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Comparison of two self-rating scales to detect depression: HADS and PHQ-9
Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry.
Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry.
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry.
2009 (English)In: British Journal of General Practice, ISSN 0960-1643, Vol. 59, no 566, e283-288 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: More than half of patients with depression go undetected. Self-rating scales can be useful in screening for depression, and measuring severity and treatment outcome. AIM: This study compares the Hospital Anxiety and Depression Scale (HADS) and the Patient Health Questionnaire (PHQ-9) with regard to their psychometric properties, and investigates their agreement at different cut-off scores. METHOD: Swedish primary care patients and psychiatric outpatients (n = 737) who reported symptoms of depression completed the self-rating scales. Data were collected from 2006 to 2007. Analyses with respect to internal consistency, factor analysis, and agreement (Cohen's kappa) at recommended cut-offs were performed. RESULTS: Both scales had high internal consistency (alpha = 0.9) and stable factor structures. Using severity cut-offs, the PHQ-9 (> or =5) diagnosed about 30% more patients than the HADS depression subscale (HADS-D; > or =8). They recognised the same prevalence of mild and moderate depression, but differed in relation to severe depression. When comparing recommended screening cut-offs, HADS-D > or =11 (33.5% of participants) and PHQ-9 > or =10 (65.9%) agreement was low (kappa = 0.35). Using the lower recommended cut-off in the HADS-D (> or =8), agreement with PHQ-9 > or =10 was moderate (kappa = 0.52). The highest agreement (kappa = 0.56) was found comparing HADS-D > or =8 with PHQ-9 > or =12. This also equalised the prevalence of depression found by the scales. CONCLUSION: The HADS and PHQ-9 are both quick and reliable. The HADS has the advantage of evaluating both depression and anxiety, and the PHQ-9 of being strictly based upon the Diagnostic and Statistical Manual of Mental Disorders. The agreement between the scales at the best suitable cut-off is moderate, although the identified prevalence was similar. This indicates that the scales do not fully identify the same cases. This difference needs to be further explored.

Place, publisher, year, edition, pages
2009. Vol. 59, no 566, e283-288 p.
URN: urn:nbn:se:umu:diva-26132DOI: 10.3399/bjgp09X454070PubMedID: 19761655OAI: diva2:236845
Available from: 2009-09-25 Created: 2009-09-25 Last updated: 2010-10-06Bibliographically approved
In thesis
1. Depression in primary care: detection, treatment, and patients’ own perspectives
Open this publication in new window or tab >>Depression in primary care: detection, treatment, and patients’ own perspectives
2010 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background Depression is a very common disorder that causes great suffering for the patient. Recognizing depressed patients in primary care (PC) settings is a challenge and only about half are identified as depressed by their general practitioner (GP). Among patients receiving antidepressants (AD) about 70 % are improved, but only about 35 % reach remission. Hence, there is a need to identify depressed patients and to develop optimal treatment strategies in PC. Self-rating scales can be helpful in assisting the recognition. Patients’ beliefs about the cause of depression and their attitudes towards treatment options have been found to influence their help-seeking behavior, coping strategies, treatment preferences and adherence. To increase depressed patients’ knowledge about their disorder and to help them reach and stay in remission, the “Contactus program” was launched in Sweden, containing patient education and group counseling, as supplement to the usual care in PC.

Aims To explore patients’ beliefs about causes and improvement factors for depression, and evaluate if the Contactus program could help to improve treatment outcome. Also, to investigate the psychometrics of two commonly used self-rating scales for depression, HADS and PHQ-9.

Methods Treatment outcome among patients participating in the Contactus program (N=205) was compared to a control group (N=114) treated as usual. The outcome was measured by HADS, GAF-self and by questionnaires. Both groups also answered an open-ended question about the cause of their depression at baseline and another question about improvement factors at follow-up after six weeks. To compare HADS and PHQ-9, patients (N=737) visiting their physician because of depression filled in both scales. The scales cut-offs were compared with Cohen’s Kappa, internal consistency was calculated and factor analysis was performed. 

Results Depressed patients participating in the Contactus program had a response rate of 55 % compared to 29 % in the control group (p=0.006). Also, remission was reached among 42 % in the Contactus group and 21 % among the controls (p=0.02). The patient’s subjective evaluation of the outcome after six weeks showed that 72% of the Contactus patients considered themselves improved vs. 47% among controls (p=0.01). The most common described reason for depression was current stress, most often work related, and own personality traits. Very few mentioned biological factors. For improvement, the most commonly mentioned aspects were participation in the Contactus program and AD. When comparing HADS to PHQ-9 their agreement at recommended cut-offs, HADS-D≥11 and PHQ-9≥10, was low (k=0.35). The highest Kappa value (0.56) and also equal prevalence of depression were found at HADS-D≥8 and PHQ≥12. Both scales had a high internal consistency (α=0.9).

Conclusions The results of this thesis indicate that patient education and group counseling are valuable supplements to usual treatment of depression in PC. It is also clear that patients and professionals often have different opinions about the causes of depression, at least concerning biological factors. The patients were generally positive to professional help. The patients’ own beliefs about their illness must be considered when developing new types of interventions and when trying to reach an understanding in the patient-doctor encounter. Finally, there are many self-rating scales for depression. Here two scales were compared and both showed good psychometric properties in terms of internal consistency and factor structure. However their optimal cut-offs were questioned. In conclusion, self-rating scales are useful in identifying depressed patients in PC and might also be apt for measuring treatment outcome. Offering the patient education about their disorder and possibility to share experiences seems to increase response and remission rates, substantially. More studies are needed to explore the effects of educational programs, group interventions, and how patients’ own believes interact with the choice of treatment, adherence and outcome.

Place, publisher, year, edition, pages
Umeå: Umeå Universitet, 2010. 63 p.
Umeå University medical dissertations, ISSN 0346-6612 ; 1308
Depression, primary care, patient education, group counselling, patients’ beliefs, treatment, causes, self-rating scales, HADS, PHQ-9
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urn:nbn:se:umu:diva-30516 (URN)978-91-7264-891-3 (ISBN)
Public defence
2010-01-29, Sal B, Tandläkarhuset, 9 tr, Norrlands Universitetssjukhus, Umeå, 09:00 (Swedish)
Available from: 2010-01-09 Created: 2010-01-07 Last updated: 2010-01-18Bibliographically approved

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