Patient Health Questionnaire-9 scores do not accurately estimate depression prevalence: individual participant data meta-analysis

Brooke Levis; Andrea Benedetti; J.P.A. Ioannidis; Ying Sun; Zelalem Negeri; Chen He; Yin Wu; Ankur Krishnan; Parash Mani Bhandari; Dipika Neupane; Mahrukh Imran; Danielle Rice; Kira Riehm; Nazanin Saadat; Marleine Azar; Jill Boruff; Pim Cuijpers; Simon Gilbody; Lorie A. Kloda; Dean  McMillan; Scott Patten; Ian Shrier; Roy Ziegelstein; Sultan Alamri; Dagmar Amtmann; Liat Ayalon; Hamid Baradaran; Anna Beraldi; Charles Bernstein; Arvin Bhana; Charles H. Bombardier; Gregory Carter; Marcos Chagas; Dixon Chabanda; Kerrie Clover; Yeates Conwell; Crisanto Diez-Quevedo; Jesse Fann; Felix Fischer; Leila Gholizadeh; Lorna J Gibson; Eric P. Green; Catherine G. Greeno; Brian J. Hall; Emily E Haroz; Khalida Ismail; Nathalie Jetté; Mohammad Khamseh; Yunxin Kwan; Maria Asunción Lara; Shen-Ing Liu; Sonia Loureiro; Bernd Lowe; Ruth Ann  Marrie; Laura Marsh; Anthony McGuire; Kumiko Muramatsu; Laura  Navarrete; Flavia Osorio; Inge Petersen; Angelo Picardi; Stephanie L.  Pugh; Terence J. Quinn; Alasdair G. Rooney; Eileen H.  Shinn; Abbey Sidebottom; Lena  Spangenberg; Pei Lin Lynnette  Tan; Martin  Taylor-Rowan; Alyna Turner; Henk van Weert; Paul A Vöhringer; Lynne I.  Wagner; Jennifer White; Kirsty Winkley; Brett D. Thombs

doi:10.1016/j.jclinepi.2020.02.002

Patient Health Questionnaire-9 scores do not accurately estimate depression prevalence: individual participant data meta-analysis

Brooke Levis, Andrea Benedetti, J.P.A. Ioannidis, Ying Sun, Zelalem Negeri, Chen He, Yin Wu, Ankur Krishnan, Parash Mani Bhandari, Dipika Neupane, Mahrukh Imran, Danielle Rice, Kira Riehm, Nazanin Saadat, Marleine Azar, Jill Boruff, Pim Cuijpers, Simon Gilbody, Lorie A. Kloda, Dean McMillanScott Patten, Ian Shrier, Roy Ziegelstein, Sultan Alamri, Dagmar Amtmann, Liat Ayalon, Hamid Baradaran, Anna Beraldi, Charles Bernstein, Arvin Bhana, Charles H. Bombardier, Gregory Carter, Marcos Chagas, Dixon Chabanda, Kerrie Clover, Yeates Conwell, Crisanto Diez-Quevedo, Jesse Fann, Felix Fischer, Leila Gholizadeh, Lorna J Gibson, Eric P. Green, Catherine G. Greeno, Brian J. Hall, Emily E Haroz, Khalida Ismail, Nathalie Jetté, Mohammad Khamseh, Yunxin Kwan, Maria Asunción Lara, Shen-Ing Liu, Sonia Loureiro, Bernd Lowe, Ruth Ann Marrie, Laura Marsh, Anthony McGuire, Kumiko Muramatsu, Laura Navarrete, Flavia Osorio, Inge Petersen, Angelo Picardi, Stephanie L. Pugh, Terence J. Quinn, Alasdair G. Rooney, Eileen H. Shinn, Abbey Sidebottom, Lena Spangenberg, Pei Lin Lynnette Tan, Martin Taylor-Rowan, Alyna Turner, Henk van Weert, Paul A Vöhringer, Lynne I. Wagner, Jennifer White, Kirsty Winkley, Brett D. Thombs

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Abstract

Objectives
Depression symptom questionnaires are not for diagnostic classification. Patient Health Questionnaire-9 (PHQ-9) scores ≥10 are nonetheless often used to estimate depression prevalence. We compared PHQ-9 ≥10 prevalence to Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (SCID) major depression prevalence and assessed whether an alternative PHQ-9 cutoff could more accurately estimate prevalence.

Study Design and Setting
Individual participant data meta-analysis of datasets comparing PHQ-9 scores to SCID major depression status.

