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Validity of the Patient Health Questionnaire-9 in Assessing Depression Following Traumatic Brain Injury

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Validity of the Patient Health Questionnaire-9 in Assessing Depression Following Traumatic Brain Injury J Head Trauma Rehabil Vol. 20, No. 6, pp. 501–511 c 2005 Lippincott Williams & Wilkins, Inc. Validity of the Patient Health Questionnaire-9 in Assessing Depression Following Traumatic Brain Injury Jesse R. Fann, MD, MPH; Charles H. Bombardier, PhD; Sureyya Dikmen, PhD; Peter Esselman, MD; Catherine A. Warms, PhD; Erika Pelzer, BS; Holly Rau, BS; Nancy Temkin, PhD Objective: To test the validity and reliability of the Patient Health Questionnaire-9 (PHQ-9) for diag- nosing major depressive disorder (MDD) among persons with traumatic brain injury (TBI). Design: Prospective cohort study. Setting: Level I trauma center. Participants: 135 adults within 1 year of complicated mild, moderate, or severe TBI. Main Outcome Measures: PHQ-9 Depression Scale, Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID). Results: Using a screening criterion of at least 5 PHQ-9 symptoms present at least several days over the last 2 weeks (with one being depressed mood or anhedonia) maximizes sensitivity (0.93) and specificity (0.89) while providing a positive predictive value of 0.63 and a negative predictive value of 0.99 when compared to SCID diagnosis of MDD. Pearson’s correlation between the PHQ-9 scores and other depression measures was 0.90 with the Hopkins Symptom Checklist depression subscale and 0.78 with the Hamilton Rating Scale for Depression. Test-retest reliability of the PHQ-9 was r = 0.76 and κ = 0.46 when using the optimal screening method. Conclusions: The PHQ-9 is a valid and reliable screening tool for detecting MDD in persons with TBI. Key words: brain injury, depression, diagnosis, PHQ, reliability, SCID, screening, trauma, validity AJOR depressive disorder (MDD) is re- widely from about 10% to more than 70%, Mported to be the most common psy- partly due to variations in the method of as- chiatric disorder following traumatic brain in- certaining depression.2 With greater recogni- jury (TBI).1 Prevalence estimates have ranged tion of the prevalence of MDD among people with TBI, researchers have called for im- proved detection and treatment of this impor- From the Departments of Psychiatry & Behavioral tant comorbid condition.2–4 Sciences (Drs Fann and Dikmen), Rehabilitation Medicine (Drs Fann, Bombardier, Dikmen, Esselman, Effective treatment of MDD requires accu- and Temkin and Mss Pelzer and Rau), Biobehavioral rate detection and diagnosis. Screening and Nursing and Health Systems (Dr Warms), diagnosis are complicated by problems with Neurological Surgery (Drs Dikmen and Temkin), Epidemiology (Dr Fann) and Biostatistics (Dr unawareness of psychological symptoms and Temkin), University of Washington, Seattle. transdiagnostic symptoms (eg, poor concen- This article has been supported by grant RO1 HD39415 tration and fatigue are associated with both from the National Center for Medical Rehabilitation Re- TBI and MDD). Despite these problems, there search. The authors thank Jason Barber, MS, for his as- is now evidence that it is scientifically and sistance with the statistical analysis. clinically appropriate to use standard Diagno- Corresponding author: Jesse R. Fann, MD, MPH, Depart- stic and Statistical Manual of Mental Disor- ment of Psychiatry & Behavioral Sciences, Box 356560, 5 1,6–9 University of Washington, Seattle, WA 98195 (e-mail: ders (DSM)criteria for diagnosing MDD. [email protected]). The validity of diagnostic interviews after TBI 501 502 JOURNAL OF HEAD TRAUMA REHABILITATION/NOVEMBER–DECEMBER 2005 is also supported by research that shows good study of the epidemiology and treatment of concordance between patient self-report and MDD in the year following TBI. the report of independent observers on a measure that includes psychological METHODS symptoms.10 While the validity of diagnostic assessments Participants is accepted, there is little consensus regard- From April 2001 through November 2004, ing how to screen for MDD after TBI in the patients with a TBI were recruited from Har- clinical setting. A wide range of depression borview Medical Center, a Level I trauma cen- measures has been used, including the Beck ter in Seattle, Wash. Subjects were hospital- 11 Depression Inventory (BDI), Center for Epi- ized patients who sustained a traumatic injury 12 demiologic Studies Depression Scale, Min- to the head, with either the lowest Glasgow 13,14 nesota Multiphasic Personality Inventory, Coma Scale (GCS) score of less than or equal Hopkins Symptom Checklist depression sub- to 12 or radiological evidence of acute brain 15 scale (SCL-20), and Neurobehavioral Func- abnormality. Other inclusion criteria were as 3 tioning Inventory. Few studies have tested follows: resident of greater Puget Sound re- screening measures against DSM-based “cri- gion (King, Pierce, Kitsap, Jefferson, Mason, terion standard” structured diagnostic inter- Thurston, or Snohomish counties); 18 years views such as the Structured Clinical Inter- of age or older; and English speaking. Subjects 16 view for DSM-IV (SCID). In one study that were excluded on the basis of homelessness did evaluate the criterion validity of the BDI, (or no contact information available), incar- the BDI was found to have low sensitivity ceration, a history of schizophrenia, or partic- (36% when the specificity was set at 80%) for ipation in an investigational drug study. The 11 major depression in people with TBI. University of Washington Institutional Review We selected the Patient Health Board approved all study procedures. All pro- Questionnaire-9 (PHQ-9) depression cedures followed Health Insurance Portability scale as our screening measure for sev- and Accountability Act guidelines. 