Assessment and determinants of depression and anxiety on a global sample of sexual and gender diverse people at high risk of HIV: a public health approach.

BACKGROUND: Sexual and gender diverse people face intersecting factors affecting their well-being and livelihood. These include homophobic reactions, stigma or discrimination at the workplace and in healthcare facilities, economic vulnerability, lack of social support, and HIV. This study aimed to examine the association between such factors and symptoms of anxiety and depression among sexual and gender diverse people. METHODS: This study is based on a sample of 108,389 gay, bisexual, queer and questioning men, and transfeminine people from 161 countries collected through a cross-sectional internet survey. We developed a multinomial logistic regression for each group to study the associations of the above factors at different severity scores for anxiety and depression symptoms. RESULTS: Almost a third (30.3%) of the participants reported experiencing moderate to severe symptoms of anxiety and depression. Higher severity scores were found for transfeminine people (39%), and queer or questioning people (34.8%). Severe symptoms of anxiety and depression were strongly correlated with economic hardship for all groups. Compared to those who are HIV-negative, those living with HIV were more likely to report severe symptoms of anxiety and depression, and the highest score was among those who do not know their HIV status. Transfeminine people were the most exposed group, with more than 80% higher risk for those living with HIV suffering from anxiety and depression. Finally, homophobic reactions were strongly associated with anxiety and depression. The relative risk of severe anxiety and depression was 3.47 times higher for transfeminine people facing transphobic reactions than those with no symptoms. Moreover, anxiety and depression correlate with stigma or discrimination in the workplace and healthcare facilities. CONCLUSIONS: The strong association between the severity of anxiety and depression, and socioeconomic inequality and HIV status highlights the need for concrete actions to meet the United Nations' pledge to end inequalities faced by communities and people affected by HIV. Moreover, the association between stigma or discrimination and anxiety and depression among sexual and gender diverse people is alarming. There is a need for bold structural public health interventions, particularly for transfeminine, queer and questioning people who represent three communities under the radar of national HIV programmes.

Does It Matter What Screener We Use? A Comparison of Ultra-brief PHQ-4 and E-mwTool-3 Screeners for Anxiety and Depression Among People With and Without HIV.

The burden of depression and anxiety disorders is high in sub-Saharan Africa, especially for people with HIV (PWH). The Patient Health Questionnaire-4 (PHQ-4) and Electronic Mental Wellness Tool-3 (E-mwTool-3) are ultra-brief screening tools for these disorders. We compared the performance of PHQ-4 and E-mwTool-3 for screening MINI-International Neuropsychiatric Interview diagnoses of depression and anxiety among a sample of individuals with and without HIV in two primary care clinics and one general hospital in Maputo City, Mozambique. Areas-under-the-curve (AUC) were calculated along with sensitivities and specificities at a range of cutoffs. For PWH, at a sum score cutoff of ≥ 1, sensitivities were strong: PHQ-4:Depression = 0.843; PHQ-4:Anxiety = 0.786; E-mwTool-3:Depression = 0.843; E-mwTool-3:Anxiety = 0.929. E-mwTool-3 performance was comparable to PHQ-4 among people with and without HIV.

Distress in soft-tissue sarcoma and gastrointestinal stromal tumours patients-Results of a German multicentre observational study (PROSa).

OBJECTIVE: Soft tissue sarcomas (STS) and gastrointestinal stromal tumours (GIST) are a group of rare malignant tumours with a high and heterogenous disease burden. As evidence is scarce, we analysed the prevalence of increased emotional distress and identified distress-associated factors in these patients. METHODS: The PROSa-study (Burden and medical care of sarcoma) was conducted between 2017 and 2020 in 39 study centres. Cross-sectional data from adult STS and GIST patients were analysed. Distress was measured with the Patient Health Questionnaire (PHQ-4). The relation of socioeconomic and clinical factors with distress was explored in adjusted logistic regression models. RESULTS: Among 897 patients, 17% reported elevated anxiety and 19% reported depression. Unemployed patients (odds ratio [OR] 6.6; 95% CI 2.9-15.0), and those with a disability pension (OR 3.1; 95% CI 1.9-5.0) were more likely to experience distress compared to employed patients. Also, patients with a disability pass had higher odds of increased distress than those without (OR 1.8; 95% CI 1.2-2.7). Lowest distress was observed in patients 2 to <5 years and ≥5 years after diagnosis (comparison: <6 months) (OR 0.4; 95% CI 0.2-0.6) and (0.3; 95% CI 0.2-0.6). Patients with thoracic STS (vs. lower limbs) had twice the odds to experience distress (OR 2.0; 95% CI 1.1-3.6). Distress was seen almost twice as often in patients with progressive disease (vs. complete remission) (OR 1.7; 95% CI 1.1-2.8). CONCLUSION: The prevalence of elevated distress in STS and GIST patients is high. In unemployed patients, in those with a disability pension and in newly diagnosed patients a noticeable increase was observed. Clinicians should be aware of these factors and consider the social aspects of the disease.

