric mental health clinics. This study investigated rates of psychiatric disorders among mothers of children presenting for psychiatric evaluation and examined the relationship between maternal diagnosis and child psychopathology. METHODS: Interviewers conducted structured diagnostic interviews with nonpsychotic, school-age children and their mothers (N=222) and collected self-report measures of symptoms, functioning, and social support. RESULTS: One-hundred-thirty-five participating mothers (61 percent) met DSM-IV criteria for a current axis I disorder, most commonly depression (35 percent) and anxiety (42 percent). Children of mothers with a diagnosis met criteria for significantly more diagnoses on the Schedule for Affective Disorders and Schizophrenia for School Age Children, Present and Lifetime version and had significantly higher scores on measures of internalizing and externalizing symptoms than children of mothers without a diagnosis. Two-thirds of mothers with a diagnosis were not receiving psychiatric treatment. CONCLUSIONS: More than half the mothers who brought their children for psychiatric treatment were themselves suffering from a psychiatric disorder. Maternal psychiatric illness was, in turn, associated with greater occurrence of psychopathology among offspring, underscoring the importance of developing interventions that address the needs of both children with psychiatric disorders and their at-risk mothers.

Weight gain information on the Internet for people who have schizophrenia.

Weight gain and chronic health problems are highly prevalent among people with schizophrenia. Basic information about diet and exercise changes would be very useful to people with schizophrenia as well as the family members and clinicians. Because people increasingly seek information from the World Wide Web, this paper reports on a survey of weight-related information on available web sites. A survey of 21 schizophrenia websites revealed that although fourteen sites (67%) included some information about weight gain and related health problems, more than half of the information was limited to site user-generated comments, and consisted of less than one paragraph of information.

Return to treatment after assessment in a community children's mental health clinic.

Most people who receive mental health assessments do not follow up on needed treatment. The authors examined factors that predicted return for at least one treatment visit among 113 children who presented for treatment at a rural community mental health center, using predictors of return for adults from a previous study. Sixty-four percent of the children, compared with 46 percent of the adults, returned at least once. Time until the first appointment predicted whether patients returned for treatment. The age of the child was the only other variable that predicted initial treatment engagement. The results strongly suggest that community mental health agencies can improve treatment acceptance rates by providing rapid response to requests for treatment.

The impact of system level factors on treatment timeliness: utilizing the Toyota Production System to implement direct intake scheduling in a semi-rural community mental health clinic.

This study examined the effect of using the Toyota Production System (TPS) to change intake procedures on treatment timeliness within a semi-rural community mental health clinic. One hundred randomly selected cases opened the year before the change and 100 randomly selected cases opened the year after the change were reviewed. An analysis of covariance demonstrated that changing intake procedures significantly decreased the number of days consumers waited for appointments (F(1,160) = 4.9; p = .03) from an average of 11 to 8 days. The pattern of difference on treatment timeliness was significantly different between adult and child programs (F(1,160) = 4.2; p = .04), with children waiting an average of 4 days longer than adults for appointments. Findings suggest that small system level changes may elicit important changes and that TPS offers a valuable model to improve processes within community mental health settings. Results also indicate that different factors drive adult and children's treatment timeliness.