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The Four-Item Patient Health Questionnaire for Anxiety and Depression

The Four-Item Patient Health Questionnaire for Anxiety and Depression

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Purpose

The PHQ-4 items are drawn from the Generalized Anxiety Disorder-7 (GAD-7) and Patient Health Questionnaire-8 (PHQ-8). The PHQ-4 briefly and accurately measures depression and anxiety.

Link to Instrument

Instrument Details

Acronym PHQ-4

Assessment Type

Patient Reported Outcomes

Administration Mode

Paper & Pencil

Cost

Not Free

Actual Cost

$0.00

Key Descriptions

  • 4-item inventory rated on a 4 point Likert-type scale
  • Minimum score: 0; maximum score: 12
  • Categories of psychological distress:
    A) None, 0-2
    B) Mild, 3-5
    C) Moderate, 6-8
    D) Severe, 9-12
  • Anxiety subscale = sum of items 1 and 2; score range, 0-6
  • Depression subscale = sum of items 3 and 4; score range, 0-6
  • On each subscale, a score of 3 or greater is considered positive for screening purposes
  • Responses are scored:
    A) 0, “not at all”
    B) 1, “several days”
    C) 2, "more than half the days”
    D) 3, “nearly every day”
  • Patients are given the paper questionnaire with written directions and asked to fill it out accordingly

Number of Items

1

Equipment Required

  • Paper & pencil
  • Writing utensil

Time to Administer

1-2 minutes

Required Training

No Training

Age Ranges

18 - 94

years

Instrument Reviewers

Adam Steuer, MS, OTR/L, CLT

ICF Domain

Activity

Professional Association Recommendation

None

Considerations

Pre-operative Surgical Patients: (Kerper et al., 2014)

  • The authors advise against using the PHQ-2 and GAD-2 as exclusive measures of depression and anxiety in preoperative surgical patients. They also suggest lowering the cut-off point from 6 to 4 in order to yield the best trade-off between sensitivity and specificity.

College Students: (Khubchandani, Brey, Kotecki, Kleinfelder, & Anderson, 2016)

  • Use of the PHQ-4 without options for confirming diagnosis can result in a number of false positives indicative of higher levels of distress and dysphoria but not clinical depression. The PHQ-4 has high sensitivity, but diagnostic tests are required for high specificity.

General Population: (L?we et al., 2010)

  • Elevated anxiety or depression scores require a thoughtful evaluation by the treating physician or psychologist before a diagnostic or therapeutic decision can be made.

Breast Cancer: (Weihs, Wiley, Crespi, Krull, & Stanton, 2017)

  • The PHQ-4 warrants further study for determining if the measure is an efficient and accurate screener of depression immediately after breast cancer diagnosis.

Cancer

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Interrater/Intrarater Reliability

Breast Cancer Survivors: (Weihs, Wiley, Crespi, Krull, & Stanton, 2017; n = 410 women; mean age = 56 (12) years; 75% some college; 67% married; 52% employed; stages 1, 2, 3, and 4: 44%, 39%, 11%, and 5%, respectively)

  • Development sub sample has moderate agreement (K = .45)

  • Validation subsample has moderate agreement where models and thresholds derived from the development process were applied to the holdout validation sample to evaluate performance (K = .50)

Criterion Validity (Predictive/Concurrent)

Predictive Validity

Breast Cancer Survivors: (Weihs et al., 2017)

  • Good predictive validity (AUC = 0.79)

 

Accuracy

Sensitivity

Specificity

PPV

NPV

Development Subsample of PHQ-4

0.72

0.65

0.80

0.77

0.69

Validation Subsample of PHQ-4

0.75

0.74

0.76

0.69

0.81

Chronic Pain

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Internal Consistency

Chronic Migraine: (Bagley et al., 2012; n = 8726; 83.5% female; 86.1% white/Caucasian; headache pain severity mild, moderate, and severe: 1.3%, 19.8%, and 78.9%, respectively

  • Excellent: Cronbach's Alpha = 0.87 to 0.96

Construct Validity

Chronic Migraine: (Bagley et al., 2012)

  • Adequate correlation with Migraine Quality of Life Questionnaire (r = 0.30 to -0.47)

Fibromyalgia: (Hauser et al., 2012; n = 1647; 94.8% female; 77.4% living with partner)

  • Adequate correlation with Somatic Severity Score (r = 0.56)