Burden of mental distress in the United States is associated with delayed medical visits and missed prescription refills during the COVID-19 pandemic.

The COVID-19 pandemic has contributed to poor health due to a decrease in healthcare utilization and those with mental health problems may be impacted. For this analysis, data came from a cross-sectional, nationally representative December 2020 survey. Logistic regression analyses examined associations between (1) mental distress and delayed medical visits, (2) mental distress and missed prescription refills, controlling for sociodemographics, pre-existing chronic conditions, and access to health insurance. We found that, compared to those that exhibited normal levels of mental distress, those with mild (aOR = 2.83, 95% CI = 2.47-3.24), moderate (aOR = 3.43, 95% CI = 2.95-3.99), and severe (aOR = 4.96, 95% CI = 4.21-5.84) mental distress showed greater odds of delaying medical visits. Similarly, compared to those that exhibited normal levels of mental distress, those with mild (aOR =3.93, 95% CI = 3.04-5.09), moderate (aOR =6.52, 95% CI = 5.07-8.43), and severe (aOR =8.69, 95% CI = 6.71-11.32) mental distress showed greater odds of missing prescription refills. Our study shows that individuals who showed signs of mental distress had increased odds of delayed medical visits and missed prescription refills, compared to those that showed normal levels of mental distress.

The factor structure and measurement invariance of the PHQ-4 and the prevalence of depression and anxiety in a Southeast Asian context amid the COVID-19 pandemic.

This study examined the psychometric properties of the Patient Health Questionnaire-4 (PHQ-4) as an ultra-brief screener of depression and anxiety in the Philippines during the COVID-19 outbreak. Data from 4,524 non-clinical community respondents aged 18-73 years old was collected online between March and July 2020. We evaluated the screener's factor structure, measurement invariance, and criterion-related validity using confirmatory factor analysis (CFA), multigroup CFA, and structural equation modeling (SEM), respectively. We also evaluated the accuracy of the PHQ-4 cut-off scores by comparing the them with the screeners' full scales (i.e., PHQ-9 and GAD-7). Using the cutoff scores of the screeners, we also estimated the prevalence rates of depression and anxiety. The PHQ-4 has good internal reliability (Cronbach's α = 0.82). The CFA results show that the two-factor model has an excellent model fit that is superior to the one-factor model. The two-factor model held through increasingly constrained multigroup CFA models across gender, age, and geographical location groups, demonstrating measurement invariance. The SEM model supported the PHQ-4's theoretical association to stress, negative affect, and positive affect, supporting the screener's criterion-related validity. In estimating prevalence rates, among those screened by the PHQ-4 cut-off scores for depression (n = 1,905, 42.11%) and anxiety (n = 1,853, 40.96%), 81.78% and 94.06% were consequently screened by the PHQ-9 and GAD-7, respectively. This study supports the reliability, validity, and measurement invariance of the PHQ-4 as an ultra-brief screener of depression and anxiety in a large community sample in Southeast Asia. The inclusion of ultra-brief screeners in COVID-19-related studies and other human disasters, especially among non-clinical samples in low- and middle-income countries, is relevant for the sustainable evaluation and monitoring of the severity mental health symptoms leading to timely and effective mental health service provision.

Locus of control moderates the association of COVID-19 stress and general mental distress: results of a Norwegian and a German-speaking cross-sectional survey.

