Accuracy of Patient Health Questionnaire-9 (PHQ-9) for screening to detect major depression: individual participant data meta-analysisBMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l1476 (Published 09 April 2019) Cite this as: BMJ 2019;365:l1476
- 1Lady Davis Institute for Medical Research of the Jewish General Hospital and McGill University, Montréal, Québec, Canada
- 2Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Québec, Canada
- Correspondence to: B D Thombs
- Accepted 13 March 2019
Objective To determine the accuracy of the Patient Health Questionnaire-9 (PHQ-9) for screening to detect major depression.
Design Individual participant data meta-analysis.
Data sources Medline, Medline In-Process and Other Non-Indexed Citations, PsycINFO, and Web of Science (January 2000-February 2015).
Inclusion criteria Eligible studies compared PHQ-9 scores with major depression diagnoses from validated diagnostic interviews. Primary study data and study level data extracted from primary reports were synthesized. For PHQ-9 cut-off scores 5-15, bivariate random effects meta-analysis was used to estimate pooled sensitivity and specificity, separately, among studies that used semistructured diagnostic interviews, which are designed for administration by clinicians; fully structured interviews, which are designed for lay administration; and the Mini International Neuropsychiatric (MINI) diagnostic interviews, a brief fully structured interview. Sensitivity and specificity were examined among participant subgroups and, separately, using meta-regression, considering all subgroup variables in a single model.
Results Data were obtained for 58 of 72 eligible studies (total n=17 357; major depression cases n=2312). Combined sensitivity and specificity was maximized at a cut-off score of 10 or above among studies using a semistructured interview (29 studies, 6725 participants; sensitivity 0.88, 95% confidence interval 0.83 to 0.92; specificity 0.85, 0.82 to 0.88). Across cut-off scores 5-15, sensitivity with semistructured interviews was 5-22% higher than for fully structured interviews (MINI excluded; 14 studies, 7680 participants) and 2-15% higher than for the MINI (15 studies, 2952 participants). Specificity was similar across diagnostic interviews. The PHQ-9 seems to be similarly sensitive but may be less specific for younger patients than for older patients; a cut-off score of 10 or above can be used regardless of age..
Conclusions PHQ-9 sensitivity compared with semistructured diagnostic interviews was greater than in previous conventional meta-analyses that combined reference standards. A cut-off score of 10 or above maximized combined sensitivity and specificity overall and for subgroups.
Registration PROSPERO CRD42014010673.
Contributors: BLevis, AB, BDT, JB, PC, SG, JPAI, LAK, DM, SBP, IS, and RCZ were responsible for the study conception and design. JB and LAK designed and conducted database searches to identify eligible studies. BDT, DHA, BA, LA, HRB, MB, CHB, PB, GC, MHC, JCNC, KC, YC, JMG, JD, JRF, FHF, DF, BG, FGS, CGG, BJH, JH, PAH, MHärter, UH, LH, SEH, MHudson, MI, KI, NJ, MEK, KMK, YK, SL, ML, SRL, BLöwe, LM, AM, SMS, TNM, KM, FLO, VP, BWP, PP, AP, KR, AGR, ISS, JS, ASidebottom, ASimning, LS, SCS, PLLT, AT, CMvdFC, HCvW, PAV, JW, MAW, KW, MY, and YZ contributed primary datasets that were included in this study. BLevis, KER, NS, MA, DBR, MJC, TAS, and BDT contributed to data extraction and coding for the meta-analysis. BLevis, AB, BDT and AWL contributed to the data analysis and interpretation. BLevis, AB, and BDT contributed to drafting the manuscript. All authors provided a critical review and approved the final manuscript. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. AB and BDT are the guarantors. The affiliations of the members of the DEPRESSD Collaboration are given in the supplementary materials.
(DEPRESSD) Collaboration members: Dickens H Akena, Bruce Arroll, Liat Ayalon, Marleine Azar, Hamid R Baradaran, Murray Baron, Andrea Benedetti, Charles H Bombardier, Jill Boruff, Peter Butterworth, Gregory Carter, Marcos H Chagas, Juliana C N Chan, Matthew J Chiovitti, Kerrie Clover, Yeates Conwell, Pim Cuijpers, Janneke M de Man-van Ginkel, Jaime Delgadillo, Jesse R Fann, Felix H Fischer, Daniel Fung, Bizu Gelaye, Simon Gilbody, Felicity Goodyear-Smith, Catherine G Greeno, Brian J Hall, John Hambridge, Patricia A Harrison, Martin Härter, Ulrich Hegerl, Leanne Hides, Stevan E Hobfoll, Marie Hudson, Masatoshi Inagaki, John P A Ioannidis, Khalida Ismail, Nathalie Jetté, Mohammad E Khamseh, Kim M Kiely, Lorie A Kloda, Yunxin Kwan, Alexander W Levis, Brooke Levis, Shen-Ing Liu, Manote Lotrakul, Sonia R Loureiro, Bernd Löwe, Laura Marsh, Anthony McGuire, Dean McMillan, Sherina Mohd Sidik, Tiago N Munhoz, Kumiko Muramatsu, Flávia L Osório, Vikram Patel, Scott B Patten, Brian W Pence, Philippe Persoons, Angelo Picardi, Danielle B Rice, Kira E Riehm, Katrin Reuter, Alasdair G. Rooney, Nazanin Saadat, Tatiana A Sanchez, Iná S Santos, Juwita Shaaban, Abbey Sidebottom, Adam Simning, Ian Shrier, Lesley Stafford, Sharon C Sung, Pei Lin Lynnette Tan, Brett D Thombs, Alyna Turner, Christina M van der Feltz-Cornelis, Henk C van Weert, Paul A Vöhringer, Jennifer White, Mary A Whooley, Kirsty Winkley, Mitsuhiko Yamada, Roy C Ziegelstein, Yuying Zhang.
