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      Factor structure and measurement invariance across various demographic groups and over time for the PHQ-9 in primary care patients in Spain

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          Abstract

          The Patient Health Questionnaire (PHQ-9) is a widely-used screening tool for depression in primary care settings. The purpose of the present study is to identify the factor structure of the PHQ-9 and to examine the measurement invariance of this instrument across different sociodemographic groups and over time in a sample of primary care patients in Spain. Data came from 836 primary care patients enrolled in a randomized controlled trial (PsicAP study) and a subsample of 218 patients who participated in a follow-up assessment at 3 months. Confirmatory factor analysis (CFA) was used to test one- and two-factor structures identified in previous studies. Analyses of multiple-group invariance were conducted to determine the extent to which the factor structure is comparable across various demographic groups (i.e., gender, age, marital status, level of education, and employment situation) and over time. Both one-factor and two-factor re-specified models met all the pre-established fit criteria. However, because the factors identified in the two-factor model were highly correlated ( r = .86), the one-factor model was preferred for its parsimony. Multi-group CFA indicated measurement invariance across different demographic groups and across time. The present findings suggest that physicians in Spain can use the PHQ-9 to obtain a global score for depression severity in different demographic groups and to reliably monitor changes over time in the primary care setting.

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          The Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales: a systematic review.

          Depression, anxiety and somatization are the most common mental disorders in primary care as well as medical specialty populations; each is present in at least 5-10% of patients and frequently comorbid with one another. An efficient means for measuring and monitoring all three conditions would be desirable. Evidence regarding the psychometric and pragmatic characteristics of the Patient Health Questionnaire (PHQ)-9 depression, generalized anxiety disorder (GAD)-7 anxiety and PHQ-15 somatic symptom scales are synthesized from two sources: (1) four multisite cross-sectional studies (three conducted in primary care and one in obstetric-gynecology practices) comprising 9740 patients, and (2) key studies from the literature that have studied these scales. The PHQ-9 and its abbreviated eight-item (PHQ-8) and two-item (PHQ-2) versions have good sensitivity and specificity for detecting depressive disorders. Likewise, the GAD-7 and its abbreviated two-item (GAD-2) version have good operating characteristics for detecting generalized anxiety, panic, social anxiety and post-traumatic stress disorder. The optimal cutpoint is > or = 10 on the parent scales (PHQ-9 and GAD-7) and > or = 3 on the ultra-brief versions (PHQ-2 and GAD-2). The PHQ-15 is equal or superior to other brief measures for assessing somatic symptoms and screening for somatoform disorders. Cutpoints of 5, 10 and 15 represent mild, moderate and severe symptom levels on all three scales. Sensitivity to change is well-established for the PHQ-9 and emerging albeit not yet definitive for the GAD-7 and PHQ-15. The PHQ-9, GAD-7 and PHQ-15 are brief well-validated measures for detecting and monitoring depression, anxiety and somatization. Copyright 2010. Published by Elsevier Inc.
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            Prevalence of mental disorders in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project.

            To describe the 12-month and lifetime prevalence rates of mood, anxiety and alcohol disorders in six European countries. A representative random sample of non-institutionalized inhabitants from Belgium, France, Germany, Italy, the Netherlands and Spain aged 18 or older (n = 21425) were interviewed between January 2001 and August 2003. DSM-IV disorders were assessed by lay interviewers using a revised version of the Composite International Diagnostic Interview (WMH-CIDI). Fourteen per cent reported a lifetime history of any mood disorder, 13.6% any anxiety disorder and 5.2% a lifetime history of any alcohol disorder. More than 6% reported any anxiety disorder, 4.2% any mood disorder, and 1.0% any alcohol disorder in the last year. Major depression and specific phobia were the most common single mental disorders. Women were twice as likely to suffer 12-month mood and anxiety disorders as men, while men were more likely to suffer alcohol abuse disorders. ESEMeD is the first study to highlight the magnitude of mental disorders in the six European countries studied. Mental disorders were frequent, more common in female, unemployed, disabled persons, or persons who were never married or previously married. Younger persons were also more likely to have mental disorders, indicating an early age of onset for mood, anxiety and alcohol disorders.
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              Psychometric comparison of PHQ-9 and HADS for measuring depression severity in primary care.