BACKGROUND: An internal locus of control (LoC I) refers to the belief that the outcome of events in one's life is contingent upon one's actions, whereas an external locus of control (LoC E) describes the belief that chance and powerful others control one's life. This study investigated whether LoC I and LoC E moderated the relationship between COVID-19 stress and general mental distress in the general population during the early months of the COVID-19 pandemic. METHODS: This cross-sectional survey study analysed data from a Norwegian (n = 1225) and a German-speaking sample (n = 1527). We measured LoC with the Locus of Control-4 Scale (IE-4), COVID-19 stress with a scale developed for this purpose, and mental distress with the Patient Health Questionnaire 4 (PHQ-4). Moderation analyses were conducted using the PROCESS macro for SPSS. RESULTS: The association between COVID-19 stress and general mental distress was strong (r = .61 and r = .55 for the Norwegian and the German-speaking sample, respectively). In both samples, LoC showed substantial moderation effects. LoC I served as a buffer (p < .001), and LoC E exacerbated (p < .001) the relation between COVID-19 stress and general mental distress. CONCLUSIONS: The data suggest that the COVID-19 pandemic is easier to bear for people who, despite pandemic-related strains, feel that they generally have influence over their own lives. An external locus of control, conversely, is associated with symptoms of depression and anxiety. The prevention of mental distress may be supported by enabling a sense of control through citizen participation in policy decisions and transparent explanation in their implementation.

The psychometric properties of PHQ-4 anxiety and depression screening scale among out of school adolescent girls and young women in Tanzania: a cross-sectional study.

BACKGROUND: Literature suggests that most mental disorders have their onset in childhood and adolescence, but go undiagnosed until adulthood. Shorter versions of the screening tools such as the Patient Health Questionnaire with four items (PHQ-4) may help to improve screening coverage. This study assessed the psychometric properties of the PHQ-4 in screening for core symptoms of depression and anxiety among out of school adolescent girls and young women (AGYW). METHODS: This is a cross-sectional analysis of data from a cluster randomized controlled trial conducted among AGYW between June and July 2018 in North-West Tanzania. Two thousand four hundred twenty-six out-of-school AGYW aged 15 to 23 years were included. Data were collected on tablets using audio computer-assisted self-interviews (ACASI). Cronbach's α was used to measure the reliability of the PHQ-4 while confirmatory factor analysis (CFA) and principal components analysis (PCA) were used for construct validity assessment. In CFA, three criteria were used to assess how well the model fits the data: Standardized Root Mean Square Residual (SRMR), the Comparative Fit Index (CFI), the Root Mean Square Error of Approximation (RMSEA) and 90% confidence interval for RMSEA. RESULTS: Of the 2426 participants, 33.8 and 35.5% screened positive for core symptoms of anxiety (GAD-2 ≥ 3) and depression (PHQ-2 ≥ 3), respectively. Cronbach's α of the PHQ-4 was 0.81. Both items-correlation and corrected items-correlation of the PHQ-4 had total correlations above 0.5 (p < 0.01). CFA showed that all items loaded significantly onto the single factor, and loadings were strong, ranging from 0.67 to 0.77 (p < 0.01). CFA indicates that the PHQ-4 scale stand for a unidimensional construct with good model fit (CFI = 0.995, SRMR = 0.013, RMSEA = 0.054 and 90% CI for RMSEA (0.031-0.079)). PCA confirmed two distinct components; GAD-2 (anxiety) and PHQ-2 (depression). Those who reported having suicidal thoughts and social function problems had significantly higher scores on PHQ-2, GAD-2, and PHQ-4 screening items (p < 0.01). CONCLUSIONS: The findings suggest that the PHQ-4 scale can reliably and validly screen for core symptoms of depression and anxiety among out of school AGYW. This tool is short and easy to administer. Thus, the PHQ-4 scale can be very useful in screening for anxiety and depression symptoms in the community, primary health facilities, research and programmatic settings.

Validation of the Malay version of the Patient Health Questionnaire-4 (PHQ-4) among Malaysian undergraduates.

The study's objective is to validate the Malay version of the Patient Health Questionnaire-4 (PHQ-4) among Malaysian undergraduates. A cross-sectional survey was distributed at three universities in Malaysia (N = 500; mean age = 21.66 ± 1.57). The internal consistency of the Malay PHQ-4 was acceptable (α = .78, 95 % CI [.74, .81]), while the test-retest reliability was good (ICC = .77, 95 % CI [.34, .91], p < .001). The one-factor structure showed the best fit in confirmatory factor analysis and was similar across sexes. The Malay PHQ-4 has acceptable psychometric properties and can be used for pre-clinical screening purposes among Malaysian undergraduate students.