Funding: This study was funded by the Canadian Institutes of Health Research (CIHR; KRS-134297). BLevis was supported by a CIHR Frederick Banting and Charles Best Canada Graduate Scholarship doctoral award. AB and BDT were supported by Fonds de recherche du Québec - Santé (FRQS) researcher salary awards. KER and NS were supported by CIHR Frederick Banting and Charles Best Canada Graduate Scholarship master’s awards. AWL and MA were supported by FRQS Masters Training Awards. DBR was supported by a Vanier Canada Graduate Scholarship. Collection of data for the study by Arroll et al was supported by a project grant from the Health Research Council of New Zealand. Data collection for the study by Ayalon et al was supported from a grant from Lundbeck International. The primary study by Khamseh et al was supported by a grant (M-288) from Tehran University of Medical Sciences. The primary study by Bombardier et al was supported by the Department of Education, National Institute on Disability and Rehabilitation Research, Spinal Cord Injury Model Systems: University of Washington (grant No H133N060033), Baylor College of Medicine (grant No H133N060003), and University of Michigan (grant No H133N060032). PB was supported by Australian Research Council Future Fellowship FT130101444. Collection of data for the primary study by Zhang et al was supported by the European Foundation for Study of Diabetes, the Chinese Diabetes Society, Lilly Foundation, Asia Diabetes Foundation, and Liao Wun Yuk Diabetes Memorial Fund. YC received support from NIMH (R24MH071604) and the Centers for Disease Control and Prevention (R49 CE002093). Collection of data for the primary study by Delgadillo et al was supported by grant from St Anne’s Community Services, Leeds, UK. Collection of data for the primary study by Fann et al was supported by grant RO1 HD39415 from the US National Center for Medical Rehabilitation Research. The primary studies by Amoozegar and by Fiest et al were funded by the Alberta Health Services, the University of Calgary Faculty of Medicine, and the Hotchkiss Brain Institute. The primary study by Fischer et al was funded by the German Federal Ministry of Education and Research (01GY1150). Data for the primary study by Gelaye et al was supported by grant from the NIH (T37 MD001449). Collection of data for the primary study by Gjerdingen et al was supported by grants from the NIMH (R34 MH072925, K02 MH65919, P30 DK50456). The primary study by Eack et al was funded by the NIMH (R24 MH56858). Collection of data for the primary study by Hobfoll et al was made possible in part by grants from NIMH (RO1 MH073687) and the Ohio Board of Regents. BJH received support from a grant awarded by the Research and Development Administration Office, University of Macau (MYRG2015-00109-FSS). Collection of data provided by MHärter and KR was supported by the Federal Ministry of Education and Research (grants No 01 GD 9802/4 and 01 GD 0101) and by the Federation of German Pension Insurance Institute. The primary study by Hides et al was funded by the Perpetual Trustees, Flora and Frank Leith Charitable Trust, Jack Brockhoff Foundation, Grosvenor Settlement, Sunshine Foundation, and Danks Trust. The primary study by Henkel et al was funded by the German Ministry of Research and Education. Data for the study by Razykov et al was collected by the Canadian Scleroderma Research Group, which was funded by the CIHR (FRN 83518), the Scleroderma Society of Canada, the Scleroderma Society of Ontario, the Scleroderma Society of Saskatchewan, Sclérodermie Québec, the Cure Scleroderma Foundation, Inova Diagnostics Inc, Euroimmun, FRQS, the Canadian Arthritis Network, and the Lady Davis Institute of Medical Research of the Jewish General Hospital, Montreal, QC. MHudson was supported by a FRQS Senior Investigator Award. Collection of data for the primary study by Hyphantis et al was supported by grant from the National Strategic Reference Framework, European Union, and the Greek Ministry of Education, Lifelong Learning and Religious Affairs (ARISTEIA-ABREVIATE, 1259). The primary study by Inagaki et al was supported by the Ministry of Health, Labour and Welfare, Japan. NJ was supported by a Canada Research Chair in Neurological Health Services Research. Collection of data for the primary study by Kiely et al was supported by National Health and Medical Research Council (grant No 1002160) and Safe Work Australia. KMK was supported by funding from a Australian National Health and Medical Research Council fellowship (grant No 1088313). The primary study by Lamers et al was funded by the Netherlands Organisation for Health Research and Development (grant No 945-03-047). The primary study by Liu et al was funded by a grant from the National Health Research Institute, Republic of China (NHRI-EX97-9706PI). The primary study by Lotrakul et al was supported by the Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (grant No 49086). BLöwe received research grants from Pfizer, Germany, and from the medical faculty of the University of