Results
A total of 9,242 participants (1,389 SCID major depression cases) from 44 primary studies were included. Pooled PHQ-9 ≥10 prevalence was 24.6% (95% confidence interval [CI]: 20.8%, 28.9%); pooled SCID major depression prevalence was 12.1% (95% CI: 9.6%, 15.2%); and pooled difference was 11.9% (95% CI: 9.3%, 14.6%). The mean study-level PHQ-9 ≥10 to SCID-based prevalence ratio was 2.5 times. PHQ-9 ≥14 and the PHQ-9 diagnostic algorithm provided prevalence closest to SCID major depression prevalence, but study-level prevalence differed from SCID-based prevalence by an average absolute difference of 4.8% for PHQ-9 ≥14 (95% prediction interval: −13.6%, 14.5%) and 5.6% for the PHQ-9 diagnostic algorithm (95% prediction interval: −16.4%, 15.0%).

Conclusion
PHQ-9 ≥10 substantially overestimates depression prevalence. There is too much heterogeneity to correct statistically in individual studies.

Original language	English
Pages (from-to)	115-128.e1
Journal	Journal of Clinical Epidemiology
Volume	122
Early online date	24 Feb 2020
DOIs	https://doi.org/10.1016/j.jclinepi.2020.02.002
Publication status	Published - 1 Jun 2020

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10.1016/j.jclinepi.2020.02.002

R1.TRUDEPRESSD_JClinEpi_Manuscript_2020_02_18_ACCEPTED_VERSION Accepted author manuscript, 612 KBLicence: CC BY-NC-ND

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Levis, B., Benedetti, A., Ioannidis, J. P. A., Sun, Y., Negeri, Z., He, C., Wu, Y., Krishnan, A., Bhandari, P. M., Neupane, D., Imran, M., Rice, D., Riehm, K., Saadat, N., Azar, M., Boruff, J., Cuijpers, P., Gilbody, S., Kloda, L. A., ... Thombs, B. D. (2020). Patient Health Questionnaire-9 scores do not accurately estimate depression prevalence: individual participant data meta-analysis. Journal of Clinical Epidemiology, 122, 115-128.e1. https://doi.org/10.1016/j.jclinepi.2020.02.002

@article{82e997ea357346fbb90f61dd60af8fbf,

title = "Patient Health Questionnaire-9 scores do not accurately estimate depression prevalence: individual participant data meta-analysis",

abstract = "ObjectivesDepression symptom questionnaires are not for diagnostic classification. Patient Health Questionnaire-9 (PHQ-9) scores ≥10 are nonetheless often used to estimate depression prevalence. We compared PHQ-9 ≥10 prevalence to Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (SCID) major depression prevalence and assessed whether an alternative PHQ-9 cutoff could more accurately estimate prevalence.Study Design and SettingIndividual participant data meta-analysis of datasets comparing PHQ-9 scores to SCID major depression status.ResultsA total of 9,242 participants (1,389 SCID major depression cases) from 44 primary studies were included. Pooled PHQ-9 ≥10 prevalence was 24.6% (95% confidence interval [CI]: 20.8%, 28.9%); pooled SCID major depression prevalence was 12.1% (95% CI: 9.6%, 15.2%); and pooled difference was 11.9% (95% CI: 9.3%, 14.6%). The mean study-level PHQ-9 ≥10 to SCID-based prevalence ratio was 2.5 times. PHQ-9 ≥14 and the PHQ-9 diagnostic algorithm provided prevalence closest to SCID major depression prevalence, but study-level prevalence differed from SCID-based prevalence by an average absolute difference of 4.8% for PHQ-9 ≥14 (95% prediction interval: −13.6%, 14.5%) and 5.6% for the PHQ-9 diagnostic algorithm (95% prediction interval: −16.4%, 15.0%).ConclusionPHQ-9 ≥10 substantially overestimates depression prevalence. There is too much heterogeneity to correct statistically in individual studies.",

author = "Brooke Levis and Andrea Benedetti and J.P.A. Ioannidis and Ying Sun and Zelalem Negeri and Chen He and Yin Wu and Ankur Krishnan and Bhandari, {Parash Mani} and Dipika Neupane and Mahrukh Imran and Danielle Rice and Kira Riehm and Nazanin Saadat and Marleine Azar and Jill Boruff and Pim Cuijpers and Simon Gilbody and Kloda, {Lorie A.} and Dean McMillan and Scott Patten and Ian Shrier and Roy Ziegelstein and Sultan Alamri and Dagmar Amtmann and Liat Ayalon and Hamid Baradaran and Anna Beraldi and Charles Bernstein and Arvin Bhana and Bombardier, {Charles H.} and Gregory Carter and Marcos Chagas and Dixon Chabanda and Kerrie Clover and Yeates Conwell and Crisanto Diez-Quevedo and Jesse Fann and Felix Fischer and Leila Gholizadeh and Gibson, {Lorna J} and Green, {Eric P.} and Greeno, {Catherine G.} and Hall, {Brian J.} and Haroz, {Emily E} and Khalida Ismail and Nathalie Jett{\'e} and Mohammad Khamseh and Yunxin Kwan and {Asunci{\'o}n Lara}, Maria and Shen-Ing Liu and Sonia Loureiro and Bernd Lowe and Marrie, {Ruth Ann} and Laura Marsh and Anthony McGuire and Kumiko Muramatsu and Laura Navarrete and Flavia Osorio and Inge Petersen and Angelo Picardi and Pugh, {Stephanie L.} and Quinn, {Terence J.} and Rooney, {Alasdair G.} and Shinn, {Eileen H.} and Abbey Sidebottom and Lena Spangenberg and Tan, {Pei Lin Lynnette} and Martin Taylor-Rowan and Alyna Turner and {van Weert}, Henk and V{\"o}hringer, {Paul A} and Wagner, {Lynne I.} and Jennifer White and Kirsty Winkley and Thombs, {Brett D.}",