[Mental distress of intensive care staff in Germany during the COVID-19 pandemic. Results from the VOICE study]. / Psychische Belastung des intensivmedizinischen Personals in Deutschland im Verlauf der COVID-19-Pandemie. Evidenz aus der VOICE-Studie.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic posed major challenges to the healthcare system worldwide and led to particular stress among healthcare workers. The aim of this analysis was to investigate the level of global mental stress of direct healthcare workers in Germany during the COVID-19 pandemic. METHODS: In this prospective cross-sectional study with four measurement points (T1: 4-5/2020, T2:11/2020-1/2021, 5-7/2021, 2-5/2022), psychological distress symptoms were recorded in an online survey with the Patient Health Questionnaire (PHQ-4) among hospital staff working in direct patient care (N = 5408 datasets). The total dataset was exploratively analyzed according to field of activity, gender, and professional group affiliation. RESULTS: Clinically relevant psychological distress (PHQ-4 ≥ 5) was present in 29.3% (n = 419/1429) of intensive care staff. A comparison of the four cross-sectional surveys showed a significant increase in the rate of clinically relevant mental distress in the first pandemic year (23.2% at T1 vs. 30.6% at T2; p < 0.01), which stabilized at a high level in the second pandemic year (33.6% at T3 and 32.0% at T4). Women did not differ from men in this respect (n = 280/919, 30.4% vs. n = 139/508, 27.4%; p = 0.74). Nursing staff were significantly more often psychologically stressed than physicians (n = 339/1105, 30.7% vs. n = 80/324, 24.7%; p = 0.03). Intensive care staff did not show significantly higher stress than staff working in nonintensive care areas (n = 419/1429, 29.3% vs. n = 1149/3979, 28.7%, p = 0.21). CONCLUSION: German healthcare workers reported high levels of mental distress during the pandemic, which increased during the course of the pandemic, but no significant difference was found between intensive care and nonintensive care staff in our sample. This may be due to the fact that the pandemic in Germany was comparatively moderate internationally and neither a collapse of the healthcare system in general nor a collapse of intensive care structures in particular took place.

Adverse Childhood Experiences and Depression among Homeless Young Adults: A Social Determinants of Health Perspective.

Homelessness is a pervasive issue in the United States that presents significant challenges to public health. Homeless young adults (HYAs) are at particular risk for increased incidence and severity of depression. Using primary survey data (n = 205) collected in the Phoenix Metropolitan Area, Arizona, from June to August 2022, this study aims to examine the relationship between adverse childhood experiences (ACEs) and depression among HYAs. We adopted the ACEs 10-item scale to measure childhood traumatic experiences, whereas depression was measured by using a PHQ-4 depression scale and diagnosed depression. Regression models were conducted to test the relationships between ACEs and depression outcomes while controlling for the covariates at the individual, interpersonal, and socioeconomic/living environment levels. The average PHQ-4 score was 5.01 (SD = 3.59), and 59.69% of HYAs reported being diagnosed previously with depression. The mean ACEs score was 5.22 out of 10. Other things being equal, for every one unit increase in ACEs scores, the odds of being diagnosed with depression increased by 11.5%, yet it was not statistically significant, while the PHQ-4 score increased by 0.445 (p < 0.001). Overall, HYAs were disproportionately affected by depression. This study elucidates the complex relationship between ACEs and depression among HYAs.

Confirmatory validation of the patient health questionnaire - 4 (PHQ-4) for gastrointestinal disorders: A large-scale cross-sectional survey.