Heidelberg, Germany (project 121/2000) for the study by Gräfe et al. The primary study by Mohd Sidik et al was funded under the Research University Grant Scheme from Universiti Putra Malaysia, Malaysia, and the Postgraduate Research Student Support Accounts of the University of Auckland, New Zealand. The primary study by Santos et al was funded by the National Program for Centers of Excellence (PRONEX/FAPERGS/CNPq, Brazil). The primary study by Muramatsu et al was supported by an educational grant from Pfizer US Pharmaceutical Inc. Collection of primary data for the study by BWP was provided by NIMH (R34MH084673). The primary studies by Osório et al were funded by Reitoria de Pesquisa da Universidade de São Paulo (grant No 09.1.01689.17.7) and Banco Santander (grant No 10.1.01232.17.9). FLO was supported by Productivity Grants (PQ-CNPq-2 number 301321/2016-7). The primary study by Picardi et al was supported by funds for current research from the Italian Ministry of Health. PP was supported by a grant from the Belgian Ministry of Public Health and Social Affairs and a restricted grant from Pfizer Belgium. JS was supported by funding from Universiti Sains Malaysia. The primary study by Rooney et al was funded by the UK National Health Service Lothian Neuro-Oncology Endowment Fund. The primary study by Sidebottom et al was funded by a grant from the United States Department of Health and Human Services, Health Resources and Services Administration (grant No R40MC07840). Simning et al’s research was supported in part by grants from the NIH (T32 GM07356), Agency for Healthcare Research and Quality (R36 HS018246), NIMH (R24 MH071604), and the National Center for Research Resources (TL1 RR024135). LS received PhD scholarship funding from the University of Melbourne. Collection of data for the studies by Turner et al were funded by a bequest from Jennie Thomas through the Hunter Medical Research Institute. The study by van Steenbergen-Weijenburg et al was funded by Innovatiefonds Zorgverzekeraars. PAV was supported by the Fund for Innovation and Competitiveness of the Chilean Ministry of Economy, Development and Tourism, through the Millennium Scientific Initiative (grant No IS130005). Collection of data for the primary study by Williams et al was supported by an NIMH grant to LM (RO1-MH069666). The primary study by Thombs et al was done with data from the Heart and Soul Study (PI Mary Whooley). The Heart and Soul Study was funded by the Department of Veterans Epidemiology Merit Review Program, the Department of Veterans Affairs Health Services Research and Development service, the National Heart Lung and Blood Institute (R01 HL079235), the American Federation for Ageing Research, the Robert Wood Johnson Foundation, and the Ischemia Research and Education Foundation. The primary study by Twist et al was funded by the UK National Institute for Health Research under its Programme Grants for Applied Research Programme (grant reference No RP-PG-0606-1142). The study by Wittkampf et al was funded by the Netherlands Organization for Health Research and Development (ZonMw) Mental Health Program (No 100.003.005 and 100.002.021) and the Academic Medical Center/University of Amsterdam. No other authors reported funding for primary studies or for their work on this study. 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.
Competing interests: All authors have completed the ICJME uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work other than that described above; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years with the following exceptions: NJ and SP received a grant, outside the submitted work, from the University of Calgary 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; JCNC is a steering committee member or consultant of Astra Zeneca, Bayer, Lilly, MSD, and Pfizer and has received sponsorships and honorariums for giving lectures and providing consultancy, and her affiliated institution has received research grants from these companies; UH was an advisory board member for Lundbeck and Servier, a consultant for Bayer Pharma, and a speaker for Roche Pharma and Servier and has received personal fees from Janssen, all outside the submitted work; MI has received a grant from Novartis Pharma and personal fees from Meiji, Mochida, Takeda, Novartis, Yoshitomi, Pfizer, Eisai, Otsuka, MSD, Technomics, and Sumitomo Dainippon, all outside of the submitted work; no other relationships or activities that could appear to have influenced the submitted work.
Ethical approval: As this study involved secondary analysis of anonymized previously collected data, the Research Ethics Committee of the Jewish General Hospital declared that this project did not need research ethics approval. However, for each included dataset, the authors confirmed that the original study received ethics approval and that all patients provided informed consent.
Transparency declaration: The manuscript’s guarantor affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.
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