17,18 eral reasons. The PHQ-9 parallels the 9 Consecutively, eligible patients with TBI diagnostic symptom criteria that define DSM- were identified via daily automatic elec- IV MDD. The format and temporal framework tronic medical records queries, cross-checked of the items also correspond to the DSM-IV against brain injury consultation lists. Re- criteria and will facilitate the follow-up review search staff approached and consented eli- of symptoms and diagnostic process. At only gible patients in the hospital. Patients dis- 9 items, the PHQ-9 is substantially shorter charged before consent were informed of the than most depression screening measures. study through a letter from an attending neu- Unlike most other measures of depression, rosurgeon and recruited through follow-up the PHQ-9 was developed, tested, and re- telephone calls. Patients were required to be fined for use with medical patients. This is fully oriented on a standardized measure and important because the criterion validity was to sign and return study consent forms prior established in a population with high rates to data collection. of other physical symptoms and associated nonspecific psychological distress. This in- Procedures strument has also demonstrated acceptability Participants were assessed every month for among nonpsychiatric patients and among 6 months and then at 8, 10, and 12 months busy primary care providers.17–19 following injury, using a structured telephone The purpose of this study was to test the va- interview conducted by trained research lidity and reliability of the PHQ-9 in screening study assistants. Subjects who failed orien- for MDD among persons with TBI who were tation screens were not assessed but were enrolled in the Surveillance Phase of a larger reevaluated monthly, resulting in some Depression Following Traumatic Brain Injury 503 patients entering the study 2 or more months within the first 24 hours after TBI or the after injury. first GCS score after paralytic agents were Subjects were screened for depression us- withdrawn if they were continued beyond ing the PHQ-9 at each telephone assessment. 24 hours. Subjects were recruited into the Depending on their score on the PHQ-9, a study if their GCS score was 12 or less or if fraction of participants was asked to complete there was radiological evidence of acute brain a SCID, preferably in person but over the tele- abnormality. phone if the patient was unable to come in Orientation for the interview. Forty-seven percent of in- vited subjects completed the SCID within 7 Potential participants were administered days of taking the screening PHQ-9 and are the standardized orientations scale from the included in our criterion validity analyses (N Cognistat.20 This 7-item scale covering orien- = 135), 23% completed the SCID more than tation to person, age, place, and time was ad- 7days after the PHQ-9, and 30% refused or ministered before every phone assessment un- missed SCID appointments. The percent of til the patient was oriented. A score of at least those meeting PHQ-9 screening criteria who 10 is “normal”on the basis of test norms20 and completed the SCID within 7 days are: 10% of wasrequired before depression screening in- those with at least 5 PHQ-9 symptoms present terviews took place. more than half the days (suicidal ideation Depression measures could be only several days), with at least one of the symptoms being a cardinal symptom Depression screening (ie, anhedonia or depressed mood); 10% oth- The PHQ-9 depression scale was used to erwise meeting this criteria with severity of screen for depressive symptoms on the ba- only several days on each symptoms; 13% oth- sis of DSM-IV diagnostic criteria.17,18,21 The erwise with a PHQ-9 sum score of ≥5; and 1% PHQ-9 was chosen because it has excellent of those with a PHQ-9 sum score of 0–4. These internal and test-retest reliability as well as completion percentages were used in weight- criterion and construct validity in medical ing the analysis so that results reflect the en- samples.17–19,21 tire screening cohort (see Statistical Analysis The PHQ-9 is a self-report measure that asks section). if the subject had been bothered by the fol- At each SCID interview, the PHQ-9, SCL-20, lowing problems in the past 2 weeks: (a) little and Hamilton Rating Scale for Depression pleasure or interest in doing things, (b)feel- (HAM-D) were also administered.
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