year = "2020",

month = jun,

day = "1",

doi = "10.1016/j.jclinepi.2020.02.002",

language = "English",

volume = "122",

pages = "115--128.e1",

journal = "Journal of Clinical Epidemiology",

issn = "0895-4356",

publisher = "Elsevier USA",

}

Levis, B, Benedetti, A, Ioannidis, JPA, Sun, Y, Negeri, Z, He, C, Wu, Y, Krishnan, A, Bhandari, PM, Neupane, D, Imran, M, Rice, D, Riehm, K, Saadat, N, Azar, M, Boruff, J, Cuijpers, P, Gilbody, S, Kloda, LA, McMillan, D, Patten, S, Shrier, I, Ziegelstein, R, Alamri, S, Amtmann, D, Ayalon, L, Baradaran, H, Beraldi, A, Bernstein, C, Bhana, A, Bombardier, CH, Carter, G, Chagas, M, Chabanda, D, Clover, K, Conwell, Y, Diez-Quevedo, C, Fann, J, Fischer, F, Gholizadeh, L, Gibson, LJ, Green, EP, Greeno, CG, Hall, BJ, Haroz, EE, Ismail, K, Jetté, N, Khamseh, M, Kwan, Y, Asunción Lara, M, Liu, S-I, Loureiro, S, Lowe, B, Marrie, RA, Marsh, L, McGuire, A, Muramatsu, K, Navarrete, L, Osorio, F, Petersen, I, Picardi, A, Pugh, SL, Quinn, TJ, Rooney, AG, Shinn, EH, Sidebottom, A, Spangenberg, L, Tan, PLL, Taylor-Rowan, M, Turner, A, van Weert, H, Vöhringer, PA, Wagner, LI, White, J, Winkley, K & Thombs, BD 2020, 'Patient Health Questionnaire-9 scores do not accurately estimate depression prevalence: individual participant data meta-analysis', Journal of Clinical Epidemiology, vol. 122, pp. 115-128.e1. https://doi.org/10.1016/j.jclinepi.2020.02.002

TY - JOUR

T1 - Patient Health Questionnaire-9 scores do not accurately estimate depression prevalence

T2 - individual participant data meta-analysis

AU - Levis, Brooke

AU - Benedetti, Andrea

AU - Ioannidis, J.P.A.

AU - Sun, Ying

AU - Negeri, Zelalem

AU - He, Chen

AU - Wu, Yin

AU - Krishnan, Ankur

AU - Bhandari, Parash Mani

AU - Neupane, Dipika

AU - Imran, Mahrukh

AU - Rice, Danielle

AU - Riehm, Kira

AU - Saadat, Nazanin

AU - Azar, Marleine

AU - Boruff, Jill

AU - Cuijpers, Pim

AU - Gilbody, Simon

AU - Kloda, Lorie A.

AU - McMillan, Dean

AU - Patten, Scott

AU - Shrier, Ian

AU - Ziegelstein, Roy

AU - Alamri, Sultan

AU - Amtmann, Dagmar

AU - Ayalon, Liat

AU - Baradaran, Hamid

AU - Beraldi, Anna

AU - Bernstein, Charles

AU - Bhana, Arvin

AU - Bombardier, Charles H.

AU - Carter, Gregory

AU - Chagas, Marcos

AU - Chabanda, Dixon

AU - Clover, Kerrie

AU - Conwell, Yeates

AU - Diez-Quevedo, Crisanto

AU - Fann, Jesse

AU - Fischer, Felix

AU - Gholizadeh, Leila

AU - Gibson, Lorna J

AU - Green, Eric P.

AU - Greeno, Catherine G.

AU - Hall, Brian J.