OBJECTIVE: Using the large Rome Foundation Global Epidemiology Survey dataset, the aim of this study was to evaluate the construct and convergent validity and internal consistency of the PHQ-4 across both gastrointestinal and non-gastrointestinal condition cohorts. Another aim was to provide descriptive information about the PHQ-4 including means, confidence intervals and percentage of caseness using a large representative sample. METHODS: A cross-sectional survey was conducted in 26 countries. Confirmatory factor and internal consistency analyses were conducted across subsamples of patients with gastrointestinal conditions (i.e., disorders of gut-brain interaction [DGBI; any DGBI, individual DGBI, and DGBI region], gastroesophageal reflux disease (GERD), coeliac disease, diverticulitis, inflammatory bowel disease (IBD), cancer anywhere in the gastrointestinal tract, peptic ulcer) and those without a gastrointestinal condition. Convergent validity was also assessed via a series of Pearson's correlation coefficients with PROMIS (physical and mental quality of life), and PHQ-12 (somatisation). RESULTS: Based on 54,127 participants (50.9% male; mean age 44.34 years) confirmatory factor analysis indicated acceptable to excellent model fits for the PHQ-4 across all subsamples and individual DGBI and DGBI region (Comparative Fit Index >0.950, Tucker-Lewis Index >0.950, Root Mean Squared Error of Approximation <0.05, and Standardised Root Mean Square Residual <0.05). The PHQ-4 was found to demonstrate convergent validity (Pearson's correlation coefficients >±0.4), and good internal consistency (Cronbach's α > 0.75). CONCLUSIONS: This study provides evidence that the PHQ-4 is a valid and reliable tool for assessing mental health symptomology in both gastrointestinal and non-gastrointestinal cohorts.

Association of Anxiety and Depressive Symptoms and Treatment Adherence Among Patients With Type 2 Diabetes Mellitus in Jazan, Saudi Arabia: A Cross-Sectional Study.

BACKGROUND: Diabetes mellitus is a serious public health concern. It is associated with many psychological problems, such as depression, anxiety, and eating disorders. These co-morbidities are associated with improper adherence to treatment, self-care, poor glycemic control, more complications, and worse outcomes. METHODS: This study aimed to measure the level of medication adherence among type 2 diabetics in Jazan, Saudi Arabia, and to find its association with their psychological status (specifically, depression and anxiety). A cross-sectional descriptive design was used among adults with type 2 diabetes at the Diabetes and Endocrinology Center in Jazan, Saudi Arabia. The estimated sample size was 480 patients. The General Medication Adherence Scale and Patient Health Questionnaire-4 (PHQ-4) were used as tools to achieve the study objectives. RESULTS: A total of 449 diabetic patients completed the survey (93.5% response rate). Patients with poor, low, and partial adherence account for 337 (75%) of patients and only 112 (25%) have good and high medication adherence. Employment and duration of illness were highly significant with a positive relationship to treatment adherence (p = 0.010 and 0.000, respectively). On the other hand, age and disease duration had a significant relationship with psychological disorders (p = 0.029 and 0.002, respectively). Of the patients, 64 (14.3%) had high scores on the PHQ-4, with depressive symptoms in 46 (10.24%) and anxiety symptoms in 75 (16.7%). Correlation analysis reveals that there is a highly significant negative correlation between psychological disorders and adherence to medications (r = -0.288, p = 0.000). CONCLUSION: A negative correlation between psychological disorders and adherence to medications was found. The findings indicate the importance of psychological support for diabetic patients for better treatment adherence.

Experienced Racism and Discrimination and Psychological Distress amid Different Phases of the COVID-19 Pandemic: Evidence from Wisconsin.

The SARS-COV-2 pandemic created an unprecedented crisis and raised concerns about racial discrimination and psychological distress. We assessed trends in COVID-19-related racism and discrimination irrespective of infection status and changes in emotional health and mental well-being outcomes due to experienced racism and discrimination. Using three waves of the Wisconsin COVID-19 Community Impact Survey (2020-2021), we compared demographics of respondents categorized by two mutually exclusive groups: reporting vs. not reporting COVID-19-related racism and discrimination. Using longitudinal logistic-multivariable regressions, we modeled changes in racism and discrimination-induced stress and 4-item patient health questionnaire screening for anxiety and depression (PHQ-4) associated with experiencing racism and discrimination. Prevalence of reported experiencing COVID-19-related racism and discrimination increased among adult Wisconsinites between 2020 and 2021: 6.28% in Wave 1, 11.13% in Wave 2 (Pearson's chi-square Wave 1 vs 2=16.96, p<.001) vs. 10.87% in Wave 3 (chi-square, Wave 1 vs 3=14.99, p<.001). Experiencing COVID-19-related racism and discrimination was associated with a higher likelihood stress (OR=3.15, 95% CI 2.32-4.29) and a higher PHQ-4 score (coeff=0.63, 95% CI 0.32-0.94). Relative to White respondents, racial/ethnic minorities had a higher likelihood of feeling stress: Black OR=7.13, 95% CI 4.68-10.85; Hispanics OR=3.81, 95% CI 2.11-6.89; and other races OR=2.61, 95% CI 1.51-4.53. Estimated associations varied across racial/ethnic groups, age groups, and survey waves. Our study showed that experienced COVID-19-related racism and discrimination increased during the first 2 years of the pandemic and was associated with greater psychological distress among Wisconsinites of all racial/ethnic groups. Public health policies promoting inclusiveness should be implemented to reduce (COVID-19-related) racism and discrimination and its long-term effects on mental health and well-being.