  • Adequate correlation with Fibromyalgia Survey Questionnaire (r = 0.48)

Non-Specific Patient Population

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Cut-Off Scores

Primary Care: (Kroenke, Spitzer, Williams, & L?we, 2009; n = 2149; aged 18-94; mean age = 47.2 (15.4) years; 66% female; 81% non-Hispanic white; 8% African-American; 8% Hispanic; 64% married; 7% had less than a high school education; 31% had a high school degree or equivalent; 62% had some college)

  • An elevated score on the PHQ-4 of 6 or greater is not diagnostic but is, instead, an indicator for further inquiry to establish the presence or absence of a clinical disorder warranting treatment

Pre-operative Surgical Patients: (Kerper et al., 2014; n = 2852; mean age = 47; 52% female; 62.6% living with a partner; 42.9% college experience)

  • PHQ-4 scores greater than or equal to 4 are significant for detecting psychological distress

General Population: (L?we et al., 2010; n = 5036; 53.6% female; mean age = 48.4 (18) years; 59.9% living with a partner)

  • PHQ-4 scores of 6 (percentile 95.7%) or greater are “yellow flags” indicating depression or anxiety disorder

  • PHQ-4 scores of 9 (percentile 99.1) or greater are “red flags” indicating depression or anxiety disorder

Normative Data

General Population: (L?we et al., 2010)

Author provided the percentile rank for PHQ-4 scores for individuals aged 14-92. For example, a PHQ-4 score of 3 for any man or woman of any age indicates a percentile rank of 75.5 in the total population.

PHQ-4 Score

N = 5003, % rank

 

0

19.6

 

1

47.6

 

2

63.1

 

3

75.5

 

4

85.9

 

5

92.7

 

6

95.7

 

7

97.5

 

8

98.5

 

9

99.1

 

10

99.4

 

11

99.7

 

12

99.9

 

Mortality Prediction: (Michal et al., 2015; n = 191 patients from N = 1384 died; deceased and alive men were 67% and 64%, respectively; age of deceased and alive men were 74.9 and 69.9 years old, respectively)

 

PHQ-4 score categories

 

 

 

 

 

Total Sample (n = 1350)

Score 0-1 (n = 688)

Score 2-3 (n = 315)

Score 4-5 (n = 203)

Score 6-12 (n = 144)

Death Rate

13.8% (n = 186)

11.0% (n = 76)

13.0% (n =  41)

17.2% (n = 35)

23.6% (n =  34)

Interrater/Intrarater Reliability

College Students: (Khubchandani et al., 2016; n = 934; mean age = 20.32 (2.72) years; 63% female; 80% Whites; 95% enrolled full time; 60% enrolled as 1st or 2nd year undergraduates; 9.2% had diagnosis of depression in the past year; 18.6% had a diagnosis of anxiety in the past year)

  • Very good agreement for anxiety screener (K = 0.81)

  • Good agreement for depression screener (K = 0.70)

Internal Consistency

Primary Care: (Kroenke et al., 2009)

  • Excellent (Cronbach's Alpha = 0.85)

Pre-operative Surgical Patients: (Kerper et al., 2014)

  • Excellent (Cronbach's Alpha = 0.83)

College Students: (Khubchandani et al., 2016)

  • Excellent (Cronbach's Alpha = 0.81)

General Population: (L?we et al., 2010)

  • Excellent (Cronbach's Alpha = 0.78)

Criterion Validity (Predictive/Concurrent)

Pre-operative Surgical Patients: (Kerper et al. 2014)

  • Excellent predictive validity (AUC = 0.88)

 

Sensitivity

Specificity

PPV

NPV

PHQ-4 Criterion Standard: BSI-GSI

0.515

0.945

0.615

0.920

  • Lowered cutoff point of less than or equal to 4, sensitivity was 80.5%, specificity was 80.2% for detecting clinically significant psychological distress according to the Global Severity Index (GSI)

College Students: (Khubchandani et al., 2016)

  • Excellent predictive validity for anxiety (AUC = 0.835)

  • Good predictive validity for depression (AUC = 0.787)

Construct Validity

Primary Care: (Kroenke et al., 2009)

  • Excellent correlation with the categories of Medical Outcomes Study Short Form General Health Survey (SF-20):

    • Excellent mental health (r = 0.80)

    • Adequate social functioning (r = 0.52)

    • Adequate general health perceptions (r = 0.48)

