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Grand Rounds

PHQ-9 Meta-Analysis: How Accurate is this Questionnaire for Depression Screening?

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BACKGROUND AND PURPOSE:

  • The Patient Health Questionnaire-9 (PHQ-9)
    • Nine-item depression screening questionnaire
    • Designed to be used in primary care and other screening settings
    • Standard cut-off positive score: ≥10
  • Levis et al. (BMJ, 2019) sought to determine the accuracy of the PHQ-9

METHODS:

  • Individual participant data meta-analysis
    • Study included all cut-off scores from all studies (not just published cut-off scores)
  • Inclusion Criteria
    • Diagnostic classification for current major depressive disorder or major depressive episode (using validated interviews)
    • Diagnostic classification made within two weeks of PHQ-9 screening (DSM and ICD codes specify symptoms must be present within previous 2 weeks)
    • Participants ≥18 years and not recruited from psychiatric settings or have symptoms of depression
  • Three different diagnostic interviews were used
    • Administered by clinicians: Semistructured diagnostic interviews
    • Lay administration: Fully structured interviews
    • Brief structured interview: Mini International Neuropsychiatric (MINI) (which may be overly inclusive)
  • Statistical Analysis for sensitivity and specificity were calculated for
    • Cut-off scores 5-15 against the 3 different interview methods
    • Excluding participants who may have received treatment for a mental health issue at time of PHQ-9 administration
    • Subgroup studies based on confounders such as age, sex, country human development index and recruitment setting

RESULTS:

  • 58 studies included
    • 17,357 participants | 2,312 with major depression
  • Combined sensitivity and specificity (29 studies, 6725 participants) using semi-structured interviews for diagnosis
    • Maximized at a cut-off score of ≥10 or above
    • Sensitivity 0.88 (95% CI, 0.83 to 0.92)
    • Specificity 0.85 (95% CI, 0.82 to 0.88)
  • With cut-off scores 5-15
    • Sensitivity was 5-22% higher with semi-structured interviews compared to fully structured interviews (MINI excluded) ,
    • Sensitivity was 2-15% higher compared to the MINI
    • Specificity was similar regardless of interview type
  • Subgroup analysis
    • Younger vs older participants: PHQ-9 is similarly sensitive but less specific
    • A cut-off score of ≥10 or higher can be used regardless of age
    • Accuracy higher in primary care settings (sensitivity 0.94, specificity 0.88)

CONCLUSION:

  • PHQ-9 performance is dependent on the interview method used to diagnose depression
    • More sensitive than previously reported when diagnosis made using semi-structured interviews administered by professionals
  • In primary care settings, the PPV would be 52%, using standard ≥10 threshold
    • Consideration should perhaps be given to using probabilities across all scores rather than a sharp threshold

Learn More – Primary Sources:

Accuracy of Patient Health Questionnaire-9 (PHQ-9) for screening to detect major depression: individual participant data meta-analysis

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Related ObG Topics:

Guidelines for the Evaluation and Treatment of Perimenopausal Depression: Summary and Recommendations
Screening for Perinatal Depression

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