Psychometric properties of the Patient Health Questionnaire-4 (PHQ-4) in 9230 adults across seven European countries: Findings from the ESTSS ADJUST study.

BACKGROUND: The four-item Patient Health Questionnaire-4 (PHQ-4) is a widely used screening measure for depression and anxiety. OBJECTIVES: This study aimed to test factor structure and measurement invariance in an adult sample of the general population across seven European countries. METHOD: A total sample of 9230 adults, 71.3 % female, Mage = 44.35 (SD = 14.11) from seven countries (Austria, Croatia, Georgia, Germany, Lithuania, Portugal, and Sweden) participated in the study. We applied confirmatory factor analysis (CFA) to examine the factor structure and measurement invariance testing to evaluate measurement equivalence across countries, gender, and age groups. RESULTS: The CFA yielded that a two-factor PHQ-4 model with separate depression and anxiety factors had the best fit. Partial scalar measurement invariance was established across different groups based on gender, age, and country. CONCLUSIONS: The PHQ-4 is a valid and reliable measure that can be applied to screen for depression and anxiety in the general population. LIMITATIONS: The limitation of the study includes the sampling, which resulted in the sample structure with the majority of females, predominantly of high education and from urban communities.

Psychometric properties of the Patient Health Questionnaire-4 among Hong Kong young adults in 2021: Associations with meaning in life and suicidal ideation.

Background: Young adults in Hong Kong are subject to elevated psychological distress given the societal stressors such as civil unrest and COVID-19 pandemic and suicide is a leading cause of death among them. The present study aimed to evaluate the psychometric properties and measurement invariance of the 4-item Patient Health Questionnaire-4 (PHQ-4) as a brief measure of psychological distress and its associations with meaning in life and suicidal ideation (SI) in young adults. Materials and methods: A mobile survey recruited a large and random sample of 1,472 young adults (Mean age = 26.3 years, 51.8% males) in Hong Kong in 2021. The participants completed the PHQ-4 and Meaning in Life Questionnaire-short form (MLQ-SF) for presence of meaning in life (MIL), SI, COVID-19 impact, and exposure to suicide. Confirmatory factor analysis was conducted to examine the factorial validity, reliability, and measurement invariance of PHQ-4 and MLQ-SF across gender, age, and distress subgroups. Multigroup structural equation model evaluated and compared the direct and indirect effects of latent MIL factor on SI via latent PHQ-4 factor across distress groups. Results: Both MIL and PHQ-4 supported a 1-factor model with good composite reliability (Ω = 0.80-0.86) and strong factor loadings (λ = 0.65-0.88). Both factors showed scalar invariance across gender, age, and distress groups. MIL showed significant and negative indirect effects (αß = -0.196, 95% CI = -0.254 to -0.144) on SI via PHQ-4. PHQ-4 showed a stronger mediating role between MIL and SI in the distress group (Δ = -0.146, 95% CI = -0.252 to -0.049) than the non-distress group. Higher MIL predicted higher likelihoods of help-seeking (Odds ratios = 1.46, 95% CI = 1.14-1.88). Conclusion: The present results support adequate psychometric properties in terms of factorial validity, reliability, convergent validity, and measurement invariance for the PHQ-4 in young adults in Hong Kong. The PHQ-4 demonstrated a substantial mediating role in the relationship between meaning in life and SI in the distress group. These findings support clinical relevance for using the PHQ-4 as a brief and valid measure of psychological distress in the Chinese context.

COVID-19: Academic, Financial, and Mental Health Challenges Faced by International Students in the United States Due to the Pandemic.