AU - Haroz, Emily E

AU - Ismail, Khalida

AU - Jetté, Nathalie

AU - Khamseh, Mohammad

AU - Kwan, Yunxin

AU - Asunción Lara, Maria

AU - Liu, Shen-Ing

AU - Loureiro, Sonia

AU - Lowe, Bernd

AU - Marrie, Ruth Ann

AU - Marsh, Laura

AU - McGuire, Anthony

AU - Muramatsu, Kumiko

AU - Navarrete, Laura

AU - Osorio, Flavia

AU - Petersen, Inge

AU - Picardi, Angelo

AU - Pugh, Stephanie L.

AU - Quinn, Terence J.

AU - Rooney, Alasdair G.

AU - Shinn, Eileen H.

AU - Sidebottom, Abbey

AU - Spangenberg, Lena

AU - Tan, Pei Lin Lynnette

AU - Taylor-Rowan, Martin

AU - Turner, Alyna

AU - van Weert, Henk

AU - Vöhringer, Paul A

AU - Wagner, Lynne I.

AU - White, Jennifer

AU - Winkley, Kirsty

AU - Thombs, Brett D.

PY - 2020/6/1

Y1 - 2020/6/1

N2 - ObjectivesDepression symptom questionnaires are not for diagnostic classification. Patient Health Questionnaire-9 (PHQ-9) scores ≥10 are nonetheless often used to estimate depression prevalence. We compared PHQ-9 ≥10 prevalence to Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (SCID) major depression prevalence and assessed whether an alternative PHQ-9 cutoff could more accurately estimate prevalence.Study Design and SettingIndividual participant data meta-analysis of datasets comparing PHQ-9 scores to SCID major depression status.ResultsA total of 9,242 participants (1,389 SCID major depression cases) from 44 primary studies were included. Pooled PHQ-9 ≥10 prevalence was 24.6% (95% confidence interval [CI]: 20.8%, 28.9%); pooled SCID major depression prevalence was 12.1% (95% CI: 9.6%, 15.2%); and pooled difference was 11.9% (95% CI: 9.3%, 14.6%). The mean study-level PHQ-9 ≥10 to SCID-based prevalence ratio was 2.5 times. PHQ-9 ≥14 and the PHQ-9 diagnostic algorithm provided prevalence closest to SCID major depression prevalence, but study-level prevalence differed from SCID-based prevalence by an average absolute difference of 4.8% for PHQ-9 ≥14 (95% prediction interval: −13.6%, 14.5%) and 5.6% for the PHQ-9 diagnostic algorithm (95% prediction interval: −16.4%, 15.0%).ConclusionPHQ-9 ≥10 substantially overestimates depression prevalence. There is too much heterogeneity to correct statistically in individual studies.

AB - ObjectivesDepression symptom questionnaires are not for diagnostic classification. Patient Health Questionnaire-9 (PHQ-9) scores ≥10 are nonetheless often used to estimate depression prevalence. We compared PHQ-9 ≥10 prevalence to Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (SCID) major depression prevalence and assessed whether an alternative PHQ-9 cutoff could more accurately estimate prevalence.Study Design and SettingIndividual participant data meta-analysis of datasets comparing PHQ-9 scores to SCID major depression status.ResultsA total of 9,242 participants (1,389 SCID major depression cases) from 44 primary studies were included. Pooled PHQ-9 ≥10 prevalence was 24.6% (95% confidence interval [CI]: 20.8%, 28.9%); pooled SCID major depression prevalence was 12.1% (95% CI: 9.6%, 15.2%); and pooled difference was 11.9% (95% CI: 9.3%, 14.6%). The mean study-level PHQ-9 ≥10 to SCID-based prevalence ratio was 2.5 times. PHQ-9 ≥14 and the PHQ-9 diagnostic algorithm provided prevalence closest to SCID major depression prevalence, but study-level prevalence differed from SCID-based prevalence by an average absolute difference of 4.8% for PHQ-9 ≥14 (95% prediction interval: −13.6%, 14.5%) and 5.6% for the PHQ-9 diagnostic algorithm (95% prediction interval: −16.4%, 15.0%).ConclusionPHQ-9 ≥10 substantially overestimates depression prevalence. There is too much heterogeneity to correct statistically in individual studies.

UR - http://www.scopus.com/inward/record.url?scp=85082494030&partnerID=8YFLogxK

U2 - 10.1016/j.jclinepi.2020.02.002

DO - 10.1016/j.jclinepi.2020.02.002

M3 - Article

SN - 0895-4356

VL - 122

SP - 115-128.e1

JO - Journal of Clinical Epidemiology

JF - Journal of Clinical Epidemiology

ER -

Patient Health Questionnaire-9 scores do not accurately estimate depression prevalence: individual participant data meta-analysis

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