              The 2004 National Institute for Health and Clinical Excellence (NICE) guidelines highlight the importance of assessing severity of depression in primary care. To assess the psychometric properties of the Patient Health Questionnaire (PHQ-9) and the depression subscale of the Hospital Anxiety and Depression Scale (HADS-D) for measuring depression severity in primary care. Psychometric assessment. Thirty-two general practices in Grampian, Scotland. Consecutive patients referred to a primary care mental health worker completed the PHQ-9 and HADS at baseline (n = 1063) and at the end of treatment (n = 544). Data were analysed to assess reliability, robustness of factor structure, convergent/discriminant validity, convergence of severity banding, and responsiveness to change. Both scales demonstrated high internal consistency at baseline and end of treatment (PHQ-9 alpha = 0.83 and 0.92; HADS-D alpha = 0.84 and 0.89). One factor emerged each for the PHQ-9 (explaining 42% of variance) and HADS-D (explaining 52% of variance). Both scales converged more with each other than with the HADS anxiety (HADS-A) subscale at baseline (P<0.001) and at end of treatment (P = 0.01). Responsiveness to change was similar: effect size for PHQ-9 = 0.99 and for the HADS-D = 1. The HADS-D and PHQ-9 differed significantly in categorising severity of depression, with the PHQ-9 categorising a greater proportion of patients with moderate/severe depression (P<0.001). The HADS-D and PHQ-9 demonstrated reliability, convergent/discriminant validity, and responsiveness to change. However, they differed considerably in how they catergorised severity. Given that treatment decisions are made on the basis of severity, further work is needed to assess the validity of the scales' severity cut-off bands.
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                Author and article information

                Contributors
                Role: Funding acquisitionRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Formal analysisRole: Writing – review & editing
                Role: ConceptualizationRole: Writing – review & editing
                Role: Writing – review & editing
                Role: Writing – review & editing
                Role: Writing – review & editing
                Role: MethodologyRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: SupervisionRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                23 February 2018
                2018
                : 13
                : 2
                : e0193356
                Affiliations
                [1 ] Mental Health Centre, University Hospital “Marqués de Valdecilla”- IDIVAL, Santander, Spain
                [2 ] Faculty of Psychology, University Siglo 21, Córdoba, Argentina
                [3 ] Department of Basic Psychology, Faculty of Psychology, University of Valencia, Valencia, Spain
                [4 ] Castilla La Nueva Primary Care Centre, Health Service of Madrid, Madrid, Spain
                [5 ] Department of Psychology, University of Córdoba/ Maimónides Institute for Research in Biomedicine of Cordoba-IMIBIC/Reina Sofía University Hospital, Córdoba, Spain
                [6 ] Department of Basic Psychology, Autonomous University of Barcelona, Bellaterra, Barcelona, Spain
                [7 ] Department of Psychology, Ulm University, Ulm, Germany
                [8 ] Department of Basic Psychology, University Complutense of Madrid, Madrid, Spain
                King's College London, UNITED KINGDOM
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                ¶ Membership of the PsicAP Research Group is provided in the Acknowledgments

                Author information
                http://orcid.org/0000-0002-3181-4731
                Article
                PONE-D-17-15825
                10.1371/journal.pone.0193356
                5825085
                29474410
                c46ee693-7f4f-4908-a3cf-2f260747ce22
                © 2018 González-Blanch et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 24 April 2017
                : 2 February 2018
                Page count
                Figures: 1, Tables: 4, Pages: 16
                Funding
                The study was supported by grants from the Secretaría de Estado de Investigación, Desarrollo e Innovación (PSI2012-36589), the Fundación Mutua Madrileña (AP105162012), and the Psicofundación (Spanish Foundation for the Promotion, Scientific and Professional Development of Psychology; PSIC-001) all awarded to Dr. Antonio Cano-Vindel. Further support was provided by a grant from the Valdecilla Biomedical Research Institute - IDIVAL (INNVAL16/08) awarded to Dr. González-Blanch. The funders had no 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.
                Categories
                Research Article
                Medicine and Health Sciences
                Mental Health and Psychiatry
                Mood Disorders
                Depression
                Medicine and Health Sciences
                Health Care
                Primary Care
                Biology and Life Sciences
                Psychology
                Emotions
                Social Sciences
                Psychology
                Emotions
                Social Sciences
                Economics
                Labor Economics
                Employment
                Medicine and Health Sciences
                Diagnostic Medicine
                People and places
                Geographical locations
                Europe
                European Union
                Spain
                Research and Analysis Methods
                Mathematical and Statistical Techniques
                Statistical Methods
                Factor Analysis
                Physical Sciences
                Mathematics
                Statistics (Mathematics)
                Statistical Methods
                Factor Analysis
                Medicine and Health Sciences
                Pharmaceutics
                Drug Therapy
                Custom metadata
                These data have been collected as a sub-study of a large Randomized Clinical Trial conducted in Spanish primary care centers. This is a multi-center Randomized Clinical Trial with medication (No EUDRACT: 2013-001955-11 and Protocol Code: ISRCTN58437086) promoted by the Psicofundación and approved by the Corporate Clinical Research Ethics Committee of Primary Care of Valencia (CEIC- APCV) (as the national research ethics committee coordinator) and the Spanish Medicines and Health Products Agency (AEMPS). Due to restrictions on sharing individual-level data by the Corporate Clinical Research Ethics Committee of Primary Care of Valencia (CEIC-APCV), data cannot be publicly available. Requests for data may be sent to the Psicofundación at the following address: Psicofundación; Calle del Conde de Peñalver, 45; 28006 Madrid, Spain; Telf:+34 914 44 90 20; secop@ 123456cop.es .

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