    • Poor role functioning (r = 0.37)

    • Poor bodily pain (r = 0.36)

    • Poor physical functioning (r = 0.36)

Pre-operative Surgical Patients: (Kerper et al. 2014)

Good discriminant validity indicated by:

  • Poor age (r = 0.05)

  • Poor gender (r = 0.13)

  • Poor partnership status (r = -0.10)

  • Poor education (r = -0.04)

  • Poor physical health (r = 0.03)

Adequate to good convergent validity has moderate to strong correlations with:

  • Good Brief System Inventory (BSI) depression scale (r = 0.68) 

  • Good BSI anxiety scale (r = 0.63)

  • Adequate BSI phobic anxiety scale (r = 0.46)

  • Good BSI interpersonal sensitivity scale (r = 0.56)

  • Good Global Severity Index (r = 0.69)

  • Good PHG single item of subjective psychosocial impairment (r = 0.70)

College Students: (Khubchandani et al., 2016)

  • Principal components analysis (PCA) using varimax rotated component-matrix for 4 screening items (2 items each for PHQ-2 and GAD-2) indicated that 83% variance was explained by the 2 components. 2 anxiety screening items had the highest loading on component 1 and the 2 depression screening items had highest loading on component 2.

4-Item Depression & Anxiety Scale

Component Loadings

 

 

Component 1

Component 2

Feeling nervous, anxious, or on edge

0.903

0.205

 

Not being able to stop or control worrying

0.861

0.313

Feeling down, depressed, or hopeless

0.378

0.795

Little interest or pleasure in doing things

0.169

0.908

General Population: (L?we et al. 2010)

  • Adequate correlation with the Rosenberg Self-Esteem Scale (r = -0.49 to -0.40)

  • Adequate correlation with the Questionnaire on Life Satisfaction (r = 0.39 to -0.39)

  • Adequate correlation with the Resilience Scale (r = 0.35 to -0.28)

Bibliography

Bagley, C. L., Rendas‐Baum, R., Maglinte, G. A., Yang, M., Varon, S. F., Lee, J., & Kosinski, M. (2012). Validating the Migraine‐Specific Quality of Life Questionnaire v2.1 in episodic and chronic migraine. Headache: The Journal of Head and Face Pain, 52(3), 409-421.

H?user, W., Jung, E., Erbsl?h-M?ller, B., Gesmann, M., Kühn-Becker, H., Petermann, F., ... & Wolfe, F. (2012). Validation of the Fibromyalgia Survey Questionnaire within a cross-sectional survey. PLoS One, 7(5), e37504.

Kerper, L., Spies, C., Tillinger, J., Wegscheider, K., Salz, A. L., Weiss-Gerlach, E., ... & Krampe, H. (2014). Screening for depression, anxiety and general psychological distress in preoperative surgical patients: A psychometric analysis of the Patient Health Questionnaire 4 (PHQ-4). Clinical Health Promotion, 4(1), 5-14.

Khubchandani, J., Brey, R., Kotecki, J., Kleinfelder, J., & Anderson, J. (2016). The psychometric properties of PHQ-4 depression and anxiety screening scale among college students. Archives of Psychiatric Nursing, 30(4), 457-462.

Kroenke, K., Spitzer, R. L., Williams, J. B., & L?we, B. (2009). An ultra-brief screening scale for anxiety and depression: The PHQ-4. Psychosomatics, 50(6), 613-621.

L?we, B., Wahl, I., Rose, M., Spitzer, C., Glaesmer, H., Wingenfeld, K., ... & Br?hler, E. (2010). A 4-item measure of depression and anxiety: Validation and standardization of the Patient Health Questionnaire-4 (PHQ-4) in the general population. Journal of Affective Disorders, 122(1), 86-95.

Michal, M., Prochaska, J. H., Keller, K., G?bel, S., Coldewey, M., Ullmann, A., ... & Beutel, M. E. (2015). Symptoms of depression and anxiety predict mortality in patients undergoing oral anticoagulation: Results from the thrombEVAL study program. International Journal of Cardiology, 187, 614-619.

Weihs, K. L., Wiley, J. F., Crespi, C. M., Krull, J. L., & Stanton, A. L. (2017). Predicting Future Major Depression and Persistent Depressive Symptoms: Development of a Prognostic Screener and PHQ4 cutoffs in Breast Cancer Patients. PsychoOncology.