Background and objective Many international students often face challenges regarding their mental health, finances, and academics. The coronavirus disease 2019 (COVID-19) outbreak may have presented unprecedented challenges to many foreign students in these aspects. Our study examined the academic, financial, and mental health challenges encountered by international students residing in the United States due to the COVID-19 pandemic. It also examined the association between the mental health of the respondents and the academic and financial challenges they encountered. Method The study involved international students enrolled at Texas A&M University, who identified themselves as non-US citizens or non-permanent residents. We conducted a cross-sectional study by using Qualtrics® to explore the three domains of the study. Questions included in previous studies were modified to assess the academic and financial status while the Patient Health Questionnaire-4 (PHQ-4) score was used to assess the mental health of the respondents. We presented descriptive statistics for all domains and used an ordered logistic regression to further analyze the effect of the other domains on the mental health of the respondents. Results Of the 281 respondents, the majority (79%) experienced challenges with online classes; 91% reported having negative emotions and some students (24%) lost funding due to the pandemic. The inability to pay bills resulted in a three-fold increase in the likelihood of reporting higher mental distress [adjusted odds ratios (aOR): 3.051, 95% CI: 1.665-5.591; p<0.001], and experiencing academic challenges led to a seven-fold increase in the likelihood of reporting higher mental distress (aOR: 7.236, 95% CI: 3.168-12.530; p<0.001). Conclusion The COVID-19 pandemic posed a major challenge to international students and its impact on the mental health of the participants was aggravated by concurrent academic and financial hardships.

Mental Health in German Paralympic Athletes During the 1st Year of the COVID-19 Pandemic Compared to a General Population Sample.

Introduction: The COVID-19 pandemic has huge influences on daily life and is not only associated with physical but also with major psychological impacts. Mental health problems and disorders are frequently present in elite paralympic athletes. Due to the pandemic situation, new stressors (e.g., loss of routine, financial insecurity) might act upon the athletes. Therefore, the assessment of mental health in athletes during the COVID-19 pandemic is important to identify prevalence of psychological problems and propose countermeasures. Methods: The mental health of German paralympic athletes was longitudinally monitored (starting in May 2019). The athletes completed the Patient Health Questionnaire 4 (PHQ-4) on a weekly basis and reported a stress level, training hours, and training load. During the pandemic, 8 measurement time points (March 2020 to April 2021) were used to reflect the psychological health course of the athletes. In parallel, a convenience sample of the general population was questioned about their psychological distress, including the PHQ-4. To be included in the analysis, participants of both groups had to complete at least 4 measurement time points. Matching of the para-athletes and the general population sample was prioritized upon completion of the same measurement time points, gender, and age. Results: Seventy-eight paralympic athletes (40 women, 38 men, age: 29.8 ± 11.4 years) met the inclusion criteria. Seventy-eight matched pairs of the general population (40 women; 38 men; age: 30.5 ± 10.9 years) were identified. The para-athletes had a significantly (p <0.0001; 0.39 < r <0.48) lower PHQ-4 value at each measurement time point compared to the matched control group. No significant age or sex differences were evident regarding the symptom burden. In para-athletes, no significant and a weak positive correlation was found between decreased training load and PHQ-4 values and a stress level, respectively. Reduced physical activity was significantly (p <0.0001) associated with higher PHQ-4 values in the general population sample. Discussion: Lower PHQ-4 values were reported by the para-athletes compared to the general population sample. However, small sample sizes must be considered while interpreting the data. Nevertheless, adequate support for individuals suffering from severe psychopathological symptoms should be provided for para-athletes as well as for the general population.

Quality of Life: Updated Psychometric Properties and New Norm Values in a Representative German Sample Focusing Socioeconomics and Mental Health.

Objectives: Quality of life (QOL) is increasingly used as indicator in health research. The aim of this paper was an updated psychometric validation and a new standardization of the German version of the EUROHIS-QOL using a sample of the German general population assessed in 2021. The study focused on socio-economic characteristics and on anxiety and depressiveness as major indicators of mental health. Methods: With 8 items, the EUROHIS-QOL is an economical instrument for self-assessment. Results: Statistical tests revealed good psychometric properties. Gender- and age-group-specific norm values were calculated. The EUROHIS-QOL showed good discriminant validity for anxiety and depression symptoms. Participants without clinically relevant scores for depressiveness and anxiety reported significantly higher QOL. Multiple regression analysis showed that unemployment, younger age, not living with a partner, and an immigrant background were important predictors of lower QOL, whereas higher income, living in one's own home, and a high level of education predicted higher QOL. Conclusion: The EUROHIS-QOL was confirmed as an economical and reliable instrument for assessing QOL in the German general population.

Stressors and Information-Seeking by Dialysis and Transplant Patients During COVID-19, Reported on a Telephone Hotline: A Mixed-Methods Study.

Rationale & Objective: In early 2020, we activated a telephone hotline, the coronavirus disease 2019 (COVID-19) Kidney or Transplant Listening and Resource Center, to learn more about the impact of the COVID-19 pandemic on the stress and information-seeking behaviors of dialysis and transplant patients. Study Design: A mixed-methods study including semi-structured, qualitative interviews probing about emotional, health, and financial challenges experienced and quantitative surveys assessing depression and anxiety levels and information-seeking behaviors. Setting & Participants: 99 participants (28 dialysis patients; 71 transplant patients), varying by race and ethnicity (Hispanic, 25.3%; White, 23.2%; Asian, 24.2%; Black, 24.2%), shared their COVID-19 pandemic experiences and information-seeking behaviors by telephone. Interviews and surveys were conducted from June 17, 2020, to November 24, 2020. Analytical Approach: Qualitative themes were identified using thematic analysis. Frequencies were calculated to assess levels of depression and anxiety using the Patient Health Questionnaire for Depression and Anxiety and types of information-seeking behaviors. Results: 7 themes and 16 subthemes emerged. Themes of commonly reported stressors include postponing medical visits; decreased accessibility of getting medication; difficulty in receiving up-to-date, patient-focused health information and dialysis supplies; and delays in medical appointments. Other stressors include losses of health insurance and income, and increased vigilance in behaviors to avoid contracting COVID-19. 15 participants had moderate to severe anxiety and depression symptoms and reported more frequent and severe panic attacks after the COVID-19 pandemic. Participants sought emotional support from family, friends, and faith communities. They also commonly obtained information from news media and reported needing more transplant-specific updates about COVID-19, and frequent communication from their kidney and transplant specialists. Limitations: This convenience sample of individuals willing to share their experiences through a telephone hotline may not generalize to all dialysis and transplant patients; stressors related to the COVID-19 pandemic for these patients continue to change. Conclusions: As the impact of the pandemic continues, needs-based interventions tailored for the kidney and transplant community, including access to mental health resources, education, and support for care transitions, should continue.

Validation of the Patient Health Questionnaire-4 (PHQ-4) to screen for depression and anxiety in the Greek general population.

OBJECTIVE: The Patient Health Questionnaire-4 (PHQ-4) is an ultra-brief self-report screening scale for depression and anxiety with promising psychometric properties; however, its reliability and validity have not been investigated in Greece yet. The objective of the current study was to investigate the reliability and validity of the PHQ-4 and to establish a cut-off score to identify depression and anxiety in the Greek general population. METHODS: The reliability of the PHQ-4 was assessed using a random sample of 204 students from Athens, Greece. The internal consistency (Cronbach's α) was evaluated whereas the test-retest reliability was measured over a one-week period with intra-class correlation (ICC). The scale's validity was assessed in a cross-sectional study of 591 adults living in Greece using confirmatory factor analysis (CFA). Cut-offs were determined using the Mini International Neuropsychiatric Interview (MINI) as the gold standard. RESULTS: Cronbach's α of the PHQ-4 was 0.80 and the overall ICC 0.96. CFA yielded a two-factor model, structurally invariant by age and gender. A GAD-2 score of 2 was the optimal cut-off point to detect any anxiety disorder (sensitivity = 0.82, specificity = 0.75) and 3 to detect generalized anxiety disorder (sensitivity = 0.77, specificity = 0.82). As for PHQ-2, a score of 2 was the optimal cut-off point to detect any depressive disorder (sensitivity = 0.87, specificity = 0.85) and 3 to detect major depressive disorder (sensitivity = 0.77, specificity = 0.94). CONCLUSIONS: The PHQ-4 is a reliable and valid screening scale for depression and anxiety in the Greek general population.